The Enigma of Survival - Pacific Standard

The Enigma of Survival

How does one tell the untraumatized majority about the conditions that constitute the underworld of trauma?
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The Evil Hours: A Biography of Post-Traumatic Stress Disorder
David J. Morris
Houghton Mifflin Harcourt

Irritable Hearts: A PTSD Love Story
Mac McClelland
Flatiron Books

The evil hour descended on David Morris in the summer of 2009. The former marine and war reporter was in a theater watching a movie with his then girlfriend and suddenly found himself pacing the lobby with no memory of having left his seat. Later, his girlfriend explained that Morris had fled after an explosion occurred onscreen.

He began having dreams of his buddies being ripped apart. When awake, he would imagine innocent items—an apple or a container of Chinese takeout—blowing up. Pathological vigilance took root: “Preparing for bed was like getting ready for a night patrol.” The dreams persisted. “Part of me,” he admits, “was ashamed of the dreams, of the realization that I was trapped inside a cliché: the veteran so obsessed with his own past that even his unconscious made love to it every night.”

Post-traumatic stress disorder is the subject of two new books, one by Morris and another by war reporter Mac McClelland. The symptoms are crippling: relentless nightmares, unbidden waking images, hyperarousal, sleeplessness, and phobias. As a diagnosis, it has existed colloquially for generations—“shell shock” is one name that survives in the modern idiom—and it has particular resonance because of this generation’s wars. (Most soldiers are spared it, though the public tends to think they are not. A 2012 poll found that most people believe that most post-9/11 veterans suffer from PTSD. The actual rate has been estimated at between two and 17 percent.)

Morris thinks the symptoms—a body and mind reacting in fear long after the threat to life and limb is gone—hardly encompass the experience of PTSD. Historically, we might have sought out not only shrinks but also “poetry, our families, or the clergy for solace post horror.” Profitably, Morris turns to everyone: the Greeks, the great poets of World War I, historians, anthropologists, and yes, psychiatrists and psychologists.

From such wide consultation comes a masterful synthesis. The Evil Hours interweaves memoir with a cultural history of war’s psychic aftermath. Morris chronicles the development of PTSD as an official diagnosis and its earlier incarnations in other wars. From Homer’s Odyssey to the venerated war poets, from the crusade for recognition by organized psychiatry to the modern science of fear and resilience, Morris gives a sweeping view of the condition, illuminated by meditation on sacrifice and danger and, in his words, “the enigma of survival.”

Morris wants to know: Why does the world look so different since he got back from Iraq? How is the Veterans Administration fighting PTSD? What does one do with the knowledge gleaned from a near-death experience? How does one tell the untraumatized majority about the conditions that constitute the underworld of trauma?

(Photo: John Gomez)

(Photo: John Gomez)

He concludes that PTSD is not merely a clinical condition but also an existential one. “Combat doesn’t happen to inert bodies,” he quotes one vet. “It happens to people.” And, in turn, its resolution depends heavily on non-medical factors such as expectations for recovery (the expectations of the afflicted as well as those around him or her), social support, and the intimate meaning one makes of wartime hardships and sacrifice. Indeed, dwelling on one’s infirmities is a prescription for invalidism.

This has implications for policy. We tell people they are broken at great peril because, when they are feeling fragile, they tend to believe it. For example, the VA often grants monthly disability checks to veterans at the first sign of debility. It does so with good intentions, but when it does so prematurely, it discourages one of the most therapeutic activities, which is participation in the workforce. Most vets with PTSD improve with aggressive treatment and rehabilitation, which must come before we evaluate veterans for lasting impairments.

Morris served in the Marine Corps in the halcyon 1990s, so he experienced most of his trauma not in uniform but as a reporter in Iraq. When he was embedded during the 2007 surge in Baghdad, an IED buried in a trashpile rocked Morris’ Humvee. For several harrowing minutes, a wheel of the burning vehicle was stuck in the blast crater, and Morris was trapped.

