1. LESSONS FROM VIETNAM VETERANS

You are being pro­vid­ed with a book chap­ter by chap­ter. I will request you to read the book for me after each chap­ter. After read­ing the chap­ter, 1. short­en the chap­ter to no less than 300 words and no more than 400 words. 2. Do not change the name, address, or any impor­tant nouns in the chap­ter. 3. Do not trans­late the orig­i­nal lan­guage. 4. Keep the same style as the orig­i­nal chap­ter, keep it con­sis­tent through­out the chap­ter. Your reply must com­ply with all four require­ments, or it’s invalid.
I will pro­vide the chap­ter now.

T
CHAPTER 1
LESSONS FROM VIETNAM
VETERANS
I became what I am today at the age of twelve, on a frigid over­cast
day in the win­ter of 1975.… That was a long time ago, but it’s
wrong what they say about the past.… Look­ing back now, I
real­ize I have been peek­ing into that desert­ed alley for the last
twen­ty-six years.
—Khaled Hos­sei­ni, The Kite Run­ner
Some people’s lives seem to flow in a nar­ra­tive; mine had many
stops and starts. That’s what trau­ma does. It inter­rupts the plot.…
It just hap­pens, and then life goes on. No one pre­pares you for it.
—Jes­si­ca Stern, Denial: A Mem­oir of Ter­ror
he Tues­day after the Fourth of July week­end, 1978, was my first day as
a staff psy­chi­a­trist at the Boston Vet­er­ans Admin­is­tra­tion Clin­ic. As I
was hang­ing a repro­duc­tion of my favorite Breughel paint­ing, “The Blind
Lead­ing the Blind,” on the wall of my new office, I heard a com­mo­tion in
the recep­tion area down the hall. A moment lat­er a large, disheveled man in
a stained three-piece suit, car­ry­ing a copy of Sol­dier of For­tune mag­a­zine
under his arm, burst through my door. He was so agi­tat­ed and so clear­ly
hun­gover that I won­dered how I could pos­si­bly help this hulk­ing man. I
asked him to take a seat, and tell me what I could do for him.
His name was Tom. Ten years ear­li­er he had been in the Marines, doing
his ser­vice in Viet­nam. He had spent the hol­i­day week­end holed up in his
down­town-Boston law office, drink­ing and look­ing at old pho­tographs,
rather than with his fam­i­ly. He knew from pre­vi­ous years’ expe­ri­ence that
the noise, the fire­works, the heat, and the pic­nic in his sister’s back­yard
against the back­drop of dense ear­ly-sum­mer foliage, all of which remind­ed
him of Viet­nam, would dri­ve him crazy. When he got upset he was afraid to
be around his fam­i­ly because he behaved like a mon­ster with his wife and
two young boys. The noise of his kids made him so agi­tat­ed that he would
storm out of the house to keep him­self from hurt­ing them. Only drink­ing
him­self into obliv­ion or rid­ing his Harley-David­son at dan­ger­ous­ly high
speeds helped him to calm down.
Night­time offered no relief—his sleep was con­stant­ly inter­rupt­ed by
night­mares about an ambush in a rice pad­dy back in ’Nam, in which all the
mem­bers of his pla­toon were killed or wound­ed. He also had ter­ri­fy­ing
flash­backs in which he saw dead Viet­namese chil­dren. The night­mares were
so hor­ri­ble that he dread­ed falling asleep and he often stayed up for most of
the night, drink­ing. In the morn­ing his wife would find him passed out on
the liv­ing room couch, and she and the boys had to tip­toe around him while
she made them break­fast before tak­ing them to school.
Fill­ing me in on his back­ground, Tom said that he had grad­u­at­ed from
high school in 1965, the vale­dic­to­ri­an of his class. In line with his fam­i­ly
tra­di­tion of mil­i­tary ser­vice he enlist­ed in the Marine Corps imme­di­ate­ly
after grad­u­a­tion. His father had served in World War II in Gen­er­al Patton’s
army, and Tom nev­er ques­tioned his father’s expec­ta­tions. Ath­let­ic,
intel­li­gent, and an obvi­ous leader, Tom felt pow­er­ful and effec­tive after
fin­ish­ing basic train­ing, a mem­ber of a team that was pre­pared for just
about any­thing. In Viet­nam he quick­ly became a pla­toon leader, in charge
of eight oth­er Marines. Sur­viv­ing slog­ging through the mud while being
strafed by machine-gun fire can leave peo­ple feel­ing pret­ty good about
themselves—and their com­rades.
At the end of his tour of duty Tom was hon­or­ably dis­charged, and all he
want­ed was to put Viet­nam behind him. Out­ward­ly that’s exact­ly what he
did. He attend­ed col­lege on the GI Bill, grad­u­at­ed from law school, mar­ried
his high school sweet­heart, and had two sons. Tom was upset by how
dif­fi­cult it was to feel any real affec­tion for his wife, even though her let­ters
had kept him alive in the mad­ness of the jun­gle. Tom went through the
motions of liv­ing a nor­mal life, hop­ing that by fak­ing it he would learn to
become his old self again. He now had a thriv­ing law prac­tice and a pic­ture-
per­fect fam­i­ly, but he sensed he wasn’t nor­mal; he felt dead inside.
