The Evil Hours
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[>] Once the dream of a handful of Vietnam veterans: See Watters, Crazy Like Us, 71.
6. Therapy
[>] The original building, completed in 1972, boasts: See http://www.sandiego.va.gov/about/(accessed August 1, 2014).
[>] It serves a regional veteran population of over: Personal communication with VA San Diego staff psychologist; personal communication with Jeanette Steele, staff reporter, San Diego Union-Tribune; Iraq and Afghanistan Veterans of America press release, September 23, 2013. “IAVA Leads Events Across San Diego.”
[>] “The primary investigator for this study has a résumé”: Personal communication with the author, March 2013.
[>] After guiding me through a thick stack of surveys: See Friedman, Handbook of PTSD, 284–285. See also F. W. Weathers et al., “Clinician Administered PTSD Scale (CAPS): A Review of the First Ten Years of Research.” Depression and Anxiety 13 (2001): 132–156. The VA has a tremendous amount of faith in the CAPS, and it is the cornerstone of its recent evidence-supported therapy campaign. According to the research, the CAPS is very reliable. However, as critics like Gary Greenberg (who’s a licensed therapist himself) have pointed out, these sorts of deliberately anonymous, neo-Kraepelinian diagnostic tools are not without their shortcomings. Greenberg argues, in his 2010 book Manufacturing Depression: The Secret History of a Modern Disease, that “the trick with the descriptive approach to diagnosis is to keep your eye on the loose-leaf notebook and not on the patient. That’s why it didn’t really matter whether my doctor knew my name or noticed that I was cracking jokes, engaging him in relatively sophisticated conversation about neurochemistry . . . Details like this would have been inconvenient to say the least . . . The [mental health] industry is working hard to eliminate the human element from psychiatry, but for now the best it can do is to circle the answers in notebooks and train practitioners to ignore what’s in front of their eyes” (63–64). Needless to say, the ideal of a diagnosis being arrived at by “a dialogue between patient and doctor,” at least with respect to PTSD and the VA, seems to be a thing of the past.
[>] “People with PTSD drink”: Personal communication with the author, March 2013.
[>] “When I started to read the symptoms online”: Author interview with Jessica G., February 2014.
[>] Several years after being raped: Sebold, Lucky, 239–240. Author interview with Sebold, July 2013.
[>] “Now, I’m gonna make mistakes and say some stupid things”: All the dialogue between Scott (not his real name) and me was digitally recorded, as were most of the therapy sessions and CAPS interviews at the VA San Diego during my time there. Wherever possible, I have used those recordings to check the accuracy of my reporting. I was admitted into the VA San Diego Healthcare System as a veteran based on my Marine Corps service in the 1990s. I have never sought nor received a disability rating from the VA.
[>] Prolonged Exposure, one of the VA’s “gold standard” PTSD therapies: See Follette et al., Cognitive-Behavioral Therapies, 66–68, for a succinct overview of the PE therapy; Foa et al., Treating the Trauma; Friedman, Handbook of PTSD, 475–476; Back et al., Concurrent Treatment of PTSD; Finley, Fields of Combat, 123. Learning about PE is often difficult for the general researcher because the therapy is referred to by so many different names. Within the scientific literature, one finds references to “prolonged exposure,” “exposure therapy,” “imaginal therapy,” “imaginal exposure,” “flooding,” and “implosive therapy,” and it is often difficult to ascertain exactly what is being discussed. This confusion is exacerbated by the fact that “prolonged exposure” is usually lumped in with the VA’s other major therapeutic modality—“cognitive processing therapy”—under the rubric of “cognitive-behavioral therapy,” even though the two therapies are very different. PE is largely derived from the work of Ivan Pavlov and Edna Foa, whereas CPT is drawn largely from the work of Aaron Beck and Patricia Resick of the VA’s National Center for PTSD.
[>] “In the meantime I experienced eight weeks of mild panic attacks”: Simpson, Touching the Void, 213. Simpson’s account of his panic attacks is included in the epilogue to the 2004 edition of Touching the Void. Simpson’s comments in the documentary film Return to Siula Grande, included in the DVD extras of the feature film based on his book, are chilling and revelatory.
[>] It was, I would later learn, a “manualized” therapy: Interview with Gary Greenberg, April 2013; interview with senior VA psychiatrist, April 2013.
