BACK into the HEART of DARKNESS

[First published in 1989 by the Institute for Research in Metapsychology, this piece was included in a 2003 anthology on the treatment of post-traumatic stress disorder in Beyond Trauma, Victor R. Volkman, ed.]

It was endless nights, trying to stay awake, stay alive, counting the hours until dawn, the days, the months, utterly alone, trusting nobody. It was waiting in rain-soaked, mud-caked fatigues for Victor Charlie, an enemy who seldom showed his face and killed mercilessly when he did, who used his school children as lethal weapons, and brutally tortured his prisoners. It was a litany of unspeakable atrocities: the grunt watching his buddy’s legs blown off by a land mine, the nose gunner smoking black tar to numb the mental imagery of his gruesome handiwork on a village, the FNG [fucking new guy] fumbling a grenade and dismembering one of his own platoon, the short-timer fragging his field commander for ordering a suicidal assault on a worthless patch of jungle. It was the freckle-faced kid so transformed by fear and rage and frustration that the sight of hacking an old woman’s ears off, smashing a baby’s head against a tree trunk and castrating a prisoner during interrogation were all met with indifference. It was laughing at a joke called the Geneva Convention, and wondering in suppressed horror just how far you could push that envelope of sanity before shit got out of hand.

It was walking point and dodging sniper fire along the DMZ one morning, then stepping off an airplane at SFO forty-eight hours later, dumped back into America’s lap, expected to act civilized. It was literally being spat upon by other Americans who could no longer distinguish between vandals and victims. It was never knowing if your friends made it back alive and living with the slow-burning fuse of survivor’s guilt, muted by the magnitude of your experience, the onslaught of ineffable emotion, the dumbfounded expressions of those who hadn’t been there and couldn’t possibly understand what you’d seen—what you’d found it necessary to do. It was separation, and divorce, and dulling the anguish with drugs and alcohol, subsequent years of sleepless nights, embarrassing startle reactions, unrelenting Technicolor memories and uncontrollable tears.

It was a war without glory, a peace without honor, an epic with no heroes.

Vietnam: A Different Kind of War

My companion—call him Pete—lights another Marlboro and continues his measured account of watching his entire platoon wiped out by an NVA [North Vietnamese Army] ambush during the first frantic days of the Tet Offensive, in January 1968. It is a graphic description of sodden fear, bleeding men, and a single, scared boy left alone too long, pushed over the edge by taunts and sniper fire from an enemy hidden in a green hell. For thirty-six hours following the ambush, Pete lived through an inferno of napalm, artillery shelling and friends dying in pieces a few yards beyond his ability to reach them, before being medivaced out of the bush with malaria. Pete was eighteen years old at the time.

His story is visceral, so much so I can feel the knot tightening in my own gut. As he speaks, the September wind outside causes the louvered glass windows in the room to slip shut with a loud crack. Pete’s creased face contorts instantaneously; his arms snap out in automatic defense; his lean body tenses like a steel spring. When he notices my alarmed expression, Pete relaxes and laughs in embarrassment.

“There was a time,” he says, “when a noise like that would have ruined my whole fucking day.”

And he’s not the only one.

Nearly a million individuals serving in the United States Armed Forces engaged in combat or were exposed to life-threatening situations in Vietnam during the years between 1964 and 1973. [1] According to a four-year study conducted by the Research Triangle Institute for the Veterans’ Administration, an estimated 480,000 of those suffer from a phenomenon known as post-traumatic stress disorder. Formerly accorded less clinical terms like “shell shock” and “battle fatigue,” PTSD is hardly peculiar to the Vietnam War, but the circumstances of those who lived through combat in that particular cataclysm are unique in American history.

During World War II, even though the pre-induction psychiatric rejection rate was nearly four times higher than that of World War I, psychiatric casualties were 300 percent higher.[2] At one point in the early 1940s, more men were being discharged for “war neurosis” than were being drafted. [3] 23 percent of the men who suffered from battlefield psychological breakdowns never returned to combat. Owing to immediate on-site treatment provided during the Korean War, psychiatric evacuations dropped to six percent of total casualties. But in Vietnam, psychological breakdowns were at an all-time low—twelve per one thousand.[4]

Several factors contributed to this apparent improvement. The DEROS [Date of Expected Return from Over Seas] system was employed for the first time in Vietnam. A soldier’s tour of duty lasted twelve months—thirteen if he was a Marine. They served their time, tried to stay in one piece, and rotated back to the States. In the meantime, the “Fertile Triangle” along the borders of Laos, Burma and Cambodia supplied some of the finest substances in the world for numbing trauma. Soldiers caught “self-medicating” or manifesting other character disorders, by any superior who gave a damn, were given administrative discharges. And thus the whole question of psychological trauma was neatly—and deceptively—avoided. As a consequence of deros, drugs, and discharges, the “official” neuropsychiatric casualty rate in Vietnam was significantly lower than in either Korea or World War II. [5] It looked like the Pentagon finally had a handle on the embarrassing problem of battle fatigue.