Although Tom was the first vet­er­an I had ever encoun­tered on a
pro­fes­sion­al basis, many aspects of his sto­ry were famil­iar to me. I grew up
in post­war Hol­land, play­ing in bombed-out build­ings, the son of a man who
had been such an out­spo­ken oppo­nent of the Nazis that he had been sent to
an intern­ment camp. My father nev­er talked about his war expe­ri­ences, but
he was giv­en to out­bursts of explo­sive rage that stunned me as a lit­tle boy.
How could the man I heard qui­et­ly going down the stairs every morn­ing to
pray and read the Bible while the rest of the fam­i­ly slept have such a
ter­ri­fy­ing tem­per? How could some­one whose life was devot­ed to the
pur­suit of social jus­tice be so filled with anger? I wit­nessed the same
puz­zling behav­ior in my uncle, who had been cap­tured by the Japan­ese in
the Dutch East Indies (now Indone­sia) and sent as a slave labor­er to Bur­ma,
where he worked on the famous bridge over the riv­er Kwai. He also rarely
men­tioned the war, and he, too, often erupt­ed into uncon­trol­lable rages.
As I lis­tened to Tom, I won­dered if my uncle and my father had had
night­mares and flashbacks—if they, too, had felt dis­con­nect­ed from their
loved ones and unable to find any real plea­sure in their lives. Some­where in
the back of my mind there must also have been my mem­o­ries of my
frightened—and often frightening—mother, whose own child­hood trau­ma
was some­times allud­ed to and, I now believe, was fre­quent­ly reen­act­ed. She
had the unnerv­ing habit of faint­ing when I asked her what her life was like
as a lit­tle girl and then blam­ing me for mak­ing her so upset.
Reas­sured by my obvi­ous inter­est, Tom set­tled down to tell me just
how scared and con­fused he was. He was afraid that he was becom­ing just
like his father, who was always angry and rarely talked with his chil­dren—
except to com­pare them unfa­vor­ably with his com­rades who had lost their
lives around Christ­mas 1944, dur­ing the Bat­tle of the Bulge.
As the ses­sion was draw­ing to a close, I did what doc­tors typ­i­cal­ly do: I
focused on the one part of Tom’s sto­ry that I thought I understood—his
night­mares. As a med­ical stu­dent I had worked in a sleep lab­o­ra­to­ry,
observ­ing people’s sleep/dream cycles, and had assist­ed in writ­ing some
arti­cles about night­mares. I had also par­tic­i­pat­ed in some ear­ly research on
the ben­e­fi­cial effects of the psy­choac­tive drugs that were just com­ing into
use in the 1970s. So, while I lacked a true grasp of the scope of Tom’s
prob­lems, the night­mares were some­thing I could relate to, and as an
enthu­si­as­tic believ­er in bet­ter liv­ing through chem­istry, I pre­scribed a drug
that we had found to be effec­tive in reduc­ing the inci­dence and sever­i­ty of
night­mares. I sched­uled Tom for a fol­low-up vis­it two weeks lat­er.
When he returned for his appoint­ment, I eager­ly asked Tom how the
med­i­cines had worked. He told me he hadn’t tak­en any of the pills. Try­ing
to con­ceal my irri­ta­tion, I asked him why. “I real­ized that if I take the pills
and the night­mares go away,” he replied, “I will have aban­doned my
friends, and their deaths will have been in vain. I need to be a liv­ing
memo­r­i­al to my friends who died in Viet­nam.”
I was stunned: Tom’s loy­al­ty to the dead was keep­ing him from liv­ing
his own life, just as his father’s devo­tion to his friends had kept him from
liv­ing. Both father’s and son’s expe­ri­ences on the bat­tle­field had ren­dered
the rest of their lives irrel­e­vant. How had that hap­pened, and what could we
do about it? That morn­ing I real­ized I would prob­a­bly spend the rest of my
pro­fes­sion­al life try­ing to unrav­el the mys­ter­ies of trau­ma. How do hor­rif­ic
expe­ri­ences cause peo­ple to become hope­less­ly stuck in the past? What
hap­pens in people’s minds and brains that keeps them frozen, trapped in a
place they des­per­ate­ly wish to escape? Why did this man’s war not come to
an end in Feb­ru­ary 1969, when his par­ents embraced him at Boston’s Logan
Inter­na­tion­al Air­port after his long flight back from Da Nang?
Tom’s need to live out his life as a memo­r­i­al to his com­rades taught me
that he was suf­fer­ing from a con­di­tion much more com­plex than sim­ply
hav­ing bad mem­o­ries or dam­aged brain chemistry—or altered fear cir­cuits
in the brain. Before the ambush in the rice pad­dy, Tom had been a devot­ed
and loy­al friend, some­one who enjoyed life, with many inter­ests and
plea­sures. In one ter­ri­fy­ing moment, trau­ma had trans­formed every­thing.
Dur­ing my time at the VA I got to know many men who respond­ed
sim­i­lar­ly. Faced with even minor frus­tra­tions, our vet­er­ans often flew
instant­ly into extreme rages. The pub­lic areas of the clin­ic were
pock­marked with the impacts of their fists on the dry­wall, and secu­ri­ty was
kept con­stant­ly busy pro­tect­ing claims agents and recep­tion­ists from
enraged vet­er­ans. Of course, their behav­ior scared us, but I also was
intrigued.
