Tali Tuvia, MD

 is a moving biographical book based on a young veteran’s experience with PTSD. Throughout his book, we enter Morris’s world and glimpse at what it means to experience trauma. It is not only captivating, but it is an extremely well-researched book that considers PTSD in personal, historical, and clinical contexts. With the large number of men and women returning from Iraq and Afghanistan, this book will prove invaluable to those of us who are called upon to help them recover as fully as possible. What follows is a Q&A . . . the exchange is between Talia Tuvia, MD, and Mr Morris.

You highlight that social support plays an important protective factor against PTSD. How can society offer more social support to those who experienced trauma?

Americans are terrible listeners as a rule. There are many ways to conceptualize what PTSD is, and one way to think about it is as a failed conversation between survivors and regular citizens. Rape victims and veterans of war often return to the everyday world and feel isolated and misunderstood-in some cases even marked by a kind of scarlet letter. One way for such people to feel empowered is to find a way to tell their story, which requires a willful act of imagination on their part. But a raw, unprocessed story of survival is unfinished if it is never heard by another human being. So I think on the most basic emotional level, we as a society need to learn to be better, more skillful listeners.

This also means making room in the culture for survival narratives to take place. One of the only rape memoirs that currently exists in our culture, a book that has saved many lives-Alice Sebold’s 

-almost never happened. The book was realized because a perceptive graduate advisor of Sebold’s (Geoffrey Wolff, then at the University of California, Irvine) encouraged her to write down her story, to get it out of her head so that she could move on to her other work. Consider that for a moment. It shows in microcosm how the culture at large might work: active listening and the processing of trauma through narrative. This also means that survivors need to do the work in figuring out a way to tell their stories and to make them heard.

I think that we also need to move beyond the stereotypes of who veterans are in America. Currently, the culture seems to recognize only 2 types: the Navy SEAL hero and the homeless vet holding a sign by the side of the road. Speaking for myself, it was very hard to talk to Americans when I got back from Iraq because people’s pity and political preconceptions always got in the way. And I think saying “thank you for your service” has become a way of avoiding a deeper, more meaningful exchange about survival, sacrifice, and loss. We’re over a decade into these wars, and there’s almost no room for nuance or an emotional understanding of the experience of serving in a place like Anbar, Iraq.

 You discuss the difficulties of explaining trauma to someone who has not experienced it. What can psychiatrists do to better understand patients’ experience with trauma?

 With respect to veterans, one thing psychiatrists can do is pay more attention to the nuts and bolts of military life, the daily existence of overseas service. In my mind, there is nothing more important that a clinician can do to strengthen the therapeutic alliance than to sit down and read a book like Phil Klay’s 

 These books impart a kind of credibility. These books give clinicians a window into the experience itself, and in far greater detail than a movie or a newspaper article.

Trauma to me is all about context and coming to an understanding of why a specific event was so horrific. This level of understanding is impossible without a grasp of the particulars of a survivor’s experience and the culture to which they belong. If you are treating rape survivors, I would recommend Alice Sebold’s 

; for refugees, Ismet Prcic’s award-winning novel 

; for natural disaster survivors, Sonali Deraniyagala’s excellent memoir 

 If President Obama named you Secretary of Veterans Affairs (VA) tomorrow, what are some of the changes that you would implement to improve the mental health care veterans receive through the VA system.

 Wow, that’s a gorilla of a question. Well, one thing that I would commit to straight away would be to have clinicians schooled up on the basics of modern American military life. The VA today is this industrial-scale treatment delivery system and trying to work it from the inside is a Herculean emotional challenge for so many vets, and the whole mad swirl of it is just too much. So many times, I would walk into the big hospital at the VA San Diego, get a look at the scene, and say, “Nope, not today.” So just to have clinicians and the guy sitting behind the information desk have an idea of where your mind might be, as a person whose trauma happened in the context of this big unfeeling bureaucracy (ie, the military) would save lives. And I hate to sound like a high school English teacher, but on a certain level, this kind of education comes down to reading books and listening to vets rather than dictating to them.

When I underwent prolonged exposure therapy at VA San Diego, I gave my therapist a copy of Tom Ricks’ 

 an award-winning history of the Iraq War. I just wanted him to know what a CH-53 was. What an up-armored Humvee looked like. He never read it. Why? Because he was a graduate student and he had a thousand other commitments. So for me, the end user, the veteran, that meant I was stuck in a room day after day talking to a very smart, well-educated, well-meaning young man who nevertheless didn’t know the first thing about Iraq or life in the Marine infantry.