Quite apart from the debilitating effects of drug and alcohol addiction, deros, like every apparent solution, created a new generation of problems. After the first few years of the war, soldiers who had trained together were rarely sent to Vietnam as a whole unit. Consequently, esprit de corps was almost nonexistent. A regular soldier would arrive in isolation as an FNG, ignorant of combat’s horrifying reality. Considered a liability by the hardened short timer—who knew the best way to stay alive was to stay aloof—the new guy learned quickly to trust no one but himself, and fuck the rest. His private war began the day he set foot in country, and ended the moment he was airlifted out.

Before his tour was up, a grunt was introduced to the grisly nuances of guerrilla warfare, where booby traps and incessant sniper fire accounted for an astonishing number of casualties, where the VC [Viet Cong] and NVA regulars were rarely even, where the enemy included women and children, where the average age of his fellow combatants was under twenty, and where the ideological justification for the war he was fighting was slippery, if not impossible to grasp. A soldier’s only consolation was the knowledge that if he survived his solitary year in hell, he’d eventually return with honor to his homeland.

Or so he thought.

But coming home usually proved a barren source of relief. In contrast to World War II—where men spent weeks, sometimes months, returning from the battlefield aboard ships, decompressing, sharing their experiences with understanding peers, and were honored as heroes with local parades and national acknowledgment when they arrived back home—the Vietnam veteran endured a solitary plane trip with strangers and a cool, if not downright hostile greeting from his fellow Americans. It is not surprising that many of these degraded warriors had difficulty readjusting to their previous environments.

And while the sheer joy of survival suppressed early symptoms of PTSD in most Vietnam veterans, for too many, an unsettling change began to manifest, anywhere from a few months to several years later, as they attempted to readjust to their former lives. It usually began with restlessness, feelings of mistrust, and cynicism evolving into depression, insomnia, a flaring temper, and a morbid obsession with memories of combat. Some experienced grave anxiety over the seemingly innocuous sight of a green tree line, an open field, a helicopter flying overhead, or the sound of popping corn.

Perhaps worst of all was the free-floating anxiety, and feelings of guilt for having survived what so many others hadn’t.

The VA: No Man Left Behind

The Veterans’ Administration’s policy was to refuse recognition as “service-related” any neuropsychiatric problems appearing more than one year after a soldier’s discharge. Consequently, treatment from the VA was difficult to obtain and disability compensation largely unavailable. [6]

It was not until the mid-1970s that the Disabled American Veterans funded the Forgotten Warrior Project, a groundbreaking study of the long-term social consequences of combat exposures conducted by John P. Wilson, PhD. As a result, the DAV opened storefront Vietnam Veteran Outreach Programs in more than seventy cities across the United States, staffed by volunteer counselors. The program’s success prompted Congress to establish the Veterans’ Administration “Vet Centers” throughout the country. [7]

But Post-Traumatic Stress Disorder was not formally recognized by the American Psychiatric Association [APA] until 1980, and its etiology is still passionately debated. Dr. Michael Cohen, an Army 1st Cavalry infantryman who served in Vietnam, became a clinical psychologist and team leader at the San Francisco Vet Center. As a member of the advisory board for the PTSD Team at the Fort Miley Veterans’ Affairs Medical Center, Dr. Cohen admitted that, even among the professionals who acknowledge the existence of PTSD, there are opposing theoretical camps. He called them “residualists” and “predispositionists.”

Cohen thought there was validity in both points of view. “The extent or duration of combat has a great deal of influence on the readjustment problems of the veteran,” he said, “but I also think that pre-military experience and development sets someone up to react to the chaos and horror of the war around him. We do know that the problem continues with time. It does not go away by itself and we have to deal with both the developmental and war issues in order to treat it.”

The APA’s official criterion for rendering a diagnosis of PTSD is that an individual has developed “characteristic symptoms following a psychologically traumatic event generally outside the range of usual human experience.”[8] While one might reasonably assume this could be applied to all combat veterans, only those who can prove service connection for delayed psychological disabilities are eligible for treatment and compensation. And that’s not so easy to do. According to a number of vets, the VA claim forms demand the veteran’s ability to succinctly describe what is wrong with him, and someone who cannot articulate his distress stands a slim chance of being compensated. One who communicates well, and understands the rules of the game, fares much better.

“I have run into psychiatrists who don't believe in PTSD,” said Gary, a decorated veteran of Korea and two tours in Vietnam. “They’re used to shell-shock victims—comatose, catatonic—and anything else is bullshit. Everybody’s reading different books.” Gary entered the VA Hospital in Helena, Montana in 1986 and subsequently the PTSD Treatment Unit in Menlo Park, California, where he spent nine months as an inpatient and another four in an outpatient self-help program. Gary claimed the VA took an adversarial stance toward vets applying for treatment. “If they can show some guy is a slow learner, a bit dyslexic, or came from a screwed-up environment before he was in the Army, then the government’s off the hook. [It] has nothing to do with what happened in Vietnam. It has to do with now. You hold the same job for eighteen years and you’re married to the same chick, you ain’t got PTSD. These guys don’t work for you, they work for the government.”

Club Fed: The VA’s Solution to PTSD

By the late 1980s, the National Center for Post-Traumatic Stress Disorder at the Menlo Park Veterans’ Administration Hospital was regarded by our capricious government as the Clinical Laboratory and Educational Center for organizations involved in the treatment of PTSD. This state-of-the-art facility and model program—nicknamed “Club Fed” by its intimates—was directed by Fred Gusman, an MSW in clinical and administrative social work with “a lot of on-the-job training.” Although a veteran of the Air Force, Gusman never served in Vietnam.

