Shooting Magical Bullets at PTSD

By Andrew ScullFebruary 26, 2015

Shooting Magical Bullets at PTSD

The Evil Hours: A Biography of Post-Traumatic Stress Disorder by David J. Morris

DAVID MORRIS served as an officer in the United States Marine Corps between 1994 and 1998, and thus by luck rather than choice he escaped combat. He describes his stint in the armed forces as routine — even boring. Dividing his time between Camp Pendleton in Southern California and the United States base in Okinawa, he spent four years doing little besides play war games and wait. And wait some more. He was a middling officer by his own account, and he left the service “feeling vaguely disappointed, incomplete, as if some secret in me had been left unrevealed.” No military adventures for him.

All that changed with the outbreak of the second Iraq War. In graduate school when the 9/11 terrorists struck, Morris sensed an opportunity to experience what he had missed — not as a soldier, but as an embedded war correspondent. One day in October 2007, while on patrol in a Sunni neighborhood west of Baghdad, he found himself in a Humvee with a platoon from the First Infantry Division. Some of the soldiers quite clearly resented his presence, and one of them confronted him directly, wondering aloud what would prompt a supposedly sane person to court harm in this way. He himself had had no choice, the soldier spat out — it was poverty, not love of country, that had made him volunteer for service. The military was his only way out of a dead-end existence, he went on, and look where it had landed him: in a hellhole. What the hell was wrong with Morris that he had chosen to come to Iraq?

Soldiers are often a superstitious lot. Knowing that their lives could end at any moment, or that they could end up maimed for life, they learn to ignore the obvious, and to engage in various forms of magical thinking. An unspoken rule dictates that one must not push one’s luck by alluding to the likelihood of impending doom. It was thus obvious what would happen after one of the other soldiers in the Humvee turned to Morris and casually asked, “Have you ever been blown up before, sir?” The Humvee’s driver was just then following a Bradley tank into a burning neighborhood. Finding himself trapped in a pall of black smoke, he attempted to reverse and turn around. A hidden explosive device, an IED, promptly detonated under the vehicle. By some miracle, no one in the truck was killed, though the driver’s eardrums were blown out.

The crippled Humvee, its right rear wheel all but destroyed, somehow limped back to base. A week later, Morris was back in California. A lucky man. But a damaged man, damaged in ways he did not yet comprehend. Greeted at LAX by his girlfriend, Erica, he set out to resume a “normal” civilian life. Postwar bliss beckoned, but there was a problem: Morris had nightmares. The couple went to the movies — to an action movie, replete with explosions. Morris blacked out, and then found himself outside the theater. (He had run out in a panic, but had no memory of doing so.) Unbearable fears continued to overwhelm him at unexpected moments: on a plane encountering turbulence, or when he got three parking tickets in a week. His fits of anger were explosive and frightening. One day, Erica simply left. She had had enough. So had Morris, but it turned out his demons could not be so easily cast aside.

Large portions of The Evil Hours are autobiography, not biography. In a moving and revealing fashion, these portions display the author’s own struggles with his mental disorder, as well as his reactions to being treated by therapists at his local VA hospital (not 10 minutes from where I live) like a clinical specimen to be dissected and remade. But Morris has also read extensively on the history of military trauma, and examined the medical literature on its etiology and treatment. He is a bit defensive at times about the whole exercise: “I hate the idea of turning writing into therapy, and I did not conceive of this book as a therapeutic project.” In the very next breath, however, he concedes that “delving into the history and literature of PTSD has, in fact, been extraordinarily useful.” And not just to him. This book’s bite lies precisely in its ability to place private troubles in a larger social, cultural, and historical context. Morris has done his homework well.


The “shell shock” crisis of the First World War made it rather obvious that modern industrialized warfare is not exactly ideally suited to preserving mental health. Within months of the start of fighting, a military stalemate had ensued. Trapped in the Flanders mud, soldiers in trenches waited for death — from high explosive shells, from flesh-tearing bayonets, from machine gun bullets, from poison gas. No army was spared the epidemic of nervous disorders that followed. By the thousands and tens of thousands, soldiers were struck dumb, lost their sight, became paralyzed or incapable of normal motion, wept, screamed uncontrollably, lost their memories, hallucinated, became insomniacs incapable of fighting. As the very name “shell shock” suggests, many military psychiatrists initially thought that the disorders were the manifestation of real damage to the nervous system produced by blasts from high explosives. But such claims became increasingly untenable. Soldiers who had not even reached the front lines became symptomatic. By contrast, those who became prisoners of war, and thus did not experience life in the trenches, did not. The military high command on both sides of the fighting declared victims cowardly malingerers. Physicians meted out sadistic treatments — torture with electric currents applied to tongues and genitals, for instance, and seemed as determined as the military high command to force victims back into the fighting.

