Military neuropsychiatrists also learned that soldiers endure the stress of battle more for the comrades fighting next to them than for country or liberty, so if a traumatized soldier was sent home to recover—standard practice in the early years of World War II—this would cause him to feel guilt and shame for abandoning his comrades, which exacerbated rather than ameliorated his condition. So the army altered its practice. Instead of sending psychiatric casualties to military hospitals or returning them to the United States, it treated traumatized soldiers in field hospitals close to the front lines and then encouraged them to rejoin their units whenever possible.
Despite the small but meaningful advances in understanding the nature of psychological trauma, when World War II ended, psychiatry quickly lost interest. Combat exhaustion was not retained as a diagnosis but instead incorporated into a broad and vague category called “gross stress reaction” as part of DSM-I and then was omitted altogether from the DSM-II. Psychiatry’s attention did not return to the psychological effects of trauma until the national nightmare that was Vietnam.
The Rap Group
Vietnam was the last American war to enlist soldiers through the draft. Unlike the world wars, the conflict in Southeast Asia was very unpopular. When the war escalated in the late 1960s, the government conducted a draft lottery to determine the order in which men would be sent to fight—and very possibly die—on the far side of the world. I was deferred from the draft due to my admission to medical school, but one of my classmates in college, a golden boy at our school—handsome, smart, athletic, class president—was drafted into the army as a lieutenant. Some years later I learned that he was killed in combat a few months after he landed in Vietnam.
The Vietnam War represented another major turning point in the American military’s relationship with psychiatry. Yet again, a new war somehow found ways of becoming even more horrific than its horrific predecessors—sheets of napalm fire rained down from the sky and sloughed the skin off children, familiar objects like pushcarts and boxes of candy became improvised explosive devices, captured American soldiers were tortured for years on end. The Vietnam War produced more cases of combat trauma than World War II. Why? Two opinions are commonly expressed.
One view is that the Greatest Generation was stronger and more stoic than the Baby Boomers who fought in Vietnam. They came of age during the Great Depression, when boys were taught to “keep a stiff upper lip” and “suck it up,” silently bearing their emotional pain. But there’s another perspective I find more plausible. According to this explanation, veterans of World War II did sustain psychic consequences similar to those experienced by veterans of Vietnam, but society was simply not prepared to recognize the symptoms. In other words, the psychic damage to World War II veterans was hiding in plain sight and simply not recognized.
World War II was justifiably celebrated as a national triumph. Returning soldiers were celebrated as great victors, and Americans turned a blind eye to their psychic suffering, since emotional disability did not fit the prevailing notion of a valiant hero. Nobody was inclined to point out the changes and problems that veterans experienced upon returning home, for fear of being labeled unpatriotic. Even so, you can plainly see the signs of combat trauma in the popular culture of that era.
The Academy Award–winning 1946 film The Best Years of Our Lives portrayed the social readjustment challenges experienced by three servicemen returning from World War II. Each exhibits limited symptoms of PTSD. Fred is fired from his job after he loses his temper and hits a customer. Al has trouble relating to his wife and children; on his first night back from the war he wants to go to a bar to drink instead of staying home. A little-known documentary film produced by John Huston, the acclaimed director of The African Queen, and narrated by his father, Walter Huston, also depicted the psychological casualties of WWII. Let There Be Light follows seventy-five traumatized soldiers after they return home. “Twenty percent of our army casualties suffered psychoneurotic symptoms,” the narrator intones, “a sense of impending disaster, hopelessness, fear, and isolation.” The film was released in 1946 but was abruptly banned from distribution by the army on the purported grounds that it invaded the privacy of the soldiers involved. In reality, the army was worried about the film’s potentially demoralizing effects on recruitment.
Another reason proposed for the increased incidence of combat trauma in Vietnam was the ambiguous motivation behind the war. In World War II, America was preemptively attacked at Pearl Harbor and menaced by a genocidal maniac bent on world domination. Good and evil were sharply differentiated, and American soldiers went into combat to fight a well-defined enemy with clarity of purpose.
