The Evil Hours (31 page)

Yes, at first glance, this was what should have been a depressing scene, and yet I was secretly elated. This was a room of suffering, a room filled with enough anxiety to power a small city, filled with guys who had paid a lot for daring to sign up, probably a lot more than they'd ever expected to pay, but to me it was a room filled with a strange kind of almost poetic beauty: something we are so rarely allowed to see in this world, trauma and loss and the work of history written on the human face. It might've just been the odd buzz I got sometimes after an evening formation in the Corps, a kind of churchy feeling, but there was, it seemed to me, something noble about the scene before me, heroic in the ancient Greek sense. This room, I saw suddenly, was part of the journey, a waystation on a great odyssey: some of us were going up, some of us going down, but all of us in the room, every one of us, whether we wanted to or not, were going somewhere.

It was like the opposite of a firefight. This was the place where the saving started, even if the therapy sucked and the gesture of showing up was all that you had to hold on to; this, too, was where the dying started, or was at the very least observed, watched by the faces that filled the room.

Later, I would get angry about the sign, which for some reason I always ended up sitting next to, so that it was one of the first things I saw whenever I entered the therapy room. The sign served an important purpose no doubt, but it was just so maddening, so disheartening to know you had something in your mind that only highly trained professionals could handle, like a test tube of Ebola. I knew this already. I just didn't need to see it in writing. It was just like the CAPS and Sarah, another example of what I was starting to think of as the Quarantine Effect, a way people had of making survivors feel like they were untouchable, members of a caste whose bad karma wasn't just contagious but actually a hazard to the general public.

Our facilitators, Chloe and Heather, were both postdoctoral students in their late twenties. Chloe was an angel of understanding, sweet in that all-American way and with a deep well of patience that I have always associated with people from small Southern towns. Heather, who, as it happened, had done my initial intake seven months prior, was tougher, with a cut-the-shit East Coast demeanor that lent her a certain authority. It felt like they came as a set, one balancing the other.

The group began, oddly enough, with a question.

Her pen poised over a whiteboard, Heather asked, “What does PTSD mean to you guys?”

“Nightmares.”

“Never feeling safe.”

“Drinking too much.”

“Feeling dead inside.”

“Not being able to talk to my wife.”

“Can't sleep.”

“Feeling like I'm missing out on my kids.”

“Isolation.”

“Waiting for another terrorist attack to happen.”

Knees started jumping up and down.

“Being angry all the time.”

“That's good,” Heather said, pausing for a moment. “That's something I hear from veterans a lot. ‘Anger is the only emotion I can do.'”

It all went on the whiteboard.

To my left, Kyle said quietly, “FTW.”

Leaning over, I asked him what FTW meant. Twisting his face to one side, he whispered conspiratorially, “Fuck the World.”

Later, Kyle told me this was his fourth time through CPT. He would feel better for a while, then the anger would come back, so he'd drop in. It was like catechism for him. Kyle was a gearhead, a guy who connected to the world through his hands when his hands were in the guts of a car. He had the heavy-lidded intensity of someone who was on meds and hating it, and talking to him, you got the sense that the volume of his personality had been seriously turned down. Before he'd been maybe a nine. Now he came across as a five and a half.

We were handed yellow workbooks that said
CPT-C PATIENT
on the cover.

Homework, Chloe explained, was a big part of CPT, and there would be worksheets to complete before coming to group each week. “You will get out of it what you put into it.” She managed to get this across without sounding like a nag. Chloe was so nice, so consistently genial, that it was hard to imagine that she ever said anything rude or unpleasant or ever cursed at other drivers while stuck in traffic.

The idea behind CPT, she continued, was to examine your thoughts and look at how thoughts lead to feelings and how these thoughts and feelings eventually lead to beliefs about yourself and the world.

“CPT teaches you to avoid extreme thoughts,” she said.