But the preternatural tenacity with which shell-shock victims clung to their symptoms made simple claims of malingering hard to sustain. The Germans ultimately adopted the label Schreckneurose, or terror neurosis. And, eventually, physicians and military leaders had to concede that trauma and psychological stress could make even apparently stable individuals break down, and become maddened with fear, disgust, and horror.

Actually, had anyone been paying attention, the extraordinary bloodletting that marked the American Civil War had provided a preview. American neurology emerged as a specialty from the experience of treating men with brain injuries, with lost limbs that gave rise to phantom pain, or with other damage to their central nervous systems. But the waiting rooms of the postwar nerve doctors were in fact crowded with veterans whose wounds were of a less obvious or visible sort. Morris tells us that at war’s end, eight percent of the Union Army alone, some 175,000 men, was listed as suffering from “nostalgia” (at the time, a synonym for depression or panic), or from a variety of other nervous complaints, or from simple insanity. Not by chance, the aftermath of the war saw an upsurge in criminal violence, including the racialized violence of the Ku Klux Klan, and genocidal campaigns against Native American tribes. Such outcomes, Morris suggests, were not unconnected to the trauma of war: “Violence changes people in mysterious ways, and when the normal human prohibitions against murder and cruelty are lifted on a wide scale, it unleashes violent impulses that are not easily controlled.”

The Second World War was, of course, the “good” war, fought by “the greatest generation” against the horrors of Hitler and Hirohito. As the nation entered the war, America’s psychiatrists promised to screen out the mentally unfit, and did so to the tune of rejecting nearly two million men from military service. To no avail. At war’s end, America had more than 50,000 mentally broken military men confined in veterans’ hospitals, and another half million were receiving pensions in 1947 for psychiatric disabilities linked to their military service. This time around, their sickness was called combat exhaustion or combat neurosis. In keeping with the code of silence embraced by those who had endured the Great Depression, not to mention the stigma that enveloped mental illness, this epidemic was endured largely in silence. Such troubles would only acquire their current name and public visibility after still another war, this time the “bad” war that was Vietnam.    

Post-traumatic stress disorder, or PTSD, was the brainchild of a handful of disgruntled Vietnam veterans and two sympathetic psychiatrists, Robert J. Lifton and Chaim Shatan. (Nixon would have probably liked the latter to drop the “h”.) Meeting with members of the fledgling Vietnam Veterans Against the War, Lifton and Shatan shared their sense that the war was an abomination: a crime against humanity. They sympathized with veterans’ struggles to develop some insight into their mental turmoil. The Pentagon, however, was busy assuring Americans that the rate of psychiatric casualties in Vietnam was lower than in any previous war. The angry veterans knew better. Borrowing from the “consciousness raising” meetings of the fledgling women’s movement, and the therapeutic communities forming around recovering alcoholics and addicts, they and their psychiatric allies set up rap sessions, and they gradually began to speak of a post-Vietnam syndrome, a concept Shatan introduced to the wider world via a New York Times op-ed piece. Veterans, he claimed, suffered from a variety of psychic ills: depression, emotional numbness, unpredictable episodes of anger and of terror, and a sense of disorientation and disaffection. In the face of fierce resistance from the Veterans Administration and its staff doctors, the two doctors vocally insisted on the reality of their patients’ suffering.

Typical of the era, elite psychiatrists like these two were psychoanalysts. (Lifton held an appointment at Harvard and Shatan at Columbia.) Psychoanalysis had dominated American psychiatry from 1945 into the 1970s, but, unbeknownst to all sides, it was about to be eclipsed, replaced by a resurgent biological reductionism, and by a renewed emphasis on precise labels for psychiatric disorders (or at least labels that trained psychiatrists could reliably muster and assign).