“The treatment here is to take a look at the person’s total life and understand how the trauma interacts with both pre- and post-trauma experiences,” Gusman explained. “There was ‘another person’ prior to the trauma and in order to understand who was affected by the trauma, you have to know who that other person was.” Gusman went on to point out that “nobody ever gets what they think they should get, or even knows what they should get. What we do know is that if a person does not follow up with outpatient treatment, and if they do not have a supportive environment, they fail. And that’s true wherever you go in the country, no matter what program you talk to.”

“They put you in a controlled environment and attempt to stabilize you,” Gary told me in reference to his own treatment at Club Fed. “But what they don’t do is follow through. A lot of vets go back to the same inappropriate behavior when they leave because they haven’t gotten rid of the feelings of guilt and trauma, and they’re back trying to stay alive on the street. When the program people hear that they say, ‘Well, he just didn’t learn anything here. He’s just not working his program.’”

Dr. Michael Cohen, who often referred veterans to the National Center for PTSD, reported that their reviews of Gusman’s treatment were mixed. “There are people who really feel that it’s turned their whole life around, and then there are those who feel it’s a total waste of time.”

Gestalting: Confrontational Therapy Redefined

Pete settles down, lights his next cigarette from the glowing butt of the last, and continues to tell me the story of his military career and subsequent downward spiral. It is like listening to the sound of a dam slowly breaking apart. A veteran of the I-Corp Combined Action Program in 1968, Pete was no stranger to unfavorable odds and extreme measures. Of the 5,000 Marines who served in the backcountry CAP units, fewer than half survived. The other half had to live with the memory of what they had done to stay alive. To fend off his personal demons, Pete chose the needle.

In 1987, recovering from heroin addiction at a VA Hospital in Phoenix, Pete applied to the Menlo Park program. Shortly after being admitted, he was interviewed by a nurse who assured him the answers to her probing questions would be held in strict confidence. The following morning, Pete was introduced to Gusman’s second in command, a social worker with first-hand experience in The Family, a Synanon-style “attack-therapy” drug rehab group, and his weapon of choice—a technique he called “gestalting.”

Fritz Perls’ Gestalt Therapy became popular in the United States during the 1960s. Defined as “a non-interpretative psychotherapy, which emphasizes awareness and personal responsibility,”[9] it has its underpinnings in German gestalt psychology, developed in the early 1900s by Max Wertheimer. Irma Lee Shepherd, one of Gestalts’ leading proponents, pointed out the dangers involved when inexperienced therapists use its powerfully confrontational techniques to “open up” unstable people with vulnerable personalities. Such people need time, support, and long-term commitment from their therapists, she insists. [10]

“When we started the program in ‘78,” Gusman explained, “we did a number of things that were derived from a treatment modality called “Creative Gestalt.” Basically, what we do is similar to any drug and alcohol program. When a new patient comes in, the whole community has a chance to meet this person. The actual technique of Gestalt is using a creative, animated, experiential way of getting people to do self-disclosure. It’s sort of a confrontation process. We review a person’s chart, what the people who interviewed them wrote; we have a lot of data. There are some people that you have to handle differently based on who they are.”

“We had to sit on this red park bench,” Pete tells me, “and all the way around in a big ‘U’ are the other guys who’ve already had this done to them. When you got in, to take away your identity, any facial hair had to come off. You wore green pajamas for the first three to six weeks and then you had to have your big brother sponsor you to come out of pajamas. So here you are sitting on this bench, a hundred guys all around, giving you the look. [The second in command] then starts the questioning and he’s got on his clipboard the ‘confidential’ interview you did with the nurse.”

Pete pauses and stares at the glowing ember at the end of his cigarette, at a memory that still burns in his mind. “There were men who had come in there severely fucked up, who’d molested children and gone through a treatment program, and he’d get them up there and force them to tell the entire community. I saw people faint, black out, run out the door, or somehow manage to hold it together, and as soon as they were allowed to go to their rooms, pack and run that night. Anything you’ve said to anybody, they stand up and tell in Gestalt.”

“Everybody’s ratting on everybody else,” Gary recalled. “You couldn’t really trust anybody and part of that therapy is to learn to trust people again.”

Dr. Kraig Strapko, an Army Special Forces Medic during the “Vietnamization” period of the early 1970s, ended his Creative Gestalt session with Gusman’s henchman ordering him to “sit down, you piece of shit.” Strapko reported that this particular social worker “treated everyone like he had a personal vendetta with them. I found it to have no therapeutic value.”

Dr. Paul Koller, team leader at the San Jose Vet Center, worked as a clinical psychologist with the Menlo Park Unit between 1982 and 1988. He agreed that gestalting “is probably the most confrontive [sic.] part of the program. It’s not my style of therapy and my initial reaction was negative, but after being there six years I really have come to appreciate the need for it as a test of motivation. If they can’t do it there, it’s relatively certain that they won’t be able to complete the program, and it’s better to find it out early.”

Other clinicians agreed with Koller on this point. “I think the basic strategy of the program was to get guys, when they were new, ready for therapy,” said Ron Kurtz, Head Nurse at the Menlo Park PTSD Unit for nine years. “I thought it was an effective tool. I’m sure that guys would disagree and were probably made to feel uncomfortable at times, but it served a purpose.”