 

Cognitive Processing Therapy is one of the most popular treatments for PTSD.
Along with PE, it is one of the VA's “Schedule A” psychotherapies. Originally created by Patricia Resick at VA Boston to treat rape victims, CPT was adapted from a popular school of psychotherapy known as Cognitive-Behavioral Therapy. Cognitive-Behavioral Therapy, or CBT, helps patients reframe environmental stimuli, redefining the ways people respond to events in their life. The theory behind CBT is that mental health is guided by adaptive reactions to the world. According to one of the architects of CBT, “As part of our emotional nature, fear occurs as a healthy adaptive response to a perceived threat or danger to one's physical safety or security. It warns individuals of an imminent threat and the need for defensive action. Yet fear can be maladaptive when it occurs in a nonthreatening or neutral situation that is interpreted as representing a potential danger or threat.” CBT was created by East Coast academics, but it has what at times can feel like a touch of Zen philosophy, specifically the notion that all events in the world are basically neutral and that it is our response to them that dictates everything that happens next. It is a psychotherapy that one of its original proponents described as a kind of “learned optimism.”

The founder of CBT, Aaron Beck, is professor emeritus of psychiatry at the University of Pennsylvania and president of the Beck Institute for Cognitive Therapy and Research. Originally trained as a psychoanalyst, Beck came up with CBT for the treatment of depression. As he put it, during the 1960s, he got “caught up in the contagion of the times,” times dominated psychiatrically by a campaign by the National Institute of Mental Health to implement “systematic clinical and biological research.”
A good Freudian, Beck began looking into the dreams of depressed patients. According to Freud's theory of melancholia, what he should have found was a kind of repressed rage, but what he found instead was that “the dreams . . . contained themes of loss, defeat, rejection, and abandonment, and the dreamer was represented as defective or diseased,” what he understood to be an amplification of the patient's waking life. Reflecting on this, Beck began to think that depression was caused less by unconscious conflicts in the mind and more by pessimistic thoughts, thoughts that became habitual ways of interpreting the world.

Something was out of balance with the patient's inner life, but it wasn't the war between the id, ego, and superego that was causing it. In Beck's view, it was the schemas, the dysfunctional beliefs that organized a patient's experience and gave rise to erroneous cognitions. To correct this, Beck began experimenting with what he referred to as “Socratic questioning,” in stark contrast to the intense retrospective probing that he had been trained in as a psychoanalyst.

Beck designed a therapy derived from behavioral therapy, fusing it with the then-emerging field of cognitive science. In cognitive therapy, he explained,

 

therapist and patient work together to identify the patient's distorted cognitions, which are derived from his dysfunctional beliefs. These cognitions and beliefs are subjected to empirical testing. In addition, through the assignment of behavioral tasks, the patient learns to master problems and situations which he previously considered insuperable, and consequently, he learns to realign his thinking with reality.

 

In a way, CBT is the ultimate evidence-based psychotherapy because its effectiveness is not only designed to be measured empirically, but the actual nuts and bolts of its methodology are based on what purports to be an empirical view of the world. As one rather smitten writer put it, “CBT teaches objectivity.”

In CPT, which applies principles of CBT to treat post-traumatic stress, the therapist begins by asking the patient to write down why they think the traumatic event occurred. Together, the patient and therapist create a “stuck point” log, cataloging the ways in which incorrect beliefs about the traumatic event prevent the patient from recovering. (In this formulation, PTSD is described not as a disease but as an instance of “nonrecovery.”) Some examples of stuck points could be “I never should have left the party with Keith. Being raped was my fault” or “Losing Nate near Sangin was my fault. My patrol took a bad route back to base and walked into that IED. As assistant patrol leader, I should have said something.” Like PE, there is a certain repetitive quality to CPT. The first few weeks of therapy involve working through a series of “A-B-C Worksheets” (
A
ctivating Event,
B
elief/Stuck Point,
C
onsequence), which helps break down the patient's inner monologue of thoughts to understand the logical sequence behind their feelings. So, for our rape victim, the sequence might go as follows: “I never should have left the party with Keith. Being raped was my fault. I feel like a damaged person.” Once the patient sees this cycle, she can begin to exert some control over the process.