Morris astutely describes this revolution. It was inspired by a Columbia psychiatrist, Robert Spitzer, whom the American Psychiatric Association had charged with devising an improved system of psychiatric classification. Spitzer was a true believer, and he had the political skills to match. He and his task force insisted that they were DOPs (data-oriented persons), and had little time or sympathy for what they saw as psychoanalytic nonsense. When Lifton and Shatan approached Spitzer about including “post-combat reaction” in the new manual, they were scornfully turned away. “You don’t have any evidence. You don’t have any figures. You don’t have any research,” Spitzer told them. The biological psychiatrists who had Spitzer’s ear were equally dismissive. Lee Robbins from Washington University in St. Louis was unsparing in his assessment: “These guys are all character disorders. They came from rotten backgrounds. They were going to be malcontents and dysfunctional anyway. […] Vietnam is not the cause of their problems. They’re alcoholics and drug addicts.” (It should be noted here that such ideas were also commonplace among many medical men seeking to explain shell shock in World War I. Drawing on then-current psychiatric theory, they had dismissed casualties as degenerates; in short, their pre-existing mental frailties explained their symptoms.)

But Spitzer’s “scientific objectivity” was a pose, an ideological one sharply at odds with how the DSM task force he led actually conducted business and reached conclusions. Spitzer had previously overseen the de-pathologization of homosexuality, which had long been dismissed by psychiatrists as a form of mental illness, but he had done so under duress. Pressured by what Morris characterizes as a relentless, almost military National Gay and Lesbian Task Force, the APA voted to disavow its earlier assertion that homosexuality was a mental disorder. Behind the scenes, Spitzer’s task force routinely engaged in similar politically motivated decision-making. He expeditiously voted on the number of symptoms (drawn from a long list) a patient needed to display to be diagnosed as schizophrenic, and he voted other psychiatric “illnesses” into (or out of) official existence. By 1975, when Shatan and his allies had cobbled together the “evidence” Spitzer had demanded, Spitzer finally relented, but he insisted that their proposed “post-catastrophic stress disorder” be relabeled “post-traumatic stress disorder,” and he eliminated any reference to Vietnam. Once launched, PTSD would soon extend itself beyond the ranks of traumatized soldiers to include victims of natural disasters and of sexual violence.

The publication of the new diagnostic manual in 1980 provided an official seal of approval for PTSD. It also marked the moment when the previous psychoanalytical dominance of the profession entered its death throes. Within less than a decade, analysts had been summarily defenestrated from their positions at the head of university departments of psychiatry. As for their psychoanalytic Institutes, these scrambled for recruits and eventually had to abandon their long-held insistence that only medics could become analysts. Whether rightly or wrongly, mainstream psychiatry now saw Freud as a corpse. The future appeared to belong to drugs and neuroscience. If Lifton and Shatan, the proponents of the PTSD diagnosis, had been convinced that they were dealing with a psychological and not a biological disorder, the newly reshaped discipline of psychiatry was no longer disposed to agree. “Accordingly,” as Morris notes,

the global research agenda for PTSD, heavily influenced by the budget priorities and interests of the U.S. Veterans Administration and the Department of Defense, has tended to [set aside the psychoanalytic, cultural, and cross-cultural aspects of the condition in] favor [of] exploring the neurological and biological foundations of PTSD.

Like the drunk looking for his lost watch under the lamppost, so academic medics, by virtue of having to chase the money, are building their careers by blindly groping after stress hormones and the chemical soup that bathes brain cells. Veterans have often been tempted to embrace this narrative; like comparable myths about the chemical origins of depression, it makes the disorder unambiguously “real” and medical, thereby in principle helping to diffuse the stigma so often attached to it. In the process, mere “subjective” experience is dismissed, and neuroscience is portrayed as the only rubric for understanding human experience. The traumatized David Morris would become intimately familiar with this clinical culture, and, as the reader may guess, not always to his advantage.