Hank Stamm, First Marines Force Recon in 1965, wonders what that purpose was. A police officer with a Masters degree in Marriage, Family, and Child Counseling, Hank completed a year long internship in 1988 at the PTSD Unit in Menlo Park. His experience included process groups, depression groups, focus groups, and psychological testing. He sat in on the majority of the Gestalt groups that year but never participated, except to clarify a question for a vet under fire. “I thought the person who was usually doing [the confrontation] was going through his own shit. I found later that he made it a personal vendetta. I got embarrassed sometimes, the way he went at them.”

Dr. Cohen observed that, “the treatment in this field is so new, and has so little precedent, that you have to begin looking at radical ways of treating the problem. Gestalt seems particularly applicable to the PTSD issue and although it may seem brutal from the outside, it’s effective. We’re talking about a population so well-defended, and so heavily into denial, that indeed it does take a bucket of cold water to get their attention. People that wind up at the PTSD Unit at Menlo Park are one stop away from killing themselves. If indeed the condition is chronic, then the best we can hope for is to help the individual get his feelings under control and wait for the next episode. We’re still struggling with that issue.”

And Dr. Koller conceded that recidivism was high. “About one-third of the people accomplish very little, one-third really get what they came for, and one-third are somewhere in the middle. There are some folks who simply become dependent on the unit. Every time life gets hard, they hide out there. We try to discourage those.”

Gary admitted some vets abuse the system. “Working your claim” in order to profit by bureaucratic snafus is not uncommon. “The VA is paying you to be sick. If you’re service-connected and you go to the hospital, you get one hundred percent when you’re there—$1,461 a month—so, these guys get a lump sum of $10,000 for being in the hospital all this time, and they abuse themselves and use up all the money. And when it gets cold under the bridge, they have a ‘relapse,’ and go back and do it again. The longer you’re into this behavior pattern, the harder it is to break out of it. You have this invisible umbilical cord attaching you to the VA for the rest of your life.”

“This is a chronic illness,” Fred Gusman concluded, “and that means that somebody being re-hospitalized after two years might be acceptable.”

Imaginal Flooding: How to Make a Grown Man Cry

Fred Gusman’s concept of “understanding who you really are” was the operating principal behind “focus,” a technique considered by the vets to be the most solemn ritual of the entire program. In Vivio or Imaginal Flooding [11] is an exposure technique used in Cognative Behavioral Therapy, and other forms of treatment since the 1960s, but at Club Fed the process seems to have been shrouded in the mystery of a Masonic ritual.

“The focus groups are this hallowed thing,” Pete tells me. “They’re encouraged to eat together, talk together, stay together. The psychologists rarely ran the focus groups; they just sat and looked at you.” Members of a focus group were encouraged to try their hand at gestalting individuals in the hot seat, probing for denial and dissimulation. After relating a few of his gruesome experiences to the group, Pete had been upbraided by his “peers” and told how things really were. “I thought I was going in with combat veterans and it turned out that of my group of twelve, only three of us were. I just knew the rest could not understand.”

Pete was subsequently taken into private session and “flooded” by one of the program’s clinical psychologists. “This guy sat me down and told me that he wanted me to relax. ‘Now, Pete, what I want you to recall is that incident you mentioned [in the focus group].’”

Pete’s CAP unit had been part of Operation Zippo, in which US troops were ordered to burn villages and force-march the inhabitants to refugee camps in Da Nang. On the banks of a raging river, during a mass-evacuation, pregnant women were miscarrying, wailing, frightened to death, so a human chain of Marines was formed to expedite the crossing. Some of them, according to Pete, had been “in country too long, seen too much death, gotten too numb.” They apparently found sport in holding small children underwater beneath their boots, then watching the corpses float down river, away from sight of their CO. Women were molested in mid-stream, and no baby ever made it across, even though Pete says he helped deliver one on the riverbank.

“So the psychologist tells me, ‘Okay, Pete, you know—and I know—that you were the one drowning them.’ And I thought, oh, my God! He must know something I didn’t. He told me to feel those hands scratching at my legs.” Pete chokes and turns away so I won’t see the tears in his eyes. “Well, Christ, I was out of it, bumping into walls, crying, and he says to me, ‘Now, we have to end off here. You come back and see me on Tuesday’—it was Friday afternoon —‘and I want you to stay with that feeling. It’s important that you stay with it.’” Pete shakes his head in disbelief. “This dogshit shrink actually convinced me that I had drowned children. That, I know I didn’t do.”

“What I’m really trying to do is to help the patient, for the very first time, to get some insight into how they think,” Gusman claimed. “And we want to dispel the myth that everybody is a steely-eyed killer.”

“I learned soon enough that you can’t really get into anything because you only have an hour,” Gary told me. “You’re in the middle of stuff and the therapist would say, ‘Hey man, hold that thought, I’ll see you next Monday.’ So I just ended up saying, ‘Look, I’m really sorry, but I haven’t got years and years to spend here doing this.’”

“Staying with the feeling” and the “fifty-minute hour”—around which so many therapists construct their practice—is of scant therapeutic value for most veterans suffering from PTSD. Once revivified in a session, the horrors of war can’t wait until the following week to be addressed. These guys have been staying with the feeling for years—and that, precisely, is their problem.