The Vietcong, in contrast, never threatened our country or people. They were ideological adversaries, merely advocating a system of government for their tiny, impoverished nation that was different from our own. Our government’s stated reason for fighting them was murky and shifting. While the South Vietnamese were our allies, they looked and talked remarkably like the northern Vietnamese we were supposed to be killing. American soldiers were fighting for an abstract political principle in a distant, steamy jungle filled with lethal traps and labyrinthine tunnels, against an enemy who was often indistinguishable from our allies. Ambiguity in a soldier’s motivation for killing an adversary seems to intensify feelings of guilt; it was easier to make peace with killing a genocidal Nazi storm trooper invading France than a Vietnamese farmer whose only crime was his preference for Communism.
The difference in America’s attitude toward World War II and Vietnam is reflected by the contrast between the monuments to the two wars in Washington, DC. The World War II monument is reminiscent of Roman civil architecture, with a fountain and noble pillars and bas-relief depictions of soldiers taking oaths, engaging in heroic combat, and burying the dead. There are two Vietnam memorials. The first is Maya Lin’s funereal black wall representing a wound gashed into the earth with the names of the 58,209 dead inscribed on its face, while across from it stands a more conventional statue depicting three soldiers in bronze. But instead of being portrayed in a patriotic pose like the iconic raising of the American flag at Iwo Jima, the three Vietnam soldiers gaze out lifelessly in a “thousand-yard stare,” a classic sign of combat trauma. (Ironically, the term “thousand-yard stare” originated in a 1944 painting of a U.S. Marine serving in the Pacific titled The Two-Thousand Yard Stare.) Instead of celebrating heroism and nationalism, the Vietnam War statue memorializes the terrible psychic toll on its combatants while the Wall symbolizes the psychic toll on the country.
“The Three Soldiers” Vietnam Monument by Frederick Hart in Washington, DC. (Carol M. Highsmith’s “America,” Library of Congress Prints and Photographs Division)
Despite the apparent progress in the treatment of “combat exhaustion” during World War II, at the height of the Vietnam War psychological trauma was still as poorly understood as schizophrenia was during the era of “schizophrenogenic mothers.” While psychoanalytically oriented treatments did seem to improve the condition of many traumatized soldiers, other soldiers seemed to get worse over time. It is astonishing, in retrospect, to consider how little was done to advance medical knowledge about psychological trauma between World War I and Vietnam, when such enormous strides were made in military medicine. In World War I, over 80 percent of combat casualties died. In the recent wars in Iraq and Afghanistan, over 80 percent of combat casualties survive as a result of the spectacular improvements in trauma surgery and medicine. PTSD, due to greater recognition but lack of scientific progress, has become the signature wound of twenty-first-century soldiers.
Rap Sessions
When traumatized Vietnam veterans returned home, they were greeted by a hostile public and an almost complete absence of medical knowledge about their condition. Abandoned and scorned, these traumatized veterans found an unlikely champion for their cause.
Chaim Shatan was a Polish-born psychoanalyst who moved to New York City in 1949 and started a
private practice. Shatan was a pacifist, and in 1967 he attended an antiwar rally where he met Robert Jay Lifton, a Yale psychiatrist who shared Shatan’s antiwar sentiments. The two men also discovered they shared something else in common: an interest in the psychological effects of war.
Lifton had spent years contemplating the nature of the emotional trauma endured by Hiroshima victims (eventually publishing his insightful analysis in the book Survivors of Hiroshima). Then, in the late ’60s, he was introduced to a veteran who had been present at the My Lai Massacre, a notorious incident where American soldiers slaughtered hundreds of unarmed Vietnamese civilians. Through this veteran, Lifton became involved with a group of Vietnam veterans who regularly got together to share their experiences with one another. They called these meetings “rap sessions.”
“These men were hurting and isolated,” Lifton recounts. “They didn’t have anybody else to talk to. The Veterans Administration was providing very little support, and civilians, including friends and family, couldn’t really understand. The only people who could relate to their experiences were other vets.”