[>] Prolonged Exposure, one of the VA’s top-tier or “Schedule A”: There are dozens of studies that have shown PE to be effective. Here are a few of the most cited publications: Edna Foa et al., Prolonged Exposure Therapy for PTSD: Emotional Processing of Traumatic Experiences (New York: Oxford University Press, 2007); Edna Foa et al., “Randomized Trial of Prolonged Exposure for Posttraumatic Stress Disorder With and Without Cognitive Restructuring: Outcome at Academic and Community Clinics.” Journal of Consulting and Clinical Psychology 73 (2005): 953–964; Mark B. Powers et al., “A Meta-Analytic Review of Prolonged Exposure for Posttraumatic Stress Disorder.” Clinical Psychology Review 30 (2010): 635–641. In 2008, the prestigious Institute of Medicine said in its evaluation of the various psychotherapies that “the committee finds that the evidence is sufficient to conclude the efficacy of exposure therapies in the treatment of PTSD.” Immediately after this, in the comment section, it added, “The evidence for efficacy of exposure therapy in veterans—especially in males with chronic PTSD—is less consistent than the general body of evidence” (97).
[>] Derived from the classical conditioning or “learning” theories: See Friedman, Handbook of PTSD, 541.
[>] “Even after a year, I still had an extremely difficult”: Foer, Extremely Loud, 17.
[>] Created by psychologist Thomas Stampfl in 1967: Leitenberg, Handbook of Social, 300–302; see also Doctor and Shapiro, Encylopedia of Trauma, 125.
[>] In 1982, Terry Keane, a psychologist at Boston University: See T. M. Keane et al., “Flooding for Combat-Related Stress Disorders: Assessment of Anxiety Reduction across Traumatic Memories.” Behavior Therapy 13 (1982): 499–510.
[>] One of the recurring concerns raised by therapists: See Finley, Fields of Combat, 125; personal communication with Caroline F., a psychotherapist in private practice.
[>] One of those most excited by the possibilities of flooding therapy: Finley, Fields of Combat, 123; Jeffrey Kluger, “The World’s Most Influential People.” Time, April 29, 2010; Louisa Kamps, “Prolonged Exposure: A Trauma Therapy Has Victims Live Out Life’s Blows Again and Again and Again.” Elle, August 24, 2009; Thomas W. Durso, “A Calming Influence.” Penn Medicine, Spring 2010, 19–23. Personal communication with VA San Diego research coordinator; personal communication with senior VA psychiatrist.
[>] However, not everyone was convinced about this new therapy: Everly, Psychotraumatology, 363.
[>] “It is not obvious that a rat’s display”: Stossel, My Age of Anxiety, 47.
[>] In 1991, Roger Pitman, a professor of psychiatry: Pitman et al., “Psychiatric Complications During Flooding Therapy for PTSD.” Journal of Clinical Psychiatry 52 (1991): 17–20; phone interview with Pitman, January 2014.
[>] A lengthier study by Pitman published in 1996: Pitman et al., “Emotional Processing and Outcome of Imaginal Flooding Therapy in Vietnam Veterans with Chronic Posttraumatic Stress Disorder.” Comprehensive Psychiatry 37 (1996): 409–418.
[>] Similar research, conducted by Zahava Solomon: Z. Solomon et al., “The ‘Koach’ Project for Treatment of Combat-Related PTSD: Rationale, Aims, and Methodology.” Journal of Traumatic Stress 5 (1992): 175–193.
[>] “it is important to emphasize that exposure”: See van der Kolk, Traumatic Stress, 435.
[>] “You’re right. We’re seeing the same things”: Phone interview with Pitman, January 2014.
[>] In 2008, undeterred by these and other disturbing: See Finley, Fields of Combat, 120–127; Kluger, “The World’s Most Influential People.”
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p; [>] Since the rollout, a number of trauma workers: Finley, Fields of Combat, 125.
[>] One research assistant at VA San Diego: Personal communication with the author, January 2014.
[>] An independent survey conducted by the: http://blog.23andme.com/23andme -research/what-works-for-ptsd/ (accessed August 1, 2014).
[>] One rape victim I interviewed, who completed: Interview with Elise Colton, April 2013.
[>] One senior VA official, who was trained: Interview with senior VA psychiatrist, 2013.
[>] Jonathan Shay, one of the most highly respected: Comments made during presentation given at San Diego State University, “PTSD and Moral Injury: What’s the Difference and Does it Matter?” October 4, 2012.
[>] In 2008, the prestigious Institute of Medicine determined: See Institute of Medicine, Treatment of Posttraumatic Stress Disorder, 95–99.
[>] In an August 2002 study in the: Edna Foa et al., “Does Imaginal Exposure Exacerbate PTSD Symptoms?” Journal of Consulting and Clinical Psychology 70 (2002): 1022–1028.