That terrifying ordeal, followed by the turmoil precipitated by his trip to the cinema, led him to the San Diego VA for treatment. There, the young clinicians were caring but didn’t much help. Morris underwent a VA-approved treatment called prolonged exposure, which entails exposing patients to their most feared experience repeatedly over several months, until the situation no longer invokes panic. Morris found PE too anxiety provoking, and quit. (In the largest study of PE in veterans, a modest 55 percent had good outcomes.)

He also underwent cognitive processing therapy, a form of group therapy aimed at clearing up distortions in thinking (i.e., the world is a dangerous place; the war made me unlovable; I need alcohol to cope).

We tell people they are broken at great peril because, when they are feeling fragile, they have a tendency to believe it.

Morris found it somewhat helpful but still incomplete, and too focused on the symptoms. A fuller reckoning with trauma, he found, required treating it as more than just a series of near-death nightmares, and instead as the transformative experience it really is. “Never was I invited to think of how my experiences might be converted into a kind of wisdom or moral insight. When I did so, on my own initiative, I was admonished for ‘intellectualizing.’” Many soldiers find war, Morris writes, “to be sublime, and more than a few of them ... were suddenly consumed by a need for answers to life’s greatest questions.”

Fortunately, VA clinicians are increasingly attuned to the existential dimensions of veterans’ needs. However, there are too few seasoned clinicians to go around, and newer mental health professionals—like the ones Morris saw—are assigned to conduct one-size-fits-all, protocol-driven treatments. There is a place for these treatments, but not at the expense of encouraging suffering veterans to see returning from war as a major existential project, a struggle to “make meaning out of chaos.” By “making meaning,” Morris means telling stories, a process with “tremendous healing power” for both the teller and the listener.

Veterans of the latest generation do not speak as one, but their stories have eloquent commonalities. They feel caught between worlds and suffer dislocation and apartness. They are tainted, or so they imagine, by having seen and done unimaginable things. Another theme is time distortion. Trauma victims tell of years lost to depression, alcohol, and rage. Some dissociate—they feel disconnection from time or even the body; they “space out.”

Traumatic memories undermine coherence. If normal memories are tamed, Morris says, the traumatic memory “stands apart, like a feral dog, snarling, wild, and unpredictable.” In the wake of trauma, one’s sense of self can destabilize. “The war gave me a kind of maturity, but it made me a child again,” Morris observes. Veterans often speak about a telescoping of the past into the prewar “self” and, beyond it, the unfurling post-war persona.

Morris calls himself an “enlightened stoic” who found deep meaning in struggle, pain, and exertion. He touts the well-studied but under-emphasized phenomenon of post-traumatic growth. And he reaches the conclusion—one he claims to have resisted for some time—that “much of what we call ‘post-traumatic stress’ is, in fact, the failure of our culture to encourage people to seek wisdom in their loss and adversity and to consider trauma in anything other than the narrow medical context.”

The Evil Hours is not an exhaustive history of PTSD. There are aspects that Morris does not discuss, such as research, summarized by the psychologist Richard J. McNally in his excellent Remembering Trauma, which suggests that people who develop PTSD after witnessing an arm’s-length catastrophe (e.g., a dead body) or after sustaining a minor one themselves (e.g., a fender bender) are more psychologically fragile to begin with. For example, after 9/11, save for people directly threatened by the impacts or who directly witnessed people jumping out of windows to their deaths, those who developed PTSD were very likely to have had a mental disorder already. Morris tends to rely on a modest stable of experts, bypassing the contributions of many other wise researchers in the field. This detracts little, however, from his achievement: a vivid portrait of the veteran’s inner world.

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PTSD is not limited to soldiers. Indeed, during the campaign to incorporate it into the DSM III in 1980, feminists decrying rape and sexual abuse marched arm in arm with anti-war psychiatrists and veterans. Irritable Hearts: A PTSD Love Story, by former Mother Jones correspondent Mac McClelland, puts rape, not combat, at its core.

