Nosopolitics of postwar trauma: a study in rhetorical networks (1967–2015)

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iii

Nosopolitics
of
Postwar
Trauma:
A
Study
in
Rhetorical
Networks
(1967
–
2015)

By

Joel
Mahmoud
Lemuel

A
dissertation
submitted
to
the
faculty
of

The
University
of
Southern
California
Graduate
School

In
partial
fulfillment
of
the
requirements
for
the
degree

Doctor
of
Philosophy
(COMMUNICATION)

Degree
Conferral
Date

August
2016

iv

THE
UNIVERSITY
OF
SOUTHERN
CALIFORNIA

The
Undersigned
Faculty
Committee
of
the
USC
Graduate
School
Approves
the

Dissertation
of

Dr.
Joel
Lemuel

Nosopolitics
of
Postwar
Trauma:
A
Study
Rhetorical
Networks
(1967
–
2015)

______________________________________________

Dr.
Gerald
Thomas
Goodnight,
Chair

Communication

______________________________________________

Dr.
Randall
Lake

Communication

______________________________________________

Dr.
Taj
Frazier

Communication

v

ACKNOWLEDGMENTS
I want to start by thanking my family: my mother PJ Lemuel, my big sisters Cyndal
Provenzano and Jacinta Bender, and my loving wife Jermeen Sherman. This dissertation was
attainable because my family believed in me, invested in me, and loved me in a way that led me
to believe that I could do anything.
A small and cherished group of friends have supported me (and my work) while
completing my Ph.D.: Alexandrina Agloro, Janeane Anderson, Emma Bloomfield, Dayna
Chatman, Diana Lee, Marcus Shepard, Nikita Hamilton, Kari Storla, and especially Laura and
Paul Alberti-Strait. I have been so fortunate to enjoy the love, encouragement, and support of
these brilliant scholars.
My dissertation defense was everything I had hoped it would be. The people in the room
represented a wide range of support. Most were there because they have nurtured this research
and/or have loved and nurtured me at some point during the last five years, perhaps most
significantly, my committee. I want to thank Tom Gerald Goodnight, Robeson Taj Frazier, and
Randall Lake for allowing this work to be what it is. That is, for allowing it to be a journey and
not a destination. Thank you for guiding me as my project evolved in its own time and for
facilitating my growth as a scholar. Thank you for sticking with me and being patient with my
process.
I want to thank all of my Los Angeles based friends and colleagues. Many of you have
read very early (and very rough) drafts of this work—giving your time and intellectual energies
to its development. Others still have shared space and ideas over coffee, lunch, dinner, and many
many drinks. Thank you for thinking with and against me, for challenging me, and most
importantly, for keeping me company.

vi

Finally, I want to acknowledge my incredible mentors. These were generous individuals
who have made significant investments in my success and in me during my time in graduate
school. Specifically, Brian Edward McBride, Marcia Dawkins, Gordon Stables, and especially
Jungmiwha Bullock, I want to publicly thank you all for your warmth, wisdom, and your sage
advice.
And last but certainly not least, I want to especially thank my wife Jermeen, for holding
me down in a way that no one else ever could. I do not have the words to accurately express
what your support means to me. Thank you for loving and nurturing my body and my spirit.
Thank you for seeing me and for being radically open to the changes I have undergone (for better
or worse) over the last six years. None of this – none of it – would have been possible without
you.
I see this dissertation, the one you are about to read, as a collective achievement, and I
appreciate all of these brilliant individuals’ contributions.

iii

Copyright
©
2016

by

Joel
Mahmoud
Lemuel

iv

ABSTRACT

This
dissertation
investigates
the
nosopolitics
of
war-‐associated
trauma:
the

contestations
over
the
problematizing
of
individual
and
collective
health
generally,
and
the

production
of
discursive
trajectories
as
they
articulate
a
more
or
less
recognizable
condition

over
time.
In
this
project,
the
trajectories
of
nosopolitics
are
developed
through
selection
of
key

moments
of
contestation
where
private
and
government
agencies,
individuals
and
collaborative

advocates
work
through
alternative
arrangements
to
assess,
analyze,
measure,
and
remediate

injuries
to
soldiers.
This
is
a
study
in
rhetorical
networks:
modes
of
communication
whereby

words,
deeds,
and
things
mesh
together,
converge
towards
a
common
trajectory,
only
to
spiral

toward
difference
and
dissensus.
The
dissertation
traces
PTSD
rhetorical
networks
historically,

from
the
bottom
up,
where
discursive
trajectories
produce,
diversify,
sustain
and
revise

contestations
over
culturally
resonant,
technically
correct,
and
politically
efficacious
responses

to
trauma.

Keywords:
rhetoric,
networks,
trauma;
PTSD;
veterans;
biopolitics

v

TABLE
OF
CONTENTS

PAGE

ABSTRACT
.............................................................................................................................................................
IV

CHAPTER
ONE
–
INTRODUCTION
...................................................................................................................
1

THE
NOSOPOLITICS
OF
POSTWAR
TRAUMA:
A
MODERN
HISTORY
OF
WAR,
STRESS,

AND
HOMECOMING
...............................................................................................................................
4

RESEARCH
METHOD
...........................................................................................................................
12

A
STUDY
IN
RHETORICAL
NETWORKS
................................................................................................................
14

Public
culture:
Narratives
and
affective
knowledge
...........................................................................
18

Medico-‐scientific
discourse:
Defining
the
boundaries
of
legitimate
science
and
medicine21

Political
policy
debate:
Deliberating
over
questions
of
justice
and
efficiency
.........................
23

RESEARCH
QUESTIONS
..........................................................................................................................................
25

ORGANIZATIONAL
PLAN
...................................................................................................................
27

Chapter
two:
PTSD
(1967-‐1980)
initiation
of
a
shallow
network
consensus
..........................
27

Chapter
three:
PTSD
(1980-‐1999)
stabilization
–
positive
spiral
rending
agreement
into

institutions
and
the
everyday
.......................................................................................................................
30

Chapter
four:
PTSD
(1999-‐2015)
21
st

century
reversal
–
negative
spiral,
unbundling,

doubts,
and
skepticism
.....................................................................................................................................
34

Chapter
five:
Conclusion
..................................................................................................................................
37

STRENGTHS
AND
LIMITATIONS
.....................................................................................................
38

CHAPTER
TWO
–
PTSD
(1967-‐1980)
INITIATION
OF
A
NETWORK
CONSENSUS
..........................
39

vi

PUBLIC
CULTURE:
PROBLEMATIC
CITIZENS
OR
INVISIBLE
HEROES?
(1967-‐1976)
.....
40

POLITICAL
POLICY
DEBATES:
CONGRESSIONAL
OVERSIGHT
OF
MEDICAL
CARE
OF

VETERANS
WOUNDED
IN
VIETNAM
(1969-‐1970)
....................................................................
44

Two
trajectories:
A
struggle
between
justice
and
efficiency
...........................................................
45

The
scale
of
the
problem
.................................................................................................................................
47

The
source
of
the
problem
..............................................................................................................................
53

The
solution
to
the
problem
and
the
role
of
the
state
........................................................................
57

PUBLIC
CULTURE:
TWO
TRAJECTORIES
–
RADICAL
REJECTION
VS.
INCREMENTAL

REFORM
(1970-‐1979)
........................................................................................................................
63

THE
RADICAL
TRAJECTORY:
THE
COUNTER-‐VA
AND
VETERANS’
RAP
GROUPS
.......................................
64

THE
REFORM
TRAJECTORY:
THERAPEUTIC
COMMUNES,
STOREFRONT
CLINICS,
AND
THE
BRENTWOOD

MODEL
......................................................................................................................................................................
66

MEDICO-‐SCIENTIFIC
DISCOURSE:
AN
EXPERT
DEBATE
OVER
PSYCHIATRIC

NOMENCLATURE
(1975-‐1979)
.......................................................................................................
69

TWO
RIVAL
NETWORKS:
POST-‐VIETNAM
SYNDROME
VS.
DISORDER
OTHERWISE
UNSPECIFIED
.........
70

THE
TOPOI
OF
NOSOLOGICAL
CONTROVERSY:
SHOULD
NOMENCLATURE
BE
BASED
ON

PHENOMENOLOGY
OR
ETIOLOGY?
.......................................................................................................................
72

TWO
TRAJECTORIES:
POST-‐VIETNAM
SYNDROME
OR
DISORDER
OTHERWISE
UNCLASSIFIED?
............
75

Building
a
reasonable
case
............................................................................................................................
80

Closing
argument:
The
invention
of
PTSD
..............................................................................................
88

CONCLUSION:
THE
INITIATION
OF
A
SHALLOW
NETWORK
CONSENSUS
(1978-‐1980)

...................................................................................................................................................................
92

CHAPTER
THREE
–
PTSD
(1975-‐1999)
MATURATION:
POSITIVE
SPIRAL
RENDING

AGREEMENT
INTO
INSTITUTIONS
AND
THE
EVERYDAY
.....................................................................
96

vii

AUTOPOIESIS:
SELF-‐AUTHENTICATION
OF
SCIENTIFIC
REASONING
AND
PRACTICE
..
97

MEDICO-‐SCIENTIFIC
DISCOURSE
IN
TECHNICAL
FORUMS
(1984-‐1994)
.......................
101

PTSD
IN
DSM-‐IV:
TWO
NOSOLOGICAL
CONTROVERSIES
...........................................................................
101

Redefining
the
scope
of
trauma:
Two
trajectories
...........................................................................
105

The
positive
trajectory:
The
rationale
in
favor
of
the
stressor
criterion
................................
106

The
negative
trajectory:
The
rationale
against
the
stressor
criterion
....................................
113

The
classification
of
PTSD:
Two
trajectories
......................................................................................
119

The
negative
trajectory:
the
rationale
against
reclassification
.................................................
120

The
positive
trajectory:
the
rationale
for
reclassification
............................................................
125

THE
CONTINGENCY
OF
RHETORICAL
NETWORKS
.........................................................................................
130

MEDICO-‐SCIENTIFIC
DISCOURSE
IN
THE
PUBLIC
SPHERE
(1974-‐1995)
.......................
135

ISTSS
(1974-‐
1993)
........................................................................................................................................
136

ISTSS
precursors
(1974-‐1980)
..................................................................................................................
138

Early
history
of
ISTSS
(1980
–
1988)
.....................................................................................................
141

POLITICAL
POLICY
DEBATES:
FEDERAL
HEARINGS
AND
DEBATES
(1983
–
1995)
.............................
144

The
Prevalence
of
PTSD
in
Vietnam
Veterans:
An
Epidemiological
Controversy
....................
144

The
VES
and
NVVRS:
Two
trajectories
..................................................................................................
145

VES
methodology:
The
DIS
............................................................................................................................
146

NVVRS
methodology:
The
composite
PTSD
variable
..........................................................................
150

The
absence
of
methodological
debate
.................................................................................................
153

POLITICAL
POLICY
DEBATES:
THE
IMPETUS
FOR
THE
NATIONAL
CENTER
FOR
PTSD
(1984
–
1995)
............
158

Rhetorical
Trajectories
of
the
SCPTSD
:
Towards
a
national
center
of
excellence
............
159

POLITICAL
POLICY
DEBATES:
BLACK
VETERANS
GROUPS,
RACISM,
AND
PTSD
(1989-‐1993)
.........
164

Two
trajectories:
Racial
justice
and
color-‐blind
efficiency
...........................................................
166

viii

Racial
differences
in
diagnosis,
assessment,
and
Intervention
....................................................
167

PTSD
as
a
public
health
problem
.............................................................................................................
175

CONCLUSION:
NETWORK
CONSENSUS
ACHIEVES
POSITIVE
SPIRAL
...............................
179

CHAPTER
FOUR
–
PTSD
(1999-‐2015)
21ST
CENTURY:
NEGATIVE
SPIRAL,
UNBUNDLING,

DOUBTS,
AND
SKEPTICISM
..........................................................................................................................
181

MEDICO-‐SCIENTIFIC
DISCOURSE
AND
PUBLIC
CULTURE
(1999-‐2014)
...................................
181

REPRESENTATIONS
OF
PHONY
VETERANS
IN
PUBLIC
CULTURE
...........................................................................
184

BEHAVIORISTIC
TRAJECTORIES
IN
MEDICO-‐SCIENTIFIC
DISCOURSE
...................................................................
185

Conceptual
problems
with
PTSD
criteria
........................................................................................................
187

Problems
with
assessment/methodological
difficulties
............................................................................
188

Recommendations
for
future
research
.............................................................................................................
191

Strategic
deployment
of
outside
knowledge
..................................................................................................
192

BIOMEDICAL/COGNITIVE
TRAJECTORIES
IN
MEDICO-‐SCIENTIFIC
DISCOURSE:
SYSTEMS-‐NEUROSCIENCE
..
196

Somatic/analytical
perspectives
on
postwar
trauma
................................................................................
200

Moral/synthetic
perspectives
on
trauma
........................................................................................................
213

A
21
ST

CENTURY
NOSOLOGICAL
CONTROVERSY:
TWO
TRAJECTORIES
–
DISORDER
VS.
INJURY
.....................
226

The
positive
trajectory:
The
rationale
in
favor
of
Posttraumatic
Stress
Injury
.............................
227

The
negative
trajectory:
The
rationale
in
favor
of
PTSD
..........................................................................
234

POLITICAL
POLICY
DEBATES:
PTSD
AND
DISABILITY
(2001-‐2014)
........................................
239

SURGING
PTSD
DISABILITY
CLAIMS
AND
INDIVIDUAL
UNEMPLOYABILITY
DESIGNATIONS
(2004-‐2010)
241

Two
trajectories:
Workers
compensation
vs.
benefit
of
last
resort
......................................................
245

The
negative
trajectory:
Individual
unemployment
as
workers’
compensation
............................
245

The
positive
trajectory:
Individual
unemployment
as
a
benefit
of
last
resort
................................
249

DISABILITY
COMPENSATION
FOR
VICTIMS
OF
MILITARY
SEXUAL
TRAUMA
(2011-‐2014)
...........................
258

ix

Two
trajectories:
Justice
vs.
efficiency
..............................................................................................................
266

The
positive
trajectory:
The
rationale
for
just
reform
...............................................................................
267

the
rationale
against
reform
.................................................................................................................................
273

VETERANS’
SELF-‐HELP
GROUPS:
CULTURAL
AND
TECHNICAL/POLITICAL
TRAJECTORIES
............................
277

PTSD
CONSENSUS
ACHIEVED
NEGATIVE
SPIRAL
............................................................................
280

CHAPTER
FIVE
-‐
CONCLUSIONS
..................................................................................................................
283

PTSD
(1967-‐1980)
INITIATION
OF
A
NETWORK
CONSENSUS
................................................................................
285

PTSD
(1975-‐1999)
MATURATION:
POSITIVE
SPIRAL
RENDING
AGREEMENT
INTO
INSTITUTIONS
AND
THE

EVERYDAY
.............................................................................................................................................................................
288

PTSD
(1975-‐1999)
21
ST

CENTURY:
NEGATIVE
SPIRAL,
UNBUNDLING,
DOUBT,
SKEPTICISM
..........................
292

STUDY
LIMITATIONS
.....................................................................................................................................
297

DIRECTIONS
FOR
FUTURE
RESEARCH
.....................................................................................................
298

REFERENCES
.....................................................................................................................................................
303

1

CHAPTER
ONE
–
INTRODUCTION

Every
war
leaves
its
scars.
The
loved
ones
often
remark
that
those
brave
men
and

women
who
return
from
war
come
back
different.
The
nature
of
the
change
depends
on
the

nature
of
the
war,
the
individuals
involved,
and
the
society
to
which
they
return.
Over
two

hundred
thousand
African
American
soldiers
fought
with
the
American
Expeditionary
Force
in

France
during
the
First
World
War.
Black
troops
made
no
ordinary
sacrifice
when
they
closed

ranks
with
their
white
counterparts
to
fight
for
America
and
her
highest
ideals
in
foreign
land

while
blacks
faced
unwavering
discrimination
and
prejudice
at
home.
Anti-‐black
racism

pervaded
the
military
at
every
level.
When
they
were
allowed
to
fight,
all-‐black
combat
units

were
forced
to
march
with
the
French
army,
under
the
command
of
foreign
commanders.

These
men
struggled
admirably
to
complete
their
missions
in
spite
of
inadequate
provisions
and

inferior
training.
However,
there
are
limits
to
what
even
the
most
resilient
soldier
can
endure.

Blacks
unable
to
cope
with
the
stress
of
war
environment
were
typically
diagnosed
with

different
conditions
than
white
troops
presenting
similar
symptoms.
“Negros
and
lower
grade

of
white
solders
were
frequently
diagnosed
with
hysteria
[a
condition
associated
with
primitive,

feminine
peoples],
while
neurasthenia
was
more
common
among
the
better
grade
of
whites

[sic]”
(Salmon,
1926,
p.
106).

World
War
I
(WWI)
ended
in
November
of
1918,
but
the
fight
was
just
beginning
for
the

black
veterans
of
America’s
Armed
Forces.
W.E.B.
Du
Bois
(1919)
succinctly
described
the
black

G.I.’s
predicament:
“We
Return.
We
Return
from
Fighting.
We
Return
Fighting”
(p.
13).
Black

veterans
returned
from
the
Great
War
not
to
a
hero’s
welcome,
but
to
increased

discrimination,
intimidation,
and
violence.
During
the
war,
new
and
more
discriminatory
Jim

2

Crow
laws
were
enacted
and
lynchings
grew
more
frequent
throughout
the
American
south.

Blacks
enlisted
in
large
numbers
hoping
to
earn
the
respect
of
white
citizens
through

demonstration
of
bravery
and
self-‐sacrifice;
many
had
learned
skilled
trades
during
the
war
and

hoped
to
come
home
to
better
jobs
and
economic
opportunity.
Instead,
they
returned
to

poorer
quality
schools,
unskilled
jobs,
and
lower-‐wages
than
their
white
comrades.
They
would

return
having
to
fight
tooth
and
nail
for
their
civil
rights.
The
circumstances
of
black
veterans

returning
from
WWI
are
particular
to
that
time
and
place,
but
certain
elements
of
this
scene
are

present
for
every
generation
of
American
veterans.
If
we
take
seriously
von
Clausewitz’
(1873)

(1873)
observation
that
war
is
a
real
political
instrument
used
to
carry
out
political
commerce

by
other
means
we
may
understand
why
so
many
veterans
describe
the
homecoming

experience
as
a
different
sort
of
war.

War’s
end
is
a
recurring
situation
that
invites
important
questions
for
the
veteran
of
a

foreign
war
and
the
society
to
which
they
return.
Can
the
soldier
survive,
not
just
the
perils
of

the
war,
but
also
its
aftermath?
What
will
they
bring
along
with
them?
What
will
be
left

behind?
Can
they
recognize
loved
ones
and
be
recognized
in
return?
How
will
they
find
their

way
in
a
postwar
society
that
looks
and
feels
foreign
to
them?
Can
a
soldier
ever,
truly,
return

home?
This
difficult
transition
from
military
service
to
life
as
a
civilian
poses
unique
problems

for
the
wounded
warrior.
In
addition
to
reconnecting
with
family
and
secure
gainful

employment,
these
veterans
must
also
recover
from
varied
traumas
–
some
of
which
are

hidden
from
view.
For
some,
healing
means
integrating
the
person
that
survived
the
war
and

the
person
they
used
to
be.
For
others,
this
means
unlearning
the
survival
strategies
they

picked
up
in
the
heat
of
battle.
The
individual
returnee
navigates
this
unfamiliar
as
a
member
of

3

the
veteran
corpus.
The
state
must
anticipate
the
wave
of
incoming
GIs
and
intervene
in
order

to
limit
the
collateral
damage
to
society.
Some
of
these
programs
are
targeted
at
the
entire

population
while
others
focus
on
specific
returning
groups.
Interventions
are
bound
up
with

various
legal
and
medico-‐scientific
discussions,
including:
the
optimal
means
of
care
for
the

wounded;
the
rehabilitation
of
those
that
are
capable
of
working
and
remuneration
those
that

are
not;
and
the
assimilation
of
returning
troops,
groups
that
are
raced
and
gendered
in

particular
ways,
into
efficient
economic
systems.
Discussion
unfolds
differently
for
each

generation
of
veterans
because
war
and
its
aftermath,
as
political
matters,
are
unpredictable.

Readjustment
programs
typically
incorporate
insights
gleaned
from
previous
experience,
but

unexpected
events
call
for
reassessment,
revision,
and
reflection.

This
dissertation
pioneers
a
method
for
critically
interrogating
the
politics
of
postwar

readjustment
through
the
examination
of
data
furnished
exclusively
by
the
process
of

communication.
It
traces
the
messy
process
through
which
words,
deeds,
and
things
mesh

together
produce,
diversify,
sustain
and
revise
contestations
over
culturally
resonant,

technically
correct,
and
politically
efficacious
responses
to
trauma.
This
chapter
begins
with
a

brief
historical
overview
of
the
contesting
agencies,
issues
and
stakes
involved
in
managing
the

aftermath
of
soldiers’
wartime
injuries
and
experiences.
Afterwards,
I
lay
out
a
framework
for

critical
inquiry
into
the
politics
of
health,
an
array
of
research
questions,
and
the
materials
to
be

analyzed.
The
chapter
concludes
with
a
plan
of
organization
and
parting
thoughts
about
the

payoff
to
this
type
of
study.

4

The
Nosopolitics
of
Postwar
Trauma:
A
Modern
History
of
War,
Stress,
and
Homecoming

French
philosopher
and
historian,
Michel
Foucault
(1980)
used
the
term
“noso-‐politics”

to
describe
the
“common
global
strategy”
derived
from
the
reciprocal
support
and
opposition

between
“’liberal
medicine
subject
to
the
mechanisms
of
individual
initiative
and
the
laws
of

the
market”
and
“a
medical
politics
drawing
support
from
structures
of
power
and
concerning

itself
with
the
health
of
the
collectivity”
(pp.
166-‐167).
Noso-‐politics
is
relatively
obscure

compared
to
some
of
the
other
concepts
popularized
in
Foucault’s
writings.
The
term
lacks
a

clear
definition,
but
it
appears
substitutable
with
(or
at
least
closely
related
to)
the
concept
of

“biopower,”
a
global
strategy
of
power
that,
starting
in
the
18
th

century,
takes
the
vitality
of

human
beings
its
object.
Foucault
(1976)
proposed
a
bi-‐polar
model
of
the
power
over
life.
At

one
pole
in
the
model
sits
an
anatamopolitics
of
the
individual.
This
is
a
general
mode
of
power

in
which
the
vital
forces
of
the
human
body
are
optimized
like
the
mechanical
properties
of
a

machine.
The
docile
body
becomes
more
useful
and
productive
as
it
is
integrated
into
efficient

economic
systems
through
discipline.
At
the
opposite
pole
sits
a
biopolitics
of
the
population.
In

this
mode,
an
array
of
regulatory
controls
and
interventions
are
deployed
to
secure
the
vital

characteristics
of
the
species
body
–
rate
of
birth
and
death,
life
expectancy,
morbidity
rates
–

by
acting
upon
the
elements
of
its’
milieu.
Rabinow
and
Rose
(2007)
define
biopower
as,

an
analytical
concept
that
brings
into
view
field
compromised
of
more
or
less

rationalized
attempts
to
intervene
upon
the
vital
characteristics
of
human
beings,

individually
and
collectively,
as
living
creatures
who
are
born,
mature,
inhabit
a
body

that
can
be
augmented
and
then
sicken
and
die
and
as
collectivities
or
populations

composed
of
such
things.
(p.
3)

5

Within
this
field,
I
define
nosopolitics
as
the
specific
strategies
of,
and
contestations
over,
the

problematizations
of
collective
human
vitality
and
productivity,
as
the
issues
relate
to
a
specific

disease,
disability,
or
illness.

The
historical
address
of
postwar
trauma
invites
the
mapping
of
diachronic
progression

and
synchronic
structures
of
nosopolitics,
in
its
varied
contexts—including
(a)
military

psychiatry,
(b)
public
argument
in
Congress,
and
(c)
popular
representation
by
the
press.
In

mapping
arguments
I
lay
out
lines
of
stasis
and
contestation
that
reveal
shifting
alliances
among

stakeholders
over
time.

The
maturation
of
psychiatry
as
a
medical
discipline
in
the
19
th

century
made
it
possible

to
identify
and
care
for
people
with
abnormal
minds.
Psychiatry
also
augmented
a
public
or

general
vocabulary
within
which
advocates
speak
generally,
accurately,
and
systematically

about
different
types
of
minds.
Even
so,
the
awareness
of
mental
dysfunction
as
a
major

military
medical
problem
developed
slowly-‐-‐
with
persistence-‐-‐across
the
twentieth
century.

The
Medical
and
Surgical
History
of
the
War
of
the
Rebellion
(1888)
detailed
tens
of
thousands

of
surgical
cases
and
diseases
occurring
during
the
American
Civil
War
(1861-‐1865).
This

document
included
statistical
summaries
relating
to
diseases,
wounds,
and
deaths
on
both

sides
composed
from
the
reports
of
military
medical
directors,
surgeons,
doctors,
and
hospital

staff.
Yet
the
report
contained
relatively
little
information
about
attending
psychiatric
illnesses.

Civil
War
soldiers
were
very
rarely
recognized
as
psychiatric
casualties.
The
few
cases
that
were

admitted
almost
exclusively
fell
in
the
catchall
category,
“insanity.”

