Our Hearts and Our Hopes are Turned to Peace: Origins of The International Society for Traumatic Stress Studies
By Sandra L. Bloom, MD and ISTSS Past President
Published in the International Handbook of Human Response to Trauma (2000), New York: Kluwer Academic/Plenum Publishers. Edited by Arieh Y. Shalev, Rachel Yehuda and Alexander C. McFarlane.
"Our hearts and our hopes are turned to peace as we assemble here in the East Room this morning", said President Johnson on the morning of November 1968. "All our efforts are being bent in its pursuit. But in this company we hear again, in our minds, the sound of distant battles".
President Johnson was addressing these words to those gathered for the Medal of Honor ceremony in honor of five heroes of the undeclared war in Vietnam. One of those heroes was a young African-American man from Detroit, Sgt. Dwight Johnson. Dwight, or "Skip" to his family and friends, had always been a good kid, an Explorer Scout and an altar boy, who could only recall losing control of his temper once in his life, when his little brother was being beaten by older boys.
But in Vietnam, when the men whose lives he had shared for eleven months, were burned to death before his eyes, he suddenly became a savage soldier, killing five to twenty enemy soldiers in the space of half an hour.
At one point, he came face to face with a Vietnamese soldier who squeezed the trigger on his weapon aimed point blank at Skip. The gun misfired and Skip killed him. But, according to the psychiatrist that saw him several years later, it was this soldier's face that continued to haunt him.
After receiving the Medal of Honor, Skip who had been unable to even get a job as a simple veteran, became a nationally celebrated hero. But his body and mind started to give way.
In September of 1970 he was sent to Valley Forge Army Hospital where the psychiatrist there diagnosed him with depression caused by post-Vietnam adjustment problems. "Since coming home from Vietnam the subject has had bad dreams", read the psychiatric report, "He didn't confide in his mother or wife, but entertained a lot of moral judgement as to what had happened at Dakto. Why had he been ordered to switch tanks the night before? Why was he spared and not the others? He experienced guilt about his survival. He wondered if he was sane" (Nordheimer, 1971).
On April 30, 1971, Dwight Johnson, now married and the father of a little boy, was shot and killed while attempting an armed robbery of a Detroit grocery store. The store owner told the police, "I first hit him with two bullets but he just stood there, with the gun in his hand, and said, 'I'm going to kill you . . .' I kept pulling the trigger until my gun was empty".
In the exchange, Dwight Johnson, an experienced combat soldier, never fired a shot. His mother's words echo down to us, twenty-seven years later, "Sometimes I wonder if Skip tired of this life and needed someone else to pull the trigger" (Nordheimer, 1971).
It is with this dramatic behavioral reenactment of one young, despairing African-American soldier that the curtain opens on the first act of the story of the International Society for Traumatic Stress Studies. The ISTSS is one organizational part of a late twentieth century social movement aimed at raising consciousness about the roots of violence by enacting and reacting to that violence everywhere.
The ISTSS was born out of the clashing ideologies that became so well articulated in the 1960's and 1970's. War crimes, war protests and war babies; child abuse, incest and women's liberation; burning monks, burning draft cards, and burning crosses; murdered college kids and show trials of accused radicals; kidnappings, terrorism and bombings; a citizenry betrayed by its government and mass protests in front of the Capitol in Washington - all play a role in the backgrounds of the people who founded the organization and in the evolution of the organization itself.
If I have learned anything from my contact with victims of violence, I have learned that it is vitally important to remember - and honor - the lessons of the past. We have to know where we came from if we are to know who we are now.
But it is extremely difficult to write history as history is being made. Since this chapter can only serve as a marker along the way, I have chosen to concentrate my attention on the origins of the Society, before those roots become even more lost in the darkness that envelopes those who move offstage. There are two fundamental aspects of the growth of this group.
First, there are the individuals who provided the action - both the victims and their advocates. One remarkable aspect of our history is the extent to which the founding mothers and fathers have had personal experience with trauma, as pointed out by van der Kolk, Weisaeth, and Van der Hart (1996).