From a philosophical point of view, CPT is, in a sense, a very American form of therapy. CPT focuses on the day-to-day business of life, of keeping the cognitive operating system up and running. CPT, as a therapeutic regimen, is not interested in the past, nor does it address any of the weighty metaphysical or social issues that trauma raises. CPT is a short-term therapy with fixed goals and limitations, a form of psychological first aid. CPT takes no moral position. It solves nothing. It helps get you out of bed in the morning.

CPT has been extensively studied and has come to represent a standard of care in the United States that insurance companies are willing to pay for.
It seems to have a significant effect on PTSD. A 2002 study by Resick, using a large sample of sexual assault victims, found that CPT worked as well as PE therapy, though CPT performed better in dealing with aspects of guilt.
(I would add, however, that CPT has a distinct advantage over PE in that it is less risky to the patient's immediate mental health and safety, an important consideration for veterans, a population known to exhibit aggressive behavior and alcoholism and to have an unusually high suicide rate.) Another study, published in
Behavior Therapy
in 2004, conducted a five-year followup of patients who underwent PE and CPT; 29 percent of the patients who had undergone PE experienced a relapse of PTSD symptoms, while none of the CPT patients had.

The major problem with discussing both CPT and PE as therapies is that they are both, more or less, explicitly designed to be studied by researchers, and as “manualized” therapies, they intentionally minimize the individual role of the therapist. A number of critics, including Gary Greenberg and B. E. Wampold, have pointed this out and believe it to be the major shortcoming of both therapies.
Their position is, roughly, that the rapport, the “therapeutic alliance,” established between patient and client is the most important thing about any therapy, and that such an alliance is, in fact, more important than the therapeutic protocol being used, an argument supported by several studies. As one rape survivor put it, “Good therapists were those who really validated my experience and helped me to control my behavior rather than trying to control me.” My friend Elise, who was raped, was blunter: “A lot of therapists lack empathy and don't really know what they're doing. It's harsh to say, but ideally, they should have experienced trauma themselves.”

One stunningly illuminating study conducted by Hans Strupp at George Washington University in 1979 proves the critics' point: Strupp took professional therapists from a variety of theoretical backgrounds and pitted them against a group of English professors, telling them to use basic therapeutic techniques and to establish an empathetic, understanding relationship with their patients.
The English professors performed as well as the experienced psychotherapists.

 

For our second session, Heather began by describing what she called “just-world theory.” A belief system that many people adhere to even if they don't realize it, just-world theory says roughly that “good things happen to good people, and bad things happen to bad people. Bad things have happened to me. Therefore, I must be bad.”

While I certainly didn't feel that the war or Saydia had made me into a bad person, the theory resonated with me. People join the Marine Corps for a million different reasons, but from my earliest days in the service, and especially after choosing the infantry, I felt driven by a kind of self-destructive impulse, a desire to experience what I thought of as the extremes of existence, to experience life at the brink. My decision to go to Iraq as a writer was an extension of this desire and had left me feeling that there was something both ennobling and degrading about war: ennobling because it taught you about the joys of survival and brotherhood, degrading because it showed you how war turned men into dogs.

Joseph Conrad, in
Heart of Darkness
, described what he called “the fascination of the abomination,” the powerful need to “live in the midst of the incomprehensible.” To truly see it, you had to be touched by it, take on some of the darkness.

Or so I thought.

As I pondered what Heather had said, I began to realize just how much this fascination of the abomination had come to color my life. Like many of my Marine buddies who had served in the Gulf War and Somalia, I returned from Iraq feeling marked, changed in some way beyond expression, and that because I had been touched by death, I no longer belonged to the normal world. It wasn't simply that I had loved the excitement of the war and that stateside life felt boring, but that the things I had seen in Iraq made it impossible for me to believe in the normal fictions that most people cling to in their daily lives: the lie that the world is safe, the lie that society is just, the lie that the government can be trusted, the lie that good works are rewarded, the lie that bad people are punished. T. E. Lawrence, who saw his cause betrayed by the British government after World War I, seemed to feel something similar, saying, “If ever there was a man squeezed right out dry by over-experience, then it's me. I don't think I'll be fit for anything ever again.”