Diagnostic
practice
in
psychiatry
made
great
strides
in
the
decades
following
the
Civil

War,
and
the
recognition
of
wartime
mental
wounds
increased
as
psychiatric
nomenclature

6

became
more
uniform.
“Medical
officers
of
various
countries
noted
an
excessive
prevalence
of

mental
disease
in
military
personnel,
particularly
in
time
of
war”
(Glass,
1966,
p.
4).
Significant

numbers
of
psychiatric
casualties
were
reported
during
the
Franco-‐Prussian
War
(1870-‐1871),

the
Spanish-‐American
War
(1898),
and
the
Boer
War
(1899-‐1902;
Brown,
1918).
During
the

Russo-‐Japanese
War
(1904-‐1905),
the
Red
Cross
was
called
in
to
assist
the
Russian
military
in

dealing
with
an
unprecedented
number
of
mental
cases.
It
was
during
this
conflict
that
a

German
physician
coined
the
term
“war
neurosis”
to
describe
the
unique
syndrome
observed
in

these
men
(Ellis,
1983).
The
states
participating
in
active
hostilities
during
World
War
I
(WWI;

1914-‐1919)
and
World
War
II
(WWII;
1937-‐1945)
were
forced
to
treat
the
mental
health
of

troops
as
an
essential
variable
influencing
to
the
success
or
failure
of
war
efforts
(Pols,
2007,

2007,
2011).
Militaries
around
the
globe
began
to
integrate
the
psychiatric
models
that

dominated
the
medical
communities
of
their
respective
nations
into
the
medical
corps

operations.

Some
physicians
subscribed
to
an
analytical/somatic
perspective.
This
view
suggests

that
the
nervous
syndrome
afflicting
soldiers
was
constituted
by
a
neurological
condition

caused
by
overstimulation
of
the
central
nervous
system
(Brown,
1918;
Brown,
1919,
1920;

Rivers,
1918a,
1918b).
Others
were
inclined
to
adopt
synthetic-‐psychological
models
in
which

neurotic
conditions
developed
because
soldiers
were
unable
to
actively
integrate
traumatic

memories
into
conscious
awareness
(Freud,
1920;
Grinker
&
Spiegel,
1945;
Janet,
1889,
1904;

Kardiner,
1941;
McDougall,
1920;
Myers,
1940).
Alternatively,
some
doctors
argued
that

combat
syndrome
should
not
be
treated
as
a
medical
condition
in
the
first
place.
These
experts

held
that
impairment
resulted
from
an
individual’s
lack
of
discipline,
not
from
a
reaction
to

7

fighting
(Bonhoeffer,
1926).

The
character
model
reinforced
the
prevailing
cultural
stereotype

that
those
who
could
not
cope
with
the
realities
of
war
were
themselves
abnormal
(Bourke,

2000;
B.
A.
Van
der
Kolk,
Weisaeth,
&
Van
Der
Hart,
1996).
Different
beliefs
had
their
outcomes

in
practice.
English
doctors
believed
generally
that
“shell
shock”
was
an
unavoidable
by-‐product

of
modern
warfare;
so,
casualties
were
evacuated
from
the
frontlines
and
transported
to

hospitals
for
treatment
(Bourke,
2000;
Mosse,
2000).
In
contrast,
most
German
and
Russian

physicians
were
convinced
that
evacuating
patients
to
the
rear
produced
chronic
disability
and

eventual
military
discharge.
These
doctors
held
that
the
“prognosis
[was]
better
if
convalescing

soldiers
remained
in
the
military
hierarchy”
where
prompt
recovery
was
expected.
Thus,
these

military
groups
administered
“treatment
in
the
forward
area,”
within
earshot
of
frontline
guns

(Crocq
&
Crocq,
2000,
p.
50).
There
was
no
consensus
on
the
causes,
treatment,
and
recovery

from
war
trauma.
Thus,
diverse
models,
surveillance
protocols,
and
cultural
norms
gave
rise
to

debates
over
the
accuracy,
efficacy,
and
prudence
of
different
conceptions
of
trauma.

After
the
conclusion
of
the
Great
War,
public
officials
and
military
command

acknowledged
the
importance
of
mental
health
preparedness
to
successful
war
efforts,
and

endeavored
to
learn
from
mistakes.
The
British
Parliament
tasked
a
committee
to
investigate

“the
different
types
of
hysteria
and
traumatic
neurosis,
commonly
called
‘shell
shock’”

(Southborough,
1922,
p.
3).
The
commission
collated
specialized
knowledge
derived
by
the

service
medical
authorities
and
the
medical
profession.
The
commission
sought
to
determine

the
origin,
nature,
and
remedial
treatment
of
trauma
in
order
to
guide
future
military
medical

operations.
Likewise,
the
U.S.
Army
Medical
Department
undertook
a
research
program
to
take

advantage
of
“the
scientific
potentialities
of
the
recorded
medical
experience
of
the
armed

8

services…
and
the
extensive
observations
which
would
subsequently
be
made
on
veterans
in

the
hospitals
and
regional
offices
of
the
Veterans
administration”
(Lynch,
1926,
p.
iii).

The

modern
military
thus
became
a
naturalized
engine
for
the
scientific
investigation
of
trauma.

In
times
of
war
and
peace,
military
personnel
comprise
a
large
population—with
a
great

diversity
of
stress,
trauma,
and
disease—available
for
study.
The
military
as
an
institution
and

science
as
a
process
of
inquiry
joined
forces
in
lieu
of
the
costs
of
20
th

century
world
conflicts.

Complete
reporting
systems
offered
opportunities
for
sampling
across
categories
such
as

diagnosis,
time,
and
geography.
Initially,
the
scientific
investigation
of
trauma
was
facilitated
by

cooperative
efforts
among
government
agencies
and
the
institutions
of
civilian
medicine.
State

actors
responsible
for
rehabilitating
and
remunerating
the
wounded
often
provided
financial

support
for
the
investigation
of
causative,
therapeutic
and
rehabilitative
factors
in
psychiatric

illnesses.
This
knowledge
directly
impacted
the
amount
of
resources
that
needed
to
be

allocated
medical
care,
pensions,
and
other
forms
of
compensation.
The
military
provided

strategic
support
in
the
form
of
access
to
military
records
and
ancillary
services.
Civilian
doctors

were
recruited
to
expand
capacity
and
reprise
government
officials
of
modern
technological

developments.

In
projects
that
bring
military
and
civilian
structures
together,
stakeholder
interests
may

vary,
research
often
remains
mixed
and
incomplete,
but
efforts
to
marshal
resources
persist

particularly
during
and
in
the
wake
of
great
conflicts—in
the
case
of
trauma,
with
mixed
results.

The
problem
of
emotional
breakdown
was
one
of
the
most
serious
medical
problems
with

which
the
American
military
had
to
contend
during
World
War
II
(WWII).

Upon
its
conclusion,

the
National
Research
Council
(NRC)
of
the
National
Academy
of
Sciences
was
tasked
with

9

conducting
research
that
could
be
used
to
advise
the
Department
of
Defense
(DOD)
and

Department
of
Veterans
Affairs
(VA)
on
the
subject
of
mental
health
preparedness.
In
1946,
the

Committee
on
Veterans
Problems
of
the
NRC
was
established
to
conduct
follow-‐up
studies

based
on
experience
with
the
military
and
the
veteran
population,
including
a
comprehensive

follow-‐up
study
on
men
with
psychoneuroses
during
WWII.
Before
laying
out
the
results
of
the

study,
the
authors
explained
the
need
for
objective
and
systematic
inquiry
on
the
subject
after

the
experience
of
the
war:

Much
of
what
had
been
learned
in
[WWI]
had
been
forgotten
and
had
to
be
learned

again.
Those
who
did
not
understand
the
nature
of
emotional
disorders
were
inclined
to

be
intolerant
and
even
contemptuous
of
the
men
who
could
not
control
their
feelings

by
‘pulling
themselves
up
by
their
boot-‐straps.’
This
was
apt
to
be
the
case
particularly

with
men
who
broke
down
in
training
camps
or
in
any
situation
other
than
combat.

Many
medical
officers
were
sensitized
to
the
diagnosis
of
psychoneurosis
by
the
fact

that
so
many
veterans
of
WWI
were
receiving
compensation
from
the
[VA]
for
neurotic

disorders
that
in
many
instances
bore
little
or
no
relationship
to
their
military
service.

There
were
pressures
to
subordinate
scientific
medicine
to
practical
realities.
It
was

feared
that
men
who
received
medical
discharges
for
psychiatric
reasons
would
be

compensated
for
their
failures.
It
was
predicted
that
they
would
cling
to
their
ills
and

become
burdens
for
the
rest
of
us
to
bear.
Even
the
reality
of
their
difficulties
was

questioned
and
little
distinction
was
made
by
some
between
simulation
of
illness
and

neurotic
disability.
(Brill
&
Beebe,
1956,
p.
vii)

10

This
passage
captures
a
range
of
stakeholders
whose
agencies
animate
legal-‐political
and

medico-‐scientific
discussions
in
search
of
cause
and
cure.
On
the
one
hand,
the
authors

acknowledge
the
psychoneuroses
are
legitimate
medical
conditions
that
cannot
be
wished
or

willed
away.
On
the
other,
they
acknowledge
the
practical
realities
and
complications
that
arise

from
the
diagnosis
of
medical
conditions
cannot
be
verified
objectively.
The
truth
of
the
matter

is
rendered
more
complicated
by
the
incentives
for
soldiers
to
simulate
illness.
Dismissing

disability
due
to
legitimate
psychiatric
impairment
is
unjust,
but
the
demands
of
an
efficient

war
effort
require
sacrifices
from
everyone
involved.

The
1956
NRC
study
findings
were
divided
into
four
main
topics:
diagnosis,
overall

adjustment,
improvement,
and
disability
compensation.
The
overall
question
was
how
much,
if

any,
attention
to
individual
soldiers
should
be
paid
in
a
timely
way,
particularly
given
the

influence
of
pre-‐existing
conditions
and
the
tendency
of
people
to
heal
up
over
time.

The
researchers
found
that
military
stress
had
a
profound
impact
on
soldiers
regardless
of

individual
characteristics
like
education,
family
history,
emotional
resiliency.
However,
their

results
suggested
the
impact
of
in-‐service
stress
was
essentially
temporary
since,
“the
overall

tendency
of
the
entire
sample
was
to
improve”
(Brill
&
Beebe,
1956,
p.
197).
Moreover,
the

results
revealed
the
eventual
course
of
illness
was
unrelated
to
the
frequency
or
intensity
of

combat
stress,
yet
pre-‐service
observations
were
statistically
significant
predictors
of
long-‐term

prognosis.
Specifically,
men
who
entered
service
with
personality
and
behavioral
disorders

were
very
likely
to
have
the
same
condition
at
follow-‐up,
even
though
the
interpersonal
and

environmental
context
had
changed.

11

Outside
of
these
pre-‐existing
personality
characteristics
that
seemed
to
predispose

particular
soldiers
to
psychiatric
conditions,
the
authors
saw
no
satisfactory
explanation
for
the

breakdown
of
one
man
and
not
another
similarly
exposed.
They
speculated
that
some
men
may

have
decreased
resistance
to
stress
of
which
even
they
may
not
be
aware:
“It
is
probable
that

the
individual
who
is
handicapped
as
to
intelligence
and
education
displaces
his
emotional

difficulties
more
than
others
onto
his
military
experience
as
a
means
of
solving
his
unconscious

conflicts”
(Brill
&
Beebe,
1956,
p.
204).
These
results
painted
the
psychoneuroses
of
war
as

natural
reactions
to
extremely
stressful
conditions
that
improve
over
time.
In
the
majority
of

cases,
chronic
illness
represented
a
heighted
susceptibility
on
the
part
of
the
individual.

The
notion
that
psychiatric
symptoms
following
sufficiently
traumatic
stress
were

transient
conditions
would
not
be
seriously
challenged
until
the
mid-‐1960s,
shortly
after
the

introduction
of
U.S.
combat
troops
in
Vietnam.
Struck
by
the
persistence
and
severity
of

‘combat
syndrome’
in
veterans
seen
in
an
outpatient
VA
clinic,
Archibald
and
Tuddenham

(1965)
undertook
a
systematic
follow-‐up
of
cases
available
to
them
using
interviews
and
self-‐
report
measures.
Based
on
this
data,
the
researchers
found
evidence
of
chronic
stress

syndrome,
which
they
described
as
“a
severely
disabling
but
nonschizophrenic
condition

involving
starling
[sic]
reactions,
sleep
difficulties,
dizziness,
blackouts,
avoidance
of
activities

similar
to
combat
experience,
internalization
of
feelings”
(p.
476).

Just
three
years
later,
the
American
Psychiatric
Association
(APA)
published
the
second

edition
of
the
Diagnostic
and
Statistical
Manual
for
Mental
Disorders
(DSM;
1968);
but,
for

reasons
that
are
not
entirely
clear,
this
revision
did
not
include
an
entry
for
any
psychiatric

disorder
produced
by
combat.
This
is
notable,
since
DSM-‐I
(1952)
included
a
listing
called

12

“Gross
Stress
Reaction”
based
on
the
work
of
Abram
Kardiner
(1941)
and
other
psychiatrists

working
with
traumatized
soldiers
during
WWII.
The
omission
was
controversial.
John
Talbott

(1969)
penned
a
critique
of
DSM-‐II
in
the
International
Journal
of
Psychiatry.
As
the
head
of
the

New
York
Psychiatric
Association,
Talbott’s
views
were
influential
within
APA.
He
was
struck
by

the
large
number
of
Vietnam
veterans
presenting
with
symptoms
consistent
with
some
type
of

combat
syndrome.
The
paper
recommended
that
future
editors
of
DSM-‐III
(1980)
reintroduce

the
Gross
Stress
Reaction
listing
or
replace
it
with
an
entity
that
served
the
same
function.
In

what
follows,
the
ensuing
debates
over
conceptualization
and
description
of
posttraumatic

stress
reactions,
the
diagnosis
and
treatment
of
“Posttraumatic
Stress
Disorder”
(PTSD),
and

the
protocols
and
procedures
instituted
to
manage
the
effects
of
the
disorder
constitute
the

object
of
analysis.

Research
Method

Nosopolitics
holds
tremendous
potential
for
analyzing
contestation,
debate,
and

antagonism
that
shifts
over
time.
Naming
and
renaming
of
disease
identifies
possibilities
of

productive
research,
draws
demarcation
lines
for
access
to
resources,
and
creates
a
focus
for

political
action.
Postwar
nosopolitics
is
particularly
fraught
because
for
many
the
effects
of
war

continue,
even
while
society
moves
generally
about
its
reconstitutive
business.
Nosological

politics
deserves
analysis
of
the
shifting
mix
of
pro’s
and
con’s
in
order
to
put
into
context

probative
issues
that
continue
and
critique
the
homogenizing
mix
of
truth,
treatment,
and

publicity
discourses.
Foucault
was
skeptical
of
totalitarian
theories
that
subjugated

heterogeneous
experiences
into
a
coerced
unitary,
moral-‐scientific
regime.
Biopower
is
the

closest
we
get
to
an
elaboration
of
nosopolitics—the
discursive
processes
of
medical

13

institutions.
Biopower
appears
in
a
series
of
lectures
delivered
during
his
tenure
at
the

prestigious
College
de
France.
5

While
these
lectures
were
littered
with
imprecise
terminology

and
conceptual
slippage,
they
demonstrated
the
general
principles
of
institutional
critique.

6

Foucault
(1977a)
identified
an
ascending
analysis
in
which
one
would
“investigate
historically,

and
beginning
from
the
lowest
level,
how
mechanisms
of
power
have
been
able
to
function”

(pp.
97).
He
dismissed
speculation
about
the
intentions
of
those
individuals
with
power
(the

history
of
persons),
or
the
prevailing
philosophy
of
an
era
(the
history
of
ideas).
Rather,
he

called
for
descriptions
of
material
practices
through
which
power
is
exercised.

Power
should

not
be
distilled
into
a
single
will
or
spirit
such
as
the
state,
the
market,
or
the
people.
Likewise,

power
should
not
be
understood
as
a
force
employed
by
vulgar
materialists
on
the
one
hand,

and
French
structuralists
on
the
other.
Rather,
critical
study
of
biopower
was
to
be
investigated

from
the
bottom
up
as
interests
spread
over
disciplines
of
control.

I
extend
this
inquiry
into
a

nosopolitics
that
maps
the
encounters
and
episodes
of
contention,
contestation,
and

controversy
among
military,
scientific
and
public
stakeholders
over
naming,
ordering,

categorizing
war
associated
mental
illness.

Critical
communication
inquiry
investigates
questions
of
stability
and
change
in
culture,

science
and
politics.

The
perspective
is
consistent
with
studies
in
the
rhetoric
of
inquiry
that

5

Security,
Territory,
Population
(1977b)
traced
the
historical
transformation
of
governmentality,
a

complex
form
of
“power
which
has
the
population
as
its
target,
political
economy
as
its
major
form
of

knowledge,
and
apparatuses
of
security
as
its
essential
technical
instrument”
(pp.
107–108).
The
precise

relationship
between
governmentality
and
biopower
remains
unclear,
but
Foucault
gave
the
impression,

in
The
Birth
of
Biopolitics
(1997),
that
these
phenomena
were
historically
contemporaneous
and

functionally
isomorphic.

6

Genealogy
and
archaeology
are
Foucault’s
preferred
methods.
The
tools
used
to
practice
either

method
are
essentially
the
same;
the
primary
difference
being
the
latter
is
appropriate
for
close
textual

analysis
of
discourse
and
the
former
is
appropriate
for
analyzing
extra-‐discursive
elements
such
as

practices,
institutions,
and
objects.

14

offer
content-‐free
methods
that
can
be
used
to
analyze
any
philosophy,
structure,
or
practice
of

communication
(Goodnight,
2012;
Hauser
&
Cushman,
1973;
Littlejohn,
1977).
7

My
dissertation

extends
this
scholarship
by
developing
from
Foucault’s
ruminations
on
the
politics
of
health
an

operational
set
of
tools
for
conducting
critical
communication
inquiry.
What
follows
is
an

exposition
of
the
research
method
developed
during
the
course
of
project.

A
Study
in
Rhetorical
Networks

This
is
a
study
in
what
I
call
rhetorical
networks
–
patterns
of
communication
by
which

symbolic
assemblages
of
words,
deeds,
and
things
grounded
in
different
forms
of
life

temporarily
converge
towards
a
common
trajectory.
My
approach
extends
poststructuralist

genealogy
by
incorporating
the
insights
and
techniques
from
rhetoric.
Foucault
(1977)
studied

biopolitics
by
blending
historical
analysis,
which
specifies
“what
is
specific
about
[mechanisms

of
power]
at
a
given
moment,
for
a
given
period,
in
a
given
field,
”
and
logical
analysis,
which

uncovers
“lateral
co-‐ordinations,
hierarchical
subordinations,
isomorphic
correspondences,

technical
identities
or
analogies,
and
chain
effects”
between
different
strategies
(p.
3).
My

dissertation
accomplishes
this
by
analyzing
controversies
that
persist
over
time
where
private

and
government
agencies,
individuals
and
collaborative
advocates
work
through
alternative

arrangements
to
assess,
analyze,
measure,
and
remediate
injuries
to
soldiers.
Rhetorical

analysis
identifies
the
tropes
that
facilitate
the
flow
of
discursive
(data,
information,
knowledge)

and
non-‐discursive
(images,
tools,
models,
apparatus)
symbolic
forms
through
time
and
space.

7

Richard
McKeon’s
(1971)
architectonic
philosophical
perspective
on
communication
broke
with

traditional
perspectives
by
theorizing
dialectic,
logic,
grammar,
and
rhetoric
as
arts
that
treat
ends
that

order
the
ends
of
subordinate
arts.
Communication
was
thus
reclaimed
as
interdisciplinary
field
of

inquiry
for
any
subject.

15

A
trope
is
a
word
or
expression
that
redirects
meaning
from
its
original
sense
in
a
new
direction

for
a
persuasive
purpose.
It
is
derived
from
the
Greek
tropos
(a
turning).
Tropes
are
much
more

than
linguistic
ornaments:
Metaphor,
metonymy,
synecdoche,
irony,
analogy,
ambiguity,
pun,

paradox,
hyperbole,
and
rhythm
are
the
vehicles
through
which
private
sentiments
and

attitudes
are
cast
into
public
form
and
become
socially
available.
Tropes
structure
the

possibilities
for
experiencing
the
world
in
its
varieties
(Lakoff
&
Johnson,
2008).

Nosological
politics
is
the
organized
practice
of
naming
by
stakeholders
who
agree
and

differ
over
truth,
resource,
and
action
questions.
Naming
is
contested
at
lines
where
issues

develop
along
mostly
familiar
lines
of
questions.
Issues
are
loci
where
questions
of
power
are

contested
through
argument.
This
study
features
arguments
(rather
than
people,
groups,
or

institutions)
as
the
primary
unit
of
analysis.
An
argument
is
a
bilateral
outgrowth
that
develops

organically
from
a
point
of
stasis,
a
“rest,
pause,
halt,
or
standing
still,
which
inevitably
occurs

between
opposite
as
well
as
between
contrary
‘moves’,
or
motions”
(Dieter,
1950,
p.
369).

During
argument,
advocates
on
either
side
provide
reasons
why
stasis
should
be
maintained
or

eliminated,
extended
or
curtailed,
established
permanently
phased
out
gradually.
There
are

four
basic
types
of
forensic
stasis:
designative
claims
(is
it?);
definitive
claims
(what
is
it?);

evaluative
claims
(what
is
its’
quality/disposition?);
and
advocative
claims
(what
should
we

do?).
Argumentative
analysis
may
proceed
by
identifying
a
stasis,
specifying
the
sides
of
the

argument,
locating
relevant
bodies
of
discourse,
and
synthesizing
these
component
elements

into
a
coherent
whole.
Alternatively,
analysis
may
work
in
the
opposite
direction
by
breaking

apart
the
constituent
parts
of
a
complete
argument,
examining
the
connections
between
varied

elements,
and
tracing
them
backwards
to
a
stasis
point
(Hauser
&
Cushman,
1973).
In
either

16

case,
rhetorical
analysis
proceeds
according
to
Stephen
Toulmin’s
(1952)
model
of
practical

reason
–
a
model
is
one
in
which
formal
validity
is
neither
necessary
nor
sufficient
for

soundness
of
argument.

The
study
identifies
textual
arguments
among
stakeholders
over
different
episodes
where

the
nature
of
the
illness,
directions
of
research,
reading
of
data,
access
to
support,
and
political

meaning
of
action
were
undergoing
stress
and
changing.
I
use
the
Toulmin
model
(1952)
that

defines
practical
reasoning
as
a
claim
coupled
with
a
justification
that
will
withstand
criticism.

Discursive
reasoning
includes
the
“grounds”
and
“warrants”
offered
in
support
of
a
claim.

Common
forms
of
support
include
evidence
based
on
observations
(reports,
statistics,
and

findings
of
physical
evidence),
various
forms
of
analysis
and
reasoning,
opinions
derived
from

credible
sources
(personal
confidants,
authorities,
and
experts),
and
premises
already
held
by

the
audience.
A
warrant
is
an
inferential
leap
required
to
connect
claim
to
the
grounds

presented.
There
are
three
main
forms
of
warrants.
In
the
first
use
of
a
warrant

(substantive/logical),
data
is
moved
in
support
of
a
claim
by
means
of
an
assumption

concerning
a
relationship
existing
among
phenomena
in
the
external
world.
Arguments
of
this

type
rely
on
generalizations,
signs,
parallel
cases,
analogies,
and
typologies.
In
the
second

category
(ethical/authority),
data
moves
to
claim
by
means
of
an
assumption
concerning
the

quality
of
the
source
from
which
the
data
is
derived.
The
final
category
(motivational/pathetic)

includes
arguments
where
data
moves
to
claim
by
means
of
an
assumption
concerning
the

inner
drives,
values,
or
aspirations
which
impel
behavior
of
the
persons
to
whom
the
argument

is
addressed.
When
the
grounds
and
warrants
in
two
different
arguments
are
of
the
same
type,

they
are
said
to
belong
to
the
same
argument
field.

Critical
communication
inquiry
studies

17

episodes
where
arguments
change
substantially.

At
such
times,
the
stories
of
war
and
peace

intersect
with
trajectories
of
argument
to
renew
old
questions
and
raise
questions
of
new

opportunities
and
obligations.

Communication
scholars
have
conceptualized
the
stories
that
assemble
context
for

argumentation
differently
over
the
years.
Frentz
and
Farrell’s
(1976)
language-‐action
model

furnishes
an
example.
The
model
consists
of
three
hierarchical
tiers.
Symbolic
acts,
"verbal

and/or
nonverbal
utterances
which
express
intentionality,"
occupy
the
lowest
level
(p.
340).