It may be that it was this close brush with the Angel of Death that has given the growing field such a continuing sense of passion, devotion and commitment. Whatever the case, there are a multitude of stories begging to be told, severely limited here by time and space. The second aspect of organizational growth is the group-as-a-whole growth that I hope will emerge in the structure of the chapter.
The origins can not be placed at the foot of one powerful individual and did not derive from a clearly thought-out, hierarchical, managerial demand. Instead, it has grown organically, from the grassroots, and has remained multidisciplinary, multinational and multi-opinioned.
War Takes Center Stage
Dr. Chaim Shatan was familiar with the symptoms of war. His father had fought in three - the Russo-Japanese War, the Balkan Wars, and the First World War before moving from Poland to Canada. His father wrote short stories about his war experiences and the son translated them from Yiddish to English.
Shatan had gone to medical school during World War II, when physicians still received training in combat-related disorders and had evaluated men suffering from the traumatic neuroses of war (Scott, 1993). A New Yorker, Shatan read the New York Times routinely and when he read the story about Dwight Johnson, he felt compelled to respond. And, as co-director of the postdoctoral psychoanalytic training clinic at New York University, he could even harbor hope that it would get published.
His op-ed piece to the New York Times was published in May, 1972 and titled, Post-Vietnam Syndrome. In his editorial, Shatan described what came to be called post-traumatic stress disorder, and told how he had noticed these symptoms in the Vietnam veterans he and his colleagues had been seeing in "group rap" sessions (Shatan, 1972; 1978a).
One of these colleagues that Shatan referred to was Robert Lifton. Lifton was an ardent antiwar activist who had served in Korea as a military psychiatrist and had already studied and written about the survivors of Hiroshima (Lifton, 1967). Lifton met Sarah Haley through the New York and Boston chapters of the group, Vietnam Veterans Against the War (V.V.A.W.).
Sarah Haley was a social worker at the Boston Veterans Administration Hospital. Unlike most of her colleagues at the time, Haley recognized that many of her patients who had served in Vietnam, were being misdiagnosed as paranoid schizophrenics or character disorders because mental health professionals were failing to recognize the symptoms related to combat. But she knew them.
She had grown up with a father who was a veteran of World War II, a special agent for the O.S.S. and an alcoholic. She had heard stories of trauma and wartime atrocities from the time she was a little girl and she had personally experienced the long-term impact of war on her father's behavior. What other colleagues found unbelievable, she found entirely realistic.
When she met a Vietnam veteran who claimed to have been involved in the massacre of a village called My Lai, she believed him. It was through Haley that Lifton met and interviewed that soldier (Scott, 1993).
In January 1970, Lifton testified to a Senate subcommittee about the brutalization of GIs in Vietnam, a brutalization that he believed "made massacres like My Lai inevitable" (Lifton, 1973, p.17). In April 1970, the U.S. invaded Cambodia and students across the country rose up in protest.
Within days, the Ohio National Guard fired into a crowd at Kent State, killing four students and wounding nine others. Chaim Shatan had previously arranged for Lifton to speak at N.Y.U. but they decided to change the topic to address the Cambodian invasion and the Kent State killings, and advertised it widely around New York City.
Many people came who were not students, including some Vietnam veterans who were members of the V.V.A.W. (Scott, 1993). The rap groups in New York evolved from this meeting and from correspondence and phone calls between Jan Crumb, then president of the Vietnam Veterans Against the War, and Lifton, beginning in November, 1970 (Lifton, 1973).
When the clinicians sat down with Jan Crumb and several others from V.V.A.W., the vets described the way the members "rapped" with each other about the war, American society and their own lives and how they felt they would like some people around with greater psychological knowledge.
Lifton suggested they form more regular rap groups with some professional involvement. With the support of the chairman of the psychoanalytic training program at N.Y.U., Shatan circulated over three hundred memos asking for professional volunteers to join in their efforts. He urged them to help, telling them that "this is an opportunity to apply our professional expertise and anti-war sentiments to help some of those Americans who have suffered most from the war (Shatan, 1971).
