Shrinks (34 page)

Russian soldier (left) and American soldier (right) exhibiting the “1,000-yard stare” characteristic of battle fatigue or combat exhaustion in World War II. (Right: U.S. Military, February 1944, National Archives 26-G-3394)

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.”