The title is brilliant: Irritable heart was the term used by physicians in the late 1800s to denote the Civil War equivalent of PTSD. And McClelland’s heart and central nervous system are both profoundly irritable. But contrary to the publisher’s portrayal of the book as a “research-driven,” searching memoir-cum-medical-mystery, Irritable Hearts is more an anguished diary of living with PTSD while fitfully falling in love with a French peacekeeper who speaks almost no English.

In 2010, McClelland spent several weeks on assignment in post-earthquake Haiti investigating rape gangs. The book is about the psychological fallout she suffers after a vaguely described incident. “It had something to do with a rape,” McClelland writes. “I was extremely startled by the scene and by the sudden screaming—not mine, but the closest I’d ever been to anyone’s complete and abject terror.” We never learn exactly what happened, though McClelland is clearly haunted. “The exact details are as bad as you might imagine, or worse than you could imagine, and I won’t share them so as not to risk retraumatizing anyone.” She is trying to be solicitous of the reader, but McClelland’s “trigger warning” is patronizing psychobabble.

War veterans, military and otherwise, have always faced re-adjustment problems—and the well-meaning public is often at a loss to understand. Many former servicemen, Morris among them, are connecting to the civilian world through writing. They don’t downplay the devastation and moral ambiguities of war. They don’t suggest through gritted teeth that “you couldn’t understand, you weren’t there,” a time-honored way of keeping others at a distance. Instead, they say, “let us tell you.” The Evil Hours is in that outward-reaching tradition. McClelland’s book is more confessional than it is educational.

Irritable Hearts maintains a frenzied pace as the hardworking, hard-drinking, sexually uninhibited McClelland describes a tumultuous long-distance romance with the man who would eventually become her husband. Most awful for her is dissociation: Her limbs become numb and feel like they float off from her body. Despite her suffering, the author continues to travel to blighted parts of the world. She credits years of work with a devoted therapist who practices “direct experience somatics” with helping her control her worst symptoms. McClelland’s book raises crucial themes in traumatic experience, such as resilience, the effect of PTSD on close friends and family, what counts as trauma (does merely witnessing the fright of another qualify?), and the importance of community support. But she is not prone to introspection or analysis. Instead, her style is raw and urgent; the pages read as if produced under pressure to get it all down quickly.

McClelland’s version of PTSD is more sterile, more disease-like, than Morris’. She writes about it as if it were solely a medical problem. She cites, approvingly, the opinion of a psychiatrist who describes traumatic experience as reflecting “damage [to] the sensory-processing and self-care parts of your brain.” Morris, by contrast, treats PTSD as both a personal and a cultural phenomenon that tells us something about timeless aspects of war, memory, and transformation.

Morris’ book is about pathos; McClelland’s, about pathology. In this way, Irritable Hearts mirrors the untutored perception of PTSD: namely, that it is ubiquitous among victims. Our culture presumes fragility. One force behind this is psychiatrists, who fall prey to the “clinician’s illusion,” whereby they assume their patients are representative of the wider population. After 9/11, health professionals predicted an epidemic of PTSD that never materialized. Hundreds of millions of dollars went to trauma therapy, and people were subtly encouraged to misinterpret justified sadness and sleeplessness as signs of mental illness. PTSD is also a diagnosis tailored for political use, and it plays into the illusion, dating to the Vietnam era, of the mentally scarred vet, the walking time bomb of films such as Taxi Driver, Rambo, and Coming Home.

In some ways, Irritable Hearts is a risky book. A journalist deliberately seeking exposure to the misery of others opens herself to criticism that it is unseemly and self-pitying to imagine that her weeks of unpleasantness warrant a book—especially as the people she writes about live long portions of their lives under these conditions. Then again, as Morris tells us, “terror, like beauty, is in the eye of the beholder.” And in McClelland’s eyes, witnessing the agony of a savaged human being was enough to temporarily disable her. Why she was so vulnerable we never really learn.

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