Above
that
sits
the
episode,
“a
rule
conforming
sequence
of
symbolic
acts
generated
by
two
or

more
actors
who
are
collectively
oriented
towards
emergent
goals”
(p.
336).
Context,
the

highest
level
in
the
model,
“specifies
the
criteria
for
interpreting
both
the
meaningfulness
and

propriety
of
any
symbolic
act.”
Within
context,
“forms
of
life”
refers
to
discursive
and
non-‐
discursive
cultural
patterns
that
give
significance
to
actions,
while
“encounters”
are
points
of

contact
in
concrete,
material
locations
that
particularize
forms
of
life
through
rules
of
propriety

(p.
335).
I
interpret
Goodnight’s
(1982)
identification
of
the
personal,
technical,
and
public

spheres
as
distinct
forms
of
life
shaping
the
expectations
of
interlocutors
who
engage
in
the

activities
of
theoretical
and
practical
reasoning
as
an
extension
of
the
language-‐action
model.

Nosopolitics
of
a
postwar
context
involves
argumentation
about
the
nature,
correction,
and

obligations
to
lifeworlds
damaged
by
events
brought
about
in
the
course
of
following
out
duty

to
one’s
country.

The
nosopolitics
of
postwar
trauma
may
be
constituted
by
a
public
culture
of
social

narratives
of
war
and
return,
a
techno-‐medical
discourse
that
debates
and
defines
diagnosis,

disability,
treatment
and
rehabilitation,
and
a
public
sphere
that
discusses
the
state
and
civil

18

society’s
allocation
of
resources
and
the
public’s
just
commitments
to
soldiers.
In
theory,
these

three
broad
contexts
can
be
identified
independently,
but
in
practice,
they
fuse
together
in

episodes
called
controversy.
Olson
and
Goodnight
(1994)
define
“controversy”
an
extended

rhetorical
engagement
that
critiques,
resituates,
and
develops
communication
practices

bridging
distinct
spheres
of
argument.
Controversy
tends
to
emerge
when
discourse

communities
are
faced
with
events
that
defy
expectations
and
unsettle
established
patterns
of

communication
and
reason.
If
common
ground
can
no
longer
hold
together
alignments
of

support
among
interested
actors
and
the
bonds
of
common
cause
are
overstressed
and

sundered,
the
resources
of
private,
technical,
and
public,
reason
are
enjoined
in
controversy.

In
this
project,
the
trajectories
of
nosopolitics
are
developed
through
selection
of
key

moments
of
contestation
where
private
and
government
agencies,
individuals
and
collaborative

advocates
work
through
alternative
arrangements
to
assess,
analyze,
measure,
and
remediate

injuries
to
soldiers.
These
trajectories
are
not
comprehensive
nor
include
all
opinions,
but
the

testimony,
documents,
studies
and
reports
selected
are
those
that
feature
key
moments
of

contention
or
struggle.

Public
culture:
Narratives
and
affective
knowledge

Coming
home
after
a
war
furnishes
a
society
with
many
problems
in
making
transition

to
a
postwar
world.
Whether
postwar
rhetors
address
transition
troubles
as
science,
therapy,

news
or
literary
expression,
such
worlds
must
deal
with
difficult
questions
of
loss.
Grief
requires

mourning.
For
the
surviving
injured
and
their
families,
war
refuses
to
be
set
aside.
Postwar

public
culture
ensnares
the
state,
public
institutions,
and
general
audiences
in
dramas
of

conflict
and
cooperation,
suffering
and
redemption,
risk
and
reward—for
doing
justice
to
those

19

suffering
from
the
war.
These
stories
are
expressed
in
common-‐sense
ways
accessible
to
all

laypersons
of
a
social
group.
Illness
narratives
communicate
how
the
sick
person
and
members

of
her
social
network
live
with
and
respond
to
symptoms
and
disability.

In
addition
to
categorizing
and
explaining
the
forms
of
distress
caused
by
pathological

processes,
these
stories
communicate
her
judgments
about
how
best
to
cope
with
practical

problems
pathology
creates
in
her
daily
living
(Kleinman,
1988,
pp.
3-‐4).
Whether
placed
into

melodrama,
tragedy
or
comedy,
such
rhetorics
trigger
and
work
off
of
sentiments
like
love,

fear,
anger,
loyalty,
hate,
gratitude,
and
disgust.
Thus
homecoming
narratives
define
and
orient

emotional
responses
to
people,
events,
and
actions
(Burke,
1968,
1969,
1984).
Such
affective

knowledge
can
be
read
from
recurring
cultural
narratives
(Fisher,
1984,
1988).

PTSD
is
a
covering
term
for
a
host
of
anxieties
about
homecoming.
13

As
duration
of
the

war
comes
to
a
close,
the
dramas
of
restoring
domestic
life
emerge.
For
some,
the
war
never

drew
much
attention.

For
others,
postwar
culture
offers
struggles
for
prosperity
and
a
new
life.

For
the
men
and
women
who
fought
and
killed,
who
still
suffer
from
wartime
events,
life
lingers

and
returns
to
normal
only
with
great
difficulty.
Societies
dating
back
to
antiquity
searched
for

a
language
to
speak
about
this
recurring
situation.
14

These
cultural
artifacts
might
be

13

Veterans’
readjustment
is
simply
one
of
many
different
trauma
cultures
affected
by
the
discourse
of

PTSD.
An
analysis
of
these
myriad
trauma
cultures
is
beyond
the
scope
of
this
investigation.
For
a

comprehensive
account
of
trauma
culture,
see
Alexander
(1971).

14

In
ancient
Mesopotamian
literature
the
Epic
of
Gilgamesh
narrates
the
tale
of
a
great
warrior
who,

after
witnessing
the
death
of
his
comrade
Enkidu,
continuously
relives
the
experience
of
his
friend’s

death
through
intrusive
collections
and
is
eventually
engulfed
by
despair
(Ben–Ezra,
2004;
Forcen
&

Shapov,
2012;
Sandars,
1972).
In
Ancient
Greek
literature,
Sophocles
recounts
the
story
of
Ajax,
a
hero

of
the
Trojan
War
who
fails
to
reintegrate
into
society
after
returning
home.
Jealous
of
the
rewards
and

recognition
given
to
other
Greek
generals,
Ajax
decides
to
take
his
revenge
by
slaughtering
herd
of

cattle
he
had
been
tricked
into
believing
were
actually
the
generals
he
despised.
Ajax
would
eventually

20

interpreted
as
equipment
for
living
–
strategies
that
size
up
typical
social
situations
in
various

ways
and
in
keeping
with
various
attitudes
(Burke,
1973).
The
study
selects
narratives
from
the

popular
press,
popular
fiction,
television
and
movies,
and
online
spaces
for
discussion
within

and
between
interested
communities
(DeGloma,
2002;
Hautzinger
&
Scandlyn,
2013;
W.
J.

Scott,
1990a).

As
veterans
began
to
return
from
the
Vietnam
War,
the
question
of
whether
battle

trauma
lingers
or
suddenly
appears
in
postwar
times
grew
increasingly
salient.
The
topic
of

postwar
readjustment
remains
urgent
in
an
age
of
seemingly
endless
warfare.

Even
though

PTSD
remains
the
dominant
figure
representing
and
explaining
the
problems
facing
returning

veterans
and
their
families,
other
terms
have
emerged
that
challenge
its
hegemony
within

social
knowledge
about
homecoming.
Such
terms
work
together
to
color
positively
and

negatively
the
range
of
motives
driving
veterans
to
behave
in
certain
ways
(to
seek
gainful

employment
or
disability
compensation;
to
simulate
health
or
illness).
I
investigate

contemporary
narratives
about
postwar
trauma
to
specify
the
value
terms
that
identify
the

gravity
of
the
conditions.
Some
of
these
terms
are
intrinsic
to
each
disorder.
I
identify
other

terms
by
examining
comparisons
between
terms
that
have
been
used
to
signify
similar

collections
of
signs
and
symptoms
(e.g.
war
neurosis,
shell
shock,
combat
hysteria,
and
soldier’s

heart)
and
by
examining
comparisons
to
similar
symptoms
attributed
to
dissimilar
“signature

wounds”
from
previous
conflicts
like
Gulf
War
Syndrome
or
Agent
Orange
exposure.
By

identifying
diachronic
patterns
in
narrative
construction,
in
addition
to
synchronic
distinctions

take
his
own
life
rather
than
live
with
the
shame
of
his
actions
(Jebb,
1896).
Similar
accounts
abound
in

the
literature
and
art
of
societies
that
that
been
touched
by
war.

21

between
different
terms
and
the
network
of
motives
to
which
they
connect,
this
project

provides
insight
into
the
continuities
and
differences
within
the
social
imaginary
about
war
and

homecoming.

Medico-‐scientific
discourse:
Defining
the
boundaries
of
legitimate
science
and
medicine

The
cognitive
dimension
of
culture
consists
of
a
thought
world
of
collective

representations
networked
together
in
a
way
that
makes
communication
possible.
In
the

context
of
nosopolitics
this
type
of
representational
work
is
embodied
in
truth
discourses
about

mental
health,
illness,
disorder,
and
disability
that
circulate
in
medico-‐scientific
discourse.

Models
of
mental
disorders
in
the
modern
era
function
as
blueprints
for
action.
The
blueprints

rationalize
protocols
and
procedures
and,
so,
justify
various
therapeutic
and
punitive

interventions
(Siegler
&
Osmond,
1974).
Weckowicz
(1984)
holds
that
all
western
models
of

mental
illness
can
be
divided
into
two
major
groups:
scientific
(logical-‐empiricist)
and
moral-‐
philosophical
(hermeneutic-‐dialectical).
Scientific
models
generally
emphasize
the
somatic;

assume
that
human
behavior
is
determined;
stress
conformity
as
the
index
of
health;
and

abstain
from
moral
judgments
about
illness
and
treatment.
Moral-‐philosophical
models

generally
prioritize
the
psyche;
take
an
indeterminate
position
on
human
behavior;
stress

individual
autonomy;
and
intertwine
classification
and
therapeutic
decisions
with
moral

judgments
(pp.
321-‐323).

Medico-‐scientific
discourse
includes
logics
of
inference,
as
well
as
means
of
ruling
in
or

out
certain
things
(causes,
conditions,
treatments,
measures,
etc.)
and
recognizing
things
that

do
or
do
not
count.
Sometimes
this
epistemic
knowledge
about
trauma
is
identified
as
abstract,

objective,
and
detached,
and
it
is
represented
by
discourse
that
is
formal,
codified,
and
explicit.

22

This
discourse
gathers
in
a
variety
of
sources
that
range
from
the
technical
to
the
popular.

These
include:
peer-‐reviewed
journals,
research
symposiums,
memos
and
reports
generated
by

professional
organizations
and
other
recognized
authorities,
books
written
by
psychiatrists
to

popular
audiences,
and
op-‐eds
written
by
prominent
mental
health
professionals.
I
examine

this
discourse
and
inquire
into
rhetorical
process
through
which
dangers
are
transformed
into

risks.
Scientific
investigators
rely
on
the
common
devices
of
rhetoric
in
asserting
claims,

attacking
opposing
claims,
and
defending
positions.
Typically,
such
arguments
are
found
in

tropes,
invocations
of
authority,
and
audience
appeals
(Ceccarelli,
2001;
Doyle,
1997;

Fahnestock,
2002;
McCloskey,
1998;
Nelson,
Megill,
&
McCloskey,
1987;
Strait,
2014).

Of

particular
interest
to
truth
discourses
are
the
manners
in
which
investigators
classify
cases,

draw
inferences,
and
develop
norms.

Other
times
truth
discourses
reveal
themselves
in
their
tacit
uses
and
deployment
–
that

is,
they
consist
of
taken-‐for-‐granted
knowledge
in
the
form
of
beliefs,
ideals,
values,
schemes,

and
mental
models
that
are
deeply
engrained
and
used
within
a
particular
epistemic
culture

(Knorr-‐Cetina,
1999;
Polyani,
1966).
Since
what
is
known
tacitly
is
difficult
to
verbalize,
it
can

only
be
shared
through
a
mixture
of
observation,
imitation,
and
practice.
Since
some
measure

of
tacit
knowing
is
captured
when
a
knowledge
holder
joins
a
new
network,
this
knowledge
is

reconstructed
by
mapping
the
points
of
contact
connecting
the
array
of
authorities
considered

competent
to
speak
about
trauma
(Goffin
&
Koners,
2011;
Haldin-‐Herrgard,
2000;
Knudsen,

2007).
The
mapping
of
tactical
deployment
of
arguments
requires
analysis
of
the
arguments

associated
with
particular
academic
departments,
professional
organizations,
think
tanks,
civil

society
groups,
and
social
movements.
Primary
evidence
of
tactical
rhetorical
efforts
consists
of

23

connection
including
personal
correspondence,
memos,
and
interviews,
with
secondary

evidence
that
includes
websites
with
links
to
others,
specialized
bibliographies
and
databases

for
traumatic
stress
studies.
Truth
discourses
feed
political
debates.

Political
policy
debate:
Deliberating
over
questions
of
justice
and
efficiency

Political
debate
includes
but
does
not
reduce
to
the
tactics
of
truth
discourses.
Rather,

debate
aims
at
satisfying
demands
for
a
moral
action
that
serves
the
common
good.
Moral

knowledge
consists
of
our
convictions
about
what
is
just
and
unjust,
right
and
wrong,
important

and
trivial
(Booth,
1973;
Wallace,
1963).
Action
is
supported
by
assertion
of
moral
knowledge

that
figures
what
it
is
the
public
must
do
in
order
to
efficiently
sustain
the
means
of
self-‐
defense
and
the
ends
of
just
treatment
for
those
who
sacrifice
life
and
limb
during
war.
War

and
postwar
concerns
with
trauma
redound
upon
the
broader
question
of
disorders
more

generally.
Traumatic
stress
treatments
are
caught
up
in
political
policy
debates
not
only
about

war
related
injuries
but
also
broader
questions
of
community
responsibility
for
mental
health

(Goodnight
&
Olson,
2006;
Segal,
2005).
This
knowledge
guides
value
judgments,
goals,
choices,

evaluations,
and
norms
of
action.

Moral
knowledge
finds
its
textual
development
in
discourses
circulating
through
federal

debates
over
questions
of
just
compensation
as
well
as
distinguishing
the
deserving
and

undeserving.
The
direction
and
magnitude
of
policy
intervention
are
at
issue.
Discourses

following
war
gather
into
Congressional
hearings
about
military
medical
operations,
veterans’

readjustment,
and
the
VA
health-‐care
system;
hearings
feature
official
reports
from

government
agencies
and
independent
but
state-‐sponsored
research
centers;
and
discussion
of

24

particular
resolutions,
regulations,
and
bills
pertaining
to
military
personnel
and
veterans

(Griffin,
1984).

Soldiers,
too,
are
called
on
to
testify
from
time
to
time.

Since
WWI,
the
military
has
invested
a
great
deal
in
the
scientific
study
of
posttraumatic

stress,
primarily
because
this
knowledge
is
integral
to
optimal
and
efficient
war
efforts.
After

the
conclusion
of
a
war,
government
officials
inquire
to
determine
if
more
needs
to
be
done
to

contain
the
threat
posed
by
emergent
psychiatric
conditions.
Within
such
scientific
inquiries,

concerns
about
justice,
access,
and
excellence
translate
into
public
demands
for
efficiency,

economy,
and
sufficiency.
Different
stakeholders
including
veterans’
advocacy
groups,
military

brass,
public
health
officials,
and
civilian
mental
health
professionals
argue
over
the
allocation

of
scare
resources.
These
debates
transpire
at
characteristic
loci
relating
to
posttraumatic

stress:
the
level
of
funding
and
human
resources
dedicated
to
diagnosis,
treatment,
prevention,

research
and
outreach
within
the
VA
healthcare
system;
the
regulations
governing
the
service-‐
connected
disabilities
and
disability
compensation;
and
the
nature
of
honorable
service
and

administrative
procedures
dealing
with
unusually
violent
or
anti-‐social
incidents.

When
experts
on
posttraumatic
stress
are
called
to
speak
in
public
forums,
they
often

change
the
style,
if
not
the
content,
of
their
arguments
to
render
them
more
accessible
to
state

elected
officials
and
the
public.
Understanding
the
mutation
and
diversification
of
scientific

reasoning
in
these
moments
requires
investigation
into
the
interpretation,
reception,
and

dissemination
of
scientific
arguments
in
the
public
sphere.
The
translation
of
technical
truth

discourse
to
the
language
of
public
issue
is
complicated.
Positivist
scientific
knowledge
is
an

abstract
system
composed
of
statements,
premises,
and
facts
organized
deductively.

Translating
this
knowledge
so
that
it
is
publically
available
and
socially
meaningful
requires
the

25

use
of
rhetorical
tropes
–
models,
analogies,
and
metaphors
–
that
can
connect
the

thoughtworld
of
science
with
lifeworld
public
affairs.

Traces
of
this
knowledge
exist
in

exchanges
among
experts
and
committed
advocates
during
Congressional
hearings
as
well
as
in

press
narratives
interpreting
official
discourse.
With
each
new
war,
each
new
round
of

returning
veterans,
controversies
appear
along
standard
lines
but
with
novel
variations
due
to

the
state
of
politics,
science,
and
the
war.

Research
Questions

Over
the
last
three
decades,
the
accepted
standing
of
PTSD
as
a
health
condition

unfolded
in
a
controversy
characterized
by
rapid
expansion
of
acceptance,
immediately

followed
by
contraction
of
approval,
belief,
and
confidence.
This
dissertation
is
designed
to

answer
the
following
primary
research
question:

1.
What
are
the
conditions
of
possibility
whereby
PTSD
achieved,
maintained,
and

relinquished
representative
hegemony
in
social,
technical,
and
political
discussions

pertaining
to
veterans’
postwar
readjustment
between
1967
and
2015?

One
way
to
answer
this
question
is
trace
the
trajectories
of
nosopolitics
as
using
tools

developed
to
analyze
the
historical
progression
of
social
movements
(Griffin,
1952).
Movement

studies
proceed
by
dividing
these
phenomena
into
discrete
phases
(inception,
momentum,
and

contraction)
signifying
episodes
in
which
advocates
reposition
and
develop
new
arguments
in

response
to
changing
dynamics
(Campbell,
1973;
Cathcart,
1983;
Griffin,
1980,
1984;
McGee,

1975;
Stewart,
1983).
To
this
end,
a
comparative
reading
across
three
different
discussions
over

traumatic
stress
in
postwar
American
society
is
conducted.
I
examine
the
initial
episode
in

which
nosopolitics
resulted
in
the
construction
of
a
shallow
consensus
anchored
by
the

26

invention
of
PTSD
(1967-‐1980);
then
the
episode
in
which
PTSD
became
embodied
in

techniques,
equipped
itself
with
instruments
for
material
intervention,
invested
itself
in

institutions
at
the
national
and
international
levels
(1980-‐1999);
and
third,
the
present,

unfinished
unraveling
of
agreements
and
renewal
of
doubts
about
the
coherence,
utility,
and

legitimacy
of
PTSD
(1999-‐2015).
The
goal
is
to
trace,
from
the
bottom
up,
the
histories
of

terminological
clusters
and
material
practices
to
critique
how
the
truth
discourses,
institutional

categories
and
justice
politics
have
been,
and
continue
to
be
invested,
colonized,
utilized,

inverted,
transformed,
displaced,
and
extended
by
general
strategies
power
on
a
national
or

global
scale.

Together
the
three
periods
unfolded
distinctive
controversies
over
the
adequacy,

magnitude,
priorities,
and
justice
of
care
across
the
whole
population
of
soldiers
and
for

specific
returning
groups.
Controversy
prompts
institutional
unraveling
where
the
taken-‐for-‐
granted
ways
of
doing
things
become
exposed.

Even
in
the
absence
of
consensus,
the
needs
of

soldiers
to
deal
with
stress
generate
urgencies.

Advocates
for
action
resort
to
nosopolitics
to

shore
up
institutional
political
support
and
to
struggle
for
changes
that
will
diminish
doubt
and

restore
confidence
or
completeness.
When
these
efforts
are
successful,
debates
reach
short-‐
term
closures,
convenient
agreements
produce
novel
appearances
of
consent,
different
agents

and
agencies
reconnect,
and
the
network
falls
into
its
patterns
of
routinization.
Regardless,

controversy
is
renewed
when
previous
agreements
that
satisfice
for
the
time
being
are
tripped

into
new
patterns
of
circulation
and
debate
becomes
renewed
for
different
audiences.
Critical

communication
inquiry
critiques
how
and
why
rhetoric
as
equipment
for
living
comes
up
short,

27

goes
wrong,
sinks
into
antagonistic
standoffs,
and
makes
do.
Thus,
this
dissertation
maps

controversy
by
addressing
the
subsequent
research
questions:

2.
What
are
the
different
nodes
of
nosopolitical
controversy
from
which
resources
are

drawn;
problems,
defined;
issues,
stated;
and
values,
weighed?

3.
How
does
nosopolitics
engage
questions
of
heterogeneity
and
difference?

Specifically,
how
are
wartime
mental
wounds
raced
and/or
gendered
for
specific

returning
groups?

When
all
is
said
and
done,
my
study
should
identify
which
essential
topics,
lines
of
force,

constrictions
and
blockages
condition
the
success
of
failure
of
postwar
nosopolitics.
Hopefully

this
analysis
will
furnish
nodes
of
authority,
leverage,
influence,
and
discussion
about
and
for

people
attributed
to
be
at
the
boundaries
of
society.

Organizational
Plan

The
dissertation
is
narrowed
into
case
studies
of
episodic
moments
treated
separately
in

chapter
2,
3,
and
4.
These
arcs
roughly
coincide
with
initiation,
stabilization,
and
reversal
of

postwar
nosopolitics
between
1967
and
2015.

Chapter
two:
PTSD
(1967-‐1980)
initiation
of
a
shallow
network
consensus

Chapter
two
traces
the
initiation
of
a
shallow
network
consensus
anchored
by
the

invention
and
public
recognition
of
PTSD.
This
episode
is
bound
by
two
particular
moments:
a

Congressional
hearing
examining
the
medical
care
of
veterans
wounded
in
Vietnam
and
the

inclusion
of
PTSD
into
psychiatric
nomenclature
of
DSM-‐III.
For
over
a
decade,
the
controversy

pertaining
to
the
mental
conditions
of
returning
troops
jumped
back
and
forth
between

different
institutional
contexts;
from
chambers
of
the
Senate
to
the
front
page
of
the
New
York

28

Times;
from
the
street
corner
psychiatry
of
the
Vietnam
Veterans
Against
the
War
(VVAW)
to

the
formal
reports
of
the
DSM-‐III
Committee.
The
energy
driving
the
controversy
eventually

dissipated
once
a
term
was
invented
that
permitted
Vietnam
veterans,
politicians,
clinicians,

scientists,
and
military
officials
to
seamlessly
integrate
knowledges
circulating
in
public
culture,

medico-‐scientific
discourse,
and
political
policy
debates.

Analysis
begins
with
homecoming
narratives
that
circulated
in
public
culture.
Every

postwar
society
has
to
deal
with
the
complications
of
civilian
integration,
but
homecoming
for

the
veteran
of
the
Vietnam
War
presented
unique
challenges.
As
the
military
drew
down
its

forces
in
the
late
1960s,
Americans
struggled
to
put
terms
to
the
human
situation
unfolding

before
their
eyes.
Press
narratives
oriented
emotional
responses
to
those
who
served
by

embedding
their
stories
in
dramas
characterized
by
apprehension
over
the
return
of

problematic
citizens
and
sympathy
for
the
invisible
veterans
living
among
us.
These
narratives

complicated
prior
scientific
consensus
regarding
the
conceptualization,
description,

assessment,
and
treatment
of
combat
trauma.
The
racial
dimensions
of
nosopolitics
were
most

evident
in
these
narratives.
When
the
press
coverage
featured
black
Vietnam
veterans,
certain

aspects
of
stories
were
heightened
to
communicate
racial
affinity
or
apprehension.
A
sample
of

newspaper
and
magazine
articles
from
1967
to
1980
were
analyzed.
Much
of
the
sample
was

taken
from
source
material
compiled
for
the
Senate
Committee
on
Veterans
Affairs.
The

volume
assembled
articles
that
“present
a
representative
spectrum
of
views”
on
the
Vietnam-‐
era
veteran
(Source
material
on
the
Vietnam
era
veteran,
1974,
p.
iii).

Nosopolitics
also
involved
contestations
in
the
public
sphere.
Political
policy
debates

about
the
readjustment
needs
of
Vietnam
veterans
hinged
on
the
determination
of
when
a

29

soldier’s
faltering
morale
and
his
difficulties
with
civilian
integration
should
be
considered
a

medical
issue
rather
than
a
moral
problems.
Many
Vietnam
veterans
were
clearly
disturbed.

Was
disturbance
caused
by
a
weak
moral
constitution
or
the
gravity
of
their
predicament?
Was

their
condition
transient
in
nature,
or
permanent?
Was
it
a
generic
response
to
combat
service

or
a
unique
reaction
to
modern
warfare?
Should
soldiers
be
trusted
to
describe
accurately
their

condition,
or
should
external
and
objective
measures
be
authoritative?
To
answer
these

questions,
medical
experts,
veterans’
service
organizations,
and
federal
agencies
drew
upon

very
different
types
of
justifications.

Outside
of
federal
debates,
networks
developed
between
civil
society
groups
formally

and
informally
connected
to
the
antiwar
movement.
These
associated
groups
evolved
to

address
the
needs
of
Vietnam
veterans—
either
by
transforming
the
VA
from
within
or

providing
external
resources
to
supplement.