Grassroots Alternatives

According to Vietnam veteran and author, Larry Heinemann, “the Veterans’ Administration—now kicked up to the Cabinet level—has never been regarded by Vietnam veterans as an advocate of their health and well-being.”[12] Luckily, there are grassroots organizations, founded by Vietnam veterans, which provide alternatives to the VA’s idea of treatment.

“The Vet Center system is based on getting out into the community and reaching the vets,” explained Dr. Michael Cohen. “Where we can’t, we subcontract with a clinician who is well-versed in the area of PTSD. For many of us, this is a mission. We’re helping each other.” But he went on to explain that outreach programs—such as Vietnam Veterans of America and Swords to Plowshares—while focusing extremely well on social services—“dabble in treatment. Essentially they hire someone who is a clinician. That person becomes the clinical coordinator and maybe starts a group, sees one or two clients for counseling, but it’s not extensive and by no means is it the primary focus of the agency.” In 1987, a grassroots movement began to grow around a technique called Traumatic Incident Reduction [TIR], developed some years earlier as means of inspecting psychic trauma. A synthesis of several classic disciplines, TIR, according to those vets who have worked with it, provided a new model for the treatment post-traumatic stress, and one unencumbered by government bureaucracy orpolitical agendas. [13]

TIR: High-Tech and High-Touch

Dave stares down at the tubular electrodes he’s holding. His eyes are narrowed, his face ruddy, like a man who is exerting an enormous amount of effort to escape from something dark and terrifying that lives in the outback of his mind.

“Have another look,” says the facilitator, a big man with a silver beard sitting across the table, operating an EDA [Electro-Dermal Activity] bio-monitoring meter wired to the electrodes in Dave’s hands.

Dave recounts his story for the third time and there is a perceptible edge to his voice, as if his boredom is curdling into frustration. “The district manager and I had this verbal agreement concerning the percentage of sales I would receive. But he decided to rearrange the commission structure before I was paid. We’re talking about nearly seven thousand dollars here. Damn it, I earned that money.” Dave breathes deeply and closes his eyes. His square jaw clenches tightly, and when he continues there is a slight trembling in his voice. “I know that I have to confront him. But every time I even think about doing it my stomach just knots up.” His face flushes with rage and humiliation. “Here I am, this bad-ass, black belt Marine, scared shitless over the thought of asking for money that’s actually owed me. I don’t understand why people always take advantage of me. Hell, I don't know why I let them.”

Dave stops and swallows hard. He looks up, angst radiating from watery blue eyes, and shrugs resignedly, signifying that he’s once again reached “the wall”—a barrier beyond which his memory cannot penetrate.

The bearded man nods in genuine empathy. The EDA meter has registered only a steady needle movement to the left, indicating an increase in Dave’s electrical resistance. “Okay,” the facilitator acknowledges. “Now, take a look and tell me if there is an earlier, similar incident?”

Dave pulls a deep breath into his lungs, closes his eyes and attempts to pierce that tenebrous cloud of the past, where unspeakable phantasms lurk and disturb the sanctity of his sleep. Suddenly, there is a sharp needle drop to the right. It rests idly on the holding pin and the facilitator has to work the calibrated dial beneath his left thumb to get it back on the meter.

“Yeah, there,” he says, “What do you see right there?”

Suddenly, Dave is a twenty-five-year-old Lance Corporal, 0351 [Infantry, Anti-tank Assault], walking through the bush near Chu Lai. It is January of 1967, and he’s on his second tour of duty, his ninety-second patrol in Vietnam. There is the smell of rain-soaked foliage and warm, redolent earth. It is dusk and the mosquitoes are beginning to swarm at the saline smell of human sweat. There are the sounds of jungle life signaling the ingress of night and, above them all, there is the sound of his own heart pumping adrenaline into his veins. It is not like a recollection, not some vague, distant memory. He is there, in the grip of a fear that has possessed him from the moment his boots touched Vietnamese soil. He has nearly eleven more months of hell to live through before they will lift his feet out of this fetid nightmare.

When the sniper fire begins, Dave drops to one knee and wields his three-point-five rocket launcher, instinctively aiming toward the outcropping of trees he believes to be the enemy position. He calls for his first gunner to stand by for loading, but the eighteen-year-old balks and runs for the nearest cover. Dave, livid with anger, rises up and in that moment is hit in the shoulder by AK-47 fire. Pain excoriates reason; rage obliterates the pain. As soon as Dave can reach the tree line he fully intends to beat the living shit out of the callow grunt that has left him with his ass in the breeze.

It’s all in slow motion now: the loping run toward the trees, the sound of “popcorn” and the rush of wind as thirty-caliber projectiles rip past his ears, the blood drenching his flack jacket, the numbing in his arm, and the overwhelming fury rising in him with the pressure of an erupting geyser. Now he spots the gunner, a solid grey silhouetted against the variegated grey of the bush, barely human in appearance, his hands shaking with spastic intensity. And in those hands is an M-16 automatic assault rifle, safety thrown, aimed directly at Dave’s chest.

Dave exhales a slow expletive, and only then realizes he’s been holding his breath a good fifteen seconds. “Shit! I just backed off, real easy. Only a flesh wound, man. No problem. I just knew if I even looked cross-eyed at this kid he would blow me away.”