I found Morris’s account of his encounter with the VA bureaucracy and its therapies especially memorable. In keeping with the current dominant approach to most forms of mental illness, modern psychopharmacology zealously aims its magic bullets at PTSD. But, as with depression, bipolar disorder, and schizophrenia, shooting pharmaceutical bullets at PTSD turns out to be less than magical. With little or no systematic research to underpin their use, SSRIs (selective serotonin reuptake inhibitors) like Zoloft, Paxil, and Prozac were blithely prescribed for PTSD patients — even though the first systematic studies claiming that these drugs provided a measure of symptomatic relief were only published beginning in 2002. Never mind! The Food and Drug Administration deemed the studies sufficient to license this class of drugs for treatment of PTSD, an approach officially endorsed by the American Psychiatric Association two years later. In reality, however, the data never provided solid support for their use on the affected veterans, and by 2008, the prestigious Institute of Medicine concurred. The Institute released a report “that officially recognized what many researchers already knew: there was no evidence that any drug actually treated PTSD across the board, SSRIs included.” At best, the VA now concluded, existing drugs had a role as an adjunctive therapy. They were not the “gold standard.” The fallout of the love affair with drugs? There was no need to listen to survivors’ stories describing “experiences that are difficult to listen to and do not easily lend themselves to scientific measurement.” The second fallout: a disposition to treat “brain-imaging technologies […] not […] as useful instruments in a larger toolkit but as actual windows into the mind” — a transparently delusional belief.

If drugs were no better than palliative much of the time (though Morris does suggest that “in many cases, Zoloft and other similar drugs have been one of the only things that have kept some trauma survivors from killing themselves”), the attempt to provide a biological account of PTSD has likewise run aground. Morris’s journey through the literature along with his own encounters with leading PTSD researchers convinced him of “the utter lack of a coherent neurobiological model” of the disorder. “PTSD,” he continues, “remains […] a cultural and existential phenomenon, a condition with no cure and little solid biological grounding.”

If not drugs, then what? Certainly not psychoanalysis. Instead, the Veterans Administration turned to forms of psychotherapy that purported to be grounded in science and in the authority of controlled laboratory trials. Morris was never assigned to a period of drug therapy, though he came close on a couple of occasions and, on his own account, self-medicated with alcohol. Perhaps that explains his (uncharacteristic) willingness to accept professional assurances that Prozac and its ilk are safe and largely free of side-effects. At any rate, Morris was assigned to purportedly “tried and true” forms of psychotherapy.

Trips to the La Jolla VA became like traveling to “a morbid version of Disneyland.” Bright-eyed and bushy-tailed young researchers arrive with clipboards to conduct intake interviews to determine if Morris is qualified for the particular variant of psychotherapy their bosses are studying. Twenty studies run at the same time, and Morris learns that volunteering for one of them is the quickest way to circumvent the interminable waiting used to ration veterans’ care. When Mark, a young technician, arrives to supervise Morris’s induction into this new world, he is quick to inform Morris that his boss is a rock star with “a résumé that is thirty-six pages long”! And he informs him that he has the great good fortune to be selected to take part in a marvelous new therapy called Prolonged Exposure [PE], which “works in about 85 percent of people.” (Talk about creating a placebo effect!)

Mark passes him to Sarah, who puts him through a lengthy series of questions rated on a four-point scale. She periodically consults a thick binder to confirm his eligibility. And she has him boil down his months-long traumatic experiences to one or two incidents, which are then also reduced to numbers. But Morris can’t conform to this twisted logic. He recalls more than the requested one or two traumas. Sarah stares into space, ignores his wanderings, and waits till she can reinsert him into the Procrustean bed she has prepared for him. “When I looked back at her, her face was blank, as if she had been waiting for me to finish. Her pencil, I noticed, was not moving.” Drug pushers, it turns out, are not the only psychiatric technicians who stop listening.

A week later, Morris gets bad news. At one point he had reported occasionally having more than three drinks in a day. That disqualified him from the study. Not to worry, said the cheery Mark, there were plenty of other promising studies that would fit his needs. Unfortunately, though, he would have to go through the mechanical rating process again, and he must be sure to include his drinking; these studies needed veterans who drank. Eventually, Morris is off to sessions with a trainee clinical psychologist, a nice and enthusiastic young man who, like his counterparts, seems blissfully ignorant of the War on Terror.