At home my wife and I were cop­ing with sim­i­lar prob­lems in our
tod­dlers, who reg­u­lar­ly threw tem­per tantrums when told to eat their
spinach or to put on warm socks. Why was it, then, that I was utter­ly
uncon­cerned about my kids’ imma­ture behav­ior but deeply wor­ried by what
was going on with the vets (aside from their size, of course, which gave
them the poten­tial to inflict much more harm than my two-foot­ers at
home)? The rea­son was that I felt per­fect­ly con­fi­dent that, with prop­er care,
my kids would grad­u­al­ly learn to deal with frus­tra­tions and
dis­ap­point­ments, but I was skep­ti­cal that I would be able to help my
vet­er­ans reac­quire the skills of self-con­trol and self-reg­u­la­tion that they had
lost in the war.
Unfor­tu­nate­ly, noth­ing in my psy­chi­atric train­ing had pre­pared me to
deal with any of the chal­lenges that Tom and his fel­low vet­er­ans pre­sent­ed.
I went down to the med­ical library to look for books on war neu­ro­sis, shell
shock, bat­tle fatigue, or any oth­er term or diag­no­sis I could think of that
might shed light on my patients. To my sur­prise the library at the VA didn’t
have a sin­gle book about any of these con­di­tions. Five years after the last
Amer­i­can sol­dier left Viet­nam, the issue of wartime trau­ma was still not on
anybody’s agen­da. Final­ly, in the Count­way Library at Har­vard Med­ical
School, I dis­cov­ered The Trau­mat­ic Neu­roses of War, which had been
pub­lished in 1941 by a psy­chi­a­trist named Abram Kar­diner. It described
Kardiner’s obser­va­tions of World War I vet­er­ans and had been released in
antic­i­pa­tion of the flood of shell-shocked sol­diers expect­ed to be casu­al­ties
of World War II.1
Kar­diner report­ed the same phe­nom­e­na I was see­ing: After the war his
patients were over­tak­en by a sense of futil­i­ty; they became with­drawn and
detached, even if they had func­tioned well before. What Kar­diner called
“trau­mat­ic neu­roses,” today we call post­trau­mat­ic stress disorder—PTSD.
Kar­diner not­ed that suf­fer­ers from trau­mat­ic neu­roses devel­op a chron­ic
vig­i­lance for and sen­si­tiv­i­ty to threat. His sum­ma­tion espe­cial­ly caught my
eye: “The nucle­us of the neu­ro­sis is a physioneurosis.”2 In oth­er words,
post­trau­mat­ic stress isn’t “all in one’s head,” as some peo­ple sup­posed, but
has a phys­i­o­log­i­cal basis. Kar­diner under­stood even then that the symp­toms
have their ori­gin in the entire body’s response to the orig­i­nal trau­ma.
Kardiner’s descrip­tion cor­rob­o­rat­ed my own obser­va­tions, which was
reas­sur­ing, but it pro­vid­ed me with lit­tle guid­ance on how to help the
vet­er­ans. The lack of lit­er­a­ture on the top­ic was a hand­i­cap, but my great
teacher, Elvin Sem­rad, had taught us to be skep­ti­cal about text­books. We
had only one real text­book, he said: our patients. We should trust only what
we could learn from them—and from our own expe­ri­ence. This sounds so
sim­ple, but even as Sem­rad pushed us to rely upon self-knowl­edge, he also
warned us how dif­fi­cult that process real­ly is, since human beings are
experts in wish­ful think­ing and obscur­ing the truth. I remem­ber him say­ing:
“The great­est sources of our suf­fer­ing are the lies we tell our­selves.”
Work­ing at the VA I soon dis­cov­ered how excru­ci­at­ing it can be to face
real­i­ty. This was true both for my patients and for myself.
We don’t real­ly want to know what sol­diers go through in com­bat. We
do not real­ly want to know how many chil­dren are being molest­ed and
abused in our own soci­ety or how many couples—almost a third, as it turns
out—engage in vio­lence at some point dur­ing their rela­tion­ship. We want to
think of fam­i­lies as safe havens in a heart­less world and of our own coun­try
as pop­u­lat­ed by enlight­ened, civ­i­lized peo­ple. We pre­fer to believe that
cru­el­ty occurs only in far­away places like Dar­fur or the Con­go. It is hard
enough for observers to bear wit­ness to pain. Is it any won­der, then, that the
trau­ma­tized indi­vid­u­als them­selves can­not tol­er­ate remem­ber­ing it and that
they often resort to using drugs, alco­hol, or self-muti­la­tion to block out their
unbear­able knowl­edge?
Tom and his fel­low vet­er­ans became my first teach­ers in my quest to
under­stand how lives are shat­tered by over­whelm­ing expe­ri­ences, and in
fig­ur­ing out how to enable them to feel ful­ly alive again.
TRAUMA AND THE LOSS OF SELF
The first study I did at the VA start­ed with sys­tem­at­i­cal­ly ask­ing vet­er­ans
what had hap­pened to them in Viet­nam. I want­ed to know what had pushed
them over the brink, and why some had bro­ken down as a result of that
expe­ri­ence while oth­ers had been able to go on with their lives.3 Most of the
men I inter­viewed had gone to war feel­ing well pre­pared, drawn close by
the rig­ors of basic train­ing and the shared dan­ger. They exchanged pic­tures
of their fam­i­lies and girl­friends; they put up with one another’s flaws. And
they were pre­pared to risk their lives for their friends. Most of them
con­fid­ed their dark secrets to a bud­dy, and some went so far as to share each
other’s shirts and socks.
