The Evil Hours (32 page)

From my earliest days as an officer candidate at Quantico, I had been told that leaders are held accountable for their actions. In my mind, the Bush administration and senior officers within the military were never held accountable for their actions. The sequence of events that culminated in 2004 with Bush's reelection after the debacle of the first battle of Fallujah and Abu Ghraib shook me to the core, controverting the lessons that as a Marine I had been raised on—that actions had consequences and that committing troops to battle was a sacred undertaking—and in the process severely damaging whatever version of the just-world theory that I had held up to that point.

About these sorts of elemental questions, questions which many survivors struggle with, questions that the ancient Greeks looked at as a violation of
themis
, or justice, CPT has curiously little to say.
More to the point, therapists using the CPT protocol tend to ask about important, weighty issues, issues that have defined history in some instances, and then when they hear your answer, they tell you that perhaps you are being a little pessimistic about it all.

When, in one of my first “A-B-C” sheets, I wrote that “A. The government lies. B. People in power are liars and their lies killed friends of mine. C. I feel sick and helpless about it,” I was urged in the corresponding example “A-B-C” worksheet and then, innocently, even sweetly, by Chloe to investigate whether my “B” belief was, in fact, “100 percent realistic.”

100 percent realistic. The government that lied to get the country to go to war. The government that lied to cover up the worst friendly fire incident since the Vietnam War, in which eighteen Marines were killed by U.S. Air Force A-10s. The government that sent too few troops to secure Iraq. The government that overruled the judgment of commanders on the ground and ordered four Marine battalions into Fallujah and then pulled them out when Iraqi legislators complained, as reported in
Salon
and the
Los Angeles Times
and later explored at length in an Oxford University study. The government that continued to insist that the Sunni insurgency was “in its last throes” even as casualties were peaking in Anbar province. The government and its successors that have continued to insist that the 2007 surge of American troops “worked” when in fact the majority of the Iraqi Army units trained by the United States crumbled in the face of an Al Qaeda assault in 2014.

Was this a case of my being a noncompliant patient again? A case of my resisting treatment on philosophical grounds? Was I being needlessly argumentative? Perhaps. Though I think the better question to be asked is if the sort of alienation and mistrust of society I experienced after Iraq wasn't extreme or “unrealistic” at all but was, in fact, entirely appropriate, appropriate for the same reasons that it was appropriate for Siegfried Sassoon to be disgusted with British society after World War I, saying, “In the name of civilization these soldiers had been martyred, and it remained for civilization to prove that their martyrdom wasn't a dirty swindle.” Was it not possible that “civilization” was being unrealistic, expecting veterans to forgive and forget? Wasn't my disillusionment the more empirically accurate response, given the lies about the use of military force that continue to inform American policy?

Another, slightly more paranoid argument that could be made here is that therapies like CPT silence trauma survivors, telling them to buck up and forget about all those regrettable events they went through, regrettable events that often resulted from abuses of power. As part of a larger argument about the need to view survivors of trauma as messengers from a kind of underground, Judith Herman asserted that “like traumatized people, we [as a society] need to understand the past in order to reclaim the present and the future.”

In all fairness, it was stimulating and useful for me to consider the myriad questions of the just-world theory. It was also useful to examine how my trust in society changed after Iraq. And it's possible that Chloe and Heather and Patricia Resick and Aaron Beck all have a point. Maybe with traumatic events, the best way to get over them is to try to see them as truly exceptional, isolated, one-off incidents, and the lessons are best examined on a case-by-case basis rather than used to judge the entire world.

But the historian in me wonders what would have happened if the VVAW agitators who fought to have PTSD recognized had come to see the Vietnam War as a truly exceptional, isolated event. A one-off. And I wonder about the direction that PTSD has taken since 1980. I wonder if by treating it with the punitive reconditioning of Prolonged Exposure and the Yankee optimism of cognitive therapy, clinicians haven't reduced the moral questions at the heart of PTSD—the proper use of military force, the safety of women in society, the efficacy of torture—to distant also-rans, asterisks in the clinician's handbook. I wonder if in the process they haven't served to reduce one of the most powerful humanistic concepts in history to a strictly technical matter. And, coincidentally, if they haven't served to realize the worst fears of the founders of PTSD, people like Robert Lifton and Arthur Egendorf, who worried that the diagnosis would be morally neutered by psychiatry.

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 psychotherapy 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%.”