Based
on
discourse
gathered
from
histories
and

biographies
of
prominent
individuals
and
organizations
in
evolution
of
PTSD,
critical
inquiry

reveals
conflicts
about
the
authority
of
truth
and
the
efficacy
of
particular
therapeutic

approaches.
The
unique
qualities
of
the
war
interacted
with
state
of
the
art
research
on
stress

and
its
limits.

Chapter
two
examines
the
strategies
of
conceptualizing,
describing,
and
categorizing

trauma
in
medico-‐scientific
discourse.
The
expert
debate
culminating
in
the
inclusion
of
PTSD
in

DSM-‐III
is
analyzed.
On
one
side
of
the
debate
stood
the
Vietnam
Veterans
Working
Group,
a

cadre
of
mental
health
professionals
that
actively
lobby
the
DSM-‐III
Taskforce
to
recognize
an

entity
that
could
be
used
to
diagnose
troubled
Vietnam
veterans
and
resuscitate
their
public

image.
On
the
other
side
was
a
group
of
scientists
from
the
department
of
psychiatry
at
the

30

University
of
Washington,
St.
Louis.
The
debate
is
reconstructed
from
arguments
in
peer-‐
reviewed
journal
articles,
conference
presentations,
popular
books,
op-‐eds,
and
formal
and

informal
documents
produced
for
the
taskforce
on
reactive
disorders
reporting
to
the
DSM-‐III

Committee.

Vietnam
veterans
and
their
advocates
worked
to
resolve
the
supposed
divide
between

scientific
skepticism
and
compassion
for
the
sick
or
disabled.
PTSD
advocates
contributed
to
the

development
of
a
shallow
consensus
through
strategies
of
conjunctions.
The
assertion
of

both/and
connectedness
circumvented
the
logic
of
disjunctive
either/or
categorical
definition.

The
official
recognition
of
PTSD
by
APA
made
it
possible
for
clinical
psychiatrists
to
be

sympathetic
to
the
plight
of
veterans
who
had
committed
unspeakable
deeds,
without
being

perceived
as
tender-‐minded
and
unscientific.
By
the
same
token,
the
PTSD
diagnosis
provided

VA
doctors
a
means
to
distinguish
legitimate
psychiatric
incapacity
from
weak
motivation
or
an

underlying
personality
disorder.
Utilizing
the
discourse
of
PTSD,
different
trajectories
borrowed

symbols
back
and
forth
for
mutual
support
and
temporarily
brought
the
controversy
to
closure.

But
the
agreement
to
an
arrangement
that
served
the
interests
of
altruists
and
skeptics
alike

would
not
be
a
permanent
one.

Chapter
three:
PTSD
(1980-‐1999)
stabilization
–
positive
spiral
rending
agreement
into

institutions
and
the
everyday

Chapter
three
maps
the
maturation
of
traumatology
in
the
1980s
and
1990s.
This
period

saw
the
discourse
of
PTSD
routinized
into
national
and
international
bureaucratic,
scientific,

and
medical
structures
and
institutions.
Nosopolitics
took
place
in
an
extended
postwar
period

with
more
time
for
questioning,
discussion,
and
adjustment.
Instead
of
reviewing
the
entire

31

structure,
the
chapter
identifies
elements
that
render
the
discourse
formation
intelligible
as
an

autopoetic
system
(Luhmann,
1986,
1995).
An
autopoetic
system
is
an
autonomous
entity
that

reproduces
itself
through
its
internal
components
and
processes.
The
system
first
self-‐
rationalizes
in
fragmented
fashion
through
a
series
of
trauma
studies
prior
to
1980.
Research

into
PTSD
functioned
to
advance
and
fortify
within
this
discursive
system.
Modern

traumatology
began
to
evolve
and
expand
rapidly
because
the
PTSD
researchers
erected
a

network
of
polysemic
symbols
that
neutralized
criticism
from
skeptics.
Scientific
justifications

unfolded
differently
in
different
contexts
(civil
society,
technical
discussions,
and
the
federal

debates).
Each
context
is
analyzed
discretely,
yet
together
they
unfold
as
generative
dynamics

that
reflect
and
reinforce
one
another
as
a
self-‐generating
discourse
trajectory
of
diagnosis,

resource
access,
treatment
and
evaluation.

The
evidence
of
stabilization
is
ample.
The
rapid
growth
of
traumatology
invited
expert

debates
about
the
quality
of
PTSD
studies
and
the
credibility
of
their
findings
in
the
1980s
and

1990s.
The
most
heated
discussions
involved
the
scientific
definition
of
trauma
and
the

classification
of
PTSD.
These
debates
intensified
as
APA
prepared
to
revise
DSM
first
in
1987

and
again
in
1994.
Analysis
reveals
that
PTSD
researchers
nurtured
the
perception
of

momentum
through
a
combination
of
self-‐vindicating
laboratory
science
and
self-‐rationalizing

argument
(Hacking,
1992a).
Controversy
arose
because
toughminded
skeptics
and
flexible

advocates
drew
on
different
visions
of
scientific
practice
as
the
backings
for
their
inferences

(Goodnight,
2006).
Traumatology
stabilized
through
the
mutual
adjustment
between
implicit

etiological
theories
(ideas),
experimental
procedures
and
instruments
(things),
and
state-‐of-‐the-‐
art
modes
of
analysis
(marks).

32

Provisional
alliances
between
PTSD
researchers
from
different
paradigms
were
able
to

deflect
toughminded
criticism
by
morphing
symbols,
but
this
strategy
risked
sacrificing
the

epistemic
status,
and
thus,
the
social
utility
of
the
diagnosis
in
the
political
policy
debates.

Advocates
worked
around
this
problem
by
leveraging
the
perception
of
scientific
momentum

and
downplaying
the
reflexive
character
of
trauma
studies
in
federal
debates.
Two
separate

discussions
are
examined.
The
first
is
a
debate
about
the
prevalence
of
PTSD
in
Vietnam

veterans
between
epidemiologists
with
two
federally
funded
studies:
the
Centers
for
Disease

Control
Vietnam
Experience
Study
(1988)
and
the
Research
Triangle
Institute’s
National

Vietnam
Veterans’
Readjustment
Survey
(1990).
The
second
discussion
consists
of

Congressional
testimony
from
the
VA’s
Special
Committee
on
PTSD
(SCPTSD).

The
SCPTSD
was

charged
with
assessing
the
VA’s
capacity
to
provide
diagnostic
and
treatment
services
to
all

veterans
eligible
for
VA
healthcare.
This
body
functioned
as
a
hub
that
circulated
various

resources
(money,
education,
expertise,
research,
and
communication)
through
a
network
of

stakeholders.
In
both
of
these
cases,
PTSD
researchers
transformed
questionable
findings
and

liberal
interpretations
(neurobiological
models
and
pharmacological
interventions)
from

medico-‐scientific
discourse
into
seemingly
indisputable
facts
and
employed
them
in
federal

policy
debates.
Science
debates
causes
and
evidence;
institutions
are
charged
with
determining

efficient
and
effective
use
of
resources
to
optimize
state
of
the
art
practice
in
the
interest
of

generating
public
confidence
and
support.

Thus,
chapter
three
turns
to
the
development
of
dedicated
institutions
that
facilitated

the
dissemination
of
PTSD
science
in
the
public
sphere.
The
International
Society
of
Traumatic

Stress
Studies
(ISTSS)
was
and
remains
the
premier
society
for
the
exchange
of
professional

33

knowledge
and
expertise
in
traumatology.
Likewise,
the
VA’s
National
Center
on
PTSD
(NCPTSD)

provided
a
context
and
impetus
through
which
neurobiologists
and
clinical
neuroscientists

developed
a
research
agenda
for
the
field.
Together,
the
ISTSS
and
the
NCPTSD
drove
the

perceived
continuity
of
trauma
studies
that
PTSD
advocates
leveraged
in
expert
debates
and

public
arguments.
These
organizations
facilitated
intragroup
ties
between
experts
with
tacit

knowledge
about
the
impact
of
trauma
and
different
traumatized
populations
and
intergroup

associations
between
PTSD
researchers
and
other
practitioners
in
other
fields.
The
cross-‐
pollination
of
subject-‐matter
expertise
with
technical
know-‐how
produced
unifying
theories,

assessment
tools,
and
therapies
that
were
mutually
adjusted
to
each
other.
Moreover,
these

organizations
codified
that
background
knowledge
in
the
form
of
scholarly
publications

designed
for
consumption
by
practitioners,
government
agencies,
and
the
lay-‐public.
Analysis
is

based
on
discourse
drawn
from
histories
and
biographies
of
persons
and
organizations,
books

for
specialized
and
general
audiences,
official
bibliographies
on
traumatic
stress
studies,
and

peer-‐reviewed
articles
and
editorials.

Special
attention
is
given
to
federal
debates
about
the
prevalence
of
PTSD
in
black

Vietnam
veterans
and
the
status
of
VA
services
for
this
specific
population.
Black
veterans’

advocacy
groups,
civil
society
organizations
working
on
behalf
of
African
Americans,
and
VA

leadership
argued
over
the
causes
for
racial
discrepancies
in
prevalence
rates,
treatment

seeking
behavior,
treatment
outcomes,
discharges,
and
disability
compensation.
These

conversations
revealed
the
racial
dimensions
of
biopolitics
in
the
1980s
and
1990s.
These

trajectories
testify
both
to
an
emerging
moral-‐political-‐scientific
consensus
while
at
the
same

time
creating
weak
spots
that
would
come
under
stress
in
the
21
st

century.

34

Chapter
four:
PTSD
(1999-‐2015)
21
st

century
reversal
–
negative
spiral,
unbundling,
doubts,

and
skepticism

America
found
itself
in
a
new
type
of
conflict
in
the
21
st

century,
a
global
war
on
terror.

Its
professional
soldiers
had
to
deal
with
specific
trauma-‐inducing
tactics
in
an
asymmetrical

war
that
assured
enemy
stealth,
civilian
camouflage,
and
anytime-‐everywhere
battlefields.

Analysis
reveals
that
interlocutors
moved
back
and
forth
through
points
of
contact
between
the

public
culture,
public
technical
discourse,
and
political
policy
debates.
Over
time,
veterans
and

their
families,
technical
experts,
and
public
advocates
began
to
use
new
terms
–
posttraumatic

injury,
posttraumatic
stress,
moral
injury,
military
sexual
trauma
–
to
describe
the
costs

incurred
by
those
who
risked
life
and
limb
in
defense
of
the
nation.
Chapter
four
traces
a

downward
spiraling
(undoing,
doubt,
and
skepticism)
rhetorical
trajectory
of
PTSD
in
the
21
st

century.

Analysis
weaves
back
and
forth
between
public
culture
and
technical
discourse.
In
1999,

popular
narratives
about
phony
veterans
energized
expert
debates
about
the
validity
of
PTSD
as

a
medical
diagnosis
and
the
reliability
of
assessment
technologies.
The
field
of
traumatic
stress

research
began
to
revisit
its
foundational
assumptions
during
this
period.
Skeptics
expressed

serious
reservations
about
motives
driving
supposedly
traumatized
combat
veterans
to
file

claims
for
disability
compensation
from
the
VA.
Academic
outsiders
were
invited
to
participate

and
PTSD
critics
leveraged
the
critical/reflexive
knowledge
they
produced
to
serve
their
own

ends.
To
restore
confidence,
PTSD
advocates
began
to
incorporate
state
of
the
art
models
and

technologies
from
systems
neuroscience.
Debate
is
reconstructed
based
on
discourse
from

35

peer-‐reviewed
journals
and
edited
volumes,
solicitations
for
federal
grants,
correspondence

between
experts,
and
media
coverage
of
government
interventions.

Nosographic
innovations
gave
rise
to
contestations
over
the
conceptualization,

assessment,
prevention,
and
treatment
of
the
disorder.
Based
on
data
obtained
from
emerging

neurotechnologies
(fMRI,
PET,
circuit
diagrams),
cognitive/biomedical
trajectories
questioned

whether
the
original
PTSD
construct
introduced
in
DSM-‐III
was
too
broad
a
category
to
useful

scientifically
or
medically.
At
the
same
time,
dynamic/humanistic
trajectories
began
to
advance

the
label
“moral
injury”
to
draw
attention
to
ethical
and
philosophical
topics
that
were
no

longer
broached
in
standard
PTSD
research.
As
a
result,
distinct
research
trajectories
emerged

for
exploring
the
neurobiological
and
moral-‐philosophical
implications
of
postwar
trauma.
At

the
same
time,
narratives
drawn
from
online
discussions
in
veterans’
self-‐help
communities

housed
on
blogs
and
social
media
sites
reveal
that
veterans
and
their
families
also
began
to
use

different
terms
to
describe
the
losses
incurred
the
war.
Such
stories
increasingly
distinguished

between
the
social
situations
facing
veterans
exposed
to
external
traumas
(PTSD
and
TBI)
and

those
suffering
from
the
effects
of
traumatic
conflicts
within
the
soul
(moral
injuries).
These

developments
influenced
and
reflected
the
declining
hegemony
of
PTSD
in
the
cultural

imagination
of
the
American
public.

The
21
st

century
also
witnessed
political
policy
debates
over
challenges,
duties,
access,

distribution,
measures
of
success,
evidence,
and
authority
relating
postwar
trauma.
The

controversy
was
populated
by
advocates
who
had
to
draw
from
both
the
old
assurances
and

new
skepticism.
This
complicated
deliberation
in
the
main
concerned
levels
of
support,
kinds
of

programs,
and
questions
of
adequacy.

Skepticism
developed
alongside
and
because
of

36

heightened
anxiety
about
the
VA’s
ability
to
meet
the
needs
of
traumatized
soldiers
returning

from
Afghanistan
and
Iraq.
Congress,
the
DOD,
and
the
VA
endeavored
to
assess
the
mental

health
of
veterans
of
Operation
Enduring
Freedom
(OEF;
2001)
and
Operation
Iraqi
Freedom

(OIF;
2003),
the
state
of
the
VA’s
PTSD
treatment
programs,
and
the
regulations,
standards,
and

efficacy
of
the
VA’s
disability
compensation
system
between
2004
and
2015.
Government

officials,
veterans’
advocacy
groups,
and
non-‐partisan
civil
society
organizations
renewed
long-‐
standing
debates
over
core
assumptions
about
PTSD
that
were
taken
for
granted
during
the

1980s
and
1990s.
Debates
are
reconstructed
from
Congressional
testimony,
peer-‐reviewed

studies,
and
public
reports.

The
gendered
dimensions
of
nosopolitics
are
especially
salient
in
chapter
four.
A
federal

debate
about
the
disability
compensation
process
for
victims
of
MST
is
analyzed.
On
one
side

were
those
who
favored
an
amendment
to
regulation
governing
service
connections
for
MST-‐
related
PTSD
claims
so
that
the
standard
of
evidence
used
in
evaluations
of
these
claims

matched
the
standard
employed
in
evaluations
of
other
PTSD
claims.
Opposing
them
were

those
who
believed
that
not
only
were
existing
regulations
flexible
enough
to
reasonably

accommodate
the
type
of
evidence
typical
of
MST-‐related
PTSD
disability
claims,
they
were

even
more
lax
than
regulations
governing
non-‐MST
claims.
Comparative
analysis
reveals

veterans’
service
organizations
and
government
agencies
renewed
more
fundamental
debates

about
boundaries
between
military
and
civilian
authority,
medical
and
criminal
frameworks,

and
the
priorities
of
women
service
members
versus
those
of
the
Armed
Services.

37

Chapter
five:
Conclusion

The
synchronic
and
diachronic
study
of
networked
rhetorical
arguments
analyzes
the

nosopolitics
for
motives,
urgencies,
doubts,
and
actions
within
given
episodes
across
temporal

trajectories.
The
questions
of
how
PTSD
is
represented
in
the
social
world
becomes
expressed

through
the
topics
of
diagnosis
and
treatment
and
thus
creates
a
sense
of
moral
duty
for

intervention
is
differently
discussed,
debated,
and
resolved
over
time.

Such
a
discourse

formation
strives
to
offset
the
pain
of
war
for
soldiers
as
best
it
can
and
for
the
public,
which

seems
plagued
by
doubts
and
concerns.

The
types
of
material
injuries,
social
composition
of

the
forces,
and
relation
of
the
discourse
to
the
rationale
for
and
outcomes
of
various
wars

intersect
and
play
out
as
entwining
and
competing
trajectories.
Inquiry
into
the
uncertainties

and
difficulties
of
dealing
with
physical
and
mental
injury
yields
more
accurate
estimates
of
the

accumulative
costs
of
war
and
empire.
In
chapter
five,
I
conclude
with
the
findings
gleaned

from
a
comparison
of
the
case
studies
in
the
preceding
chapters
and
their
relevance
for

populations
that
have
been
taken
into
cultural/social,
political/bureaucratic,
and

scientific/medical
discussions
in
the
21
st

century.

This
chapter
five
also
details
the
ways
in
which
rhetorical
inquiry
into
nosopolitics
as

social
movement
adds
value
and
alternatives
to
the
scholarship
in
the
rhetoric
of
inquiry.
By

tracking
the
development,
evolution,
transformation,
and
mutation
of
particular
rhetorical

networks
by
and
for
a
range
of
audiences
in
the
public
culture,
technical
discourse,
and
political

debates,
critical
communication
inquiry
provides
a
middle
path
between
the
linguistic
and

material
research
perspectives.
My
approach
also
furnishes
resources
for
appreciation
and

38

critique
because
questions
of
individuality,
difference,
and
otherness,
(especially
as
they

pertain
to
race
and
gender)
arise
contextually
through
the
progression
of
nosopolitics.

Strengths
and
Limitations

There
are
strengths
and
limitations
to
any
research
method.
This
dissertation
focuses

rhetorical
inquiry
on
a
particular
set
of
research
questions
that
are
crucial
to
understanding
the

way
nosopolitics
of
postwar
trauma
unfolds
in
network
society.
Comparative
analysis
of

rhetorical
networks
in
successive
episodes
reveals
the
ways
arguments
about
duties,
science,

distribution,
support,
and
measures
of
success
change
over
time.
This
provides
insight
into
the

origins
of
a
nosopolitics
as
well
as
the
constitutive
dynamics
of
its
doing
and
undoing.
The

contribution
of
rhetorical
analysis
is
to
show
how
the
stuff
of
words
and
things
work
to

produce,
diversify,
sustain,
renew,
and
perpetuate
nosopolitics.

The
study
of
rhetorical

controversy
invites
more
than
a
single
intervention.

The
strength
of
a
study
is
measured
by

tying
together
different
discourses
and
topics
across
stakeholders,
acts
of
intervention,
and

policies
over
time.
I
focus
attention
on
historical
moments
characterized
by
significant

movement
in
social,
technical,
and
public
reasoning
about
the
manifold
relationships
between

war
and
readjustment;
sympathy
and
fear;
efficiency
and
justice;
illness
and
health;
brain
and

mind
in
choosing
illustrative
examples
of
advocacy
through
tests,
studies,
testimony,
speeches.

39

CHAPTER
TWO
–
PTSD
(1967-‐1980)
INITIATION
OF
A
NETWORK
CONSENSUS

The
return
of
the
Vietnam
veteran
marked
the
beginning
of
an
extended
controversy

from
1967
to
1980
over
identification,
treatment,
and
accommodation
of
wartime
mental

wounds.
Biopolitics
took
on
cultural
(press
narratives/civil
society
groups),
political
(federal

debates),
and
technical
(scientific/medical)
aspects.
Comparative
analysis
reveals
that
each

trajectory
sets
in
place
key
topics
with
higher
or
lower
standards
of
presumption
related
to

norms,
duties,
and
the
obligations
of
intervention.
Nosopolitical
inquiry
traces
these

trajectories
over
time
in
order
to
map
contesting
networks
of
motives.
Chapter
two
maps
the

initiation
of
a
shallow
network
consensus
by
sampling
and
developing
traces
from
public

culture,
public
technical
discourse,
and
political
policy
debates.
Each
context
had
different

agents,
agencies,
and
distinct
issues
of
contestation
that
invite
different
types
of
inquiry.

The
energy
fueling
the
post-‐Vietnam
controversy
emanated
from
the
public
culture.

Vietnam
veterans
and
their
families
constructed
illness
narratives
that
invited
public
and

technical
discussion
about
the
protocols
and
procedures
relating
to
disability
and
disease.
On

one
side
of
the
debate,
there
appeared
to
be
networks
of
alliances
between
tough-‐minded

experts
and
politicians
who
set
a
high
standard
for
recognizing
the
nature
of
wartime
stress
as
a

disease
and
for
the
success
of
treatment
in
the
particular
case.
On
the
other,
advocates

collaborating
through
associative
thinking
were
willing
to
lower
the
presumption
on

recognition,
diagnosis
and
treatment
of
the
condition,
in
favor
of
building
generalities
from
past

experience
and
arguing
the
unique
hazards
of
the
present.
The
controversy
reached
closure

when
competing
networks
formed
a
provisional
consensus
around
PTSD
–
an
enthymematic

40

conduit
that
translated
illness
narratives
from
Vietnam
veterans
into
technical
knowledge

about
psychiatric
disorder.

Public
Culture:
Problematic
Citizens
or
Invisible
Heroes?
(1967-‐1976)

Every
postwar
society
has
to
deal
with
the
complications
of
civilian
integration,
but

readjustment
was
especially
difficult
for
the
Vietvets.
American
attitudes
about
the
Vietnam

War
were
characterized
by
phases
of
ambition
and
disillusionment
between
1965
and
1976.

Press
narratives
during
this
period
oriented
emotional
responses
to
ex-‐servicemen
by

embedding
their
stories
into
dramas
characterized
by
apprehension
over
the
return
of
a

problematic
citizen
and
sympathy
for
the
invisible
veteran
living
among
us.
Race
was
a

prominent
theme
in
social
knowledge
during
this
period
because
the
Vietnam
War
was

conducted
against
the
backdrop
of
the
African
American
Civil
Rights
Movement
(1954-‐1968).

When
the
press
coverage
featured
black
Vietnam
veterans,
certain
aspects
of
the
problematic

citizen
and
‘invisible
hero’
narratives
were
heightened
to
communicate
racial
affinity
or

apprehension.

Press
articles
expressed
disquiet
about
returning
soldiers
by
placing
their
particular

struggles
in
the
context
of
a
consistent
historical
narrative
about
postwar
readjustment
issues.

Throughout
American
history,
there
has
been
a
fascination
with
and
a
fear
of
the
trained

solider
returning
to
wreak
havoc
on
society
(Archer
&
Gartner,
1976).
Within
this
drama
the

Vietvet
was
an
unstable
and
unpredictable
head-‐case.
He
may
have
suffered
from
any
number

of
psychological
hang-‐ups
including
depression,
social
alienation,
emotional
irritability,
poor

control
over
aggression,
alcoholism,
and
drug
addiction
(“Home
From
The
War,”
1971).
Because

of
his
anti-‐social
disposition,
he
avoided
meeting
new
people
or
joining
political
organizations

41

(Goodman,
1968).

He
excelled
in
combat
in
spite
of
these
problems
because
he
was
naturally
a

violent
individual.
Upon
his
return
to
civilian
life,
he
sought
outlets
for
these
repressed
urges.

He
was
prone
to
criminal
activity
including
hijackings,
armed-‐robberies,
and
even
murder
(“The

Vietnam
Vet:
‘No
One
Gives
A
Damn,’”
1971).
His
violence
was
capable
of
touching
anyone,

including
women
and
small
children.
The
black
veteran
retuning
from
Vietnam
was
regarded
as

even
more
dangerous.
During
the
war,
the
black
GI
volunteered
to
participate
in
more

dangerous
missions
to
prove
his
mettle
and
to
satisfy
to
his
primal
urges
(Armstrong,
1968;

Furlong,
1967).
Many
feared
that,
without
a
natural
outlet
for
his
violence,
this
ferocious

warrior
would
use
his
training
to
support
radical
black
nationalists
groups
in
waging
civil
war

against
American
society
(Young,
1976).

Other
stories
did
not
demonize
ex-‐servicemen,
but
rather
evoked
pity
by
casting
these

men
as
a
threat
to
public
safety.
In
these
narratives,
the
Vietvet
never
sampled
drugs
before

enlisting.
Rather,
he
picked
up
habits
in
Vietnam
where
temptation
was
great
and
drugs
were

plentiful
(Osnos,
1973).
Addiction
was
a
postwar
problem,
comparable
to
those
of
venereal

disease
and
alcoholism
for
WWII
veterans
(“Growing
Worry
Over
Drug-‐Hooked
GI’s,”
1971).

The
prospect
of
thousands
of
trained
soldiers
returning
to
society
as
junkies
served
as
the
casus

belli
for
the
War
on
Drugs.
The
government
had
to
be
held
accountable
for
disciplining
and

rehabilitating
these
men,
lest
they
be
handed
a
slip
of
paper
or
thrown
onto
the
streets
for

society
to
deal
with
(Wyant,
1971).
Having
been
previously
exposed
to
narcotics
in
America’s

ghettos,
the
black
GI
was
believed
to
be
even
more
likely
to
return
from
Vietnam
a
junkie.
Upon

homecoming,
it
was
asserted,
he
would
support
his
habit
with
all
manner
of
criminal
activity

(Osnos,
1973).