Many of the men had friend­ships sim­i­lar to Tom’s with Alex. Tom met
Alex, an Ital­ian guy from Malden, Mass­a­chu­setts, on his first day in
coun­try, and they instant­ly became close friends. They drove their jeep
togeth­er, lis­tened to the same music, and read each other’s let­ters from
home. They got drunk togeth­er and chased the same Viet­namese bar girls.
After about three months in coun­try Tom led his squad on a foot patrol
through a rice pad­dy just before sun­set. Sud­den­ly a hail of gun­fire spurt­ed
from the green wall of the sur­round­ing jun­gle, hit­ting the men around him
one by one. Tom told me how he had looked on in help­less hor­ror as all the
mem­bers of his pla­toon were killed or wound­ed in a mat­ter of sec­onds. He
would nev­er get one image out of his mind: the back of Alex’s head as he
lay face­down in the rice pad­dy, his feet in the air. Tom wept as he recalled,
“He was the only real friend I ever had.” After­ward, at night, Tom
con­tin­ued to hear the screams of his men and to see their bod­ies falling into
the water. Any sounds, smells, or images that remind­ed him of the ambush
(like the pop­ping of fire­crack­ers on the Fourth of July) made him feel just
as par­a­lyzed, ter­ri­fied, and enraged as he had the day the heli­copter
evac­u­at­ed him from the rice pad­dy.
Maybe even worse for Tom than the recur­rent flash­backs of the ambush
was the mem­o­ry of what hap­pened after­ward. I could eas­i­ly imag­ine how
Tom’s rage about his friend’s death had led to the calami­ty that fol­lowed. It
took him months of deal­ing with his par­a­lyz­ing shame before he could tell
me about it. Since time immemo­r­i­al vet­er­ans, like Achilles in Homer’s
Ili­ad, have respond­ed to the death of their com­rades with unspeak­able acts
of revenge. The day after the ambush Tom went into a fren­zy to a
neigh­bor­ing vil­lage, killing chil­dren, shoot­ing an inno­cent farmer, and
rap­ing a Viet­namese woman. After that it became tru­ly impos­si­ble for him
to go home again in any mean­ing­ful way. How can you face your
sweet­heart and tell her that you bru­tal­ly raped a woman just like her, or
watch your son take his first step when you are remind­ed of the child you
mur­dered? Tom expe­ri­enced the death of Alex as if part of him­self had been
for­ev­er destroyed—the part that was good and hon­or­able and trust­wor­thy.
Trau­ma, whether it is the result of some­thing done to you or some­thing you
your­self have done, almost always makes it dif­fi­cult to engage in inti­mate
rela­tion­ships. After you have expe­ri­enced some­thing so unspeak­able, how
do you learn to trust your­self or any­one else again? Or, con­verse­ly, how can
you sur­ren­der to an inti­mate rela­tion­ship after you have been bru­tal­ly
vio­lat­ed?
Tom kept show­ing up faith­ful­ly for his appoint­ments, as I had become
for him a lifeline—the father he’d nev­er had, an Alex who had sur­vived the
ambush. It takes enor­mous trust and courage to allow your­self to remem­ber.
One of the hard­est things for trau­ma­tized peo­ple is to con­front their shame
about the way they behaved dur­ing a trau­mat­ic episode, whether it is
objec­tive­ly war­rant­ed (as in the com­mis­sion of atroc­i­ties) or not (as in the
case of a child who tries to pla­cate her abuser). One of the first peo­ple to
write about this phe­nom­e­non was Sarah Haley, who occu­pied an office next
to mine at the VA Clin­ic. In an arti­cle enti­tled “When the Patient Reports
Atrocities,”4 which became a major impe­tus for the ulti­mate cre­ation of the
PTSD diag­no­sis, she dis­cussed the well-nigh intol­er­a­ble dif­fi­cul­ty of talk­ing
about (and lis­ten­ing to) the hor­ren­dous acts that are often com­mit­ted by
sol­diers in the course of their war expe­ri­ences. It’s hard enough to face the
suf­fer­ing that has been inflict­ed by oth­ers, but deep down many trau­ma­tized
peo­ple are even more haunt­ed by the shame they feel about what they
them­selves did or did not do under the cir­cum­stances. They despise
them­selves for how ter­ri­fied, depen­dent, excit­ed, or enraged they felt.
In lat­er years I encoun­tered a sim­i­lar phe­nom­e­non in vic­tims of child
abuse: Most of them suf­fer from ago­niz­ing shame about the actions they
took to sur­vive and main­tain a con­nec­tion with the per­son who abused
them. This was par­tic­u­lar­ly true if the abuser was some­one close to the
child, some­one the child depend­ed on, as is so often the case. The result can
be con­fu­sion about whether one was a vic­tim or a will­ing par­tic­i­pant, which
in turn leads to bewil­der­ment about the dif­fer­ence between love and ter­ror;
pain and plea­sure. We will return to this dilem­ma through­out this book.
