Couch is a series about psychotherapy.
Going in for therapy at a Veterans Affairs hospital is a lot like arriving at a large airport in a foreign country. You pass through a maze of confusing signage. Your documents are scrutinized. There are long lines you must stand in and a series of bureaucratic rituals that must be endured before anything resembling a human encounter occurs.
In April 2013, after doing a series of intake interviews and sitting on a waiting list for three months, I had my first human encounter with my assigned therapist at the big V.A. hospital in San Diego. Little did I know that the delay in treatment would be less agonizing than the treatment itself.
My first session began with my therapist, a graduate student finishing up his doctorate in clinical psychology, offering a kind of apology. “Now, I’m probably going to make some mistakes and say some stupid things,” he said. “Are you going to be O.K. with that?”
I understood. Two decades before, as a newly minted infantry lieutenant in the Marine Corps, I’d been charged with the welfare of a platoon of 30 young Marines. Too often my best wasn’t good enough, and I made a number of errors in judgment while in command, errors that bother me to this day. Offering my therapist some grace seemed like my only option.
I’d come to the V.A. for a number of reasons. After being discharged in 1998 from the Marine Corps, I worked as a reporter in Iraq from 2004 until one day in 2007, when I was nearly killed by an improvised explosive device, or I.E.D., in southern Baghdad. Occasionally I had weird dreams about the war that mixed people and places from my time in the Marines with my time in Iraq. But what really concerned me was something that happened a few years later. I was sitting in a movie theater with my girlfriend when the world suddenly went black. When I regained consciousness, I was pacing the lobby of the theater, looking at people’s hands to make sure they weren’t carrying weapons.
Afterward, I asked my girlfriend what happened. “There was an explosion in the movie,” she said. “You got up and ran out.”
Post-traumatic stress disorder has stalked me for most of my adult life. I don’t mean to say that I’ve suffered from it all that time. But the idea of it, the specter of it, has haunted me, as it haunts virtually everyone who has served in the military. You may not have PTSD, but most of your fellow citizens assume you do, and this fact alone has a powerful effect.
A year or so after the episode at the movie theater, with my symptoms not improving, I went to the V.A. for help.
There are two widely used treatments for PTSD at the V.A. One is called cognitive processing therapy. The other is prolonged exposure therapy, the effectiveness of which the V.A. heavily promotes. After explaining my symptoms to the intake coordinator, I was told that prolonged exposure was the best therapy for me. He said that the treatment worked for about 85 percent of people (“some pretty darn high odds if you ask me”).
My therapist, with whom I would meet twice a week, started with a short overview. Prolonged exposure therapy was developed in the 1980s by Edna Foa, a professor of clinical psychology, and colleagues of hers at the University of Pennsylvania. It is built on the idea that after traumatic experiences like I.E.D. ambushes, plane crashes and sexual assaults, survivors can “overlearn” from the event, allowing fears arising from their trauma to dictate their behavior in everyday life. Some survivors find that the only way to feel safe is to restrict their daily routine to a small range of activities. One Iraq veteran I knew, who had lost several buddies in an I.E.D. blast near Falluja, stopped leaving his apartment.
The promise of prolonged exposure is that your response to your trauma can be unlearned by telling the story of it over and over again. The patient is asked to close his eyes, put himself back in the moment of maximum terror and recount the details of what happened. According to the theory, the more often the story is told in the safety of the therapy room, the more the memory of the event will be detoxified, stripped of its traumatic charge and transformed into something resembling a normal memory.
The process sounded like all my dealings with the V.A.: Before you could find any relief, you had to traverse a little bit of hell.
MY therapist instructed me to select a traumatic event to focus on. As someone who had spent 10 months in some of the deadliest parts of Iraq, I had collected a number of near-death experiences. Would I choose the time I rode in a helicopter that was nearly shot down over Falluja? The I.E.D. ambush I saw near the town of Karma that killed two Pennsylvania National Guardsmen? The week I spent with some Marines from my old battalion when we were shelled for seven days straight? To focus on a single event seemed absurd, the equivalent of fast-forwarding to a single scene in an action film and judging the entire movie based on that.