The bearded man nods, signifying understanding. “I got that,” he says. Dave knows he has. “Let’s go back to the beginning and run through it again.”

Dave does so, three more times. At first it is painful, then boring, and then, on the fourth recounting, Dave chuckles to himself. It is a small escape of air accompanying a great explosion of clarity. The EDA’s needle has fallen sharply to the right and is now sweeping back and forth across the dial in a rhythmic float. According to the meter, Dave’s electrical resistance has dissipated. The facilitator nods and queries, “So, how are you doing?”

Dave looks up and his eyes sparkle with amusement. “I’m doing fine.” His face has relaxed, as if some emotional pillory has been lifted from his neck. “It’s a stupid thing, really. It just occurred to me that not all the people I have to confront in life are armed and dangerous. I guess its okay to be pissed off if you’ve got a good reason to be.”

The bearded man returns Dave’s broad smile; it’s hard to judge which of them feels a greater sense of accomplishment in this moment. “That’s great, Dave. We’ll end right here.”

Dave’s TIR session lasted one hour and twenty-two minutes. But for him, its brief duration opened a window of resolution in a world of despair.

By 1986, twenty years after his tour of duty in Vietnam, Dave had sunk into self-imposed isolation. His marriage had failed, several business deals had fallen through, his latest girlfriend had left, and he was drinking heavily. Dave called the VA Hospital in Menlo Park and was connected to a counselor from a local veterans’ outreach program. He determined that Dave was probably suffering from PTSD, and suggested he join a ninety-minute Thursday evening rap group for combat veterans.

“It was not as advertised,” Dave told me in disgust. “I think that the program was compensated by head count. Of the eleven there, only three were combat veterans. There was never any therapy given or suggested or directed. It was evaluative; they would encourage the other people in the group to give their observations, corrections, and opinions to you directly. The deeper you dug your traumatic hole, the better it was. That’s working your program. I got into drinking heavily again and finally quit going.”

Shortly thereafter, Pete met Dave at a Club Fed graduate function and told him about TIR, a therapy Pete credited with changing the direction of his life. And although untrained in the procedure, Pete ran Dave through a rudimentary session, enough to convince Dave of TIR’s potential.

Traumatic Incident Reduction was developed by Dr. Frank Gerbode, along with several colleagues, as an alternative to psychotherapy. An Honors graduate from Stanford in Philosophy, Dr. Gerbode received an MD from Yale Medical School and completed his psychiatric residency at Stanford Medical Center in the early 1970s. “I also worked at the VA on a psychiatric ward. They were completely eclectic,” he laughs. “They were honestly searching and groping and trying to find an answer, and they sorely needed to find a fast, effective, and systematic approach to PTSD. That, I feel, is what TIR has to offer.”

According to Dr. Gerbode, “The purpose of TIR is to trace back sequences of traumatic incidents to their roots and thereby to reduce or eliminate the charge [repressed, unfulfilled intention] contained therein by completing the activity cycles that were interrupted by acts of repression. Each sequence of incidents depends for its force on the root incident from which it stems...In most cases, however, it is not possible to proceed directly to the root incident of a sequence. So much charge is usually contained in later incidents that memory of the root incident is partially or totally blocked. It is therefore necessary to proceed backward from present time, addressing later incidents first and discharging them somewhat before looking for earlier ones.”[14]

Although Dr. Gerbode labels it “retrospection” rather than “regression,” TIR nevertheless has its roots in the precursor to psychoanalysis. In the late 1800s, Josef Breuer, a Viennese physician used an abreaction procedure he called the “talking cure—a recalling or re-experiencing of stressful or disturbing situations or events which appear to have precipitated a neurosis.”[15] His young colleague, Sigmund Freud, used the technique as his working model for psychoanalysis, noting that the key to a recent disturbance lay in an earlier, similar trauma, sometimes an entire chain of incidents.[16]

Far from exclusively Freudian in his approach, Dr. Gerbode incorporated the repetitive and gradient aspects of Behavior Therapy’s “desensitization” process, developed by Joseph Wolpe and Arnold Lazarus, wrapped in the “person-centered” rubric of Carl Rogers, wherein a therapist refrains from offering any interpretation of his client’s personal experiences.

In the practice of Traumatic Incident Reduction, the client is called a “viewer” and the therapist a “facilitator,” nomenclature strategically designed to obviate the “patient/therapist” model. “I do not refer to people as patients, nor to people who render help to other people as therapists,” says Gerbode. “I concur fully with Thomas Szasz, who has brilliantly shown that the concept of ‘mental illness’ is a mere metaphor, and a useless and destructive one at that.”[17]

Critical to the technique’s successful application are the concepts of a safe environment and end points. “TIR requires a great deal of attention and concentration, and so the environment in which it occurs must be very safe...Flexible session lengths are essential to the creation of a safe environment. It is vital for the facilitator to be able to end a session at an ‘end point,’ where the viewer feels good because something has been resolved. If the viewer feels confident that he will have time to resolve anything he encounters during a session, he will allow himself to get into highly charged areas.”[18]

Dr. Robert Moore, a clinical psychologist in Cognitive and Behavioral Therapy from Clearwater Florida, has used the technique, with impressive results, with his own clients. “I went to San Francisco and took an opportunity to get acquainted with it because it sounded good, and found out that it didn’t just sound good. There isn’t anything going on in the professional community among my colleagues in psychology, or psychiatry, or counseling, or psychotherapy that equals it. My experience is that if somebody is willing to persist with the procedure, it is inevitable that he gets relief. I’m quite convinced that Traumatic Incident Reduction is the state-of-the-art handling for post-traumatic stress disorder.”