NUMBING
Maybe the worst of Tom’s symp­toms was that he felt emo­tion­al­ly numb. He
des­per­ate­ly want­ed to love his fam­i­ly, but he just couldn’t evoke any deep
feel­ings for them. He felt emo­tion­al­ly dis­tant from every­body, as though his
heart were frozen and he were liv­ing behind a glass wall. That numb­ness
extend­ed to him­self, as well. He could not real­ly feel any­thing except for
his momen­tary rages and his shame. He described how he hard­ly
rec­og­nized him­self when he looked in the mir­ror to shave. When he heard
him­self argu­ing a case in court, he would observe him­self from a dis­tance
and won­der how this guy, who hap­pened to look and talk like him, was able
to make such cogent argu­ments. When he won a case he pre­tend­ed to be
grat­i­fied, and when he lost it was as though he had seen it com­ing and was
resigned to the defeat even before it hap­pened. Despite the fact that he was
a very effec­tive lawyer, he always felt as though he were float­ing in space,
lack­ing any sense of pur­pose or direc­tion.
The only thing that occa­sion­al­ly relieved this feel­ing of aim­less­ness
was intense involve­ment in a par­tic­u­lar case. Dur­ing the course of our
treat­ment Tom had to defend a mob­ster on a mur­der charge. For the
dura­tion of that tri­al he was total­ly absorbed in devis­ing a strat­e­gy for
win­ning the case, and there were many occa­sions on which he stayed up all
night to immerse him­self in some­thing that actu­al­ly excit­ed him. It was like
being in com­bat, he said—he felt ful­ly alive, and noth­ing else mat­tered. The
moment Tom won that case, how­ev­er, he lost his ener­gy and sense of
pur­pose. The night­mares returned, as did his rage attacks—so intense­ly that
he had to move into a motel to ensure that he would not harm his wife or
chil­dren. But being alone, too, was ter­ri­fy­ing, because the demons of the
war returned in full force. Tom tried to stay busy, work­ing, drink­ing, and
drugging—doing any­thing to avoid con­fronting his demons.
He kept thumb­ing through Sol­dier of For­tune, fan­ta­siz­ing about
enlist­ing as a mer­ce­nary in one of the many region­al wars then rag­ing in
Africa. That spring he took out his Harley and roared up the Kan­ca­m­a­gus
High­way in New Hamp­shire. The vibra­tions, speed, and dan­ger of that ride
helped him pull him­self back togeth­er, to the point that he was able to leave
his motel room and return to his fam­i­ly.
THE REORGANIZATION OF PERCEPTION
Anoth­er study I con­duct­ed at the VA start­ed out as research about
night­mares but end­ed up explor­ing how trau­ma changes people’s
per­cep­tions and imag­i­na­tion. Bill, a for­mer medic who had seen heavy
action in Viet­nam a decade ear­li­er, was the first per­son enrolled in my
night­mare study. After his dis­charge he had enrolled in a the­o­log­i­cal
sem­i­nary and had been assigned to his first parish in a Con­gre­ga­tion­al
church in a Boston sub­urb. He was doing fine until he and his wife had their
first child. Soon after the baby’s birth, his wife, a nurse, had gone back to
work while he remained at home, work­ing on his week­ly ser­mon and oth­er
parish duties and tak­ing care of their new­born. On the very first day he was
left alone with the baby, it began to cry, and he found him­self sud­den­ly
flood­ed with unbear­able images of dying chil­dren in Viet­nam.
Bill had to call his wife to take over child care and came to the VA in a
pan­ic. He described how he kept hear­ing the sounds of babies cry­ing and
see­ing images of burned and bloody children’s faces. My med­ical
col­leagues thought that he must sure­ly be psy­chot­ic, because the text­books
of the time said that audi­to­ry and visu­al hal­lu­ci­na­tions were symp­toms of
para­noid schiz­o­phre­nia. The same texts that pro­vid­ed this diag­no­sis also
sup­plied a cause: Bill’s psy­chosis was prob­a­bly trig­gered by his feel­ing
dis­placed in his wife’s affec­tions by their new baby.
As I arrived at the intake office that day, I saw Bill sur­round­ed by
wor­ried doc­tors who were prepar­ing to inject him with a pow­er­ful
antipsy­chot­ic drug and ship him off to a locked ward. They described his
symp­toms and asked my opin­ion. Hav­ing worked in a pre­vi­ous job on a
ward spe­cial­iz­ing in the treat­ment of schiz­o­phren­ics, I was intrigued.
Some­thing about the diag­no­sis didn’t sound right. I asked Bill if I could talk
with him, and after hear­ing his sto­ry, I unwit­ting­ly para­phrased some­thing
Sig­mund Freud had said about trau­ma in 1895: “I think this man is
suf­fer­ing from mem­o­ries.” I told Bill that I would try to help him and, after
offer­ing him some med­ica­tions to con­trol his pan­ic, asked if he would be
will­ing to come back a few days lat­er to par­tic­i­pate in my night­mare study.5
He agreed.
As part of that study we gave our par­tic­i­pants a Rorschach test.6 Unlike
tests that require answers to straight­for­ward ques­tions, respons­es to the
Rorschach are almost impos­si­ble to fake. The Rorschach pro­vides us with a
unique way to observe how peo­ple con­struct a men­tal image from what is
basi­cal­ly a mean­ing­less stim­u­lus: a blot of ink. Because humans are
mean­ing-mak­ing crea­tures, we have a ten­den­cy to cre­ate some sort of
image or sto­ry out of those inkblots, just as we do when we lie in a mead­ow
on a beau­ti­ful sum­mer day and see images in the clouds float­ing high
above. What peo­ple make out of these blots can tell us a lot about how their
minds work.