He outlined for them three theoretical questions that he believed needed to be answered. What are the differences between Vietnam veterans and World War II veterans? Can we clarify the psychodynamics of war atrocities and demonstrate how they grow organically out of modern combat training? What is happening in the group process experience between veterans and professionals?
The enticements worked. Within five days, his memo had drawn forty volunteers. A panel of professional psychological and psychiatric colleagues in the New York area was formed. Most came from the New York University Postdoctoral Psychoanalytic Program, others from prestigious programs like the W. A. White Institute for Psychoanalysis and the New York Psychoanalytic Institute.
These clinicians participated in the groups until at least 1976 (Shatan, 1987). They called themselves "professionals" rather than "therapists" because they "had a sense of groping toward, or perhaps being caught up in, a new group form. Though far from clear about exactly what that form would be, we found ourselves responding to the general atmosphere by stressing informality and avoiding a medical model" (Lifton, 1973, p.77).
Word got out to the Vietnam vets through word of mouth, churches, and some media coverage and they started to come. Jack Smith and Arthur Egendorf, both veterans, were early members of the rap groups in New York.
In 1971, Shatan and Peter Bourne testified at the court martial of a Marine POW who was being charged with desertion, though he clearly suffered from traumatic stress. The papers written by Bourne and published in 1969 and 1971 about war neurosis were ignored.
The refusal to see the damage that had been done to these men motivated Shatan even further. The response to Shatan's op-ed article was overwhelming. He heard from over 1,250 rap groups from around the country as well as student health and financial aid offices on many campuses, and even veterans in prison.
Groups had already been meeting informally with psychiatrists in Philadelphia, Atlanta, and Boston (Shatan, 1987). All were functioning outside of the established VA services either because they were past the two-year limit for service-connected disabilities or because they found the traditional service, geared to World War II veterans, hostile to them and unwilling to meet their needs (Scott, 1993).
There was at this time, tremendous hostility towards the returning Vietnam veterans, particularly those who had become disillusioned with the war. And the hostility came from the left and the right sides of the political spectrum. John Kerry (now Senator John Kerry) was a founder of the V.V.A.W. and holder of three Purple Hearts, a Bronze Star, and a Silver Star for his service in Vietnam.
He reported that a Minnesota American Legion post excluded Vietnam vets because they had lost the war. Meanwhile, there were antiwar activists and pacifists calling the veterans "baby-killers" (Shatan, 1987).
Even the military victimized the vets as they were leaving the war through the practice of giving "bad discharge numbers". According to a discreet coding system, numbers were entered on discharge papers that identified veterans who had been seen as "troublemakers" while in the service, and then these codes were distributed to employers and personnel officers.
In the media, especially television, the stigmatization was furthered by the portrayal of Vietnam veterans as dangerous and psychotic freaks, murderers and rapists (Leventman, 1978). In 1978, Leventman, citing an earlier article of his own said, "nothing reflects so much of what is wrong with American society as its treatment of Vietnam veterans . . . one can only reiterate that the negative legacy of Vietnam lies more in civilian society than in the psyches of veterans" (p. 295).
In response to this discrimination, the veterans and their supporters organized a counter-VA consisting of therapeutic communes, storefront clinics, vet centers, and bars. They organized social and political protests. They conducted street theater with mock pacification operations in New Jersey villages.
In January of 1971, they organized war crime hearings called the "Winter Soldier Investigation" in Detroit, sponsored by Jane Fonda, among others. One hundred and fifteen veterans, as well as Robert Lifton, presented testimony about atrocities committed in Vietnam, while Fonda, and antiwar activist, Mark Lane, filmed the testimony and arranged for distribution.
