Capable, gung-ho, cocky Hoss was demoralized by the thought that he might be forced to find another line of work. Diving was what he excelled at. Was he just supposed to accept the fact that at twenty-five he had to relinquish the career he was meant to have? When he returned home to Idaho, he found himself feeling irritable and depressed. He kept having the same harrowing nightmare where he was trapped in a maze, opening every door he saw, frantically looking for the way out. Instead, behind each door, he found a flood of water threatening to wash over him.
He realized he needed help, so he went to see the counselor his health insurer recommended. The guy looked even younger than Hoss. “I need a counselor,” Hoss said.
“For what?”
So Hoss told him his story.
“Whoa,” the young counselor said, “that’s definitely out of my league.”
Next came a more experienced therapist, who told Hoss, “You have post-traumatic stress disorder.”
“I think you’re wrong,” Hoss replied. He’d heard about PTSD, of course, but he associated the diagnosis with veterans returning from the battlefield. He had always had a lot of respect for combat vets. As wrenching as the tunnel accident had been, he somehow didn’t think it put him in the same category. It took him some time to accept the fact that even though the disorder was yoked to the battlefield on account of its history, war wasn’t necessary to trigger it.
The researcher who helped lay the groundwork for PTSD in the 1970s was a former Marine by the name of Charles Figley. He’d volunteered for combat duty in Vietnam and came back disillusioned and angry. At protests organized by Vietnam Veterans Against the War, he got to know lots of vets struggling with nightmares, rage, terror, and addiction. The wreckage he saw was unmistakable, and the similarities striking, yet the Veterans Administration was both unwilling and ill equipped to understand what was happening. Figley returned to school to study psychology and human development. As an assistant professor at Purdue University, he interviewed combat vets and established the Consortium on Veterans Studies to pull together others doing similar work. In his 1978 book Stress Disorders Among Vietnam Veterans, he described the markers for “catastrophe-related stress,” in which vets felt helpless to stop reliving a traumatic event329.
As soon as word about the book began circulating, a young psychologist named Terry Keane, who was working for the VA in Jackson, Mississippi, flew to Indiana to meet with Figley. Keane had begun as a substance abuse researcher but shifted his focus after noticing that his patients who were Vietnam vets were all showing the same kinds of symptoms. When he would ask them why they got drunk or high, they’d invariably reply, “Because I can’t go to sleep.”
“Why not?”
“I’m afraid of the nightmares.”
“What are they about?”
“What I saw in the war.”
Figley opened all his files330 to the young psychologist from Mississippi, who was stunned at how closely they matched those of his own patients. Keane in turn described for Figley the novel approach that he and his colleagues were using to treat the psychological wounds of veterans. The technique, an early form of what would later be called exposure therapy, focused on helping desensitize patients to their most paralyzing memories by having them recount them, in full detail, again and again. These painful discussions, balanced with relaxation techniques, were designed to help patients gain control over what haunted them.
Two years later the American Psychiatric Association gave the disorder its new clunky four-letter acronym and included PTSD in the third edition of the Diagnostic and Statistical Manual of Mental Disorders, the bible of the mental health field.
Meanwhile, Keane continued his intense therapy. During one excruciating session, a Vietnam vet lurched over to Keane’s trash can to throw up. Keane learned that his patient was reliving the horror of seeing his buddy blown up by a rocket-propelled grenade just a few feet away. That explosion had sent his friend’s flesh flying into the patient’s mouth. Vomiting had become the patient’s way of coping with that hideous memory—and ridding his mouth of the lingering taste of burnt flesh.
In the late 1980s, Keane became director of the National Center for PTSD’s behavioral science division in Boston. When he collaborated with psychologists treating victims of rape or industrial accidents, he was once again struck by how much the symptoms resembled those of combat vets. All of these patients relived the trauma in flashbacks and nightmares. They became hyperaroused: simply watching the nightly news or seeing a place that looked like the scene of the trauma could trigger it all over again. But mostly they were numb, shutting down as caregivers or spouses.
Many victims turned to alcohol and drugs to relieve their symptoms. Even for people who previously had been heavy users, the character of the substance abuse fundamentally changed after the trauma. Whereas they had once partied to feel good, they now used drugs and alcohol as joyless self-medication.
One of the mysteries of PTSD is that people exposed to the same trauma are often affected in profoundly different ways. Keane interviewed a host of high-achieving business and civic leaders who had served in Vietnam. He wondered what explained their resilience when members of their same platoons had turned into the scary-looking guys lying on park benches, swigging from bottles and swearing at passersby.
Keane found that it wasn’t a matter of intelligence or capability. (Temperament and predisposition appear to play important roles.) Most of the vets he worked with were savvy guys who had no trouble finding jobs. What was hard was holding on to them. Plagued by feelings of abandonment and vulnerability from the original trauma, PTSD sufferers often resort to substance abuse and anger. While booze and most drugs numb the sense of powerlessness, the anger displaces it, allowing a reassertion of control. But both introduce serious new stressors. It’s hard to hold down a job and keep a marriage together if you’re constantly drunk or angry.
Keane eventually became one of the nation’s leading voices on PTSD. He developed some of the most widely used assessment measures for the disorder, which is now believed to affect 24 million Americans331, or about 8 percent of the population, at some point in their lives. And it afflicts not just combat troops but all sorts of civilians, from cops and paramedics to victims of rape and childhood trauma. While a wide range of treatments have emerged over the years, all of them come with drawbacks. Keane admits there is no magic bullet, but he continues to argue for cognitive behavioral therapy—which includes exposure therapy—since it has the most evidence to support its effectiveness, as well as the backing of the Institute of Medicine. Figley, meanwhile, came to believe that the mental health field’s emphasis on evidence-based treatments is too restrictive, since a significant number of people hate exposure therapy and some even appear to be retraumatized by it. Still, both men agree that those suffering from PTSD need to find a way to deal with the trauma head-on, if they are to have any hope of returning to a normal life.
Although PTSD was birthed by the Vietnam War, it describes psychological wounds that are as old as military history itself. One of Keane’s colleagues at the Boston VA won a MacArthur Foundation “genius grant” for his work identifying PTSD parallels in the ancient Greek epic poems the Iliad and the Odyssey and using them to inform contemporary treatment. That psychiatrist332 found in his combat-vet patients the same violent tempers, danger seeking, and aimlessness that Homer ascribed to Achilles and Odysseus. The road home after trauma can be as treacherous as any battlefield.
329 (Chapter 15, note 1)
vets felt helpless to stop reliving a traumatic event: Charles Figley,
330 (Chapter 15, note 2)
Figley opened all his files: Charles Figley and Terence Keane both confirmed these details in separate interviews with me in 2012.
331 (Chapter 15, note 3)
is now believed to affect 24 million Americans: Keane, interview by author; U.S. Department of Labor, “Frequently Asked Questions About Post-Traumatic Stress Disorder (PTSD) & Employment,” America’s Heroes at Work, www.americasheroesatwork.gov/forEmployers/factsheets/FAQPTSD/.
332 (Chapter 15, note 4)
That psychiatrist: Dr. Jonathan Shay connected PTSD to Achilles and Odysseus. See Anna Badkhen, “Psychiatrist Treated Veterans Using Homer Work Made Him MacArthur Fellow,”