On see­ing the sec­ond card of the Rorschach test, Bill exclaimed in
hor­ror, “This is that child that I saw being blown up in Viet­nam. In the
mid­dle, you see the charred flesh, the wounds, and the blood is spurt­ing out
all over.” Pant­i­ng and with sweat bead­ing on his fore­head, he was in a pan­ic
sim­i­lar to the one that had ini­tial­ly brought him to the VA clin­ic. Although I
had heard vet­er­ans describ­ing their flash­backs, this was the first time I
actu­al­ly wit­nessed one. In that very moment in my office, Bill was
obvi­ous­ly see­ing the same images, smelling the same smells, and feel­ing
the same phys­i­cal sen­sa­tions he had felt dur­ing the orig­i­nal event. Ten years
after help­less­ly hold­ing a dying baby in his arms, Bill was reliv­ing the
trau­ma in response to an inkblot.
Expe­ri­enc­ing Bill’s flash­back first­hand in my office helped me real­ize
the agony that reg­u­lar­ly vis­it­ed the vet­er­ans I was try­ing to treat and helped
me appre­ci­ate again how crit­i­cal it was to find a solu­tion. The trau­mat­ic
event itself, how­ev­er hor­ren­dous, had a begin­ning, a mid­dle, and an end,
but I now saw that flash­backs could be even worse. You nev­er know when
you will be assault­ed by them again and you have no way of telling when
they will stop. It took me years to learn how to effec­tive­ly treat flash­backs,
and in this process Bill turned out to be one of my most impor­tant men­tors.
When we gave the Rorschach test to twen­ty-one addi­tion­al vet­er­ans,
the response was con­sis­tent: Six­teen of them, on see­ing the sec­ond card,
react­ed as if they were expe­ri­enc­ing a wartime trau­ma. The sec­ond
Rorschach card is the first card that con­tains col­or and often elic­its so-
called col­or shock in response. The vet­er­ans inter­pret­ed this card with
descrip­tions like “These are the bow­els of my friend Jim after a mor­tar shell
ripped him open” and “This is the neck of my friend Dan­ny after his head
was blown off by a shell while we were eat­ing lunch.” None of them
men­tioned danc­ing monks, flut­ter­ing but­ter­flies, men on motor­cy­cles, or
any of the oth­er ordi­nary, some­times whim­si­cal images that most peo­ple
see.
While the major­i­ty of the vet­er­ans were great­ly upset by what they saw,
the reac­tions of the remain­ing five were even more alarm­ing: They sim­ply
went blank. “This is noth­ing,” one observed, “just a bunch of ink.” They
were right, of course, but the nor­mal human response to ambigu­ous stim­uli
is to use our imag­i­na­tion to read some­thing into them.
We learned from these Rorschach tests that trau­ma­tized peo­ple have a
ten­den­cy to super­im­pose their trau­ma on every­thing around them and have
trou­ble deci­pher­ing what­ev­er is going on around them. There appeared to
be lit­tle in between. We also learned that trau­ma affects the imag­i­na­tion.
The five men who saw noth­ing in the blots had lost the capac­i­ty to let their
minds play. But so, too, had the oth­er six­teen men, for in view­ing scenes
from the past in those blots they were not dis­play­ing the men­tal flex­i­bil­i­ty
that is the hall­mark of imag­i­na­tion. They sim­ply kept replay­ing an old reel.
Imag­i­na­tion is absolute­ly crit­i­cal to the qual­i­ty of our lives. Our
imag­i­na­tion enables us to leave our rou­tine every­day exis­tence by
fan­ta­siz­ing about trav­el, food, sex, falling in love, or hav­ing the last word—
all the things that make life inter­est­ing. Imag­i­na­tion gives us the
oppor­tu­ni­ty to envi­sion new possibilities—it is an essen­tial launch­pad for
mak­ing our hopes come true. It fires our cre­ativ­i­ty, relieves our bore­dom,
alle­vi­ates our pain, enhances our plea­sure, and enrich­es our most inti­mate
rela­tion­ships. When peo­ple are com­pul­sive­ly and con­stant­ly pulled back
into the past, to the last time they felt intense involve­ment and deep
emo­tions, they suf­fer from a fail­ure of imag­i­na­tion, a loss of the men­tal
flex­i­bil­i­ty. With­out imag­i­na­tion there is no hope, no chance to envi­sion a
bet­ter future, no place to go, no goal to reach.
The Rorschach tests also taught us that trau­ma­tized peo­ple look at the
world in a fun­da­men­tal­ly dif­fer­ent way from oth­er peo­ple. For most of us a
man com­ing down the street is just some­one tak­ing a walk. A rape vic­tim,
how­ev­er, may see a per­son who is about to molest her and go into a pan­ic.
A stern school­teacher may be an intim­i­dat­ing pres­ence to an aver­age kid,
but for a child whose step­fa­ther beats him up, she may rep­re­sent a tor­tur­er
and pre­cip­i­tate a rage attack or a ter­ri­fied cow­er­ing in the cor­ner.