Except for Life magazine, however, the event got very little national media coverage. In April 1971, the V.V.A.W. organized a march on Washington. The military had called the invasion of Cambodia and Laos, "Operation Dewey Canyon II, and the V.V.A.W. named their action "Operation Dewey Canyon III", designating it as a "limited incursion into the country of Congress". Their weeklong occupation of Washington culminated in a ceremony on the Capitol steps, a "medal turn-in" ceremony.
Jack Smith recalls, "I can still hear the dings of those medals, the Bronze Stars and the Silver Stars bouncing off the statue of John Marshall, and the Purple Hearts, behind the barricades" (Scott, 1993, p.23). They published an anthology of war poems and used the money to help a Quaker rehabilitation center in South Vietnam and to help rebuild Hanoi's foremost hospital, destroyed in the carpet-bombing.
They founded free clinics in poverty areas and staffed them with former nurses and medics. They offered legal aid and regular visits to vets in prison. And mental health professionals, moving beyond therapy and detachment to advocacy participated, "we went, with the vets, wherever we could be heard: to conventions, war crimes hearings, churches, Congress, the media, and abroad. We, too, suffered insomnia and had combat nightmares (Shatan, 1987, p.8).
Meanwhile, out on the West Coast, Dr. Philip May, a schizophrenia expert, was director of psychological services for the Brentwood Veterans Administration Hospital. in 1971. He recognized that Vietnam veterans were not getting the services they needed, so he hired Shad Meshad, a social worker and Vietnam vet himself, to evaluate the situation.
Meshad had already started one of the first rap groups in the country, in the Los Angeles area and was highly critical of the VA services. He had been a medic in Vietnam, was seriously wounded, and had endured several painful operations in the States. He knew what veterans were contending with from a first hand perspective (Meshad, 1997; Scott, 1993).
So did William Mahedy, who had served as a chaplain in Vietnam and was working as a social worker at Brentwood, "Most Brentwood psychiatrists that I met during this period had not the slightest clue how to deal with Vietnam veterans . . . they didn't know how to treat combat-related stress. Nor could they provide any guidance to the kind of total reintegration into society that we knew was necessary" (Mahedy, 1986, p.56).
In response, Meshad created the highly unconventional Vietnam Veteran Resocialization Unit within the Brentwood VA hospital, with the support of the director at Brentwood and set up storefront clinics where rap groups were held.
By 1973, Robert Lifton's book Home from the War was published, the first widely read book about the plight of the Vietnam veterans. He and Shatan had made strong and supportive connections with the American Orthopsychiatric Association and several universities. Both were impressed by the growing grassroots movement and believed that it could be strengthened even further.
In 1970, the National Council of Churches (NCC) had established an office under Reverend Richard Kilmer, an ordained Presbyterian minister, in order to help those hurt by the war in Vietnam. At first the NCC focused efforts on draft resisters and antiwar protestors, but in 1973, at the urging of Shatan and Lifton, the NCC began laying plans for the First National Conference on the Emotional Needs of Vietnam-Era Veterans.
According to Jack Smith, the veterans had pointed out to Reverend Kilmer that they had an obligation to minister to people who were in the war as well as out of it and the churches began to listen. The Missouri Synod of the Lutheran Church put up $80,000 for expenses and agreed to host the meeting at its seminary in St. Louis, appropriately situated right in the middle of the country.
Arthur Egendorf developed a list of veterans, psychiatrists and others who were actively involved in helping Vietnam veterans around the country. According to Shatan, about one hundred and thirty people attended the conference, "60 vets, 30 shrinks, 30 chaplains, and 10 central office people [VA] who came on at the last minute (Scott, 1993, p.45). At the conference, Lifton and Shatan spent time with reporters talking about the problems of Vietnam veterans.
The conference lasted for three days, April 26-28, 1973, and out of the conference the National Vietnam Veterans Resource project (N.V.R.P.) was created with a governing council of 16 people co-directed by Chaim Shatan and Jack Smith, with representatives from all three groups - veterans, chaplains, and mental health professionals. The project was to have several functions: to search and gather data on the effects of combat stress and to help coordinate a self-help movement of veterans groups (Shatan, 1987; 1997a).
