The Evil Hours (29 page)

And I continued to stab my phone until I had bent the knife blade fully ninety degrees. Outside the window of my apartment, I could hear my neighbors debating the pros and cons of calling the police.

 

Prolonged Exposure, one of the VA's top-tier or “Schedule A” PTSD therapies, is one of the most thoroughly researched and empirically validated psychiatric treatments in existence.
The body of science supporting its use is over a century old and reaches back to the very dawn of psychology, when the fledgling discipline was still trying to carve a niche from the fields of philosophy and literature. It is no exaggeration to say that PE has the best scientific pedigree of any trauma therapy protocol. Derived from the classical conditioning or “learning” theories first described by Pavlov in the late 1800s, the principle behind PE is very simple: almost all human behaviors are learned, and they can be unlearned by manipulating the stimuli that a person is exposed to.

Applying behavior learning theory to PTSD, researchers have created an extensive model of how the disorder develops and persists. These theorists posit that once exposed to a traumatic stimulus, a person suffering from post-traumatic stress will continue to avoid situations reminiscent of the original trauma, a process that can prevent the victim from ever healing or moving on. In time, the original traumatic stimulus can begin to evolve, metastasize, to include a number of random stimuli associated with the trauma, until vast swaths of the world become fear inducing. This effect is depicted in Jonathan Safran Foer's novel
Extremely Loud and Incredibly Close
, where the narrator, talking about the aftermath of 9/11, says,

 

Even after a year, I still had an extremely difficult time doing certain things, like taking showers, for some reason, and getting into elevators, obviously. There was a lot of stuff that made me panicky, like suspension bridges, germs, airplanes, fireworks, Arab people on the subway (even though I'm not racist), Arab people in restaurants and coffee shops and other public places, scaffolding, sewers and subway grates, bags without owners, shoes, people with mustaches, smoke, knots, tall buildings, turbans. A lot of the time I'd get that feeling like I was in the middle of a huge black ocean, or in deep space, but not in the fascinating way. It's just that everything was incredibly far away from me.

 

Within VA circles, it is not uncommon to hear something similar to this “huge black ocean” effect, and one often hears clinicians describing their patients as living inside a “PTSD bubble,” a severely limited range of activities that doesn't trigger their symptoms. For one Iraq veteran I interviewed, who lost several of his buddies in Fallujah, this “bubble” consisted of a single bedroom in his apartment and nothing else. Just being out on his balcony triggered bad memories.

One of the more recent therapies derived from classical learning theory is what is known as “flooding.” Created by psychologist Thomas Stampfl in 1967, flooding involves exposing a patient to a concentrated dose of a frightening stimulus, such as putting a person with arachnophobia in a room full of harmless spiders.
One of the classic examples of successful flooding involved an adolescent girl with a phobia of traveling in a car: she was driven around for four hours until her fear disappeared. During World War II, a group of American soldiers who showed an aversion to loud noises and even music were hospitalized and forced to view documentary war footage that featured an increasingly loud soundtrack of combat noises. Most of the soldiers, while terrified at first, eventually grew bored and all but one showed a decrease in symptoms. Flooding has since been shown to be an effective treatment for a number of phobias and for obsessive-compulsive disorder.

The idea of using flooding on PTSD patients occurred almost immediately after the condition was recognized by psychiatry in 1980. Because putting combat veterans back into wartime situations was not logistically feasible (or ethical for that matter), researchers began hunting for other ways to selectively reexpose PTSD-positive veterans to their traumatic memories. In 1982, Terry Keane, a psychologist at Boston University, began exploring the idea of using a directed reminiscence technique called “flooding in imagination” or “imaginals” to reactivate and, in some way, modify the traumatic memories of Vietnam veterans.
A number of investigators continued to study the problem, and by the end of the 1980s, it was clear that flooding, or some derivation of it, held the potential to be a benchmark treatment for PTSD.