Many of these problems have been solved by the retail-style Vet Centers, which are smaller, semi-autonomous care facilities that exist within the VA system. But most veterans don’t know about them because they’re not a part of the VA’s large “Evidence-Supported Treatment” campaign, which is where the action is right now. So the Vet Centers need better marketing and need to be integrated into the overall VA campaign plan to combat PTSD, rather than being treated like the red-headed stepchild of the system, which is how it works now.

Which brings me to my next point-some senior psychiatrists within the VA that I interviewed for my book confided in me their fear that today’s crop of young clinicians have been so thoroughly schooled in the mass-produced, one-size-fits-all treatments like prolonged exposure and cognitive processing therapy that they don’t even know how to do individualized therapy any more.

 there are major problems with these therapies. Specifically, the VA’s number one PTSD therapy-prolonged exposure-has a significant adverse effect profile that the VA refuses to acknowledge. It’s driving veterans away from treatment by telling them that the only way forward is by having them forcibly re-tell the stories of their worst traumas over and over again. Which is exactly what I was told-“We’ve done the science. Your feelings, your insomnia, your nightmares don’t fit into the paradigm. Sorry.”

The VA likes to counter these sorts of criticisms by simply repeating the company line that prolonged exposure has the best empirical track record out there when, in fact, much of the evidence for this therapy is drawn from studies of rape victims; so again, there is this fundamental misunderstanding of what being in a war is like that is simply lost on most clinicians within the VA. Combat operations have a cumulative effect that is qualitatively different than sexual assault, which is more often a single event, but no one on the inside will admit this publicly because it doesn’t fit into the current clinical paradigm. In the meantime, veterans drop out of therapy, and in some cases end up killing themselves.

 You state that alcohol, taken in moderation, is one of the best drugs for treating PTSD. I think the idea of encouraging alcohol consumption in patients suffering mental distress is scary for most psychiatrists. Can you say a few more words on how alcohol worked for you and/or have you seen it work for other people?

 Advocating alcohol use in even the smallest amounts is taboo in American medical circles, in part because of our puritan legacy and partly because of the influence of quasi-religious groups such as Alcoholics Anonymous, whose methods have come under scrutiny recently by writers like Lance Dodes.8 In my book I make an argument that is really just common sense: having a couple of drinks can be beneficial. Alcohol reduces anxiety and allows access to emotions and inner landscapes that are unavailable during sobriety.

A similar argument can be made about marijuana and MDMA [3,4- methylenedioxymethamphetamine]. Researchers who attempt to look into clinical applications for these substances are often banished to the fringes of the medical community because of a kind of close-mindedness that masquerades as empiricism. This is yet another example of the importance of understanding how culture and history inform the conceptualization of trauma by societies. Ben Shephard,

 a controversial British historian, argues that “culture is more important than biology,” with respect to trauma. I sometimes tend to agree with him.

 and David Brooks both have had high praise for your work. It is very likely that all of our readers by this time have either heard interviews with you on NPR or read about your book in print or digital media. As our readers are mainly practicing psychiatrists, what do you hope they, in their professional capacity, will take away after reading your book?

I hope that readers come away with a greater sense of what trauma is like from the inside, from the perspective of a veteran, from the perspective of a rape survivor, from the perspective of a genocide survivor, as well as an understanding of PTSD as a historical entity. Conversations within the medical and research communities are almost completely dominated by physicians. In allocating resources, addressing what works and what doesn’t work, one almost never hears from patients or nurses and this robs the conversation of richness and an essential context.

Medicine today is dominated by a campaign for evidence-based treatments. In the main, this is a good thing. Nevertheless, trauma doesn’t happen in a vacuum and not enough attention is being paid to other non–data-driven forms of evidence. Good journalism is a form of evidence. Anecdotes and case studies are a form of evidence. Literature in the form of poetry and novels is a form of evidence. I hope that your readers can get a greater sense of how stories of survival over the centuries from Odysseus to Siegfried Sassoon to Alice Sebold can inform the healing process in a positive way. When I interviewed Steve House, an acclaimed mountaineer, about his recovery from a very serious fall, his drive to get better motivated me to take charge of my recovery in a new way. In short, stories are some of the best medicine out there.

Dr Forman is Assistant Professor of Psychiatry at Albert Einstein College of Medicine and Director of the Addiction Consultation Service at Montefiore Medical Center in the Bronx, NY. Dr Tuvia is a third-year psychiatry resident at Albert Einstein College of Medicine, Montefiore Medical Center. Mr Morris, a war correspondent and a former Marine, is the author of The Evil Hours, published by Houghton Mifflin Harcourt in 2015.

: The American Military Adventure in Iraq, 2003 to 2005. New York: Penguin Books; 2007.

http://opinionator.blogs.nytimes.com/author/david-j-morris/?_r=0

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