The Evil Hours (50 page)

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More often than not, it is the powerless:
Transcript of Nicosia interview with Arthur Egendorf (November 3, 1988) at BCAH.

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“There are always moral questions, which are inseparable”:
Quoted in Nicosia,
Home to War
, 173.

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An influential 1995 article in the
American Journal of Psychiatry: R. Yehuda et al., “Conflict between Current Knowledge,” 1705–1713.

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And because it is instigated by an external agent:
Author interview with Gaithri Fernando, May 2013.

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This has resulted in a clinical culture, especially within psychiatry:
See Satel and Lilienfeld,
Brainwashed
, for more on the rise of neuroscience.

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“All of us have our own, distinctive mental worlds”:
Sacks,
Man Who Mistook
, 129.

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In 1979, at the dawn of contemporary neuroscience:
See Eric R. Kandel, “Psychotherapy and the Single Synapse.”
New England Journal of Medicine
301 (1974): 1028–1037.

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In his bestselling book
Listening to Prozac: Kramer,
Listening to Prozac
, x. In 1993, Kramer wrote that “my sense when I began my inquiries—and this is still my sense today—is that the new biological materialism is a cultural phenomenon that goes beyond the scientific evidence. There have always been observations favoring nature over nurture. What changes, in response to the spirit of the times, is the choice of evidence to which we attend” (xiv). Given the rise of the neuroculture in academe as well as in the culture generally, Kramer's words seem prescient.

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Between 1987, the year Prozac was introduced:
van der Kolk, unpublished manuscript, “The Body Keeps the Score.”

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This accidental discovery, of a drug associated:
Personal communication with Dewleen Baker.

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This lack of a scientific basis for using SSRIs to treat PTSD:
See Institute of Medicine,
Treatment of Posttraumatic Stress Disorder
, 2008. See also Shiromani, ed.,
Post-Traumatic Stress Disorder
, 338.

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As one Oxford University psychiatrist put it recently:
See Burns,
Psychiatry
, 2006.

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One Manchester, New Hampshire, physician and lawyer argued:
Dr. Albert Drukteinis.

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In 1995, Cathy Caruth, a trauma scholar at Emory University:
Caruth,
Trauma
, 9.

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By the 1990s, PTSD as a concept had outgrown:
See Luckhurst,
Trauma Question
.

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“
After the formulation and extension of PTSD in the 1980s”:
Ibid., 203–209.

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“the timeless time of the post-traumatic condition”:
Ibid., 206.

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By September 11, 2001, PTSD as a cultural phenomenon:
See Gonzales,
Surviving Survival
, 7. See also Seeley,
Therapy after Terror
, 2008.

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To the dismay of infantrymen who fought in Iraq and Afghanistan:
See the late Matt Power's “Confessions of a Drone Warrior” in the October 23, 2013, issue of
GQ
.

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“Based on prior experience from other mass disasters”:
Watters,
Crazy Like Us
, 69.

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Robert Gates, the secretary of defense under Presidents Bush:
See Robert Gates, “The Quiet Fury of Robert Gates.”
Wall Street Journal
, January 7, 2014.

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Once the dream of a handful of Vietnam veterans:
See Watters,
Crazy Like Us
, 71.

 

6. Therapy

 

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The original building, completed in 1972, boasts:
See
http://www.sandiego.va.gov/about/(accessed August 1, 2014)
.

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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.”

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“The primary investigator for this study has a résumé”:
Personal communication with the author, March 2013.

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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.

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“People with PTSD drink”:
Personal communication with the author, March 2013.

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“When I started to read the symptoms online”:
Author interview with Jessica G., February 2014.

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Several years after being raped:
Sebold,
Lucky
, 239–240. Author interview with Sebold, July 2013.

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“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.

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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.

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“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.

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It was, I would later learn, a “manualized” therapy:
Interview with Gary Greenberg, April 2013; interview with senior VA psychiatrist, April 2013.

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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).

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Derived from the classical conditioning or “learning” theories:
See Friedman,
Handbook of PTSD
, 541.

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“Even after a year, I still had an extremely difficult”:
Foer,
Extremely Loud
, 17.

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Created by psychologist Thomas Stampfl in 1967:
Leitenberg,
Handbook of Social
, 300–302; see also Doctor and Shapiro,
Encylopedia of Trauma
, 125.

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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.

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One of the recurring concerns raised by therapists:
See Finley,
Fields of Combat
, 125; personal communication with Caroline F., a psychotherapist in private practice.

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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.

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However, not everyone was convinced about this new therapy:
Everly,
Psychotraumatology
, 363.

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“It is not obvious that a rat's display”:
Stossel,
My Age of Anxiety
, 47.

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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.

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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.

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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.

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“it is important to emphasize that exposure”:
See van der Kolk,
Traumatic Stress
, 435.

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“You're right. We're seeing the same things”:
Phone interview with Pitman, January 2014.

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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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Since the rollout, a number of trauma workers:
Finley,
Fields of Combat
, 125.

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One research assistant at VA San Diego:
Personal communication with the author, January 2014.

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An independent survey conducted by the:
http://blog.23andme.com/23andme -research/what-works-for-ptsd/ (accessed August 1, 2014)
.

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One rape victim I interviewed, who completed:
Interview with Elise Colton, April 2013.

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One senior VA official, who was trained:
Interview with senior VA psychiatrist, 2013.

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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.