The Washington PostDemocracy Dies in Darkness

The VA treated my PTSD all wrong

Its therapists tell veterans not to talk about politics. But that's exactly what they need to do to heal.

(Alex Wong/Getty Images)

The first time I saw war up close was in May 2004, on a reporting trip to Iraq where I watched the first battle of Fallujah winding down. I had resigned my commission in the Marine Corps a few years before and had gone to Iraq out of a sense of obligation: As a reporter who understood a thing or two about tactics, who better to write about it than me? Ten years later, I was diagnosed with PTSD by the Department of Veterans Affairs. I had been having nightmares and was sleeping poorly. One day after taking a walk near my mother’s house, I became convinced that I was hearing the Muslim call to prayer echoing down the winding streets of suburban San Diego. I called the VA soon after.

After suffering through the usual bureaucratic indignities — in my case sitting on a waiting list for three months — I started treatment at the big VA hospital in La Jolla, which included weekly appointments with a therapist who was finishing up his doctorate. Oddly, whenever I brought up the issues that bothered me the most — the catastrophic mismanagement of the war by the Bush administration, the pointless slaughter I’d seen in Fallujah, the casually bloodthirsty way Americans would talk about Iraq and about Arabs in general — my therapist would change the subject. I was admonished for “intellectualizing” my trauma and encouraged to focus instead on an IED ambush I had survived in Baghdad in 2007, as if that one event were the key to unlocking all my feelings about the war. Eventually this made my insomnia and anger issues worse, so I quit.

It was almost as if politics had been ruled off-limits by the VA, a negation of everything I’d been taught as a Marine officer, which began with Clausewitz’s dictum that war is a “continuation of politics by other means.”

When I asked around, I found other veterans felt the way I did. Some of my peers told me that the war had destroyed their sense of what America was and negated the idealism that inspired them to enlist in the first place. As one friend who served in Mosul with the Virginia National Guard told me recently, “for me the most damaging thing to my mental health is the lack of official clarity on the lies that took us into the war. More than all the violence and the other s— that I saw, it’s the lies.”

As Garett Reppenhagen, an army sniper in Iraq, explained in a recent article for Salon, “I was taken aside more than once at the VA during group therapy and told that the VA is not a platform to express my political views. [To me] my recovery hinged on the fact that I felt guilt and shame over committing atrocities against an occupied country. We went over there and brutalized and oppressed, and that is part of my psychological and moral injuries. If I can’t talk about it at the VA, then the VA can’t help me.”

Another Iraq veteran I spoke to told me that he stopped raising the issue of politics in therapy because it made his therapist “visibly uncomfortable” and fumble her words, as if she were violating some VA protocol.

Puzzled by this, I went to the library and began looking into the history of PTSD. What I found was shocking. I’d always had a vague awareness that PTSD was connected to the Vietnam War, but I what I didn’t realize was the original proponents of what became the PTSD diagnosis were all radical anti-Vietnam protesters who were convinced that American culture was the culprit. These activists argued that our country was locked into a kind of “psycho-mythology of war-making” that resulted in “a brutalization of its warriors and of the American psyche.”

These early PTSD advocates, from a group known as the Vietnam Veterans Against the War, saw their personal psychological struggles as inextricable from a larger failed American morality, a morality that made atrocities like My Lai not only foreseeable but inevitable. Many of them believed that Vietnam was only the most visible symptom of a larger “moral pollution” at the heart of American society that made such atrocities seem reasonable. As Robert Lifton, a psychiatrist closely associated with VVAW, put it, “There are always moral questions, which are inseparable from political questions, that are at issue. I think some psychologists make the mistake of imagining that it’s all a technical matter. For the healing process to take place, the veteran needs to confront what they have been a part of. It’s almost beyond politics, though it ultimately gets to the question of: Should we have been there? Or: Why was I sent there?”

It’s a powerful feeling when you discover that you are not alone in history, when you see that your feelings echo across the decades. My feelings were virtually identical to the original moral argument behind the PTSD concept, an argument that said, roughly: War has long-term psychological consequences and immoral, unjust wars have even greater psychological consequences.

Curious, I started doing more research, searching for answers to a few fundamental questions: Why were the VA therapists I worked with so uninterested in the larger moral issues? What had caused this sea change in the VA and in psychiatry at large?

When I dug into the history, I discovered that this shift wasn’t a systematic attempt by the VA to suppress the thorny political and moral questions relating to PTSD; instead it was the result of a broader campaign by biological psychiatrists to treat mental disorders as diseases arising from malfunctioning systems within the human brain. Instead of “psycho-mythology,” “moral pollution” and “atrocity-producing situations,” clinicians today talk about fear activation, hyperarousal, the amygdala and the behavior of stress hormones like cortisol. The idea that veterans and trauma survivors of any kind might experience a crisis of faith in society is completely foreign to most PTSD therapists today.

This effort to depoliticize PTSD and treat it like any other psychiatric disorder began almost immediately after it was inducted into the bible of psychiatry, the “Diagnostic and Statistical Manual of Mental Disorders,” in 1980. As Matthew Friedman, the longest-serving director of the VA’s National Center for PTSD, said in a 1984 interview, the early pioneers of the PTSD diagnosis, people like Lifton, perceived it as a “psychological disorder, rather than a biological disorder,” adding that his job as he saw it was to take PTSD into the psychiatric mainstream, which by the 1980s had become increasingly focused on the biological characteristics of mental illness. As one senior VA official who has treated PTSD for over 30 years explained to me, “biological research is at the forefront of PTSD research today because that’s where the money is.”

Beginning in the mid-1990s, some trauma theorists like Jonathan Shay, a retired VA psychiatrist, repackaged some of the ideas first identified by VVAW and began promoting a concept he called “moral injury.” This moral injury paradigm, which is very popular in veteran circles today, is built on the idea that veterans often experience “injuries” to their conscience because of their actions during war.

However, a number of researchers, such as Brett Litz of Boston University, have argued that prolonged exposure— the type of therapy I underwent at the VA in San Diego — can actually exacerbate PTSD symptoms arising from morally damaging experiences like “friendly fire” or being ordered to torture foreign detainees.

Seeing how coldly scientific and divorced from its moral roots PTSD has become, it is hard to not conclude that modern psychiatry has completely betrayed the original intentions of the Vietnam veterans who fought to have their struggles recognized and morally neutered their original argument. As Arthur Egendorf, a founding member of VVAW, told me recently “I spent many years in outrage, incomprehension, often flailing about when I saw where things were going after the American Psychiatric Association and its ‘biopsychiatry bias’ got a hold of the new [PTSD] diagnosis.”

Throughout history, the great movements to address the trauma of war have always been linked to the morality of war itself. Siegfried Sassoon, the World War I poet, ended his account of shell shock with the following provocation: “In the name of civilization these soldiers have been martyred, and it remained for civilization to prove that their martyrdom wasn’t a dirty swindle.” The war in Iraq was nothing if not a dirty swindle, and it remains for America to prove to its veterans that it has learned anything from their martyrdom.