42

In
contrast
to
these
pessimistic
narratives,
other
stories
generated
sympathy
and

concern.
These
compared
the
homecoming
of
the
Vietnam
veteran
to
that
of
soldiers
from
past

wars.
In
these
accounts,
the
returning
veteran
was
portrayed
as
an
honorable
and
committed

individual
who
struggled
to
adjust
to
an
ambivalent,
if
not
hostile
society.
Whatever
his
initial

misgivings,
the
veteran
had
given
his
all
during
his
course
of
service.
But
after
risking
life
and

limb
on
foreign
soil,
all
veterans
slipped
back
quietly
into
society
feeling
forgotten
and

betrayed.
Unlike
his
predecessors,
he
did
not
come
home
to
victory
parades,
brass
bands,
or

cheering
crowds
(Ayers,
1970).

The
invisible
hero
was
said
to
feel
anonymous,
even
to
his
friends
and
family
(Furlong,

1967).
The
rest
of
society
changed
while
he
was
fighting
for
his
life
in
the
jungles
of
Vietnam.

Regardless
of
one’s
position
on
the
war,
there
seemed
to
be
a
conscious
desire
across
the

entire
nation
to
ignore
his
presence,
feelings,
and
experiences.
People
rarely
had
time
to

engage
him
and
when
they
did,
they
treated
him
as
a
chump
that
was
suckered
into
playing
a

game
rigged
against
him
(Broder,
1973;
Clemons,
1970).
He
kept
to
himself
whether
he
was
in

the
classroom,
the
veterans’
hall,
or
the
workplace
because
only
another
Vietnam
veteran

could
understand
what
he
was
going
through.
Feeling
unappreciated,
misunderstood,
and

alone,
he
gradually
detached
from
social
interaction
all
together.

To
make
matters
worse,
the
ex-‐serviceman
turned
to
alcohol
and
drugs
to
escape
from

a
reality
that
was
too
much
to
bear.
He
picked
up
the
habit
overseas,
because
it
was
the
only

way
to
cope
with
the
stress
of
the
war
(Johnson,
1971).
In
the
heat
of
battle,
he
was
forced
to

do
many
things
that
he
deeply
regretted
and
he
struggled
to
accept
the
person
he
had
become.

Even
if
he
could
summon
the
courage
to
seek
help
for
his
troubles,
he
was
often
vilified
for

43

doing
things
his
government
knew
all
along
that
guerilla
war
necessitated.
He
struggled
to
find

work
and
his
health
was
deteriorating.
Some
contemplated
suicide
because
life
seemed

meaningless
(Nordheimer,
1972).
The
black
GI
was
the
quintessential
invisible
veteran
in

sympathetic
narratives.
Blacks
enlisted
in
large
numbers,
partially
because
of
the
draft,
and
in

part
because
of
the
military’s
concerted
effort
to
integrate
the
military
in
the
1960s
(Stern,

1968).
Many
soldiers
resented
the
fact
that
they
were
drafted
into
fighting
a
morally

ambiguous
war,
but
those
misgivings
were
heighted
for
the
black
man
fighting
a
white
man’s

war.
The
black
GI
made
no
ordinary
sacrifice
in
closing
ranks
with
his
white
peers
to
fight
for

America’s
highest
ideals
in
a
foreign
land,
while
blacks
faced
unwavering
discrimination
and

prejudice
on
the
home
front
(Young,
1976).

The
black
soldier
volunteered
for
more
dangerous
missions
during
the
war
to

demonstrate
bravery
and
self-‐sacrifice
(Armstrong,
1968).
For
his
trouble,
he
was
rewarded,

not
with
the
respect
of
white
citizens,
but
with
a
greater
psychological
burden
than
his
peers.

The
racism
his
white
comrades
directed
towards
the
Vietnamese
seemed
too
familiar.
The

black
GI
saw
himself
in
the
faces
of
the
‘gooks’
he
killed.
Drugs
and
alcohol
offered
some
solace

if
not
reprieve
from
his
living
hell
(Nordheimer,
1972;
Stern,
1968).
The
black
veteran
went
to

war
hoping
his
sacrifice
would
be
rewarded
with
better
economic
and
political
opportunity.

Instead
he
came
home
to
no
fanfare
of
any
kind.
Within
his
community,
he
was
treated
as
a

sell-‐out,
or
worse,
a
baby
killer.
Even
though
he
learned
new
skills
and
demonstrated
valor
in

the
line
of
duty,
he
could
not
find
work
upon
returning
home.
The
economy
squeezed
all

veterans,
but
it
squeezed
him
tightest.
He
fought
for
American
ideals
in
the
jungles
of
Vietnam.

He
returned
fighting
for
a
future
that
appeared
more
bleak
than
ever
(Bims,
1971;
Chew,
1973).

44

Political
Policy
Debates:
Congressional
Oversight
of
Medical
Care
of
Veterans
Wounded
in

Vietnam
(1969-‐1970)

In
the
late
1960s,
illness
narratives
circulating
in
the
social
realm
invited
public-‐moral

debates
over
the
means
and
ends
of
medical
care
for
those
who
sacrificed
life
and
limb
during

the
war.
Senator
Alan
Cranston
began
touring
VA
hospitals
in
response
to
complaints
from

constituents
in
the
Los
Angeles
area.
The
tours
convinced
him
that
Vietnam
veterans
required

additional
support
programs
after
touring
VA
hospitals.
Cranston
took
on
the
task
of
bringing

about
changes
in
the
VA
system
to
meet
the
unique
psychological
needs
of
Vietnam
veterans,

since
they
had
no
effective
advocate
in
Congress
at
the
time.
Prior
to
1971,
the
House

Committee
on
Veterans
Affairs
(HCVA)
was
the
most
influential
body
in
Congress
affecting

legislation
pertaining
to
veterans.
Veterans
of
the
Second
World
War
dominated
the

committee.
These
men
had
firm
ideas
about
what
kind
of
legislation
veterans
needed.
In

contrast,
the
Senate
did
not
have
a
separate
committee
dealing
with
veterans’
issues.
Instead
it

assigned
jurisdiction
over
veterans’
benefits
to
the
Finance
Committee
and
over
other
veterans’

affairs
to
the
Labor
and
Public
Welfare
Committee
(W.
J.
Scott,
1993).

After
the
creation
of
the
Senate
Committee
on
Veterans
Affairs
(SCVA)
in
1971,

Cranston
proposed
the
Ex-‐Serviceman’s
Counseling
and
Readjustment
Act
–
a
bill
that
created

specialized
readjustment
counseling
as
well
as
programs
for
drug
and
alcohol
rehabilitation
for

Vietnam
veterans.
The
bill
passed
the
Senate
three
separate
times
between
1971
and
1975,

only
to
die
each
time
in
the
House
(Bloom,
2000).
Prospects
of
readjustment
counseling

dredged
up
conflicts
between
generations
of
veterans—
laying
bare
the
differences
among

45

groups
divided
over
the
conduct
of
the
Vietnam
War.
This
debate
and
would
not
be
fully

resolved
until
1979
(Scott,
1993).

The
issue
of
readjustment
counseling
was
discussed
at
length
during
a
1969
hearing

before
a
subcommittee
of
the
Senate
Committee
on
Labor
and
Public
Welfare.
More
than
forty

witnesses
appeared
before
the
committee
including
VA
bureaucrats;
military
doctors
and

Department
of
Defense
(DOD)
officials;
physicians
and
epidemiologists
from
federal
research

institutions;
drug
enforcement
agents;
psychiatrists
and
therapists
based
in
private
clinics
and

research
institutions;
and
veterans’
organizations.
Witnesses
testified
on
a
range
of
topics

including
enemy
ballistics;
the
variety
of
casualties;
the
state
of
medical
care
in
the
field
and

within
the
VA
system;
the
prognosis
for
different
classes
of
injuries;
and
the
threat
to
public

safety
posed
by
the
returning
veterans
who
might
be
psychologically
disturbed
or
otherwise

maladjusted.
I
reconstruct
this
federal
debate
in
which
interlocutors
struggle
to
demarcate
the

boundaries
of
honorable
service,
as
well
as
the
duties
and
responsibilities
of
the
public

regarding
just
treatment
for
those
who
sacrificed
life
and
limb
during
war.
The
debate
turned

on
three
topics:
the
scale
of
injury,
the
sources
of
illness,
and
the
solution
to
the
problems

presented
by
returning
Vietnam
veterans.
Each
topic
offered
a
stasis
point
between
competing

cases
placed
in
contention
for
the
national
debate.

Two
trajectories:
A
struggle
between
justice
and
efficiency

During
this
political
debate,
antiwar
activists,
Vietnam
veterans,
and
the
mental
health

professionals
advanced
a
case
for
justice.
This
trajectory
connected
Vietnam
service
to
a

spectrum
of
the
psychological
disturbances
that
plagued
returnees.
Discourse
converged

around
the
claim
that
the
Vietnam
War
was
qualitatively
distinct
from
previous
military

46

campaigns.
These
arguments
leveraged
the
lived
experience
of
Vietnam
veterans
along
with
an

emerging
body
of
knowledge
on
the
psychology
of
the
survivor
in
order
to
push
traditional

expectations
regarding
the
boundaries
of
honorable
service
and
the
role
of
the
state
in
the

provision
of
care
for
wounded
soldiers.
In
the
1970s,
the
VA
did
not
recognize
exclusively

psychological
conditions
like
substance
abuse
as
legitimate
service-‐connected
disabilities.
The

trauma
or
mental
health
impairment
designations
were
reserved
for
conditions
authorities

believed
to
be
directly
caused
by
environmental
factors
on
the
battlefield.
Extending
this

designation,
advocates
argued
that
as
a
group
returning
soldiers
did
face
readjustment

problems
that
had
collective
practical
and
symbolic
implications
for
veterans
and
the
broader

public.
The
facts
and
figures
produced
in
these
hearings
constituted
powerful
rhetorical

resources
for
advocates
interested
in
helping
returning
veterans.

A
broad
group
constituted
the
opposition.
Prowar
officials,
military
brass,
VA

bureaucrats,
law
enforcement
officers,
veterans
from
previous
eras,
and
the
organizations

representing
their
interests
did
not
admit
to
the
need
for
a
novel
national
program.
Existing

institutional
arrangements
were
offered
to
meet
individual
problems
on
a
case-‐by-‐case
basis.

These
advocates
supported
the
common
claim
that
the
experience
of
war
and
the
expectations

of
honorable
service
were
fundamentally
the
same
regardless
of
public
sentiment.
These

advocates
held
that
amnesty
programs,
service
connections
for
substance
abuse,
and
publicly

funded
treatment
for
non-‐service
connected
disabilities
as
radical
departures
from
established

roles
and
responsibilities
of
soldiers,
the
state,
and
the
citizenry.
In
lieu
of
sweeping
changes,

this
trajectory
pointed
in
the
direction
of
marginal
reforms
designed
to
improve
the
efficient

operation
of
the
existing
system.
For
example,
some
Congressmen
asserted
that
patient-‐to-‐

47

staff
ratios
could
be
aided
by
removing
the
artificial
cap
on
VA
personnel.
Alternatively,
the

federal
government
could
make
the
VA
an
attractive
destination
for
up-‐and-‐coming
physicians

by
allocating
more
funds
for
research
and
increasing
pay
to
make
it
more
comparable
with
the

civilian
sector
compensation.

The
scale
of
the
problem

The
rationale
for
justice
treated
America’s
involvement
in
Vietnam
as
a
war
unlike
any

other.
According
to
Cranston
(chair),
the
readjustment
hearings
were
designed
to
investigate

the
impact
of
“the
most
crippling
war”
in
American
history.

There
was
almost
complete

unanimity
on
this
point.
Witness
testimony
compared
Vietnam-‐era
GIs
to
veterans
of
the

Korean
War
and
World
War
II.
Topics
of
comparison
included
enemy
ballistics,
morality
rates,

the
range
of
disabilities,
the
state
of
treatment,
and
progress
of
related
medical
research.
All
of

these
facts
and
figures
pointed
to
the
same
conclusion:
“The
result
of
all
this
is
that
although

terribly
wounded,
men
are
surviving
this
war
would
not
have
survived
other
wars
[sic]”

(Medical
Care,
1969,
p.
3).
In
general,
justice
advocates
emphasized
the
qualitative
over
the

quantitative,
and
improvements
in
psychological
treatment
rather
than
biological
advances
as

necessary.

Justice
demanded
that
America
make
special
accommodations
for
survivors
of
the

Vietnam
War.

Robert
Lifton
provided
the
most
detailed
exposition
of
survivor
psychology.
Lifton

served
as
an
Air
Force
psychiatrist
during
the
Korean
War
and
subsequently
worked
with

veterans
at
VA
hospitals,
outpatient
clinics,
and
the
Walter
Reed
Army
Institute
of
Research.

His
testimony
covered
“the
psychological
predicament
of
the
Vietnam
veteran,
both
from

48

standpoint
of
war
in
general
and
of
the
nature
of
this
particular
war”

(Medical
Care,
1969,
p.

492).

Lifton
had
previously
studied
the
psychology
of
individuals
that
survived
catastrophic
tragedies

(1956,
1957,
1964,
1968).
He
explained
that
the
transition
from
the
extreme
situation
of
the

war
environment
to
the
civilian
world
was
difficult
for
combat
veterans
of
any
war.
All
veterans

struggled
with
anxiety
associated
with
“indelible
images
of
death,
dying,
and
suffering,”
and

“feelings
of
guilt
and
shame,”
resulting
from
the
simple
fact
“that
[these
men]
survived
while
so

many
others
died.
Moreover,
most
veterans
were
consumed
with
“finding
meaning
and

justification
in
having
survived,
and
in
having
fought
and
killed.”
A
veteran’s
overall
adjustment

was
greatly
influenced
by
the
extent
to
which
he
could
“become
inwardly
convinced
that
his

war,
and
his
participation
in
that
war,
had
purpose
and
significance.”
All
of
this
was
true
for
a

veteran
of
the
Vietnam
War
but
the
experiences
of
these
men
were
also
influenced
by
certain

characteristics
particular
to
that
conflict.
The
average
Vietnam
GI
found
himself
in
a
“strange,

faraway,
and
very
alien
place”
in
the
midst
of
guerilla
war
in
which
“the
environment
[was]
not

only
dangerous
and
unpredictable
but
devoid
of
landmarks
that
might
warn
of
danger
of
help

him
identify
the
enemy.”
As
a
result,
he
faced
“a
combination
of
profound
inner
confusion,

helplessness,
and
terror”
(Medical
Care,
1969,
p.
492).

To
make
matters
worse,
the
Vietnam
veteran
was
deprived
of
the
minimal
psychological

satisfactions
of
war.
Lifton
explained
that
in
an
ordinary
war,
battle
lines
and
established

methods
for
contacting
the
enemy
and
carrying
out
individual
and
group
tasks
with

aggressiveness
and
courage
provide
a
structure
and
a
ritual
for
expressing
the
survivor’s

impulse
toward
revenge.
But
in
Vietnam,
the
“enemy
[was]
everyone
and
no
one,
never
still,

49

rarely
visible,
and
usually
indistinguishable
for
the
ordinary
peasant.”
With
no
method
of

release,
the
soldier’s
fear,
rage,
and
frustration
mounted
over
time.
Moreover,
the
typical

soldier
noticed
the
South
Vietnamese
troops
fought
poorly
or
not
at
all:
rather
than
ask
himself

why
this
was
so,
he
came
to
look
upon
the
Vietnamese
“as
inferior
people
or
even
nonhuman

creatures.”

This
dehumanization
of
the
Vietnamese
was
furthered
by
his
participation
in

everyday
actions
such
as
the
saturation
of
villages
with
bombs
and
artillery
fire
or
the
burning

of
entire
hamlets.
“Observing
the
deaths
and
injuries
of
Vietnamese
civilians
on
such
a
massive

scale”
made
him
feel
as
though
“the
Vietnamese
[had]
become
more
or
less
expendable.”
In

short,
Lifton
argued
that
Vietnam
veterans
deserved
special
treatment
because
they
survived
a

“special
kind
of
war”
(Medical
Care,
1969,
p.
494).

Opposing
advocates
conceded
that
the
nature
of
combat
in
Vietnam
was
different
from

previous
conflicts,
but
they
did
not
conclude
that
structural
changes
in
the
nature
of
warfare

fundamentally
altered
the
moral
and
psychological
aspects
of
war
as
a
human
experience.

General
Whelan,
the
Special
Assistant
to
the
Army
Surgeon
General,
expressed
this
perspective

by
explaining
that,
“[e]very
war
has
its
distinguishing
features,
its
peculiar
environment,
its
own

problems.”
From
Whelan’s
perspective,
the
differences
in
Vietnam
were
more
“in
emphasis
or

mix
than
in
kind”
(Medical
Care,
1969,
p.
95).
Every
generation
must
adapt
to
new
technologies

of
destruction.
Vietnam
GIs
were
no
less
prepared
to
defeat
a
guerrilla
insurgency
than

American
Expeditionary
Forces
were
for
military
innovations
unleashed
during
the
Great
War.

The
signature
wounds
of
combat
vary
but
the
essence
of
war
endures.

The
nosopolitics
of
assessment
denied
the
uniqueness
and
significance
of
Vietnam

outcomes
by
defining
soma
as
a
key
category
for
injury,
distinct
from
psychic
issues,
associated

50

with
post-‐battle
stress.
Further,
support
of
incremental
change
was
rationalized
by
measuring

outcomes
according
to
quantity
of
lives
saved
rather
than
attending
to
the
subsequent
quality

of
life
for
survivors.
Whelan’s
statement
prepared
by
the
DOD
best
exemplifies
the

prioritization
of
soma.
The
report
analyzed
“data
on
nonfatal
wounds
and
on
deaths
–
both

battle
deaths
and
nonbattle
deaths”
in
Vietnam
“including
comparisons
with
our
experience
in

Korea
and
World
War
II”
(Medical
Care,
1969,
p.
92).
It
divided
wounds
into
two
broad

categories:
injury
and
incidence.
Injury
referred
to
patients
wounded
or
injured
as
a
result
of

actions
of
hostile
enemy
forces.
Injuries
to
the
head,
neck,
chest
or
abdomen
comprised
the

majority
of
seriously
wounded
cases.
Other
injuries
specifically
mentioned
in
the
prepared

statement
included
dysfunction
of
the
musculoskeletal
system
and
situations
requiring
major

amputations.
Injury
sustained
outside
of
combat
was
categorized
as
an
incidence.
While
the

accompanying
tables
listed
“neuropsychiatric
conditions”
among
the
categories
of
incidence,

there
was
no
mention
of
psychological
dysfunction
within
the
body
of
the
prepared
statement

(p.
99).
This
omission
is
telling
in
light
of
the
fact
that
the
report
did
spotlight
other
categories

such
as
infectious
disease
or
incidental
wounds
sustained
during
maintenance
and
operation
of

heavy
machinery.

The
lack
of
psychiatric
expertise
on
the
panel
of
high-‐ranking
DOD
representatives

provides
further
evidence
of
a
somatic
emphasis.
All
of
the
witnesses,
including
the
Surgeon

General
of
the
United
States
Army,
were
doctors
with
very
limited
training
in
psychiatric

medicine.
Predictably,
their
testimony
lacked
nuance
and
detail
when
it
touched
upon

psychiatric
matters.
For
example,
the
prepared
statement
summarized
statistics
on
Army

casualties
in
Vietnam
and
compared
them
with
the
military’s
experiences
in
Korea
and
World

51

War
II.
This
data
included
the
“survival
rate,”
“battle
death
rate,”
“the
ratio
of
wounded
to

killed
in
action”
and
the
percentages
of
casualties
admitted
to
medical
treatment
facilities
for

all
three
conflicts
(Medical
Care,
1969,
p.
93).
But
when
pressed
for
some
indication,
statistical

or
otherwise,
as
to
the
severity
of
the
drug
addiction
problem
among
Vietnam
GIs,
Whelan

responded:

I
don’t
see
how
we
can
say
what
the
incidence
is,
and
whether
it
is
increasing.
We
can

point
to
individual
cases
and
say,
‘This
fellow
was
a
case
of
drug
abuse,’
but
that
does

not
give
us
a
real
feel
for
how
extensive
it
might
be.”
(Medical
Care,
1969,p.
132).

The
panel
proudly
described
medical
treatments
such
as
emerging
antibacterial

therapies
for
burn
patients
or
the
state
of
the
art
in
vascular
surgery
in
graphic
detail.
But
when

discussion
turned
to
the
subject
of
neuropsychiatric
disturbances,
witnesses
primarily
dwelt
on

the
narrow
boundaries
of
the
military’s
medical
responsibilities.
For
example,
when
pressed
for

details
about
the
military’s
treatment
and
rehabilitation
programs
for
alcohol
and
drug
abuse,

one
officer
admitted,
“the
medical
department
does
not
attempt
to
rehabilitate
the
drug
addict

and
the
habitual
drug
offender”
(Medical
Care,
1969,
p.
131).
Psychiatric
and
other
medical

help
was
available
to
the
occasional
drug
user
if
they
expressed
a
desire
to
utilize
these

resources.
The
majority
of
cases
were
handled
in
an
administrative
fashion,
and
through

command
rather
than
medical
channels.
The
officer
admitted
that
“courts
say
it
is
a
medical

issue”
but
maintains
“we
cannot
deal
with
chronic
nature
of
this
in
a
military
medical

installation”
(Medical
Care,
1969,
p.
131).
Ironically,
the
panel
spent
more
time
explaining
the

cases
that
military
medical
facilities
did
not
deal
with,
than
it
did
describing
the
course
of

treatment
in
legitimate
cases.

52

Army
allied
medical
professionals
were
primarily
concerned
with
improving
the

efficiency
of
the
war
effort
and
the
public
health
apparatus.
Thus,
doctors
and
administrators

held
on
to
the
case-‐by-‐case
response
to
needs,
placing
the
burden
on
the
individual
to
show

need.

The
Veterans
Administration
was
justified
in
and
had
to
continue
to
distinguish
between

legitimate
psychiatric
conditions
and
incapacity
due
to
“weakness
of
motivation”
or
“some

underlying
personality
disorder”
(Medical
Care,
1969,
p.
149).

Psychological
conditions
were
placed
along
a
continuum
based
on
their
perceived

legitimacy;
the
most
legitimate
conditions
qualified
for
a
psychiatric
discharge
while
the
least

legitimate
were
dealt
with
administratively.
Legitimate
conditions
included
the
psychoses
and

severe
cases
of
psychoneuroses,
which
required
prolonged
hospitalization.
Illegitimate

conditions
included
chronic
drug
addiction,
personality
disorders,
transient
personality

disruptions,
and
deviant
sexual
behavior.
According
to
DOD
records,
the
percentage
of
soldiers

receiving
psychiatric
discharges
was
lower
for
the
Vietnam
War
than
it
was
during
the
Korean

War
or
World
War
II.
Phillip
Lee,
formerly
the
Secretary
of
Health
and
Human
Service’s
primary

advisor
on
matters
involving
the
nation’s
health,
attributed
the
disparity
to
high
standard
of

care
delivered
to
Vietnam
GIs.
Backed
by
objective
statistics,
the
rationale
for
efficiency
framed

the
claim
that
Vietnam
was
a
‘special
kind
of
war’
as
biased
and
politically
motivated.

The
rationale
for
justice
challenged
the
face
validity
of
the
official
statistics
by
drawing

upon
psychiatrists’
clinical
experiences
with
Vietnam
veterans.
According
to
Phillip
May,
a

professor
of
psychiatry
and
a
consultant
with
the
Brentwood
VA
hospital,
the
diagnostic

protocols
developed
during
World
Wars
II
and
I
were
likely
to
underestimate
the
incidence
of

psychiatric
impairment
in
the
Vietnam
War
because
“the
nature
of
illness
changed
with
the

53

times
and
the
culture.”
For
this
reason,
“illness
produced
or
aggravated
by
combat
stress
may

not
necessarily
manifest
itself
in
overt
psychosis
of
that
kind
that
[doctors]
have
been
used
to

seeing”

(Medical
Care,
1969,
p.
410).
Similarly,
Lifton
argued
that
many
Vietnam
GIs
would
not

have
“disabling
psychiatric
impairments
that
[could]
be
labeled
as
such”
(Medical
Care,
1969,
p.

495).
Instead,
he
predicted
various
kinds
of
psychological
disturbance
to
appear
in
Vietnam

veterans
ranging
from
“mild
withdrawal
to
periodic
depression
to
severe
psychosomatic

disorder
to
disabling
psychosis”
(Medical
Care,
1969,
p.
495).
Lifton
and
May
were
in

agreement
that
the
symptoms
presented
by
veterans
were
real
and
serious,
even
if
they
did

not
fit
neatly
into
any
established
psychiatric
category.

Sympathetic
psychiatrists
devoted
special
attention
to
the
inability
of
official
statistics
to

account
for
the
delayed
combat
stress
reaction
they
observed
in
Vietnam
veterans.
Lifton

noted
that
psychological
disturbances
could
“appear
very
quickly
in
some,
but
in
others
lie

dormant
for
a
period
of
months
or
even
years
and
then
emerge
in
response
to
various
internal

or
external
pressures”
(Medical
Care,
1969,
p.
495).
The
only
valid
statistical
study
of
these

long-‐term
effects
would
have
to
wait
ten
or
twenty
years
after
combat
exposure.