However, as any medical researcher can attest, the road from laboratory discovery to the widespread use of a therapy is often very long. Funding constraints, politics, institutional inertia, careerism, along with simple intellectual trendiness, intrude upon the scientific process in ways that can frustrate even the veteran investigator. With the increasing specialization of modern science, it is not uncommon for the most innovative researchers to be overlooked by influential funding bodies and the scientific press because they struggle to lobby for their own work. As one senior VA official lamented to me, “Often what passes for science is just simple popularity.”

Proponents of flooding and the various exposure therapies were also confronted with a unique set of challenges. Practicing therapists have always been deeply uneasy about subjecting traumatized patients to such an unusually arduous form of therapy. One of the recurring concerns raised by therapists was the possibility that the therapy might, in fact, be “retraumatizing” to a patient, a prospect that flew in the face of the clinician's credo of reducing human suffering.
Opponents of such therapies even theorized that flooding could cause psychosis in some patients, effectively destroying any hope for recovery.

One of those most excited by the possibilities of flooding therapy was Edna Foa, a psychologist at the University of Pennsylvania.
Charismatic, media savvy, and possessing a seemingly limitless store of energy, Foa regularly crisscrosses the country delivering lectures and workshops on PTSD treatment. (One participant, describing one of her legendary workshops, said, “I didn't see her sit down for four days.”) Born in Haifa, Israel, and trained in clinical psychology at the University of Missouri, Foa began investigating postrape interventions in the early 1980s, cobbling a variety of therapeutic techniques together. But she was frustrated by the lack of progress. It wasn't until 2000, during a sabbatical in Israel with her husband, that the light bulb went on.

Just five days after they arrived, the Second Intifada began. A conflict that killed over four thousand people, it spurred Foa to shift her research toward the treatment of combat PTSD. Building on Keane's work, she went on to refine the techniques of flooding and imaginal therapy, combining them with an “in vivo” component that allowed patients to apply techniques learned in a therapist's office in the crucible of the real world. A number of studies, many of them overseen by Foa, have shown that PE can dramatically reduce PTSD symptoms. Sometimes jokingly referred to as the “doyen” of Prolonged Exposure, in 2010 Foa was named one of
Time
magazine's one hundred most influential people for her work in treating post-traumatic stress.

However, not everyone was convinced about this new therapy, including Stanley Rachman, a psychologist at the University of British Columbia, who in 1985 warned against drawing a direct analogy between “fear acquisition” behaviors in animals and humans.
As Jerome Kagan, a professor at Harvard, wrote, “It is not obvious that a rat's display of an enhanced startle reaction . . . [is a] fruitful model for all human anxiety states.”
The idea that humans enjoy a much richer and more complex inner life than other mammals, and that this fact might influence the onset of PTSD, was noted by a handful of other theorists.

In 1991, Roger Pitman, a professor of psychiatry at Harvard Medical School and an experienced PTSD researcher, released a case study of six Vietnam veterans treated with flooding that raised grave concerns about the approach.
During a twelve-week course of treatment, two of the veterans became suicidal. Another, with a history of alcoholism, broke 19 months of sobriety shortly after beginning flooding therapy. Others became severely depressed. One patient began suffering panic attacks between treatment sessions. “Mr. B.,” a forty-five-year-old veteran, said, “Your research has worked on one level but has exacerbated problems on another dozen . . . it has opened up horrible holes in my personality that I had been successful in glossing over.” In the conclusion of the study, Pitman and his team raised a red flag, saying, “We feel we have accumulated sufficient experience to call into question the reassurance that flooding does not risk retraumatizing the PTSD patient.” A lengthier study by Pitman published in 1996 found that applying what amounted to a therapy for simple phobias to a far more complex condition like PTSD had serious drawbacks, asserting that in addition to the unknown side effects of PE, “PTSD may not be amenable to modification by exposure.”