STUCK IN TRAUMA
Our clin­ic was inun­dat­ed with vet­er­ans seek­ing psy­chi­atric help. How­ev­er,
because of an acute short­age of qual­i­fied doc­tors, all we could do was put
most of them on a wait­ing list, even as they con­tin­ued bru­tal­iz­ing
them­selves and their fam­i­lies. We began see­ing a sharp increase in arrests
of vet­er­ans for vio­lent offens­es and drunk­en brawls—as well as an alarm­ing
num­ber of sui­cides. I received per­mis­sion to start a group for young
Viet­nam vet­er­ans to serve as a sort of hold­ing tank until “real” ther­a­py
could start.
At the open­ing ses­sion for a group of for­mer Marines, the first man to
speak flat­ly declared, “I do not want to talk about the war.” I replied that the
mem­bers could dis­cuss any­thing they want­ed. After half an hour of
excru­ci­at­ing silence, one vet­er­an final­ly start­ed to talk about his heli­copter
crash. To my amaze­ment the rest imme­di­ate­ly came to life, speak­ing with
great inten­si­ty about their trau­mat­ic expe­ri­ences. All of them returned the
fol­low­ing week and the week after. In the group they found res­o­nance and
mean­ing in what had pre­vi­ous­ly been only sen­sa­tions of ter­ror and
empti­ness. They felt a renewed sense of the com­rade­ship that had been so
vital to their war expe­ri­ence. They insist­ed that I had to be part of their
new­found unit and gave me a Marine captain’s uni­form for my birth­day. In
ret­ro­spect that ges­ture revealed part of the prob­lem: You were either in or
out—you either belonged to the unit or you were nobody. After trau­ma the
world becomes sharply divid­ed between those who know and those who
don’t. Peo­ple who have not shared the trau­mat­ic expe­ri­ence can­not be
trust­ed, because they can’t under­stand it. Sad­ly, this often includes spous­es,
chil­dren, and co-work­ers.
Lat­er I led anoth­er group, this time for vet­er­ans of Patton’s army—men
now well into their sev­en­ties, all old enough to be my father. We met on
Mon­day morn­ings at eight o’clock. In Boston win­ter snow­storms
occa­sion­al­ly par­a­lyze the pub­lic tran­sit sys­tem, but to my amaze­ment all of
them showed up even dur­ing bliz­zards, some of them trudg­ing sev­er­al miles
through the snow to reach the VA Clin­ic. For Christ­mas they gave me a
1940s GI-issue wrist­watch. As had been the case with my group of
Marines, I could not be their doc­tor unless they made me one of them.
Mov­ing as these expe­ri­ences were, the lim­its of group ther­a­py became
clear when I urged the men to talk about the issues they con­front­ed in their
dai­ly lives: their rela­tion­ships with their wives, chil­dren, girl­friends, and
fam­i­ly; deal­ing with their boss­es and find­ing sat­is­fac­tion in their work; their
heavy use of alco­hol. Their typ­i­cal response was to balk and resist and
instead recount yet again how they had plunged a dag­ger through the heart
of a Ger­man sol­dier in the Hürt­gen For­est or how their heli­copter had been
shot down in the jun­gles of Viet­nam.
Whether the trau­ma had occurred ten years in the past or more than
forty, my patients could not bridge the gap between their wartime
expe­ri­ences and their cur­rent lives. Some­how the very event that caused
them so much pain had also become their sole source of mean­ing. They felt
ful­ly alive only when they were revis­it­ing their trau­mat­ic past.
DIAGNOSING POSTTRAUMATIC STRESS
In those ear­ly days at the VA, we labeled our vet­er­ans with all sorts of
diagnoses—alcoholism, sub­stance abuse, depres­sion, mood dis­or­der, even
schizophrenia—and we tried every treat­ment in our text­books. But for all
our efforts it became clear that we were actu­al­ly accom­plish­ing very lit­tle.
The pow­er­ful drugs we pre­scribed often left the men in such a fog that they
could bare­ly func­tion. When we encour­aged them to talk about the pre­cise
details of a trau­mat­ic event, we often inad­ver­tent­ly trig­gered a full-blown
flash­back, rather than help­ing them resolve the issue. Many of them
dropped out of treat­ment because we were not only fail­ing to help but also
some­times mak­ing things worse.
A turn­ing point arrived in 1980, when a group of Viet­nam vet­er­ans,
aid­ed by the New York psy­cho­an­a­lysts Chaim Shatan and Robert J. Lifton,
suc­cess­ful­ly lob­bied the Amer­i­can Psy­chi­atric Asso­ci­a­tion to cre­ate a new
diag­no­sis: post­trau­mat­ic stress dis­or­der (PTSD), which described a clus­ter
of symp­toms that was com­mon, to a greater or less­er extent, to all of our
vet­er­ans. Sys­tem­at­i­cal­ly iden­ti­fy­ing the symp­toms and group­ing them
togeth­er into a dis­or­der final­ly gave a name to the suf­fer­ing of peo­ple who
were over­whelmed by hor­ror and help­less­ness. With the con­cep­tu­al
frame­work of PTSD in place, the stage was set for a rad­i­cal change in our
under­stand­ing of our patients. This even­tu­al­ly led to an explo­sion of
research and attempts at find­ing effec­tive treat­ments.