The
source
of
the
problem

Justice
advocates
began
from
the
premise
that
the
war
was
unjust
and
its
outcomes,

especially
the
difficulties
Vietnam
returnees
experienced
as
they
readjusted
to
civilian
life,

should
be
treated
in
that
context.
The
clinical
impressions
formed
by
sympathetic
psychiatrists

pointed
to
a
significant
relationship
between
the
ambiguities
and
conflicts
about
the
war
in

general
and
veterans’
psychological
state.
According
to
Stewart
Wolfe,
the
immense

satisfaction
derived
from
victory
balanced
to
some
extent
the
sacrifices
that
veterans
made

54

during
World
Wars
II
and
I.
These
men
received
a
hero’s
welcome
after
sacrificing
life
and
limb

in
defense
of
God
and
country.
“Without
that
satisfaction
of
achievement,”
Wolfe
predicted
“a

good
many
casualties
of
readjustment
to
civilian
life
after
this
group
of
soldiers
have
come

home”
(Medical
Care,
1969,
p.
273).
Wolfe’s
statement
was
fairly
modest
in
comparison
to

Lifton’s
bold
proclamations.
The
latter
argued
that
“no
one
[could]
emerge
from
that

environment
without
profound
inner
questions
concerning
the
American
mission
in
Vietnam

and
the
ostensibly
democratic
nature
of
our
allies
there”
(p.
494).
Justice
required
that
the

nation
make
sacrifices
to
accommodate
the
incoming
wave
of
discharged
GIs
who
were
drafted

to
fight
on
a
battlefield
without
glory.

Sympathetic
practitioners
used
illness
narratives
constructed
by
Vietnam
veterans
to

corroborate
their
technical
arguments.
Max
Cleland,
a
disabled
U.S.
Army
veteran
who
would

later
become
the
head
of
the
VA,
explained
the
psychological
toll
of
war
and
readjustment:

To
the
devastating
psychological
effect
of
getting
maimed,
paralyzed,
or
[becoming]
in

some
way
unable
to
reenter
American
life
as
you
left
it,
[was]
the
added
psychological

weight
that
it
may
not
have
been
worth
it,
that
the
war
may
have
been
a
cruel
hoax,
an

American
tragedy,
that
left
a
small
minority
of
young
American
males
holding
the
bag.

(Medical
Care,
1969,
p.
273)

Cleland
placed
special
emphasis
on
the
“delayed,
severe
psychological
symptom”
peculiar
to
“a

Vietnam
returnee,
wounded
or
not.”
He
made
clear
that
this
“inevitable
psychological

depression”
was
not
a
condition
that
resulted
from
combat
exposure.
Rather,
it
was
a
delayed

reaction
that
came
back
months
latter
"like
a
series
of
secondary
explosions
long
after
the

excitement
of
battle
is
far
behind”
and
“the
reinforcement
of
your
comrades-‐in-‐arms
is
a
thing

55

of
the
past.”
The
psychological
disturbances
plaguing
veterans
were
instigated
by
their

collective
doubts
about
the
morality
of
the
war
and
the
significance
of
their
sacrifice
(p.
273).

As
a
WWII
veteran,
Cranston
could
personally
attest
to
the
experience
of
combat
in

Vietnam,
but
he
used
his
position
as
committee
chair
to
push
the
conversation
in
the
direction

of
politics.
Cranston
was
a
liberal
Democrat
who
vocally
opposed
the
war.
He
invariably

questioned
witnesses
about
the
psychological
effects
produced
by
“the
controversy”
over
the

war,
including
“the
dispute
as
to
its
origins,”
“the
dispute
as
to
its
purposes,”
that
fact
that
the

military
had
apparently
decided
America
could
not
win
“a
military
victory
in
the
usual
sense,”

and
“that
fact
that
men
[were]
still
fighting
in
a
war
under
those
circumstances”
(Medical
Care,

1969,
p.
87).
This
line
of
questioning
provided
a
context
for
witnesses
to
frame
soldiers’

individual
failings
within
the
broader
context
of
America’s
collective
failure.

The
role
of
the
politics
and
belief
in
veterans’
psychology
was
an
essential
component
of

the
rationale
for
justice.
If
these
conditions
were
caused
by
the
controversy
surrounding
the

war,
rather
than
the
war
itself,
then
the
American
public
could
not
justly
blame
veterans
for

their
readjustment
issues.
Cleland’s
testimony
challenged
the
conception
of
Vietnam
veterans

as
“emotional
pansies.”
He
described
his
brothers
in
arms
as
“aggressive,
highly
motivated,
and

young”

(Medical
Care,
1969,
pp.
272–273).
Similarly,
Lifton
explained
that
the
men
who

participated
in
the
My
Lai
massacre
were
brutalized
during
the
war
and
eventually
lost
their

capacity
to
feel.
These
soldiers
gunned
down
“little
babies
and
old
men”
in
an
attempt
to

“finally
put
their
world
back
in
order.”
For
this
reason,
Lifton
felt
it
was
unwise
to
“separate
the

larger
historical
contradictions
surrounding
American
involvement
in
Vietnam
from
the

individual
psychological
responses
of
our
soldiers”
(pp.
494-‐496).

56

By
forging
a
direct
link
between
the
psychological
disturbances
and
the
controversy
over

the
war,
the
rationale
for
justice
pushed
the
boundaries
of
public
discourse
about
honorable

service.
How
was
it
possible
to
label
the
behavior
of
maladjusted
veterans
as
dishonorable

when
the
majority
of
Americans
agreed
that
the
entire
war,
from
its
conception
to
its

execution,
was
not
only
immoral
but
also
pointless?
How
was
it
possible
to
question
the
resolve

and
character
of
soldiers
fighting
overseas
when
the
American
public
had
lost
its
stomach
for

war?
Justice
required
that
these
men
“get
the
best
treatment
possible,
that
they
will
be
given

every
benefit
of
the
doubt”
upon
their
return
(Medical
Care,
1969,
pp.
273–274)

In
contrast,
the
rationale
for
efficiency
maintained
that
Vietnam
veterans
who
struggled

to
cope
with
the
reality
of
war
or
who
had
trouble
reintegrating
into
American
society
lacked

their
forbearers’
moral
fortitude
and
sense
of
duty.
The
discourse
came
primarily
from
medical

professionals
who
were
concerned
with
improving
the
efficiency
of
the
war
effort
or
the
public

health
apparatus.
Russell
Lee
(founder
of
the
Palo
Alto
medical
clinic
and
a
participant
in

President
Truman’s
commission
on
health)
argued
that
“[a]
person
who
was
involved
in
the
war

with
tremendous
enthusiasm,
with
a
high
level
of
patriotism
and
emotion
[was]
much
less
likely

to
get
things
called
combat
fatigue
or
shellshock.”
Lee
believed
the
incidence
of

psychoneuroses
was
higher
among
Vietnam
GIs
because
“there
[was
not]
anything
like
the
100-‐
percent
devotion
to
the
cause
that
existed
in
World
War
I.”
He
recalled
that
veterans
of
the

Great
War
were
“were
all
100-‐percent
for
the
Government,
for
the
war,
for
getting
the
Kaiser

and
all
that”
(Medical
Care,
1969,
p.
214).
On
its
face,
Lee’s
statement
was
not
substantially

different
from
Lifton’s
argument
about
the
direct
relationship
between
psychological

57

disturbances
and
controversy
over
the
war.
But
whereas
Lifton
focused
on
America’s
collective

conflicts
and
ambiguities,
Lee
focused
on
the
moral
conflicts
within
the
individual
soldier.

Lee
did
not
explicitly
criticize
Vietnam-‐era
veterans
for
lacking
patriotism,
but
he

indirectly
questioned
their
character
and
judgment
by
associating
them
with
the
rebellious

counterculture
of
the
1960s.
He
attributed
the
epidemic
of
drug
abuse
within
the
Armed
Forces

to
an
emerging
drug
culture
in
which
“the
idea
of
turning
to
drugs
to
solve
your
mental
hang-‐
ups
[was]
more
or
less
considered
moral
among
certain
groups
of
young
people.”
This
drug

culture
led
to
mental
and
psychological
disturbances
that
“don’t
exist
if
a
person
meets
his

problems
and
solves
them
without
doing
drugs
to
get
‘turned
off’”
(Medical
Care,
1969,
p.
214).

From
Lee’s
perspective,
the
controversy
over
the
war
was
significant,
but
only
in
the
sense
that

Vietnam
GIs,
relative
to
their
forbearers,
were
not
as
invested
in
the
war
effort.

The
solution
to
the
problem
and
the
role
of
the
state

According
to
the
rationale
for
justice,
the
state
was
primarily
responsible
for
the

treatment
and
rehabilitation
of
conditions
that
complicated
Vietnam
veterans’
readjustment.

Cranston
best
exemplified
this
perspective
when
he
framed
just
treatment
and
full

rehabilitation
as
“essential
services
that
[were]
as
much
a
part
of
the
cost
of
war
as
the
actual

purchase
of
munitions
and
weapons
and
serviceman’s
pay.”
Cranston
found
it
unfathomable

for
American
society
to
call
upon
Vietnam
veterans
to
make
still
another
sacrifice
and
forego

the
medical
care
they
deserved
“in
order
to
protect
the
dollars
that
other
people
have

accumulated
meanwhile”

(Medical
Care,
1969,
p.
382).

In
contrast,
the
rationale
for
efficiency
emphasized
the
need
to
balance
the
quality
of

the
care
provided
to
Vietnam
veterans
against
the
economic
concerns
like
rising
inflation,

58

budgetary
constraints,
personnel
shortages,
and
competition
from
older
generations
of

veterans.
For
example,
Pannill
analogized
the
VA
system
to
“prepaid
health
care
for
the

veteran,”
in
which
he
has
not
paid
the
premiums,
“but
he
has
earned
them
by
virtue
of
his

military
service.”
Pannill
argued
the
cost
control
measures
required
to
sustain
any
health
care

system
needed
to
“reside
in
the
administrative
and
professional
components”
of
the
VA.
From

his
perspective,
the
veteran
health
care
crisis
could
be
traced
to
the
simple
fact
that
the
VA
was

“reaching
beyond
[its]
capability
of
providing”
(Medical
Care,
1969,
pp.
481–482).
Within
this

discourse
trajectory,
special
treatment
programs
for
Vietnam
veterans
constituted
an

unnecessary,
inefficient
allocation
of
resources
that
threatened
the
integrity
of
the
entire

system.

The
rationale
for
justice
pushed
back
against
the
implication
that
Vietnam
veterans

were
demanding
special
treatment.
According
to
Louis
West,
psychiatric
treatment
was

delivered
at
a
relatively
high
standard
for
veterans
of
World
War
II
and
the
Korean
conflict,
but

“the
needs
of
Vietnam
veterans
[were]
not
being
nearly
so
well
met”
(Medical
Care,
1969,
p.

221).
Of
course,
meeting
these
needs
was
no
small
feat.
At
a
minimum
it
necessitated
more

flexible
eligibility
requirements
and
increased
sensitivity
to
the
perspectives
of
Vietnam

veterans.
In
terms
of
specific
legislative
and
regulatory
reforms,
the
rationale
for
justice
pointed

toward
less
stringent
eligibility
requirements
for
service
connections
related
to
psychological

disorders,
outpatient
substance
abuse
counseling
for
Vietnam
veterans
housed
within
the
VA

system,
and
an
amnesty
program
within
the
military
that
protects
GIs
from
criminal

investigations
and
dishonorable
discharges
if
they
seek
help
for
narcotic
addictions.

59

Typically,
service-‐connected
disability
status
was
only
granted
to
conditions
caused
by

combat
exposure.
Moreover,
any
accompanying
symptoms
had
to
manifest
during
the
course

of
service.
These
stringent
requirements
seemed
to
rule
out
service
connections
for
many

Vietnam
GIs
whose
psychological
symptoms
did
not
appear
until
after
they
returned
home.

Sympathetic
psychiatrists
rejected
stringent
cutoff
periods
for
service
connections.
Rather
than

using
rigid
a
priori
rules
to
designate
service
connections,
Lifton
advocated
a
contextual

approach
that
began
from
the
condition
itself
and
subsequently
investigated
any
possible

relationship
to
exposure
during
the
war.
May
even
recommended
that
new
legislation
“include

a
negative
definition
[…]
that
says
that
you
must
not
think
of
psychosis
in
the
way
that
you
have

thought
of
it
in
the
1940-‐50
era”
(Medical
Care,
1969,
p.
412).

In
contrast,
the
rationale
for
efficiency
balanced
Vietnam
veterans’
psychological
needs

against
the
needs
of
all
veterans.
From
this
perspective,
the
VA
system
did
an
exemplary
job

meeting
veterans’
medical
needs.
Any
problems
stemmed
from
arbitrary
personnel
limitations

and
insufficient
funds.
Efficiency
discourse
focused
on
quantitative
reforms
that
increased
the

amount
of
funds
allocated
to
treatment
and
research,
the
number
of
personnel
that
the
VA
can

employ,
and
the
numbers
of
beds
available
for
medical
and
surgical
care
through
the

construction
of
new
hospitals.
These
measures
were
supposedly
more
efficient
because
they

could
potentially
benefit
veterans
from
any
generation.
Much
of
this
discourse
emanated
from

older
veterans
and
the
organizations
representing
their
interests.
A
representative
from

Disabled
American
Veterans
(DAV),
one
of
three
major
veterans’
service
organizations,

explained
the
stakes
of
the
debate
for
older
vets:

60

The
VA
has
established
a
priority
system,
and
of
course
this
priority
system
is
absolutely

necessary
[…]
The
service-‐connected
emergency
is
No.
1
and
it
does
on
down
the
line
to

a
nonservice
connected
[…]
a
veteran
of
World
War
I
who
is
not
service
connected
has

got
as
much
chance
of
getting
into
a
VA
hospital
as
I
have
of
getting
into
Heaven.

(Medical
Care,
1969,
p.
456)

Instead
of
arguing
directly
against
the
Vietnam
veteran’s
interests,
these
organizations
simply

emphasized
how
tragic
it
would
be
if
older
veterans
were
forgotten
in
the
Vietnam
era.

Taking
the
opposite
position,
the
rationale
for
justice
expanded
the
scope
of
behaviors

that
should
be
properly
considered
as
medical
conditions
rather
than
moral
problems.

According
to
DOD
guidelines,
drug
addiction
could
not
be
service-‐related
unless
it
was

secondary
to
another
service-‐connected
situation
(Drug
Abuse,
1970).
From
the
military

perspective,
drug
abuse
resulted
from
weakness
of
motivation
so
the
incapacity
it
caused
was

categorically
distinct
from
a
legitimate
medical
condition.
In
contrast,
sympathetic
psychiatrists

advocated
rehabilitation
services
for
narcotic
addiction
because
they
saw
“the
use
of
drugs
as

not
themselves
a
cause
of
these
matters,
but
an
expression
of
these
difficulties”
(Medical
Care,

1969,
p.
502).
As
Lifton
put
it:
“It
would
be
hard
for
any
disorder
arising
within
2
years
after

exposure
to
this
extreme
experience
in
Vietnam
not
to
have
some
connection
with
this

experience.
It
would
be
bound
to”
(p.
499).

In
contrast,
the
rationale
for
efficiency
did
not
point
in
the
direction
of
reforms
that

pushed
the
boundaries
of
public
discourse.
Almost
everyone
could
agree
that
the
demand
for

veteran
health
care
exceeded
the
current
supply.
Reasonable
people
might
have
quibbled

about
solutions,
but
none
of
these
arguments
required
a
radical
departure
from
the
status
quo

61

morality
and
wisdom.
For
example,
veterans’
organizations
focused
on
the
lack
of
dynamic

rehabilitation
and
occupational
therapy
for
patients
with
spinal
cord
injuries
because
this
type

of
care
was
not
bound
up
with
moral
debates
about
the
relationship
between
veterans
and
the

state.
The
president
of
the
California
Paralyzed
Veterans
Association
argued
occupational

therapy
was
necessary
to
prevent
paraplegic
vets
from
becoming
“parasites
of
the
government

for
the
rest
of
their
lives”
(Medical
Care,
1969,
p.
438).

Aside
from
legal
and
regulatory
reforms,
the
rationale
for
justice
prioritized
increased

“sensitivity
training”
for
doctors,
bureaucrats,
and
the
general
public
(Medical
Care,
1969,
p.

497).

The
precise
meaning
of
the
phrase
changed

based
on
the
speaker
and
the
context
in

which
it
is
used,
but
it
generally
referred
to
a
constellation
of
practices
united
by
the
notion

that
the
treatment
and
rehabilitation
of
Vietnam
GIs
would
be
more
successful
to
the
extent

that
individuals
involved
understand
more
about
the
psychology
of
the
survivor
in
general
and

the
nature
of
the
Vietnam
war
in
particular.
For
James
Lieberman,
a
consultant
with
the

National
Institutes
of
Mental
Health,
sensitivity
training
was
a
generic
term
“for
a
lot
of
things

that
go
on
to
help
people
relate
better
to
other
people”
(Medical
Care,
1969,
p.
80).

In
a
clinical
setting,
sensitivity
training
referred
to
one
type
of
experience-‐based
learning

in
which
doctors
and
patients,
“work
together
in
a
small
group
over
an
extended
period
of
time,

learning
through
analysis
of
their
own
experiences,
including
feeling,
reactions,
perceptions,

and
behavior”
(Medical
Care,
1969,
p.
80).

According
to
one
VA
consultant,
the
objective
was

“to
help
[doctors]
develop
increased
sensitivity
towards
the
needs
and
reactions
of
[patients]

and
to
become
more
aware
of
the
impact
they
are
having
on
[patients]”
(Medical
Care,
1969,
p.

308).
Sensitivity
training
did
not
call
for
improved
medical
and
psychiatric
facilities,
but
rather
it

62

demanded
that
America
tackle
the
root
of
the
problem
head
on,
rather
than
working
around

the
edges.
Lifton
explained
that
if
America
was
really
concerned
about
the
psychological
and

spiritual
health
of
Vietnam
veterans
it
would
“cease
victimizing
and
brutalizing
them
in
this

war”
(p.
496).

In
contrast,
sensitivity
training
received
relatively
little
attention
within
the
rationale
for

efficiency.
Doctors
admitted
that
sensitivity
training
could
be
beneficial
when
conducted

properly,
but
they
noted
that
indulging
a
patient’s
feelings
could
be
taken
too
far.
Examples
of

over-‐indulgence
included
“groups
who
take
off
their
clothes
and
hug
each
other
to
bring
about

a
feeling
of
community
love
and
sharing”
(Medical
Care,
1969,
p.
239).
Efficiency
advocates

claimed
the
patient’s
feelings
should
not
be
prioritized
over
objective
knowledge
wielded
by

trained
medical
professionals
and
cost-‐conscious
administrators.
These
interlocutors
advocated

the
exploitation
of
modern
diagnostic
and
accounting
technology
because
doctors
needed

objective
tools
that
could
quickly
and
accurately
diagnose
patients
and
streamline
treatment
in

order
to
control
costs.

For
example,
a
tax
consultant
with
experience
auditing
government
contracts
testified

that
the
VA
could
redirect
“wasted”
funds
and
expedite
claims
by
employing
“modern

techniques
of
handling
and
processing
cases”
(Medical
Care,
1969,
p.
467).
Alternatively,
Lee

recommended
that
every
Veterans
Hospital
be
equipped
with
“multiphasic
diagnostic

examinations,
largely
based
on
the
utilization
of
electronic
and
other
advanced
devices,
and

without
utilization
of
very
many
physician’s
services.”
This
would
render
“elaborate
and

expensive
old
time,
comprehensive
examinations”
increasingly
unnecessary
and
free
up
time

for
doctors
to
care
for
severely
wounded
patients.
Because
this
technology
had,
“great

63

predictive
value
in
determining
what
illnesses
the
individual
veteran
is
likely
to
suffer
in
the

future,”
the
VA
could
use
automated
post-‐discharge
screening
examinations
to
render
firm
and

object
determinations
of
service-‐connected
disability
(Medical
Care,
1969,
p.
177).

Public
Culture:
Two
Trajectories
–
Radical
Rejection
vs.
Incremental
Reform
(1970-‐1979)

Political
debates
over
the
nosopolitics
of
postwar
adjustment
would
not
be
fully

resolved
until
1979
(Scott,
1993).
In
the
meantime,
social
movements
and
non-‐governmental

organizations
stepped
in
to
meet
Vietnam
veterans’
unique
psychological
needs.
Most
Vietnam

veterans
had
a
low
profile
in
the
early
1970s,
but
many
were
not
willing
to
sneak
back
into

American
society
and
resume
life
as
if
the
war
never
happened.
The
antiwar
movement
(1964
-‐
1973)
provided
an
outlet
for
troubled
veterans
to
gain
some
measure
of
control
over
their
lives

by
protesting
America’s
participation
in
the
Vietnam
War.
This
movement
refers
to
a
series
of

public
demonstrations
and
marches
between
1964
and
1971
as
well
as
the
countercultural

songs,
plays,
literary
works,
and
organizations
that
encouraged
a
spirit
of
non-‐conformism,

peace,
and
anti-‐establishmentarianism
(DeBenedetti
&
Chatfield,
1990;
Garfinkle,
1995;

Halstead,
1978).
Vietnam
Veterans
Against
the
War
(VVAW),
a
national
veterans’
organization

founded
in
1967,
was
the
most
significant
antiwar
organization
during
this
period.

Through
the
antiwar
movement,
veterans’
advocates
leveraged
the
resources
of
public

culture
–
mainly
personal
anecdotes
and
press
narratives
describing
Vietvets
and
the

vicissitudes
they
faced
–
to
challenge
prevailing
ways
of
knowing
in
public-‐technical
discourse

about
postwar
readjustment.
These
efforts
took
two
distinct
trajectories.
The
radical
rejection

trajectory
consisted
of
self-‐organized
groups
where
clusters
of
Vietvets
would
meet
with
each

other
to
‘rap’
about
their
experiences
(Bloom,
2000,
p.
31).
In
contrast,
the
incremental
reform

64

trajectory
rationalized
modifications
to
the
services
available
within
the
VA
system
including

the
addition
of
therapeutic
communes
and
storefront
clinics.
Rhetorical
analysis
of
the

strategies,
tactics,
and
alliances
within
these
trajectories
provides
insight
into
the
cultural

dimension
of
biopolitics.
Analysis
is
based
on
discourse
drawn
from
personal
and
institutional

biographies,
interviews,
and
peer-‐reviewed
journal
articles.

The
Radical
Trajectory:
The
Counter-‐VA
and
Veterans’
Rap
Groups

In
April
1970,
the
Ohio
National
Guard
fired
into
a
crowd
of
protestors
at
Kent
State

University,
killing
four
students
and
wounding
nine
others.
Chaim
Shatan,
a
faculty
member
at

New
York
University’s
post-‐doctoral
psychoanalytic
training
program,
invited
Robert
Lifton
to

speak
about
the
incident
and
the
larger
controversy
surrounding
the
war.
A
few
months
earlier,

Lifton
had
testified
before
a
Senate
subcommittee
on
the
brutalization
of
soldiers
in
Vietnam.

The
talk
was
well
attended.
The
audience
included
many
people
who
were
not
students,

including
several
veterans
who
were
members
of
VAVA.
A
few
months
later,
Jan
Crumb
(VVAW

president)
reached
out
to
Lifton
and
Shatan
for
assistance
addressing
the
severe
psychological

problems
experienced
by
Vietnam
veterans
in
the
New
York
area
(Bloom,
2000).

Lifton
and
Shatan
met
subsequently
with
several
VVAW
members
in
the
organization’s

New
York
City
office.
The
veterans
explained
that
they
spent
much
of
their
time
‘rapping’
about

their
thoughts
and
feelings
concerning
their
experiences
in
the
war,
American
society,
and
life

after
service.
The
group
thought
it
was
a
good
idea
to
formalize
the
rap
sessions.
They
invited

Lifton
and
Shatan
to
join
them,
“not
as
group
therapists,
but
as
coequals.”
The
veterans
were

wary
of
psychiatrists
because
of
experiences
with
the
VA;
but
they
thought
the
rap
groups

would
benefit
from
the
presence
of
trained
professionals
with
insight
into
survivor
psychology.

65

Shatan
circulated
information
about
the
groups
to
psychiatrists
and
psychoanalysts
in
the
New

York
City
area
(W.
J.
Scott,
1993,
p.
14).

The
rap
sessions
were
very
informal.
Participants
addressed
each
other
by
their
first

names.
Everyone
was
invited
to
describe
his
experiences
and
feelings
about
the
war.
The

experience
was
difficult
for
veterans
and
clinicians
alike.
Veterans
struggled
to
talk
openly.

Clinicians
were
not
used
to
investigating
their
own
thoughts
and
feelings
during
the
therapy

sessions.
Jack
Smith
was
one
of
the
veterans
who
appeared
at
first
formal
rap
group
session.

Smith
served
as
a
Marine
in
1968
and
1969.
He
had
originally
supported
America’s
mission
in
as

well
as
the
conduct
of
the
Vietnam
War.
But
his
experiences
as
a
marine
led
him
to
question

the
execution
of
the
war,
if
not
its
intentions.
The
raps
groups
were
therapeutic
for
Smith

precisely
because
he
was
not
experiencing
the
discussion
as
therapy.
He
stayed
with
the
groups

because
they
provided
a
safe
place
for
him
to
sort
out
his
feelings
without
assuming
the
role
of

a
victim
or
a
head
case.
He
recalled
thinking,
“How
are
we
going
to
get
out
act
together
so

we’re
not
undone
by
our
feelings
about
what’s
going
on,
and
how
are
we
going
to
convey
that’s

going
on
to
the
general
public”
(Scott,
1993,
p.
17).