Those who pay even a modicum of attention may be aware of the commotion starting to swirl around the side-effects of psychopharmaceutic substances: the tardive dyskinesia and the diabetes that so often accompany the administration of anti-psychotics; the impotence, memory loss, and heightened suicidal ideation that are potential side-effects of the SSRIs. But, as Morris was about to discover, drugs are not the only psychiatric treatments with side-effects. His encounter with PE left him figuratively shaken and literally shaking. The idea of the therapy was to “flood” him with memories like the ones that had traumatized him, albeit in the safety of the therapist’s office, and to desensitize him over time: to wean him from the trauma-induced bad behaviors, and so to transform the original horrors into something like fiction. No deviation from the script was allowed. Ninety minutes each week of recalling the same terror. No wandering off point. No elaboration or free association. Repeat. Repeat again. And again. “A therapy, in other words, whose results were designed by researchers for researchers, a therapy designed to be touted by medical administrators as being ‘efficacious’ and scientifically tested.” Punitive and excruciating, the treatment made Morris steadily worse, until one afternoon he turned violent, fortunately within the confines of his apartment, smashing furniture, stabbing his cell phone, raging and screaming till his neighbors contemplated calling the police. Morris must have been one of the 15 percent not cured by this therapeutic magic. Or perhaps the statistics were as bogus as those promulgated by Big Pharma regarding their magic potions. Perhaps subjecting deeply traumatized people to more trauma was not the best of ideas. Perhaps a treatment originally designed for simple phobias was a poor match for those who had endured psychic hell.

In 2008, an Israeli study of army veterans suffering from PTSD in the aftermath of the Intifada reported an increase in the extent and severity of their psychotic symptoms post-“flooding.” Undeterred, the VA plowed ahead with its new “gold standard.” Clinicians and patients protested, one of the former calling its use “unconscionable.” Morris interviewed a rape victim who had also been given the treatment. “Flooding,” she told him, “That’s about right. I am once again flooded with fear and paranoia.” Such reports are dismissed by the bureaucrats as mere anecdotes, carrying no weight compared to their quantified, statistically significant measures. An efficient, assembly line therapy, cheap and easily mass-produced — it’s small wonder that they tune out the discordant voices.

Morris had had enough. He became what the VA called a “non-compliant patient.” He explained to the polite young therapist, through clenched teeth, that to urge him to continue with a therapy that was making him violent was “completely insane.” What is it, he wondered, about PTSD “that makes such sadistic methods seem reasonable”?

But the VA was not done with him yet, nor he with the VA. Immediately feeling better after quitting PE, and continuing to improve for a few weeks more, he was nonetheless far from cured. He approached the hospital to learn about other options and was referred to the other “gold standard therapy”: Cognitive Processing Therapy, or CPT, a group treatment designed to teach its patients to avoid extreme thoughts. CPT has no interest in the past, and once again (it is a mass therapy after all) is intentionally designed to minimize the role of the individual therapist. Patients haunted by murdered memories (and memories of murder) must find ways to forget. It’s a matter of ABCs. Morris is told by his sweet young therapist to write out a list of things that bother him:

1. The government lies.
2. People in power are liars and their lies killed friends of mine.
3. I feel sick and helpless about it.

To which the sweet young thing, like most of us knowing nothing of the war in question, suggests Morris investigate whether his “‘B’ belief was, in fact, ‘100 percent’ realistic.”

Yes, Morris concludes, it is. Bush, Cheney, and their ilk escaped all accountability for their crimes. They lied to justify the war. Their minions covered up friendly fire incidents. They sent far too few troops to pacify Iraq once conquered. They overruled the judgments of their commanders. They insisted the Sunni insurgency was in its last throes even as conditions steadily worsened. They boasted that the surge they had devised to pull the fat out of the fire was working, when in fact the American-trained Iraqi troops crumbled and collapsed at the first hint of opposition. They ordered and condoned torture. They presided over and excused Abu Ghraib. And what price had they paid for the death and destruction they had wrought? Morris decided that his disgust was warranted, just as, at the conclusion of the First World War, the poet Siegfried Sassoon had decided the same: “In the name of civilization these soldiers had been martyred, and it remained for civilization to prove that their martyrdom wasn’t a dirty swindle” — an urgent necessity that didn’t disappear because a dirty swindle was the least of it.

In the end, the CPT helped Morris a bit with his symptoms. But fundamentally it was a superficial band-aid; it did not salve his inner wounds. “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’ and for straying from the strictures of the therapeutic regime.”