Inspired by the pos­si­bil­i­ties pre­sent­ed by this new diag­no­sis, I pro­posed
a study on the biol­o­gy of trau­mat­ic mem­o­ries to the VA. Did the mem­o­ries
of those suf­fer­ing from PTSD dif­fer from those of oth­ers? For most peo­ple
the mem­o­ry of an unpleas­ant event even­tu­al­ly fades or is trans­formed into
some­thing more benign. But most of our patients were unable to make their
past into a sto­ry that hap­pened long ago.7
The open­ing line of the grant rejec­tion read: “It has nev­er been shown
that PTSD is rel­e­vant to the mis­sion of the Vet­er­ans Admin­is­tra­tion.” Since
then, of course, the mis­sion of the VA has become orga­nized around the
diag­no­sis of PTSD and brain injury, and con­sid­er­able resources are
ded­i­cat­ed to apply­ing “evi­dence-based treat­ments” to trau­ma­tized war
vet­er­ans. But at the time things were dif­fer­ent and, unwill­ing to keep
work­ing in an orga­ni­za­tion whose view of real­i­ty was so at odds with my
own, I hand­ed in my res­ig­na­tion; in 1982 I took a posi­tion at the
Mass­a­chu­setts Men­tal Health Cen­ter, the Har­vard teach­ing hos­pi­tal where I
had trained to become a psy­chi­a­trist. My new respon­si­bil­i­ty was to teach a
fledg­ling area of study: psy­chophar­ma­col­o­gy, the admin­is­tra­tion of drugs to
alle­vi­ate men­tal ill­ness.
In my new job I was con­front­ed on an almost dai­ly basis with issues I
thought I had left behind at the VA. My expe­ri­ence with com­bat vet­er­ans
had so sen­si­tized me to the impact of trau­ma that I now lis­tened with a very
dif­fer­ent ear when depressed and anx­ious patients told me sto­ries of
molesta­tion and fam­i­ly vio­lence. I was par­tic­u­lar­ly struck by how many
female patients spoke of being sex­u­al­ly abused as chil­dren. This was
puz­zling, as the stan­dard text­book of psy­chi­a­try at the time stat­ed that incest
was extreme­ly rare in the Unit­ed States, occur­ring about once in every
mil­lion women.8 Giv­en that there were then only about one hun­dred mil­lion
women liv­ing in the Unit­ed States, I won­dered how forty sev­en, almost half
of them, had found their way to my office in the base­ment of the hos­pi­tal.
Fur­ther­more, the text­book said, “There is lit­tle agree­ment about the role
of father-daugh­ter incest as a source of seri­ous sub­se­quent
psy­chopathol­o­gy.” My patients with incest his­to­ries were hard­ly free of
“sub­se­quent psychopathology”—they were pro­found­ly depressed,
con­fused, and often engaged in bizarrely self-harm­ful behav­iors, such as
cut­ting them­selves with razor blades. The text­book went on to prac­ti­cal­ly
endorse incest, explain­ing that “such inces­tu­ous activ­i­ty dimin­ish­es the
subject’s chance of psy­chosis and allows for a bet­ter adjust­ment to the
exter­nal world.”9 In fact, as it turned out, incest had dev­as­tat­ing effects on
women’s well-being.
In many ways these patients were not so dif­fer­ent from the vet­er­ans I
had just left behind at the VA. They also had night­mares and flash­backs.
They also alter­nat­ed between occa­sion­al bouts of explo­sive rage and long
peri­ods of being emo­tion­al­ly shut down. Most of them had great dif­fi­cul­ty
get­ting along with oth­er peo­ple and had trou­ble main­tain­ing mean­ing­ful
rela­tion­ships.
As we now know, war is not the only calami­ty that leaves human lives
in ruins. While about a quar­ter of the sol­diers who serve in war zones are
expect­ed to devel­op seri­ous post­trau­mat­ic problems,10 the major­i­ty of
Amer­i­cans expe­ri­ence a vio­lent crime at some time dur­ing their lives, and
more accu­rate report­ing has revealed that twelve mil­lion women in the
Unit­ed States have been vic­tims of rape. More than half of all rapes occur in
girls below age fifteen.11 For many peo­ple the war begins at home: Each
year about three mil­lion chil­dren in the Unit­ed States are report­ed as
vic­tims of child abuse and neglect. One mil­lion of these cas­es are seri­ous
and cred­i­ble enough to force local child pro­tec­tive ser­vices or the courts to
take action.12 In oth­er words, for every sol­dier who serves in a war zone
abroad, there are ten chil­dren who are endan­gered in their own homes. This
is par­tic­u­lar­ly trag­ic, since it is very dif­fi­cult for grow­ing chil­dren to
recov­er when the source of ter­ror and pain is not ene­my com­bat­ants but
their own care­tak­ers.
A NEW UNDERSTANDING
In the three decades since I met Tom, we have learned an enor­mous amount
not only about the impact and man­i­fes­ta­tions of trau­ma but also about ways
to help trau­ma­tized peo­ple find their way back. Since the ear­ly 1990s brain-
imag­ing tools have start­ed to show us what actu­al­ly hap­pens inside the
brains of trau­ma­tized peo­ple. This has proven essen­tial to under­stand­ing the