Scott
(1993)
has
observed
that
the
rap
groups
differed
both
from
psychodynamic

therapy
and
from
various
forms
of
street
corner
psychiatry.
In
the
context
of
traditional

psychodynamic
therapy,
healing
is
achieved
through
transference;
projecting
unconscious

conflicts
onto
the
psychiatrist
so
that
they
can
be
resolved
in
the
process
of
counseling.
The
rap

group
complicated
this
model
because
it
did
not
assign
privileged
status
to
professionals.

Rather,
healing
was
achieved
collectively
as
all
participants
came
to
terms
with
feelings
in
the

process
of
discussion.
The
rap
group
also
differed
from
most
other
varieties
of
street-‐corner

66

psychiatry
because
veterans
and
therapists
tended
to
go
public
with
their
experiences
and

conclusions.
Shatan
(1973)
recalls
that
“[a]ctive
participation
in
the
public
arena
[in]
opposition

to
the
very
war
policies
they
helped
carry
out
was
essential”
to
the
therapeutic
experience
(pp.

648-‐649).
These
emergent
practices
can
be
understood
as
technologies
of
the
self,
“modes
of

subjectification
through
which
subjects
work
on
themselves
qua
living
beings”
(Rabinow
&

Rose,
2007,
p.
34).
The
Vietnam
veteran
was
brought
to
work
on
himself,
in
opposition
to

psychiatric
authority,
by
means
of
practices
of
the
self,
in
the
name
of
his
individual
mental

health
as
well
as
the
well-‐being
of
the
entire
nation.
In
other
words,
technologies
of
the
self

were
shaped
by
cultural
knowledge
about
the
peculiar
vicissitudes
facing
Vietnam
veterans.

The
Reform
Trajectory:
Therapeutic
Communes,
Storefront
Clinics,
and
the
Brentwood
Model

Around
the
same
time,
clinicians
within
the
VA—
who
believed
in
the
importance
of

official
nomenclature,
protocols,
and
procedures—
tried
to
transform
the
system
from
the

inside
in
order
to
better
meet
the
needs
of
Vietvets.
In
1969,
Sarah
Haley
began
working
at
the

Boston
VA
as
a
counselor.
Haley
noticed
that
the
treatment
veterans
received
varied
a
great

deal
based
on
the
therapists’
personal
and
clinical
experience.
At
the
time,
official
psychiatric

nomenclature
did
not
recognize
a
disorder
related
to
combat
exposure.
A
listing
called
‘gross

stress
reaction’
had
been
included
in
DSM-‐I.
For
reasons
that
remain
unclear
still,
the

designation
was
not
included
in
DSM-‐II.
Even
were
VA
doctors
willing
to
be
sympathetic
to

Vietnam
veterans,
they
had
no
official
diagnosis
to
give.
Haley
observed
that
some
therapists

recognized
the
hallmark
symptoms
of
traumatic
war
neurosis.
They
held
it
to
be
their
job,
their

task,
to
talk
with
the
person
about
what
happened
in
Vietnam.
They
would
ask
patients
about

67

particularly
traumatic
experiences
and
the
feelings
associated
with
these
episodes.
Other

clinicians
saw
these
patients’
needs
either
as
psychosis
or
character
disorders
(Bloom,
2000).

Haley
tried
to
remedy
this
situation
by
giving
Vietvets
resources
to
navigate
the

problematic
VA
system.
In
1971,
she
provided
a
rating
scheme
for
the
Boston
chapter
of
VVAW

to
guide
decisions
about
which
facilities
to
attend
for
psychiatric
treatment.
She
recalled:
“I

highlighted
in
red
the
people
who
it
was
worthwhile
for
the
vets
to
see,
those
people
who

would
be
empathetic.
I
marked
others
in
black,
skull
and
crossbones
–
don’t
send
anyone
to

this
team”
(Scott,
1993,
p.
43).
Haley
also
tried
to
improve
the
standard
of
care
within
the
VA

by
fostering
a
culture
of
empathy
for
Vietvets.
She
published
an
article
in
the
Archives
of

General
Psychiatry
(1974)
detailing
the
complicated
relationship
between
therapists
and

patients
that
reported
participation
in
atrocities
such
as
the
massacre
at
My
Lai.
The
paper

advised
clinicians
in
this
situation
to
confront
their
own
sadistic
feelings
in
response
to
the

patient
as
well
as
their
own
potential:

The
therapist
must
be
able
to
envision
the
possibility
that
under
extreme
physical
and

psychic
stress,
or
in
an
atmosphere
of
over
license
and
encouragement,
he/she,
too,

might
very
well
murder.
Without
this
effort
by
the
therapist,
treatment
is
between
the

‘good’
therapist
and
the
‘bad,’
out-‐of-‐control
patient,
and
the
patient
leaves
or
stays

only
because
he
has
found
the
censure
he
consciously
or
unconsciously
feels
he

deserves.”
(p.
194)

Haley
fought
tooth
and
nail
to
get
approval
from
a
VA
publication
board
to
publish
the
essay.

She
eventually
connected
with
Lifton
and
Shatan
through
the
Boston
and
New
York
chapters
of

VVAW
(Scott,
1993).

68

On
the
other
side
of
the
country,
other
VA
clinicians
took
notice
of
counter-‐VA
activity

and
took
steps
to
emulate
the
informal
rap
group
model.
Philip
May,
the
director
of

psychological
services
for
the
Brentwood
VA
Hospital,
recognized
the
VA
system
was
not

meeting
veteran
needs.
Coincidentally,
May
had
also
testified
during
the
Senate
hearing
on

veterans’
medical
care
as
an
expert
on
wartime
and
postwar
schizophrenia.
In
1971,
he
reached

out
to
Shad
Meshad,
a
social
worker
and
founder
of
one
of
the
nation’s
first
rap
groups,
to

assess
the
quality
of
Brentwood’s
services
and
their
fit
with
the
needs
of
Vietnam
veterans.

As
a
Vietvet
himself,
Meshad
had
firsthand
knowledge
about
the
challenges
posed
by

the
VA
system.
Meshad
was
gravely
wounded
while
working
as
a
medical
director
in
Vietnam.

Following
his
return,
he
endured
several
painful
operations
and
struggled
intensely
to
come
to

terms
with
what
happened
to
him
as
a
soldier
and
as
a
veteran.
This
experience
led
him
to

organize
on
behalf
of
Vietnam
veterans
and
to
openly
criticize
the
adequacy
of
VA
services

(MacPherson,
2009).
Meshad’s
report
was
blunt
and
unflattering.
He
noted
that
veterans
were

afraid
to
be
honest
and
open
about
their
condition,
the
hospital
staff
was
hostile
and

unresponsive,
and
most
VA
services
were
useless
(W.
J.
Scott,
1993,
p.
36).
May
used
the
report

to
press
for
changes
in
the
VA
system.
Director
John
Valance
authorized
Meshad
to
create
the

Vietnam
Veteran
Resocialization
Unit
within
the
Brentwood
VA
and
set
up
“storefront
clinics”

where
rap
groups
were
held
(Bloom,
2000,
p.
32).

Meshad’s
“simple
and
pragmatic”
philosophy
was
drawn
“from
his
own
experience

rather
than
orthodox
psychiatry.”
He
felt
Vietvets
needed
“the
opportunity
to
articulate
and

make
sense
of
their
combat
experiences”
as
well
as
meaningful
employment.
Meshad
would

reassign
any
psychiatrists
that
did
not
conform
to
this
therapeutic
framework.
Many

69

psychiatrists
and
psychologists,
accustomed
to
deference
in
the
VA
setting,
resented
this

arrangement.
Nevertheless,
May
and
Valance
continued
to
back
Meshad.
The
activities
at
the

Brentwood
facility
eventually
became
the
model
for
a
national
program
adopted
by
the
VA
in

1979
(W.
J.
Scott,
1993,
p.
36).

The
antiwar
movement
played
a
vital
role
in
biopolitics
during
the
1970s.
This
period

witnessed
the
emergence
of
civil
society
groups
that
tried
to
meet
the
needs
of
Vietnam

veterans
either
by
transforming
the
VA
from
inside
or
supplementing
these
resources
from
the

outside.
However,
the
radical
and
reform
trajectories
both
offered
partial
solutions.
Many

veterans’
advocates
believed
that
lasting
systemic
reform
required
a
change
in
official

psychiatric
nomenclature.

Medico-‐Scientific
Discourse:
An
Expert
Debate
Over
Psychiatric
Nomenclature
(1975-‐1979)

Through
varied
self-‐organized
initiatives
and
internal
VA
reforms,
VVAW
and
other
civil

society
groups
were
somewhat
successful
at
meeting
the
needs
of
troubled
Vietvets.
Even
still,

the
lack
of
an
official
diagnosis
for
post-‐combat
trauma
remained
a
pressing
issue
in
technical

and
legal
contexts,
such
as
the
legislative
process.
In
fact,
this
was
one
of
the
major
issues

holding
up
Senator
Cranston’s
readjustment
counseling
bill.
Guy
McMichael
(as
cited
in
Scott,

1993),
who
served
as
legal
counsel
for
SCVA
from
1971-‐1976,
recalled
the
readjustment
bill

language
was
atypically
vague
since
“there
was
no
definable
[diagnosis]
known
as
‘post-‐
traumatic
stress
syndrome.’
Moreover,
“attitudes
were
intermixed
with
whatever
medical

values
[these
possible
diagnoses]
might
have,
and
[the
bill]
became
very
contentious
and
was

contentious
during
most
of
the
70s”
(p.
69).

70

Official
representation
matters,
especially
in
the
context
of
criminal
proceedings.
At

some
point
in
the
early
1970s,
a
public
defender
in
Ashbury
Park,
New
York,
attempted
to
use
a

‘traumatic
war
neurosis’
defense
in
a
case
in
which
his
client,
a
Vietvet,
was
charged
with

destruction
of
property.
The
judge
denied
the
defense
on
the
grounds
that
there
was
no
such

listing
in
DSM-‐II.
The
attorney
contacted
Shatan
asking
for
advice.
He
suggested
the
attorney

contact
Robert
Spitzer,
the
chair
of
the
DSM-‐III
committee.
Spitzer
told
the
attorney
there
were

no
current
plans
to
include
a
combat-‐related
disorder
in
DSM-‐III
(Bloom,
2000).
Word
got
back

to
Shatan
through
a
reporter
for
the
Village
Voice.
The
news
caught
Shatan
by
surprise.
He

believed
that
sufficient
empirical
evidence
existed
to
support
a
diagnostic
entity
for
combat-‐
related
stress,
but
he
knew
that
he
and
his
colleagues
would
have
to
organize
quickly
to
make

sure
it
was
included
in
DSM-‐III
(Scott,
1993).

Two
Rival
Networks:
Post-‐Vietnam
Syndrome
vs.
Disorder
Otherwise
Unspecified

The
trajectory
of
public-‐technical
discourse
shifted
to
questions
of
diagnosis
and

nomenclature.
First,
Shatan
and
Smith
secured
a
grant
from
the
American
Orthopsychiatric

Association
(AOA)
to
write
up
a
diagnostic
entity
for
combat-‐related
stress.
Next,
they
reached

out
to
John
Talbott,
the
head
of
the
New
York
City
chapter
of
the
New
York
Psychiatric

Association.
A
few
years
earlier,
Talbott
(1969)
had
written
an
article
criticizing
DSM-‐II
over
the

mysterious
disappearance
of
the
‘gross
stress
reaction’
listing.
Talbott
was
a
colleague
of

Spitzer’s
and
an
influential
voice
in
APA.
He
sponsored
monthly
meetings
in
New
York
where
he

invited
Shatan,
Haley,
and
others
to
give
presentations
on
the
mental
health
issues
observed
in

Vietnam
veterans
to
raise
awareness
and
gain
visibility
within
APA.

71

In
1975,
Shatan’s
group
participated
in
high
profile
meetings
at
all
the
major
related

associations
including
the
AOA,
APA,
the
American
Psychological
Association
(ApA),
and
the

American
Sociological
Association
(ASA).
That
year,
the
group
arranged
a
meeting
with
Spitzer

at
the
APA
annual
conference
in
Anaheim,
California.
Spitzer
explained
that
there
were
other

researchers
studying
veterans’
readjustment.
The
most
notable
of
these
were
a
pair
of

epidemiologists
–
John
Helzer
and
Lee
Robins
–
from
the
University
of
Washington
in
St.
Louis

(WUSTL).
Samuel
Guze,
chair
of
the
department
of
psychiatry
at
WUSTL,
believed
the
future
of

the
psychiatry
rested
upon
its
ability
to
demonstrate
that
it
could
diagnosis
a
given
condition

and
treat
it
(Guze
&
Healy,
2000,
p.
398).
“These
issues
will
not
be
settled
by
debate
but
by

data”

(Guze,
1970,
p.
662).
Such
data
necessitated
experimental
designs
with
controlled

observations
that
allow
scientists
to
identify
causal
relationships
between
variables.
WUSTL

scientists
took
the
position
was
that
the
techniques
used
in
medicine
–
epidemiology,

laboratory
studies,
and
family
studies
–
were
the
most
appropriate
tools
for
the
production
of

psychiatric
knowledge.
Helzer
and
Robins
argued
that
DSM-‐III
did
not
require
a
separate

diagnostic
entity
for
combat-‐related
stress.
Spitzer
challenged
the
Shatan
and
his
associates
to

disprove
that
claim.
In
response,
Haley,
Lifton,
Shatan,
Smith
and
others
formed
the
Vietnam

Veterans
Working
Group
(VVWG;
Scott,
1990b).

A
decision
by
the
APA
to
recognize
an
entity
that
could
be
used
to
diagnose
combat-‐
trauma
would
be
a
boon
for
individuals
seeking
to
secure
additional
resources
for
Vietnam

veterans
and
to
restore
their
tainted
image
in
the
eyes
of
the
American
public.
But
this

outcome
was
not
a
foregone
conclusion.
According
to
Scott
(1990b):

72

PTSD
is
in
DSM-‐III
because
a
core
of
psychiatrists
and
veterans
worked
consciously
and

deliberately
for
years
to
put
it
there.
They
ultimately
succeeded
because
they
were

better
organized,
more
politically
active,
and
enjoyed
more
lucky
breaks
than
their

opposition.
(p.
307-‐308)

Without
the
active
efforts
of
an
influential
group
of
investigators,
it
is
doubtful
an
entity
such
as

PTSD
would
have
entered
official
psychiatric
nomenclature
in
1980.
But
rhetoricians
are
keenly

aware
of
the
limits
of
organization,
activity,
and
luck.
Ultimately,
APA
recognized
PTSD
because

the
VVWG
made
a
more
persuasive
argument
than
their
opponents
from
WUSTL.
The

remainder
of
this
chapter
analyzes
the
events
leading
up
PTSD’s
recognition
as
medico-‐
scientific
argument
over
the
technical
definition
of
combat
trauma
in
order
to
clarify
exactly

why
decision-‐makers
found
particular
arguments
more
persuasive.
This
debate
is
reconstructed

from
arguments
advanced
in
variety
of
forums
including
journal
articles,
conference

presentations,
books,
op-‐eds,
and
formal
and
informal
documents
produced
by
and
for
the

committee
on
reactive
disorders
reporting
to
the
DSM-‐III
Committee.

The
Topoi
of
Nosological
Controversy:
Should
Nomenclature
Be
Based
on
Phenomenology
or

Etiology?

I
define
a
nosological
controversy
is
one
in
which
medical
authorities
cannot
reach

agreement
on
diagnostic
nomenclature
because
of
disagreements
regarding
the
adequacy
of

scientific
models,
the
means
of
inclusion/exclusion,
acceptable
forms
of
proof,
and
standards
of

presumption.
There
are
several
outstanding
philosophical
disputes
in
western
psychiatry

including
(a)
mind-‐body
relationships,
(b)
the
belief
in
determinism
versus
indeterminism
in

human
behavior,
(c)
the
place
of
moral
values,
and
(d)
a
preference
for
autonomy
versus

73

conformity
(Weckowicz,
1984,
pp.
9–18).
These
topoi
reflect
two
different
perspectives
on
the

nature
of
human
beings
and
human
science:
a
scientific
(logical-‐empiricist)
perspective
and
a

moral-‐philosophical
(hermeneutical-‐dialectical)
perspective
(p.
321)
Nosological
controversies

emerge
when
psychiatrists
dogmatically
cling
to
one
set
of
assumptions
instead
of
treating

different
models
as
complimentary
(Radnitzky
&
Giorgi,
1973).

This
dynamic
was
apparent
as

APA
made
preparations
to
release
DSM-‐III.

During
the
1960s,
the
psychiatric
establishment
fell
out
of
favor
as
a
number
of
social

movements
questioned
the
validity
of
Freudian
models
and
the
legitimacy
of
the
psychiatric

institutions
as
extensions
of
state
power.
Leaders
in
the
antipsychiatry
movement
were

prominent
figures
within
the
counterculture
of
the
1960s.
Their
message
resonated
with
the

anti-‐authority
ethos
of
the
time
and
this
made
it
attractive
to
college
students
and
intellectuals

(Decker,
2013).

Coincidentally,
pressure
began
to
mount
for
doctors
to
revise
their
reliance
on

psychodynamic
approaches
as
private
insurance
companies
and
public-‐third
party
payers

started
to
foot
the
bill
for
expensive
psychotherapy
sessions
(Mayes
&
Horwitz,
2005).
Thus

DSM-‐III
presented
an
opportunity
to
restore
the
field’s
reputation.
Spitzer
used
his
influence
as

the
chair
of
the
DSM-‐III
committee
to
set
the
discipline
down
the
path
to
becoming
a
modern

science.

When
neither
etiology
not
underlying
process
could
be
scientifically
validated,
Spitzer

and
his
associates
at
WUSTL
felt
nosological
classification
should
be
based
on
shared

phenomenological
characteristics.
A
diagnostic
construct
has
validity
to
the
extent
that
the

defining
features
of
the
disorder
provide
useful
information
beyond
that
which
is
contained
in

the
definition
of
the
disorder.
This
information
may
be
about
etiology,
risk
factors,
or
the
usual

74

course
of
the
illness.
The
most
important
validity
factor
is
whether
the
diagnosis
helps
in

decisions
about
management
and
treatment.
The
members
of
the
DSM-‐III
committee
believed

the
phenomenological
approach
to
diagnosis
would
allow
researchers
with
different
theoretical

perspectives
on
the
etiology
of
mental
disorders
to
use
the
same
diagnostic
system
reliably

(Bayer
&
Spitzer,
1985;
Feighner
et
al.,
1972;
Spitzer,
2001).
A
diagnosis
is
reliable
to
the
extent

that
clinicians
can
independently
agree
on
its
identification
in
a
heterogeneous
group
of

patients.
Spitzer
believed
a
descriptive
system
would
provide
a
means
to
hold
doctors

accountable
and
control
the
over-‐medicalization
of
behaviors
deemed
socially
unacceptable.

Although
it
is
possible
for
a
reliable
diagnosis
to
lack
validity,
unreliability
provides
an
upper

limit
for
valid
diagnoses.
In
other
words,
it
is
impossible
to
study
a
disorder
to
develop
effective

treatment
without
first
recognizing
the
disorder.
Spitzer
(2001)
took
the
position
that
a

common
nosological
system
would
facilitate
experimental
and
epidemiological
studies
that

might
validate
psychiatric
knowledge
and
place
the
discipline
on
the
equal
footing
with
the
rest

of
modern
medicine.

Opposing
this
perspective
were
psychiatrists
who
argued,
“decades
of
experience
with

clinically
complex
issues
[involving]
psychotherapeutic
work
with
patients
had
established
the

validity
of
the
psychodynamic
perspective”
(Bayer
&
Spitzer,
1985,
p.
187).
Most
American

psychiatrists
in
the
postwar
era
were
trained
in
the
psychoanalytic
tradition.
The
prevalence
of

psychodynamic
perspectives
can
be
traced
back
to
the
U.S.
military’s
effort
to
mobilize
civilian

psychiatry
to
optimize
the
operations
of
the
medical
corps
during
WWII.
Many
civilian

psychiatrists
had
direct
experience
treating
soldiers
diagnosed
with
war
neurosis
during
the
war

(Decker,
2013;
Leys,
2010).
Dynamically
inclined
doctors
were
very
skeptical
of
the
perspective

75

espoused
by
the
DSM
committee
because
it
denigrated
the
discipline’s
traditions
while

marginalizing
Freudian
theories
and
techniques
(Guze
&
Healy,
2000).
Indeed,
Spitzer
and
his

associates
went
to
great
lengths
to
exclude
diagnoses
that
implied
unproven
dynamic
theories

about
etiology.
In
what
was
considered
a
very
bold
move
at
the
time,
the
DSM-‐III
committee

opted
to
completely
eliminate
“neurosis”
as
a
diagnostic
class
because
most
psychiatrists
felt

this
was
an
etiological
rather
than
a
descriptive
concept
(Bayer
and
Spitzer,
1985,
p.
187).
This

philosophical
dispute
over
the
superiority
of
a
nosological
system
that
prioritized

phenomenology
or
etiology
provided
the
initial
point
of
departure
the
argument
between

WUSTL
and
the
VVWG.

Two
Trajectories:
Post-‐Vietnam
Syndrome
or
Disorder
Otherwise
Unclassified?

The
VVWG’s
positive
trajectory
rationalized
the
recognition
of
an
entity
that
could
be

used
to
diagnose
troubled
Vietnam
veterans.
The
VVWG
included
stakeholders
from
different

argumentative
fields
including
humanistic
practitioners
(Haley),
dynamically
inclined
physicians

(Lifton
and
Shatan)
and
veterans
(Smith).
These
advocates
argued
that
combat
exposure
in

Vietnam
was
psychopathogenic
and
resulted
in
“Post-‐Vietnam
Syndrome”
(PVS).
Shatan
(1973)

laid
out
the
case
for
PVS
in
a
paper
presented
at
the
AOA’s
annual
meeting.
The
paper

explained
that
combat
service
in
Vietnam
resulted
in
the
delayed
onset
of
a
distinct
syndrome

marked
by
guilt
feelings
and
self-‐punishment;
the
feeling
of
being
scapegoated;
rage
and
other

violent
impulses
against
indiscriminate
targets;
and
alienation
from
one’s
own
feelings
and

from
other
people.
Any
psychiatrists
trained
in
the
Freudian
tradition
should
recognize
this

array
of
symptoms
as
the
hallmark
of
frustrated
mourning
or
submerged
grief.
Shatan
took
the

position
that
the
primary
obligation
of
clinicians
dealing
with
traumatized
veterans
was
to

76

facilitate
the
work
of
mourning.
With
adequate
support,
veterans
could
open
themselves
again

to
feelings,
and
to
make
bearable
their
journey
back
to
civilian
reality
(pp.
645-‐646).

The
case
for
PVS
did
not
lend
itself
to
experimental
designs
because
the
VVWG
had

“neither
universal
samples
of
a
total
population
of
counter-‐guerrilla
warriors,
nor
adequate

matching
controls”
(Shatan
1973,
p.
645).
The
data
were
drawn
almost
exclusively
from

personal
narratives
that
Vietnam
veterans
offered
in
the
New
York
rap
groups.
Since
the
VVWG

got
involved
with
the
rap
groups
through
their
antiwar
activism,
the
objectivity
of
this
data
was

put
into
question.
Yet,
Lifton
(1976)
maintained
that
involvement
in
politics
did
not

compromise
the
scientific
authority
of
the
Working
Group.
In
his
view,
the
best
science

emerged
from
a
dialectic
between
ethical
involvement
and
intellectual
rigor.
From
his

perspective,
the
VVWG
decision
to
foreground
their
political
commitments
made
their
work

more
rather
than
less
scientific.
Moreover,
Shatan
(1973)
argued
WUSTL’s

insistence
that

psychiatric
syndromes
needed
to
be
validated
with
exclusively
statistical
support
was
akin
to

“playing
Russian
Roulette
with
the
lives
and
minds
of
many
Vietnam
veterans”
(p.
640).

The
VVWG’s
affirmative
trajectory
clashed
with
the
one
espoused
by
Helzer,
Robins
and

their
associates
from
the
WUSTL.
These
advocates
took
the
position
that
unvalidated
conditions

needed
only
be
referred
to
as
‘disorders
otherwise
unclassified’
(Feighner
et
al.,
1972).
At

bottom,
they
felt
that
including
an
unproven
post
combat
disorder
would
weaken
the
principle

underlying
DSM-‐III
and,
thus,
the
credibility
of
the
field
as
a
whole:

To
abdicate
the
role
of
constructive
critic
is
to
abandon
the
field
to
the
tenderminded.

The
difficulties
of
the
field
seem
to
require
just
the
opposite:
a
commitment
to

toughmindedness.
Just
because
it
is
difficult
to
make
valid
observations
and
accurate

77

measurements,
just
because
objectivity
is
so
elusive,
just
because
unintended
error
is
so

easy,
it
is
necessary
to
be
even
more
careful
than
would
be
necessary
in
a
more

developed
field.
(Guze,
1970,
p.
670)

In
response
to
the
charge
that
a
toughminded
approach
in
this
instance
was
inhumane,
Guze

(1970)
wrote,

It
is
asserted,
or
implied,
that
a
critic
who
demands
‘data’
who
asks
about
controls,
who

insists
that
the
burden
of
proof
is
on
the
affirmative,
reveals
thereby
that
he
is
not

interested
in
people.