Both Drs. Moore and Gerbode presented case studies on their work with TIR and conducted workshops at the annual conference of the International Society for Traumatic Stress Studies, held in New Orleans during October of 1990, impressing a number of clinical practitioners in the field with the technological simplicity and logic of their approach.

Use of an Electro-Dermal Activity meter enables a facilitator to enter areas of memory just below the level of consciousness that are occluded to the viewer, but the electronic aid is by no means mandatory to the success of a session. “Most of the people I have worked with don’t have any trouble locating key incidents. They’re sitting in them when they walk in the door,” observes Gerald French, co-author of the definitive text on TIR, [19] Dave’s facilitator, and a non-veteran. “All the literature you read on PTSD says it’s got to be a vet that works with another vet. I think what we’ve done proves it doesn’t have to be. It isn’t a problem for the facilitator as long as the viewer trusts you.”

Gary’s facilitator is a forty-five-year-old mother of three who has never been anywhere near a boot camp, let alone a battlefield. Yet Gary feels comfortable telling her things he could not even admit to other vets. “I probably feel a lot better now than even before I went into the service,” Gary admits, adding a note of cynicism. “Many vets will hesitate to use TIR because it might interfere with their disability claim.”

Bruce, a veteran of the 864th Army Engineers at Cam Rahn Bay in 1965, spent eight months at the Menlo Park PTSD Unit. Although he felt that he got something out of the program, he soon found himself back in the Palo Alto VA Hospital with a lot of unresolved issues, a broken relationship, and flashbacks. In June of 1989, Bruce began working with TIR. “I had almost two years of straight hospital time and I have done more in two weeks with TIR. It’s the first time I truly feel like I’ve got some direction back in my life.”

Dr. Gerbode believed the beauty of TIR facilitation is that it could be taught to veterans without any specialized backgrounds, enabling them to effectively co-facilitate. He developed a basic training course that teaches the rudimentary skills in about six weeks.

Lori Beth Bisbey, a former volunteer at the Vet Centers and counselor with the Federal prison system, conducted the first technically scientific study of TIR in the early 1990s. Utilizing fifty-seven crime victims, Bisbey compared the efficacy of TIR with that of a direct therapeutic exposure [DTE] and an untreated control group. Her results proved both treatment modalities to be effective, but determined that the TIR group showed significantly greater improvement in their condition.[20]

Acutely aware of the credence accorded double-blind studies by members of his profession, Dr. Gerbode was the first to express caution in his evaluation of the data. “We want to be fairly modest in our claims at this point. It seems that the one thing we can be sure of is that the specific symptoms of PTSD—the nightmares, free-floating anxiety, flashbacks, severe emotional distress—are basically handled. Usually, these people have other things that are upsetting them that don’t necessarily have anything to do with PTSD. I think those could be handled, but it would take a more extensive program.”

Lieutenant Colonel Chris Christensen was not very interested in the “scientific” imprimatur of double-blind studies. When the combat veteran and undercover sniper in Vietnam learned that his son had been murdered in Texas, Christensen loaded enough armament into the trunk of his car to take out half of San Antonio. But on his way through California, he had the good sense to call Pete—who he’d serendipitously heard interviewed on a radio program—instead of continuing south to seek revenge. After an emergency session, administered without ceremony in Pete’s driveway, Christensen underwent a full course in TIR with Gerbode and French before returning to Idaho, where 110,000 vets compose more than ten percent of the state’s population. Trained as a social worker, Christensen immediately began applying what he called “Wildcat TIR” to his comrades in PTSD.

“When I arrived at Job Services in Lewiston, Idaho, there were in excess of 150 disabled veterans on the rolls seeking employment. With the skills learned through TIR training—I’m talking the one week, forty-hour intensive course—I would estimate that I have worked with sixty of those people, anywhere from two hours to twenty hours, max—the average probably running closer to fourteen or fifteen hours. And out of those sixty people that I worked with, I had two—that’s one, two—left on the rolls, seeking employment, when I left Idaho [in 1991].”

Christensen took no credit for his extraordinary work. “They did it,” he insisted. “What a wonderful gift, to walk into a VA hospital, to be able to take one of their ‘rejects’ that they haven’t been able to help in twelve, fourteen, eighteen months, and in a period of two or three weeks, give them a tool they can use the rest of their lives, and see a marked improvement. I don't know what this stuff is, but by God, it works!”

Recalling his intervention with Chris, Pete leans into his words with evangelistic zeal, a fierce desire to drive home his point. “I can’t even describe what I went through for twenty years, but I know very much what it’s like when I see another guy sitting in it.” Pete momentarily appraises the louvered window that slammed shut in the wind as we talked several hours ago. He remembers just how far he’s come since those months at Club Fed when he could not imagine passing a single hour in peace. “Look, I’m not saying TIR is a panacea,” he concludes with characteristic understatement, “But I think fifty hours would handle the shit out of most people.”