Readers of The Evil Hours may be startled by the attitudes of some of the soldiers with whom Morris was embedded toward the country they were allegedly sent to defend. Take one of the soldiers in the platoon riding in the Humvee before they were all blown up. The Reaper, as Morris nicknamed him, had been posted to Iraq for an eternity, 13 months straight. His disaffection from his fellow countrymen was palpable: “I’m serious, sir. I can’t stand Americans.” It was a sentiment Morris came to share. The willful ignorance of his fellow citizens especially angered him. Their careless lack of attention to the horrors experienced and inflicted in their name

was an obscenity surpassed only by the obscenity of the war itself. […] Coming home and feeling the dullness of people, the pride they took in their ignorance […]. How could this be allowed to happen? […] In time, I resolved to hate the country I’d once served: the fat, sheltered land with its surplus of riches, its helicopter moms and real estate agents — narrow-minded, smug, and only dimly aware of any lives other than their own.

At the very end of the book, Morris returns to this theme. Years have passed since he left Iraq when he comes across the writings of Siegfried Sassoon again, this time by way of a poem. Sassoon was a fantastically brave First World War officer, known as “Mad Jack” for his exploits. Sickened, however, by what he came to see as pointless slaughter, and yet still serving as an officer on active duty, he publicly denounced the war and the politicians who were murdering a generation. Instead of being court-martialed and shot, he found himself labeled a victim of shell shock. His criticisms, after all, were clearly the ravings of a madman. Treated in a mental hospital he called Dottyville, he subsequently returned to the front, for he found himself unable to abandon his men to their fate. He fought still more recklessly than before, but somehow survived.

Sassoon remained a fierce critic of the venal politicians and the conscienceless generals who had sent his whole generation to die in the mud and muck of the trenches. He had a visceral contempt, too, for the blimpish civilians who had turned on any who “shirked their duty” and who prattled about the glories of war. And he had contempt for the yellow journalists who had hyped up nationalist feelings and sanitized the slaughter. The hero had grown to loathe them all. In Fight to a Finish, he indulges in a fantasy of his men and himself wreaking revenge.

In the poem, the soldiers are invited to take part in a victory march down Whitehall. The streets are lined with the smug, safe journalists who have exploited the courage of the fighting men and helped to send their mates to their deaths, building journalistic fortunes in the process (plus ça change …). Suddenly, one group of soldiers, bayonets fixed, breaks rank and rushes the journalists, who scream like pigs as they are stabbed to death. Meanwhile, Sassoon and his men peel off and charge into Parliament, grenades at the ready. The politicians who launched the war are about to have its realities brought home to them, if only for the few, terror-filled seconds before they meet their fate.

Fight to a Finish is a brutal and sadistic poem, but one whose emotions Morris understands: “I recognized the anger, the feelings beneath it, feelings so potent that you never spoke of them, even to friends. Even to lovers. Even to yourself most of the time.” One wonders how many young soldiers feel like this on their return?

It is a disturbing thought. Perhaps it is one that ought to give those of us fortunate to have been spared the traumas of the battlefield nightmares of our own. What other horrors may we yet prove to have wrought?


Andrew Scull’s new book, Madness in Civilization: A Cultural History of Insanity, from the Bible to Freud, from the Madhouse to Modern Medicine, will be published by Princeton University Press on March 23.

LARB Contributor

Andrew Scull taught at the University of Pennsylvania and Princeton prior to becoming a professor at UCSD. His articles have appeared in leading journals in a variety of disciplines, including British Journal of PsychiatryPsychological MedicineLancetEuropean Journal of SociologyMedical HistoryVictorian Studies, and Stanford Law Review. He has held fellowships from (among others) the Guggenheim Foundation, the American Council of Learned Societies, and the Davis Center for Historical Studies, and in 1992-1993 was the president of the Society for the Social History of Medicine. His most recent books are Madness in Civilization: From the Bible to Freud, and from the Madhouse to Modern Medicine, and Psychiatry and Its Discontents. In the spring of 2022, Belknap Press/Harvard University Press will publish his new history of American psychiatry, Desperate Remedies: Psychiatry’s Turbulent Quest to Cure Mental Illness.


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