There were direct consequences for this kind of advocacy. Beginning in 1970, Shatan came under government surveillance. Returning from a meeting at the Pentagon in June of 1973, he found his phone had been tapped. After a visit to Washington to offer assistance to American POW's returning from Hanoi, he discovered that someone had tampered with his mail.
In July of 1973, Shatan had been contacted by William Kunstler's Center for Constitutional Rights for help in preparing a "post-Vietnam syndrome" defense for the " Gainesville", eight veterans who had been charged with planning to blow up the 1972 Democratic and Republican conventions. After this, the interference with his mail was stepped up so that if mail came from veterans' organizations, people who worked with Vietnam vets, or Robert Lifton, it was bound to be searched (Scott, 1993).
The FBI tried to infiltrate the rap groups by sending in informers posing as veterans seeking help (Lifton, 1978). Through the Freedom of Information act, Shatan found that plans were even afoot to entrap him with blueprints of government munitions plants (Shatan, 1987). His response was to talk longer, louder, and more frequently in order to bring attention to the readjustment problems of the veterans and to make their cause more publicly visible and therefore less vulnerable to government sabotage.
The VA Central Office attacked Lifton and Shatan in the press when they made a guess that 20% of men who had served in Vietnam were paying a heavy psychological price, when the VA claimed that only 5% of the men had combat-related psychological symptoms. Both were labeled as being "hung up on the war" and accused of "dishonoring brave men" (Shatan, 1985).
Both Shatan and Lifton knew that it was impossible to separate the professional work they were doing with these men from their political activism. As Lifton recalls, "I believe that we always function within this dialectic between ethical involvement and intellectual rigor, and that bringing our advocacy "out front" and articulating it makes us more, rather than less scientific . . . From the beginning the therapeutic and political aspects of our work developed simultaneously" (Lifton, 1978, pp. 211 & 212).
It was difficult for Vietnam veterans to get the services they needed from the VA for several reasons, besides the existing, sometimes virulent, prejudice against the men who had fought in Vietnam and were suffering from the delayed effects of combat stress. First, there was no diagnostic code for combat stress in DSM-II. This latest edition of the Diagnostic and Statistic Manual for Mental Disorders, published by the American Psychiatric Association, had been published in 1968.
As Art Blank, points out, "As the return of troops from Viet Nam was reaching a crescendo, the psychiatric profession's official diagnostic guide backed away from stress disorder even further, and the condition vanished into the interstices of "adjustment reaction of adult life" (Blank, 1985, p.73).
But even under DSM-I there had been no classification for delayed stress reactions. So, if the symptoms presented more than a year after discharge from active duty, the VA did not consider them to be service-related problems. If veterans presented with post-traumatic psychiatric symptoms, they were misdiagnosed as suffering from depression, paranoid schizophrenia, character disorders, or behavior disorders (Blank, 1985; Wilson, 1988).
Senator Alan Cranston, a World War II veteran and a member of the Senate's Committee on Veterans Affairs, became convinced that the psychological needs of Vietnam veterans were different from those of older veterans. Starting in 1971 he tried to bring about changes in the VA system by seeking better funding for the Vietnam veterans to obtain drug and alcohol rehabilitation as well as the initiation of readjustment counseling services.
The bill he proposed passed the Senate in 1973 and 1975, but the House refused to pass it. The House was dominated by World War II veterans, who had an unwillingness to concede that the Vietnam War had produced different problems than had been previously recognized. In addition, the American Legion as well as the Veterans of Foreign Wars lobbied against the bill. Taking a more long-term approach, Cranston appointed Max Cleland as a member of his staff to review the VA hospitals.
Max Cleland was a Vietnam veteran who had lost an arm and both legs in the war and had testified for Cranston at the Senate Committee on Veterans Affairs in 1971. In his new position, Cleland visited Shad Meshad's storefront operations at Brentwood. Both Cleland and Meshad testified in 1975 before Senator Cranston's Subcommittee on Health and Hospitals, providing clear evidence that the VA hospitals were not meeting the needs of Vietnam veterans (Scott, 1993).