In the end I chose the story of the I.E.D. ambush I survived in 2007 in southern Baghdad. Over the course of our sessions, my therapist had me tell the story of the ambush dozens of times. I would close my eyes and put myself back inside the Humvee with the patrol from the Army’s First Infantry Division, back inside my body armor, back inside the sound of the I.E.D.s going off, back inside the cave of smoke that threatened to envelop us all forever.
It was a difficult, emotionally draining scene to revisit. This was the work site of prolonged exposure therapy, where the heart’s truest labor was supposed to happen. Given enough time and enough story “reps,” when I opened my eyes again, I wouldn’t feel forever perched on the precipice of a smoke-wreathed eternity. I wouldn’t feel scared anymore.
But after a month of therapy, I began to have problems. When I think back on that time, the word that comes to mind is “nausea.” I felt sick inside, the blood hot in my veins. Never a good sleeper, I became an insomniac of the highest order. I couldn’t read, let alone write. I laced up my sneakers and went for a run around my neighborhood, hoping for release in some roadwork; after a couple of blocks, my calves seized up. It was like my body was at war with itself. One day, my cellphone failed to dial out and I stabbed it repeatedly with a stainless steel knife until I bent the blade 90 degrees.
When I mentioned all this to my therapist, he seemed unsurprised.
“You weren’t drunk at the time?” he asked.
“No. That came later.”
Following a heated discussion, in which I declared the therapy “insane and dangerous” and my therapist ardently defended it, we decided to call it quits. Before I left, he admonished me: “P.E. has worked for many, many people, so I would be careful about saying that it doesn’t work just because it didn’t work for you.”
WITHIN a few weeks, my body returned to normal. My agitation subsided to the lower, simmering level it had been at before I went to the V.A. I began once more to sleep, read and write. I never spoke about the I.E.D. attack again.
In one sense, my therapist was right: Prolonged exposure has worked for many people. It has arguably the best empirical support of any PTSD therapy currently in use by the V.A. One recent study found that among veterans who completed at least eight sessions of treatment, prolonged exposure therapy decreased the proportion who screened positive for PTSD by about 40 percentage points. But the treatment may not be as effective as the V.A. would have you believe: About a quarter of the veterans in that study dropped out of the treatment prematurely, much as I had.
After my experience with prolonged exposure, I did some research and found that some red flags had been raised about it. In 1991, for example, Roger K. Pitman, a professor of psychiatry at Harvard Medical School, conducted a study of exposure therapy on Vietnam veterans and observed some troubling complications: One subject developed suicidal thoughts, and others became severely depressed or suffered panic attacks. A similar study, published in the Journal of Traumatic Stress in 1992, found that Israeli army veterans experienced an increase in the “extent and severity of their psychiatric symptomology.”
There are many reasons to be disappointed, even angry with the V.A. right now — the unforgivably long wait times, the erratic quality of care, the reports of administrators’ falsifying records to cover up those shortcomings. My own disappointment is that after waiting three months, after completing endless forms, I was offered an overhyped therapy built on the premise that the best way to escape the aftereffects of hell was to go through hell again.
A month after dropping out of prolonged exposure therapy, I began a treatment of cognitive processing therapy at the V.A. Here, our group was asked to examine our thoughts and feelings about our war experiences without revisiting specific traumas. We were allowed to let sleeping dogs lie. This has helped. As I wrote in my journal at the time, “If P.E. is a kind of emotional chemo, then C.P.T. is a kind of emotional tai chi.”
I never saw my therapist again at the V.A., but I did I run into him one day at the Y.M.C.A. pool near my house. Recognizing him in the water, I said hello and mentioned a surfing trip I had planned to Costa Rica for the following month. We chatted about the many wonders of Central America, the beauty of the jungle, the power of the waves down there. Away from the hospital, he seemed able to express himself in a way he hadn’t before. He seemed looser, more at ease.
Before us, a classic California tableau was painting itself, the sun setting through bands of liquid gold. Whatever secrets might have passed between us in the therapy room, whatever mistakes we might have committed together or on our own, whatever things separate survivor from healer, were gone. We were just two people alive together in the dying light. Before I ducked back under the water he turned to me and said, “Look at all that, isn’t it beautiful, the colors and everything?”
David J. Morris, a former Marine infantry officer, is the author of the forthcoming book “The Evil Hours: A Biography of Post-Traumatic Stress Disorder.”