[>] “something intended to be effective works better”: Greenberg, Manufacturing Depression, 306. See also D. Westen et al., “Empirically Supported Complexity: Re-thinking Evidence-Based Practice in Psychotherapy.” Current Directions in Psychological Science 14 (2005): 266–271.
[>] Greenberg also rails against another statistical procedure: Greenberg, Manufacturing Depression, 307. Phone interview with Greenberg, April 2013. Several critics of PE pointed out this experimental design flaw to me. The fact remains that PE has the highest recorded dropout rate of any PTSD therapy, which makes one wonder why the VA chose it as one of its frontline therapies, when there are other, safer, less controversial, and less expensive therapies available.
[>] The controversy surrounding PE also resembles: See Jonah Lehrer, “The Forgetting Pill Erases Painful Memories Forever.” Wired, February 17, 2012. While much of Lehrer’s work has been retracted due to factual issues, this article was cleared by Wired’s editors, according to a review later published at Slate magazine. Lehrer’s article does a good job of succinctly reviewing the CISD controversy. Another researcher, at UC Irvine, whom I spoke to confirmed Lehrer’s assessment of CISD’s lack of empirical support.
[>] For his part, Roger Pitman remains skeptical of PE: Phone interview with Pitman, January 2014.
[>] “It is important to emphasize that exposure may”: See van der Kolk, Traumatic Stress, 435.
[>] Prior to undergoing PE, I had, in fact, read: See Shephard, War of Nerves, 2001. See also Laurent Tatu, “The ‘Torpillage’ Neurologists of World War I.” Historical Neurology 75 (2010): 279–283 .
[>] There are no documented cases of veterans or other PTSD survivors: Shay, on page 187 of Achilles in Vietnam, says, “During the early days of the current era of PTSD treatment, mental health professionals shared the folk belief that simply ‘getting it all out’ would result in safety, sobriety, and self-care. The consequences of these well-intentioned ‘combat debriefings’ were catastrophic, resulting in many suicides, according to veterans in our program who participated.” The “combat debriefings” Shay describes are not the same thing as PE therapy, but they seem to be motivated by the same purgative principle—that the contagion of trauma can be expelled, washed away, “cleaned out” like a festering wound, to use Scott’s metaphor. For more on this, see Herman, Trauma and Recovery, 172.
[>] “dialectic of trauma”: Herman, Trauma and Recovery, 47.
[>] There were the usual introductions: I have changed the names and significant life details of these veterans in order to protect their privacy.
[>] Cognitive Processing Therapy is one of the most popular: For an overview of CPT, see Victoria M. Follette and Josef Ruzek, eds. Cognitive-Behavioral Therapies for Trauma, 100–102. For more on Aaron Beck, see Greenberg, Manufacturing Depression, 288–290; Clark and Beck, Cognitive Therapy of Anxiety Disorders.
[>] “caught up in the contagion of the times”: Quoted in Greenberg, Manufacturing Depression, 288.
[>] “therapist and patient work together to identify”: Ibid., 289.
[>] “CBT teaches objectivity”: Solomon, Noonday Demon, 107.
[>] CPT has been extensively studied: See P. A. Resick et al., “Cognitive Processing Therapy for Sexual Assault Victims.” Journal of Consulting and Clinical Psychology 60 (1992): 748–756. See also Candice M. Monson et al., “Cognitive Processing Therapy for Veterans with Military-Related Posttraumatic Stress Disorder.” Journal of Consulting and Clinical Psychology 74 (2006): 898–907.
[>] A 2002 study by Resick, using a large sample of sexual assault: P. A. Resick et al., “Comparison of Cognitive-Processing Therapy with Prolonged Exposure and a Waiting Condition for the Treatment of Chronic Posttraumatic Stress Disorder in Female Rape Victims.” Journal of Consulting and Clinical Psychology 70 (2002): 867–879.
[>] Another study, published in Behavior Therapy in 2004: Nicholas Tarrier et al., “Treatment of Chronic PTSD by Cognitive Therapy and Exposure: 5-Year Follow-Up.” Behavior Therapy 35 (2004): 231–246.
[>] A number of critics, including Gary Greenberg and B. E. Wampold: See Greenberg, Manufacturing Depression, 302–314; Wampold, Great Psychotherapy Debate, 2001.
[>] One stunningly illuminating study conducted by Hans Strupp: Hans Strupp et al., “Specific vs Nonspecific Factors in Psychotherapy: A Controlled Study of Outcome.” Archives of General Psychiatry 36 (1979): 1125–1136.