Around 1970, Lifton invited his new friend Shatan to attend a rap session in New York. By the end of the meeting, Shatan was pale. These veterans had witnessed or participated in unimaginable atrocities—some had been ordered to shoot women and children and even babies—and they described these gruesome events in graphic detail. Shatan immediately realized that these rap sessions held the potential to illuminate the psychological effects of combat trauma.
“It was an opportunity to develop a new therapeutic paradigm,” Lifton explains. “We didn’t see the vets as a clinical population with a clinical diagnosis, at least not at the time. It was a very collegial and collaborative environment. The vets knew about the war, and the shrinks knew a little about what made people tick.”
Shatan gradually appreciated that the veterans were experiencing a consistent set of psychological symptoms from their wartime experiences, and that their condition did not conform to the explanations provided by psychoanalytical theory. Shatan was trained in the Freudian doctrine, which held that combat neurosis “unmasked” negative experiences from childhood, but he recognized that these veterans were reacting to their recent wartime experiences themselves rather than anything buried in their past.
“We came to realize just how amazingly neglected the study of trauma was in psychiatry,” Lifton remembers. “There was no meaningful understanding of trauma. I mean, this was a time when German biological psychiatrists were contesting their country’s restitution payments to Holocaust survivors, because they claimed that there had to be a ‘preexisting tendency towards illness’ which was responsible for any pathogenic effects.”
Working in these unstructured, egalitarian, and decidedly antiwar rap sessions, Shatan meticulously assembled a clinical picture of wartime trauma, a picture quite different from the prevailing view. On May 6, 1972, he published an article in the New York Times in which he publicly described his findings for the first time, and added his own appellation to the conditions previously described as soldier’s heart, shell shock, battle fatigue, and combat neurosis: “Post-Vietnam Syndrome.”
In the article, Shatan wrote that Post-Vietnam Syndrome manifested itself fully after a veteran returned from Asia. The soldier would experience “growing apathy, cynicism, alienation, depression, mistrust and expectation of betrayal, as well as an inability to concentrate, insomnia, nightmares, restlessness, rootlessness, and impatience with almost any job or course of study.” Shatan identified a heavy moral component to veterans’ suffering, including guilt, revulsion, and self-punishment. Shatan emphasized that the most poignant feature of Post-Vietnam Syndrome was a veteran’s agonizing doubt about his ability to love others and to be loved.
Shatan’s new clinical syndrome immediately became fodder for the polarized politics over the Vietnam War. Supporters of the war denied that combat had any psychiatric effects on soldiers at all, while opponents of the war embraced Post-Vietnam Syndrome and insisted it would cripple the military and overwhelm hospitals, leading to a national medical crisis. Hawkish psychiatrists retorted that the DSM-II did not even recognize combat exhaustion; the Nixon administration began harassing Shatan and Lifton as antiwar activists, and the FBI monitored their mail. Dovish psychiatrists responded by wildly exaggerating the consequences of Post-Vietnam Syndrome and the potential for violence in its victims, a conviction that soon turned into a caricature of demented danger.
A 1975 Baltimore Sun headline referred to returning Vietnam veterans as “Time Bombs.” Four months later, the prominent New York Times columnist Tom Wicker told the story of a Vietnam veteran who slept with a gun under his pillow and shot his wife during a nightmare: “This is only one example of the serious but largely unnoticed problem of Post-Vietnam Syndrome.”
The image of the Vietnam vet as a “trip-wire killer” was seized upon by Hollywood. In Martin Scorsese’s 1976 film Taxi Driver, Robert De Niro is unable to distinguish between the New York present and his Vietnam past, driving him to murder. In the 1978 film Coming Home, Bruce Dern plays a traumatized vet, unable to readjust after returning to the States, who threatens to kill his wife (Jane Fonda) and his wife’s new paramour, a paraplegic vet played by Jon Voight, before finally killing himself.