Last Exit: The Cynical Reality

There were no winners in Vietnam, only survivors who found themselves, in the twilight of the slaughter, desperately searching for a way to make some sense out of the insanity they had witnessed. Many never found it. “66,000 Vietnam veterans—particularly combat veterans—committed suicide within the first year of returning home from service,” said Joe Fegan, Public Information Officer for Chapter 464 of the Vietnam Veterans of America. “It exceeded the total number of deaths in the war. The cause was the trauma suffered.”

The survivors—every one of them—carry forever the mental image pictures of what they have seen and done. Like all soldiers, they harden themselves to those disturbing mementos; store them in the armored lock-box of their dignity. But sooner or later, all warriors must confront that darkness within their own hearts. For them it is the ultimate, inescapable battle—and regrettably one in which they lacks many compassionate allies.

In 1990, I discussed these unsettling suicide statistics with an old friend, a Freudian psychoanalyst of international renown. Fascinated by the implications of PTSD, he eagerly read the above manuscript, based on my interviews with twenty combat veterans and therapists. His written response elegantly encapsulated the cynicism these veterans constantly face:

“Certainly, one can applaud any effort to help the guys you introduce us to; but your enthusiasm for the creativity and the idealism of the therapists—and the contrast to the distant establishment that you implicitly portray—strikes me as naïve. What comes across to me is that the psychologists, et al are glamorizing themselves and their results in order to make a living and feel effective—they’re working their counter-claims just as the vets are working their claims. It’s a tragedy—humanly and understandably corrupt. One can be sympathetic without sentimentalizing it. I’d rather see you work it into a short story that captures the painful, relatively hopeless reality. Something in the spirit of Last Exit to Brooklyn.”

Chris Christensen died in Germany of natural causes in October 1992, while arranging airlifts of humanitarian aid to the desperate inhabitants of the former Yugoslavia. And I’m glad I never showed him the psychiatrist’s letter, because the big-hearted grizzly bear of a man would probably have stalked into my friend’s neatly appointed Victorian office, slapped him in the face with a long list of the vets Chris had "naïvely" helped—pro bono—leveled his steely gray eyes at the analyst, and growled: “You tell these folks it’s hopeless, doc!”

Notes:

[1] Goodwin, Jim, The Etiology of Combat-Related Post Traumatic Stress Disorder (Cincinnati: Disabled American Veterans,1987) p.11.

[2] Figley, Charles R., Stress Disorders among Vietnam Veterans: Theory, Research and Treatment (New York: Brunner/Mazel,1978)

[3] Tiffany, W.J. & Allerton, W.S., "Army Psychiatry in the Mid-60s" (American Journal of Psychiatry, 1967, 123: 810-821)

[4] Bourne, P.G., Men, Stress and Vietnam (Boston: Little, Brown, 1970)

[5] The President’s Commission on Mental Health, 1978

[6] Ibid. See note 1.

[7] Williams, Tom, Post-Traumatic Stress Disorder: A Handbook for Clinicians (Cincinnati: Disabled American Veterans, 1987). See National Commander’s address.

[8] From the Diagnostic and Statistical Manual, Third Edition (DSM-III) of the American Psychiatric Association (APA, 1980).

[9] The Oxford Companion to the Mind, (Oxford: Oxford University Press, 1987).

[10] Shepherd, I.L. "Limitations and Caution in the Gestalt Approach," Gestalt Therapy Now, (eds.) Fagan, J. and Shepherd, I. L., (New York: 1970)

[11] Keane, T,M., & Kaloupek, D.G., (1982) “Imaginal Flooding in the Treatment of Post-Traumatic Stress Disorder.“ Journal of Consulting & Clinical Psychology, Issue 50, pps. 138-140.

[12] Heinemann, Larry, "The Road From Afghanistan," (Playboy, July 1989, p.163)

[13] Joyce Carbonell and Charles Figley of Florida State University identified four promising “power therapies” in a 1993-98 study of trauma victims. In addition to TIR, they included: Eye Movement Desensitization and Reprocessing [EMDR], developed by Francine Shapiro; Thought Field Therapy [TFT], originally the Roger Callahan Technique; and Visual-Kinesthetic Dissociation [VKD], based on the Neuro-Linguistic Programing theories of Richard Bandler and John Grinder. All have proven relatively effective.

[14] Gerbode, Frank A., M.D., "Handling the Effects of Past Traumatic Incidents" (Journal of the Institute for Research in Metapsychology, 1988, Vol.1, Issue 4, p.6).

[15] Ibid. See note 9.

[16] Freud, Sigmund, Two Short Accounts of Psychoanalysis, (tr.) James Strachey (Singapore: Penguin Books, 1984), p.37.

[17] Gerbode, Frank A., Beyond Psychology, (Palo Alto: IRM Press, 1988), p.215.

[18] Ibid. See note 17.

[19] French, Gerald D., and Harris, Chrys J., Traumatic Incident Reduction [TIR], (Boca Raton: CRC Press, 1999).

[20] Bisbey, L.B., No Longer a Victim: A treatment outcome study of crime victims with posttraumatic stress disorder. (Doctoral Dissertation, California School of Professional Psychology in San Diego, 1995).