The Evil Hours (28 page)

After the usual introductions, we chatted briefly about rock climbing and Chicago, where he had done his graduate work. Then we dove in.

Prolonged Exposure, one of the VA's “gold standard” PTSD therapies, has two major components, both of which are designed to extinguish fears arising from trauma and allow the patient to regain control of their environment by ridding themselves of “avoidant” behaviors.
A form of flooding therapy, “PE,” as it is known, is based on classical learning theory, which has its origins in the work of Ivan Pavlov, the famed Russian physiologist, who noticed, by accident, that dogs became conditioned to salivate when they heard the sound of a bell they associated with food. The first part of the treatment, to be done at the hospital, was known as “imaginals” and would involve me closing my eyes and retelling the story of a traumatic event of my choice a number of times. This would continue until I was no longer afraid of it, and it no longer activated a fear response in my body, until in the sometimes-confusing language of conditioning it became “habituated.”

For the second component, known as “in vivos,” I would be asked to do things in the real world that in some way resembled the traumatic event in question. The theory behind this was that by reactivating the fearful memories in the safety of a therapist's office and in the relative safety of the real non-Iraq world, I would unlearn bad trauma-related behaviors and learn to incorporate new information about the world. I would unlearn the trauma in a way not unlike the way that Pavlov trained his dogs to associate food with other, unrelated stimuli.

With both of these activities, the governing principle was uncoupling the fear response that had been created by the event from another stimulus, whether it be driving down an alley that subliminally reminded me of driving in Iraq or riding on an airliner that subliminally reminded me of the Sea Stallion over Fallujah. Finally, I would be asked to listen to a recording of our sessions at home at least once a week.

At this point, Scott, ever the salesman, started in fast and heavy with the similes. PE was like knee surgery, he explained. It was like physical therapy, it was like unlearning a dog phobia, it was like learning to surf, because at first you got swamped by the white water, but eventually you learned how to stand up on top of it. Trauma, he continued, was like having a folder full of papers thrown up into the air. “What we're going to do is collect all those papers up and get them sorted and into neater piles.” The keys, he said, were working up in intensity and repetition. We would start slow, with me telling my story, and keep at it.

“Think about it like the gym,” he said before letting me go.

For our second session, Scott began by describing how the autonomic nervous system worked with respect to PTSD. “Something triggers you, whether it's driving or walking into a crowd, something that reminds you of Iraq and you get that fight-or-flight response going, right? And your autonomic nervous system can only maintain that for about forty minutes. And then that's when you crash, right?” I agreed. To help me control this involuntary response, he took me through what he called a “rebreathing drill,” a progressive relaxation technique that reminded me of yoga.

Instructing me to close my eyes, he walked me through several repetitions, slowing my breath down incrementally. “This is your homework for this week. When you're feeling activated, I want you to give this a try. Okay?”

Our sessions, ninety minutes twice a week in a shabby office filled with furniture from Ronald Reagan's first term, were focused on the involuntary aspects of post-traumatic stress. Basically, anything beneath the realm of conscious thought was on the table. Although I didn't know it at the time, what we were doing was zeroing in on the animal aspects of trauma, trying to fix what had happened at the mammalian level of stimulus and response, all the survival instincts that can go awry in the aftermath—sensing stimuli learned in a survival situation and attending to them in a nonsurvival context, the brain making patterns where there are none.

“The body knows things long before the mind catches up to them,” novelist Sue Monk Kidd wrote in
The Secret Life of Bees
. The problem is that once the brain learns something in a survival situation, it becomes very difficult to unlearn it, as if it cannot disobey its first commandment:
Thou shalt attend to danger
. Prolonged Exposure is essentially designed to force the brain to do just that, to unlearn the first commandment. This is not an easy task, to be sure, because when an intense life-threatening event happens even once, it is etched into the brain in a way that nonthreatening events aren't.

Joe Simpson, the British mountaineer and author, describes undergoing a crude, real-life version of Prolonged Exposure in his book
Touching the Void
. After being diagnosed with PTSD, he was told he'd have to wait six months before seeing a therapist. “In the meantime I experienced eight weeks of mild panic attacks, a tendency to cry unexpectedly and a persistent feeling of vulnerability. Then I gave a corporate motivational presentation recounting the ‘Void' story and within days the symptoms had disappeared . . . Telling and retelling the ‘Void' story had inadvertently proved to be a good treatment for the condition. Apparently it is a common practice for psychotherapists to make a victim recount as vividly as they can the full horrors of their experience. With each telling of their real story it gradually becomes a fiction, becomes someone else's experience, and they can separate themselves from the trauma.”

After discussing some of the basics of the treatment and what to expect, Scott and I started in on the imaginals. He asked me to close my eyes and put myself back in the Humvee in Saydia, narrating it all in the present tense, as if I were actually there again. I described driving down the boulevard, turning onto the smoke-covered street, seeing the burning houses, realizing we were in a dead end, hearing the Bradley ahead beginning to turn around, the Humvee starting to back up, and the boom. After this first “repetition,” he asked me how I was feeling, if my heart rate and my breathing were up. They were.

“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
fuck
s and
goddam
s 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.