While the public came to believe that many returning veterans needed psychiatric care, most veterans found little solace in shrinks, who tried to goad their patients into finding the source of their anguish within themselves. The rap sessions, on the other hand, became a powerful source of comfort and healing. Hearing the experiences of other men who were going through the same thing helped vets to make sense of their own pain and suffering. The Veterans Administration eventually recognized the therapeutic benefits of the rap sessions and reached out to Shatan and Lifton to emulate their methods on a wider scale.
Meanwhile, Shatan and Lifton puzzled over the process by which Post-Vietnam Syndrome produced such dramatic and debilitating effects in its victims. One clue lay in its similarity to the emotional trauma in other groups of victims, such as the Hiroshima survivors documented by Lifton, as well as those who were imprisoned in Nazi concentration camps. Many Holocaust survivors aged prematurely, confused the present with the past, and suffered from depression, anxiety, and nightmares. Having learned to function in a world without morality or humanity, these survivors often found it difficult to relate to ordinary people in ordinary situations.
Shatan concluded that Post-Vietnam Syndrome, as a particular form of psychological trauma, was a legitimate mental illness—and should be formally acknowledged as such. Although the Vietnam War was raging in the late 1960s as the DSM-II was being assembled, no diagnosis specific to psychological trauma, let alone combat trauma, was included. As had been the case with DSM-I, trauma-related symptoms were classified under a broad diagnostic rubric, “adjustment reaction to adult life.” Veterans who had watched children bayoneted and comrades burned alive were understandably outraged when informed that they had “a problem in adult adjustment.”
When Shatan learned that the DSM was undergoing revision and that the Task Force was not planning to include any kind of diagnosis for trauma, he knew he had to take action. In 1975, he arranged to meet with Robert Spitzer, who he already knew professionally, at the APA annual meeting in Anaheim, California, and lobbied vehemently for the inclusion of Post-Vietnam Syndrome in DSM-III. Initially, Spitzer was skeptical of Shatan’s proposed syndrome. But Shatan persevered, sending Spitzer reams of information describing the symptoms, including Lifton’s work on Hiroshima victims—the kind of diagnostic data that was always sure to get Spitzer’s attention. Spitzer eventually relented and in 1977 agreed to create a Committee on Reactive Disorders and assigned one of his Task Force members, Nancy Andreasen, the job of formally vetting Shatan’s proposal.
Andreasen was a smart and tough-minded psychiatrist who had worked in the Burn Unit of New York Hospital–Cornell Medical Center as a medical stu
dent, an experience that would shape her attitude toward Post-Vietnam Syndrome. “Bob Spitzer asked me to deal with Shatan’s Syndrome,” Andreasen explained, “but he did not know that I was already an expert on the topic of stress-induced neuropsychiatric disorders. I began my psychiatry career by studying the physical and mental consequences of one of the most horrible stresses that human beings can experience: severe burn injuries.”
Gradually, Andreasen came to agree with Shatan’s conclusions: that a consistent syndrome of symptoms could develop from any traumatic event, whether losing your home in a fire, getting mugged in a park, or being in a firefight during combat. Since she had previously classified the psychology of burn victims as “stress-induced disorders,” Andreasen christened her broadened conceptualization of Post-Vietnam Syndrome as “Post-Traumatic Stress Disorder” and proposed the following summary: “The essential feature is the development of characteristic symptoms following a psychologically traumatic event that is generally outside the range of usual human experience.”
Despite the meager scientific evidence available on the disorder beyond Shatan and Lifton’s observations from the veteran rap groups, the Task Force accepted Andreasen’s proposal with little opposition. Spitzer later acknowledged to me that if Shatan had not pressed his case for Post-Vietnam Syndrome, most likely it would never have ended up in the DSM-III.
Since then, traumatized veterans have had a much easier time getting the medical attention they need, since both the military and psychiatry finally acknowledged that they were suffering from a genuine medical condition.
But while the DSM-III bestowed legitimacy on the suffering of soldiers traumatized in war—as well as the suffering of victims of rape, assault, torture, burns, bombings, natural disasters, and financial catastrophe—when the Manual was published in 1980, psychiatrists still knew precious little about the pathological basis of PTSD and what might be going on in the brains of its victims.
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