[>] About these sorts of elemental questions: For more on the idea of moral injury and violation of themis (Greek for “justice”), see Shay, Achilles in Vietnam, 3-21.
[>] “For most of the 20th century, psychoanalytic theory”: Ghislaine Boulanger, “Witnesses to Reality: Working Psychodynamically with Survivors of Terror.” Psychoanalytic Dialogues 18 (2008): 640.
[>] The VA, which sets the tone for PTSD treatment worldwide: For the VA’s PTSD treatment guidelines, go to: http://www.ptsd.va.gov/professional/treatment/over view/index.asp.; see also Carr, “Combat and Human Existence,” 494.
[>] “Biological research is where the money is”: Interview with senior VA psychiatrist, April 2013.
[>] “Sixty years after its introduction”: Kandel, In Search of Memory, 365.
[>] Russell Carr, a navy psychiatrist at Bethesda–Walter Reed: Carr, “Combat and Human Existence,” 471–496; “The Problem of Therapeutic Alliance When Treating Combat-Related PTSD.” Presentation by Commander Russell Carr, MC, USN, Navy and Marine Corps Combat and Operational Stress Control Conference, San Diego, California, May 23, 2012.
[>] Intersubjectivity theory, the school of thought that Carr: See Stolorow, Trauma and Human Existence. Carr, in “Combat and Human Existence,” said, “As I left for a deployment to Iraq in the summer of 2008, I was wrestling with how to reach soldiers with traumatized experiences that left them with profound shame and difficulties with their relationships with others . . . A few months into the deployment, I developed an even stronger sense of urgency as one of my patients killed himself. I felt the effects of his suicide on his unit, the medical staff who tried to resuscitate him, and the other mental health team on base . . . As I thought of him and continued to meet with my other patients there in Iraq, I felt a strong urgency to find a better way to understand the effects of trauma. I then stumbled upon the writings of Robert Stolorow. I obtained a copy of his recent book, Trauma and Human Existence. It fundamentally changed how I work with traumatized military personnel” (473–474).
[>] As Stolorow sees it, everyone wants to be understood: See Carr, “Combat and Human Existence,” 475–476.
[>] In his military practice, Carr treats some of the most chronic and complex: Interview with Russell Carr, April 2013.
[>] “Doc, you get this more than anyone I’ve talked to about it”: Carr, “Combat and Human Existence,” 474.
7. Drugs
[>] In the world of memory science, McGaugh: This chapter is based on my interviews with McGaugh, emails exchanged from 2007 to 2
013, the UC Irvine website, and interviews with his colleagues. In his book Memory and Emotion: The Making of Lasting Memories (New York: Columbia University Press, 2003), McGaugh describes the thought process behind some of his discoveries and some of the aspects of his academic training. After interviewing McGaugh, I stumbled across a fascinating article published in the New England Journal of Medicine by Troy Lisa Holbrook (“Morphine Use after Combat Injury in Iraq and Post-Traumatic Stress Disorder,” January 14, 2010), which seemed to confirm much of McGaugh’s work and was derived from data collected in Iraq. Holbrook and her colleagues found that giving wounded soldiers and Marines morphine “during early resuscitation and trauma care” cut their risk of getting PTSD by 50 percent. Without realizing it, medics and physicians in Iraq had disrupted traumatic memory overconsolidation in a manner similar to what McGaugh had done in the lab.
[>] If McGaugh’s work has a governing principle: McGaugh, Memory and Emotion, 83.
[>] “In medieval times, before writing was used to keep”: McGaugh, Memory and Emotion, ix.
[>] Scientists have known for a long time that certain: K. S. Lashley, “The Effects of Strychnine and Caffeine upon the Rate of Learning.” Psychobiology 1 (1917): 141–170.
[>] McGaugh stumbled across Lashley’s research in the fifties: McGaugh, Memory and Emotion, 60–61.
[>] Soon after getting his PhD, McGaugh began experimenting: McGaugh, Memory and Emotion, 63–70.
[>] They soon discovered that adrenaline, the chemical released: Ibid., 73, 97–108.
[>] This drug—propranolol, a beta-blocker developed: Ibid., 100–106. See also L. Cahill and J. L. McGaugh, “Modulation of Memory Storage.” Current Opinion in Neurobiology 6 (1996): 237–242; Roger K. Pitman, “Pilot Study of Secondary Prevention of Posttraumatic Stress Disorder with Propranolol.” Biological Psychiatry 51 (2002), 189–192; Friedman, Handbook of PTSD, 392.
[>] As I would learn later, the other not-small problem: Phone interview with Roger Pitman, April 2014.