Similar research, conducted by Zahava Solomon, a leading Israeli investigator, and published in the
Journal of Traumatic Stress
in 1992, found that after flooding treatment, Israeli army veterans reported an increase in the “extent and severity of their psychiatric symptomology.”
One of the most cited volumes on traumatic stress, edited by another Harvard researcher, Bessel van der Kolk, concluded its review of PE by saying that “it is important to emphasize that exposure may lead to serious complications.”
In a recent phone interview, Pitman told me that after releasing his results, a number of his colleagues approached him confidentially, saying, “You're right. We're seeing the same things you are.”

In 2008, undeterred by these and other disturbing studies, the VA began a broad rollout of PE therapy that one Yale psychologist called “unparalleled in the mental health field.”
To support this effort, the VA began holding workshops across the country, enlisting Foa as one of their lead trainers. (“To Foa, spreading the word is what matters most now,” wrote Jeffrey Kluger, her profiler at
Time
.)

Since the rollout, a number of trauma workers, both inside and outside of the VA, have expressed concerns about the safety of PE, arguing that it is at best unproven for combat PTSD and at worst unethical.
One clinician quoted in
Fields of Combat
, a book-length study of the politics of PTSD treatment authored by a VA medical anthropologist in San Antonio, described its use on recent Iraq and Afghanistan veterans as “unconscionable.” Another said that it seemed “too atomized” to be effective on veterans because of its focus on onetime traumatic events. One research assistant at VA San Diego that I spoke to said she had heard other veterans complain about PE, describing the dropout rate as “very high.”
An independent survey conducted by the health website
23andme.com
in 2012 found that among 531 PTSD sufferers, Prolonged Exposure was rated as the least popular and least effective among 31 different treatments.
One rape victim I interviewed, who completed a two-month course of flooding treatment, said, “Flooding. That's about right. I am once again flooded with fear and paranoia.”

Part of this new, risky campaign against PTSD can be understood by examining the larger political situation that the VA finds itself in. As more veterans from the War on Terror come home and wrestle with PTSD, the VA has come under increasing pressure to respond to the crisis in a dramatic fashion. For leaders within the VA, many of whom came of age in the aftermath of Vietnam, the signs were all too familiar: a huge wave of veterans returning home from unpopular wars, greeted by a health care system whose resources were stretched to the limit. The 2007 Walter Reed hospital scandal, whose political fallout included the VA, helped bring about a sea change in the way PTSD therapies are delivered to veterans. The days when veterans were screened and then assigned to an individual therapist who would work continuously with them for years are probably numbered. (The revelations in 2014 of exceedingly long wait times for veterans at the VA hospital in Phoenix, which resulted in the deaths of several veterans and eventually led to the ouster of VA Secretary Eric Shinseki, has only increased the pressure on the VA to deliver quick and efficient care.)

The focus within the VA now is upon large, scalable, “Evidence-Supported Treatments” like PE and Cognitive Processing Therapy (CPT), which together are frequently referred to as the VA's “gold standard” PTSD treatments. This state of affairs also has a generational component. One senior VA official, who was trained as a psychoanalyst and has been treating PTSD for over thirty years, complained to me, “These new treatments have me worried that clinicians will never learn how to do actual therapy.”
Jonathan Shay, one of the most highly respected trauma theorists in America, cited the recent focus on efficiency and what amounts to mass-produced therapy as one of the major reasons for his retirement from the VA.

Nevertheless, there are good reasons for the VA's transition to PE and CPT. The science behind them is held in very high regard by a number of experts, and because of their relative simplicity, they hold the potential to treat greater numbers of veterans than other long-term therapies. In 2008, the prestigious Institute of Medicine determined that PE was one of only a few therapies shown to be effective in reducing PTSD symptoms.
Dozens of studies confirming the effectiveness of PE have been published in many of the world's top peer-reviewed scientific publications. In an August 2002 study in the
Journal of Consulting and Clinical Psychology
, titled “Does Imaginal Exposure Exacerbate PTSD Symptoms?” Foa acknowledged the widespread safety concerns related to PE but concluded that “prolonged exposure has gained more empirical support for its efficacy than any other treatment for PTSD, and some studies even suggest that it is the most efficient treatment for this disorder.”