Besides the problems with the psychiatric diagnostic schemas, there was no organized Vietnam veterans' pressure group advocating for a change in benefits (Scott, 1993). The work of the National Vietnam Veterans Resource Project (N.V.R.P.), created during the First National Conference on the Emotional Needs of Vietnam-Era Veterans, began immediately after the conference. By 1974, the N.V.R.P. had catalogued 2,700 diverse veterans' self-help programs, 2,000 of them on college campuses, some out in the community and others in prisons (Lifton, 1973; Shatan, 1974).
Jack Smith sought funding for an empirical study and called it the Vietnam Generation Study, since the intention was to study both veterans and draft resisters. He and a colleague obtained funding from the National Council of Churches, the Russell Sage Foundation, and the Edward F. Hazen Foundation to begin a pilot study (Scott, 1993). In 1975, the Senate Committee for Veterans Affairs initiated a bill, approved by Congress, mandating the VA to conduct a study to assess the needs of Vietnam veterans. As a result, the VA provided funds to Arthur Egendorf and the NVRP to complete the Vietnam Generation Study, which eventually culminated in Legacies of Vietnam (Egendorf et al., 1979; 1981; Laufer, 1985).
The Mysterious Disappearance of Combat Stress
The first version of the Diagnostic and Statistical Manual formulated by the American Psychiatric Association was published in 1952, while American psychiatrists were actively treating veterans of World War II and Korea. "Gross stress reaction" was used to describe the aftereffects of previously normal persons who began having symptoms related to intolerable stress.
DSM-II was published in 1968, at the height of the TET offensive in Vietnam and "gross stress reaction" was replaced with "(transient) adjustment disorder of adult life". The only mention of combat -- as "fear associated with military combat and manifested by trembling, running, and hiding" -- was put in the same category as an "unwanted pregnancy" (Shatan, 1985).
As Chaim Shatan wrote many years later, The disappearance of stress reactions from DSM-II remains a mystery. Its causes have not been established. I have not been able to find a soul who will say they know how or why it happened . . . [but] we can say that the diagnostic lacuna in DSM-II had great political value during the Vietnam war . . . every diagnosis is a potential political act (1985, p.2-3).
For Figley, the absence in DSM-II of a diagnostic category specific to combat trauma can be attributed to the lack of American involvement in a war during that period, as WWII and Korean veterans became integrated into the community (Figley, 1978a). But Blank also believed that the elimination of "gross stress reaction" had been politically motivated, if not consciously, then unconsciously.
On looking back he concurs with Shatan, "These dramatic shifts from DSM-I to DSM-III suggest the hypothesis that - as part of a highly complex social and intellectual phenomenon - irrational influences have deeply affected the recognition and appreciation of accurate guidance by organized psychiatry" (Blank, 1985, p. 74).
Wilson has puzzled over this mystery as well, pointing out that after the death of Freud the collective knowledge about psychological trauma seemed to go underground and by the time of DMS-II had all but evaporated. "What makes this so peculiar is that by 1968, the cumulative historical events involving war, civil violence, nuclear warfare, etc., produced more trauma, killing, mass destruction, and death in a limited time frame than at any prior time in recorded history" (Wilson, 1995, p.15).
Blank even now predicts that, for similar reasons, there will be a move to exclude PTSD as a diagnostic category when the DSM-V is formulated in the future (Blank, 1997a).
Whatever the reasons - and there probably were many - as early as 1969, John Talbott recommended that the future editors of DSM-III re-introduce the gross stress reaction listing. Talbott, later to become President of the American Psychiatric Association, had served in Vietnam as a psychiatrist. He conducted some of the initial interviews for the Vietnam Generation Study and was stunned by how much of this "post-Vietnam syndrome" he had been failing to diagnose in part because there was no way to make the diagnosis under DSM-II (Scott, 1990; 1993).