Scientific
skepticism
is
in
no
way
incompatible
with
compassion

for
the
sick
or
disabled.
In
fact,
it
is
the
desire
to
help
patients
that
causes
one
to
be

frustrated
by
the
lack
of
definite
knowledge
about
what
really
helps
and
what
does
not.

(p.
670)

The
path
maximizing
therapeutic
interventions
was
through
scientific
understanding
of

psychopathology.
Thus
the
negative
trajectory
placed
the
burden
of
proof
on
those
who

asserted
that
a
disease
existed
in
the
first
place.
Burke
(1974)
has
identified
this
rhetorical
style

as
the
“naturalistic”
strategy
of
communicating
information
about
scientific
facts:

There
is
a
so-‐called
science
that
identifies
‘truth’
with
‘debunking;
-‐-‐
and
I
am
simply

trying
to
point
out
that
such
‘truth’
is
no
less
a
‘stylization’
than
any
other.
The
man
who

embodies
it
in
his
work
may
be
as
‘tender-‐minded’
as
the
next
fellow;
usually,
in
fact,
I

think
he
is
even
more
so
–
as
will
be
revealed
when
you
find
his
‘hard
hitting’
and
one

point
in
his
communication
compensated
by
a
great
humanitarian
softness
at
another

point.
(p.
128)

78

Stylization
in
some
form
–
sentimentalization
or
brutalization
–
is
inevitable
when

communicating
about
scientific
knowledge,
and
these
styles
impart
meaning
to
the
facts
under

consideration.
Nosopolitics
enforces
accountability
by
placing
science
in
the
context
of
dramas

that
generate
concern
by
rousing
passion.
WUSTL
advocates
and
the
VVWG
argued
their

respective
commitments
made
their
work
more
scientific;
they
simply
disagreed
about
which

values
characterized
good
science.
WUSTL,
the
ideal
scientist
was
brave
enough
to
admit
that

her
ignorance:
For
the
VVWG,
the
doctor
that
let
incomplete
knowledge
or
substandard

instruments
stop
her
from
caring
for
the
sick
was
no
scientist
at
all.

WUSTL
scientists
were
unimpressed
by
the
type
of
evidence
marshaled
by
the
VVWG.

They
argued
specific
associations
needed
be
to
proven
before
causal
connections
between

social
environment
and
disorder
could
be
established
(Guze,
1970).
It
was
true
thousands
of

combat
veterans
turned
to
drugs
and
alcohol
to
cope
with
their
experiences,
but
this
fact
alone

was
not
sufficient
evidence
to
establish
that
Vietnam
combat
was
psychopathogenic.
It
merely

begs
the
question:
Did
being
assigned
to
combat
roles
make
it
more
likely
that
men
would
later

be
diagnosed
with
depressive
symptoms?
Or
were
combat
assignments
influenced
by
pre-‐
Vietnam
characteristics
–
uncontrollable
aggression
or
problems
with
authority
–
that
also

predicted
psychopathology?
Retrospective
designs
obtained
from
hospitals,
drug
clinics,
and

other
legal
or
medical
channels
did
not
permit
researchers
to
test
the
direction
of
association

between
variables
(Helzer,
Robins,
&
Davis,
1976a).

79

WUSTL
advocates
supported
their
arguments
with
epidemiological
studies
designed
to

test
the
causal
connections
between
combat
service
and
the
psychological
disturbances

observed
in
Vietnam
veterans
(Helzer
et
al.,
1976a;
Helzer,
Robins,
&
Davis,
1976b;
Helzer,

Robins,
Wish,
&
Hesselbrock,
1979).
In
one
study,
after
controlling
for
“pre-‐service
factors
that

are
clearly
related
to
later
psychological
adjustment,”
including
age,
race,
education,
marital

status,
suspected
antisocial
personality,
and
drug
use,
Helzer,
Robins,
Wish,
and
Hesselbrock

(1979)
found
that
“the
weak
association
between
combat
experience
and
depressive
symptoms

would
suggest
that
the
Viet
Nam
conflict
produced
few
long-‐term
psychological
effects”
(pp.

528-‐529).

In
another
study,
Helzer,
Robins,
and
Davis
(1976a)
found
that
the
most
striking

predictor
of
narcotic
abuse
was
a
premilitary
history
of
antisocial
behavior.
The
researchers

quantified
this
variable
by
constructing
a
10-‐point
deviancy
scale
on
which
each
man
received
a

maximum
of
two
points
in
each
of
five
categories
of
behavior
(arrests,
fighting,
early

drunkenness,
truancy,
and
school
incompletion).
Information
on
pre-‐service
history
was

obtained
via
self-‐report
and
official
government
records.

In
many
ways,
the
negative
trajectory
seemed
to
converge
with
the
rationale
for

efficiency
observed
in
political
debates
in
the
1970s.
First,
federal
drug
enforcement
agencies,

the
DOD,
and
the
VA
funded
most
of
these
studies
through
research
grants.
Second,

government
agents
generally
adopted
the
position
that
the
majority
of
the
psychological

disturbances
observed
in
Vietnam
GIs
should
be
dealt
with
administratively
instead
of
through

medical
channels
(Medical
Care,
1969).
The
findings
and
conclusions
WUSTL
produced
seemed

to
corroborate
the
government’s
claim.
Reasonable
minds
may
disagree
as
to
whether
it
is

appropriate
to
lump
a
wide
range
of
behaviors
such
as
a
failure
to
complete
high
school
(which

80

may
be
conceptually
distinct
from
truancy)
or
fighting
(which,
depending
on
context,
might
be

considered
socially
appropriate
given
the
times)
under
a
single
variable,
but
it
is
hard
to
dispute

that
the
variable
labeled
“a
history
of
anti-‐social
behavior”
bears
more
than
a
passing

resemblance
to
General
Whelan’s
description
of
soldiers
suffering
from
“weakness
of

motivation
or
“some
underlying
personality
disorder”
(Helzer
et
al.,
1976a,
p.
188;
Medical

Care,
1969,
p.
149).
Taken
together,
these
trajectories
give
the
impression
that
Vietnam

veterans
had
trouble
reintegrating
into
American
society
because
they
lacked
their
forbearers’

moral
fortitude
and
sense
of
duty.

Building
a
reasonable
case

Unfortunately
for
the
VVWG,
the
tough-‐minded
empiricists
on
the
DSM-‐III
committee

were
the
final
arbiters
of
the
debate.
Spitzer
had
appointed
researchers
with
whom
he
was

comfortable
in
his
capacity
as
chair.
The
committee
members
generally
adhered
to
the
belief

that
psychiatry
should
adopt
the
medical
model
(Healey
&
Spitzer,
2000,
p.
418).
If
the
VVWG

was
going
to
be
successful,
it
would
need
to
support
its
case
with
data
that
seemed
reasonable

to
the
committee.
To
bolster
the
support
for
it
argument,
the
VVWG
deployed
two

complementary
argumentative
strategies:
(1)
argument
from
parallel
cases
and
(2)
causal

arguments
(Toulmin,
1952).
That
is,
veterans’
advocates
networked
with
different
stakeholders,

borrowing
topics
and
symbols
for
mutual
support.
In
the
end,
the
VVWG
reconstituted
its

rhetorical
network
by
incorporating
clinical
reports
from
war
veterans,
field
studies
of
survivors

of
natural
and
human-‐made
disasters,
and
laboratory
studies
of
stress
response
tendencies.

These
data
were
produced
with
different
instruments,
in
accordance
with
various
systematic

theories,
by
authorities
from
varied
backgrounds
united
by
a
common
sensibility.

81

argument
from
parallel
cases

First,
the
VVWG
identified
similar
stress
syndromes
that
emerged
in
populations

without
the
same
cultural
stigma
as
Vietnam
veterans.
These
associationists
reached

backwards
in
time
to
establish
the
historical
continuity
of
a
psychosomatic
syndrome
related
to

combat
experience.
They
pulled
together
a
workshop
on
combat
disorders
during
AOA’s
annual

meeting
in
1976
and
invited
the
Nancy
Andreasen
(chair
of
the
DSM
subcommittee
on
reactive

disorders)
to
review
the
data
for
their
new
diagnostic
category.
Haley
(as
cited
in
Scott,
1990)

recalls
her
exchange
with
Andreasen:

What
I
did
was
stay
after
work
at
the
VA
and,
without
anybody
knowing
it;
I
went

through
the
records
of
all
the
Vietnam
veterans
we
have
seen
in
a
year.
I
looked
at
what

their
diagnoses
were.
What
I
looked
at
was
the
official,
the
DSM-‐II,
diagnosis
–
the

official
one
that
you
had
to
put
down
coded
in
the
record.
But
then
in
parentheses
[for

some]
was
a
working
diagnosis.
The
working
diagnosis
was
usually
‘traumatic
war

neurosis.’
And
so
what
I
said
was,
‘Look
it,
Nancy,
we
had
to
give
these
guys
…
diagnoses

[consistent
with
DSM-‐II],
but
if
you
look
at
what
[some]
clinicians
are
actually
doing…

they’re
basing
their
treatment
on
the
fact
that
they
recognize
in
these
fellows
similar

traumatic
war
neurosis
as
they
saw
in
the
Second
World
War
and
the
Korean
War

veterans…’
That
really
turned
her
around.
(p.
307)

Apparently,
Andreasen
found
it
significant
that
the
war
neurosis
diagnosis
had
face
validity
with

VA
doctors
who
served
in
early
conflicts.
Perhaps
it
was
proof
positive
that
this
particular

diagnosis
held
clinical
utility
for
doctors
that
were
unlikely
share
the
same
political
leanings
as

the
Working
Group.
In
an
editorial
published
in
the
American
Journal
of
Psychiatry,
Andreasen

82

(2014)
recollected:
“The
purpose
and
the
concept
were
correct,
but
the
name
and
the

specificity
were
not”
(p.
1321).

The
VVWG
also
reached
laterally
to
find
analogies
across
a
range
of
catastrophic
events.

Identifying
similar
conditions
that
occurred
to
civilians
might
be
particularly
useful
strategy
for

persuading
Andreasen
because
she
had
recognized
a
similar
“stress
syndrome
characterized
by

reliving,
indicators
of
autonomic
overarousal,
and
other
such
features”
while
studying
the

psychological
consequences
of
severe
burns
injuries
earlier
in
her
career
(Andreasen,
2014,
p.

1322;
Andreasen
&
Norris,
1972;
Andreasen,
Norris,
&
Hartford,
1971;
Andreasen
&
Noyes,

1975).
The
group
began
to
collaborate
with
Harley
Shands
–
the
chief
of
psychiatry
at
Roosevelt

Hospital
in
New
York.
Shands
had
worked
extensively
with
people
who
had
been
injured

severely
on
the
job.
He
noticed
that
many
of
these
‘compensation
patients’
displayed

symptoms
very
similar
to
those
observed
in
combat
veterans
(W.
J.
Scott,
1990b,
p.
306).
These

dual
strategies
(backward
and
lateral)
risked
diminishing
the
symbolic
utility
of
the
PVS
label

because
they
downplayed
the
significance
of
the
Vietnam
combat
exposure
as
a
uniquely

stressful
environment.
But
in
the
end,
the
label
would
have
little
practical
utility
for
veterans
if

the
group
could
not
persuade
the
committee
to
include
a
formal
diagnosis
in
DSM-‐III.

Proponents
also
analogized
the
vicissitudes
facing
veterans
to
pathologies
that

manifested
in
survivors
of
massive
tragedies.
William
Niederland
and
Henry
Krystal’s
(1971)

research
on
concentration
camp
survivors
proved
useful
in
this
regard.
While
collaborating
with

Lifton
during
a
set
of
workshops
on
massive
psychic
trauma,
they
found
many
similarities

between
the
survivors
of
Nazi
persecutions
and
the
Hiroshima
atomic
bombing
disaster.
Even

though
Niederland
and
Krystal’s
fieldwork
used
concentration
camp
survivors
as
a

83

demonstration
group,
they
argued
their
diagnostic,
phenomenological,
and
therapeutic
findings

apply
to
other
situations
of
massive
psychic
trauma
(Niederland,
1972,
p.
229).
The
similarities

between
individuals
that
survived
the
Holocaust
or
atomic
bombing
of
Hiroshima
extend

beyond
a
common
psychopathology.
Both
groups
were
widely
regarded
as
victims
by
the

American
public
in
the
1970s.
The
VVWG’s
strategy
tapped
into
that
affective
knowledge
and

leveraged
this
cultural
resource
to
rehabilitate
the
image
of
Vietnam
veterans.

causal
argument

Adherents
of
the
medical
model
dismissed
psychodynamic
processes
as
baseless

because
such
phenomena
could
not
be
observed
directly
(Guze
&
Healy,
2000,
p.
399).
In

response,
the
Working
Group
attempted
to
bolster
the
strength
of
its
argument
by

incorporating
quantitative
studies
that
could
demonstrate
the
generality
of
clinical
findings.

They
networked
with
Mardi
Horowitz,
a
cognitive
scientist
who
was
in
the
final
stages
of
his

experimental
research
on
stress
response.
His
goal
was
to
validate
psychodynamic
theories

using
the
tools
of
laboratory
research.
Horowitz
(1993)
believed
psychoanalytic
concepts
could

be
tested
so
long
as
the
design
included:
(1)
a
clear
statement
about
the
psychopathological

states
under
consideration,
(2)
clear
typologies
of
patient
styles
for
the
organization
and

processing
of
thought
and
emotion
during
such
states,
and
(3)
a
clarification
of
the
interaction

between
the
patient’s
style
and
state
and
different
types
of
psychotherapy
(p.
4).
For
example,

cognitive
scientists
could
test
the
hypothesis
that
“intrusive
and
repetitive
thought”
was
a

general
stress
response
tendency
through
experiments
(Horowitz
&
Wilner,
1976,
p.
1343).
In
a

laboratory
setting,
controls
for
population
could
be
introduced
and
low-‐to-‐moderate
level

stress
could
be
induced
using
emotionally
arousing
films.
Intrusive
and
repetitive
thought
could

84

be
operationally
defined,
measured
with
using
self-‐report,
and
quantified
with
content
analysis

procedures.
The
experimental
approach
would
ideally
facilitate
the
progressive
clarification
and

systematization
of
psychoanalytic
concepts
derived
from
clinical
experience
rather
than
archaic

rules
of
thumb.

Horowitz’
research
built
upon
two
distinct
paradigms
for
experimental
research
on

stress:
a
biological/analytic
model
in
which
events
were
defined
in
terms
of
their
objective

intensity,
and
a
cognitive/synthetic
model
in
which
events
were
defined
according
to
internal

assessments
(interpretation,
implications,
meaning)
of
incoming
information.
The

biological/analytic
paradigm
can
be
traced
back
to
the
work
of
Hans
Selye
(1956),
the
biologist

who
famously
defined
stress
as
a
“stereotyped
pattern
of
biochemical,
functional,
and

structural
changes”
in
response
to
“increased
demand”
(p.
14).
From
this
quantitative

perspective,
magnitude
constituted
the
only
significant
characteristic
of
stressors
because
the

body
could
not
distinguish
between
the
qualities
of
stress:
“All
that
counts
is
the
intensity
of

the
demand
for
readjustment
or
adaption.”
Events
associated
with
different
emotions
such
as

“sorrow
and
joy
[sic]”
provoked
“identical
biological
reactions”
(p.
15).
Selye
believed
human

stress
response
patterns
were
not
fundamentally
different
from
those
observed
in
non-‐
humans.

The
earliest
formulation
of
the
cognitive/synthetic
paradigm
for
experimental
research

can
be
traced
to
the
work
of
Richard
Lazarus
(1966),
a
scientist
who
emphasized
the
complexity

of
the
interaction
between
soma,
psyche,
and
milieu.
Taking
Selye’s
classical
paradigm
as
a

point
of
departure,
Lazarus
distinguished
between
“threat”
(psychological
stress)
and
“noxious

85

stressors”
(physiological
stress).
He
contrasted
the
cognitive
processing
paradigm
with

experimental
tradition
in
the
behavioral
sciences
(p.
15).

Lazarus
(1966)
criticized
behaviorists
for
making
sweeping
generalizations
about

complex
human
behavior
based
on
experimental
observations
on
non-‐human
animals.
“In

order
to
a
have
a
general
theory
of
psychological
stress
for
all
animals,
[the
behaviorists]
tends

to
eliminate
categories
which
are
prime
theoretical
tools
for
understanding
the
person”
(p.
15).

Lazarus
believed
affective
processes
were
consequences
rather
than
the
causes
of
the
ways
in

which
“the
animal
or
person
appraises
a
situation”
(p.
70).

He
drew
attention
to
humans’

unique
capacity
for
high
level
cognitive
processing
that
restrains
libidinal
desire
and
facilitates

ethical
reflection.
The
fact
that
Lazarus
did
not
believe
human
stress
response
could
be
reduced

to
some
substrate
that
could
be
measured
physiologically
should
not
be
confused
with
the

claim
that
he
rejected
quantitative
research.
Rather,
he
argued
stress
should
be
considered
a

field
of
study
rather
than
a
specific
process
or
state.
Psychological
Stress
and
the
Coping
Process

(1966)
constituted
Lazarus’
attempt
to
broaden
the
conceptual
net
of
stress
research
and

elaborate
mediating
cognitive
processes
using
a
combination
of
qualitative
and
quantitative

methods.

Lazarus’
experimental
studies
exploring
the
impact
of
stressful
films
were
important

precursors
for
Horowitz’
(1976)
stress
response
model.
The
latter
was
based
on
studies
that

conceptualized
stress
as
a
strain
on
“cognitive
processing”
(Horowitz
&
Wilner,
1976,
p.
1462).

Those
studies
found
that
“[i]ntrusive
and
repetitive
thoughts”
continuously
entered

consciousness
following
traumatic
events.
The
researchers
thought
these
findings
to
signaled

how
difficult
it
was
to
integrate
traumatic
information
with
existing
concepts
of
self
and
beliefs

86

about
the
external
world
(p.
1339).
These
results
seem
consistent
with
the
clinical
picture
of

PVS
proposed
by
the
VVWG:

The
so-‐called
Post
Vietnam
Syndrome
confronts
us
with
the
unconsummated
grief
of

soldiers,
impacted
grief,
in
which
an
encapsulated,
never-‐ending
past
deprives
the

present
of
meaning.
Their
sorrow
is
unspent,
the
grief
of
their
wounds
is
untold,
their

guilt
is
unexpiated.
(Shatan,
1973,
p.
648)

Cognitive
scientists
and
psychoanalysts
produced
knowledge
in
very
different
ways.
They

observed
different
phenomena,
they
used
different
instruments,
and
they
recorded
different

types
of
data.
But
it
appears
that
both
camps
treat
the
relationship
between
trauma
and
the

mind
in
cognitive/synthetic
terms:
That
is,
symptoms
should
subside
to
the
extent
that
patients

successfully
synthesize
new
information
into
a
cohesive
cognitive
schema.

However,
the
influence
of
the
biological/analytic
paradigm
was
evidence
in
this
the

early
experimental
trauma
research.
One
of
most
significant
findings
from
Horowitz
and

Wilner’s
(1976)
study
was
that
the
tendency
to
repetitive
intrusion
was
a
general
response
to

stress
of
any
type,
including
“minor
or
moderately
stressful
events”
(p.
1339).
Moreover,
the

researchers
found
that
repetitive
intrusion
“may
occur
following
the
evocation
of
any
strong

and
undischarged
emotion
of
any
important
but
incompletely
processes
set
of
information”

regardless
of
whether
the
emotion
has
a
positive
or
negative
valence
(p.
1342).
In
other
words,

the
pathological
state
in
question
tended
to
occur
after
all
stressful
events
and
the
only

significant
differences
between
the
disturbances
afflicting
Vietnam
veterans
and
the
recurring

dreams
people
experience
after
watching
violent
or
pornographic
movies,
was
the
magnitude

87

of
stress
involved.
Surprisingly,
the
authors
omitted
any
explicit
reference
to
Selye’s
(1956)

seminal
work
on
the
quantitative
stress
paradigm.

In
contrast,
Horowitz
and
Wilner
(1976)
explicitly
acknowledged
Lazarus’
experimental

methods
as
“important
precursors”
to
their
study
(p.
1339).
The
irony
is
that
Lazarus
would

almost
certainly
find
their
conclusions
about
the
weak
relationship
between
stress
response

and
the
emotional
valence
of
stress
problematic.
The
variable
predicting
stress
response
was

the
kind
of
threat
interpreted
rather
than
degree
of
noxious
stimulus
experienced
in
the

cognitive/synthetic
paradigm.
Lazarus
(1966)
thought
emotional
states
correlated
with
the

quality
of
stress
response
because
the
former
signaled
a
change
in
cognitive
orientation

towards
some
stimulus
object.
He
thought
‘general
stress
responses’
were
artifacts
produced

by
behaviorist
methods:
“A
hypothetical
construct,
such
as
anxiety,
must
not
be
thought
of
in
a

systematic
usage
as
causing
anything
at
all
(p.
25).
Even
though
their
study
operationalized

stress
in
a
way
that
broke
with
the
principle
at
the
core
of
Lazarus’
cognitive/synthetic

experimental
research
paradigm,
Horowitz
and
Wilner
were
able
to
cultivate
a
strong
sense
of

historical
continuity
by
employing
similar
inductions
(short
films)
and
research
instruments

(closed-‐ended
self
report).

It
was
probably
this
historical
narrative,
rather
than
the
logical
implications
of
Horowitz

and
Wilner’s
(1976)
early
work,
that
motivated
the
VVWG
to
incorporate
elements
of
this

cognitive
research
into
the
network
of
evidence
supporting
their
arguments.
The
VVWG’s

revised
argument
seemed
stronger
because
it
included
a
causal
inference
about
human
biology

that
could
be
generalized
beyond
the
specific
context
of
war
veterans.
Moreover,
this
move

allowed
the
group
to
leverage
Horowitz’
reputation
as
a
dedicated
empiricist
to
bolster
its
own

88

credibility.
Experimental
stress
response
models
proved
the
case
and
showed
that
the
group’s

compassion
for
Vietnam
veterans
did
not
cloud
its
judgment
or
interfere
with
a
commitment
to

toughminded
science.

On
the
other
hand,
the
VVWG’s
strategy
entailed
significant
risks.
Rhetorical
networks

create
thin
consensus
by
borrowing
symbols
back
and
forth
for
mutual
support,
but
this
takes

on
the
effect
of
bringing
negative
arguments
into
play
that
were
thought
to
be
previously

settled.
The
reckoning
arrived
as
the
twentieth
century
drew
to
a
close.
A
complete
explanation

of
this
dynamic
is
beyond
the
scope
of
this
chapter.
For
now
it
shall
suffice
to
note
that
evolving

contingencies
forced
humanistic
practitioners
and
dynamically
oriented
physicians
to

reconsider
what
once
seemed
like
a
natural
alliances
with
biologists
and
cognitive
scientists.

When
nosopolitics
over-‐determines
biological/analytic
stress
models
the
moral,
philosophical,

and
hermeneutical
aspects
of
combat
trauma
are
increasingly
marginalized.

Closing
argument:
The
invention
of
PTSD

The
VVWG
outlined
their
final
recommendation
for
coding
in
DSM-‐III
in
a
position
paper

authored
by
Shatan,
Haley,
and
Smith
(1977).
They
called
for
an
entry
labeled
‘catastrophic

stress
disorder,’
with
a
subcategory
called
PTSD.
The
subcommittee
on
reactive
disorders

ultimately
decided
to
recommend
a
diagnosis
under
the
label
‘post-‐traumatic
stress
disorder’
in

January
1978.

Although
Andreasen
wrote
the
entire
text
description
of
the
disorder,
it
appears

almost
exactly
as
the
Working
Group
had
prepared
it
(Andreasen,
2014;
W.
J.
Scott,
1990b).

PTSD
criteria
were
divided
into
four
categories.
The
first
criterion
described
the

traumatic
event
while
the
others
describe
the
nature
and
duration
of
the
symptoms.
This

stressor
criterion
required
the
person
have
experienced
an
event
that
was
“generally
outside

89

the
range
of
usual
human
experience”
(American
Psychiatric
Association,
1980,
p.
236).
All

other
criteria
described
symptom
categories
including
re-‐experiencing
the
traumatic
event;

avoidance
of
stimuli
associated
with
the
trauma;
and
increased
autonomic
arousal.
PTSD
was

relatively
unique
insofar
as
the
vast
majority
of
psychiatric
disorders
included
within
DSM-‐III

were
only
classified
by
the
presence
of
a
particular
behavioral
syndrome;
that
is,
the
collection

of
signs
and
symptoms
that
are
observed
in,
and
characteristic
of,
a
single
condition.
32

In

contrast,
PTSD
was
also
defined
by
its
cause
(a
traumatic
stressor)
and
its
symptoms
were

connected
to
one
another
through
a
theoretical
model
of
illness
that
was
implied,
but
not

explicitly
explained.

PTSD
persuades
because
it
facilitates
autopsis
–
a
rhetorical
figure
that
roughly
means

“seeing
with
one’s
own
eyes.”
33

Stated
differently,
PTSD
is
an
argument
in
which
the
premises

(diagnostic
criteria)
do
not
necessitate
any
particular
conclusion
(etiological
hypothesis).
The

technical
term
for
such
an
argument
is
the
enthymeme
–
a
rhetorical
inference
used
to
reason

about
matters
of
opinion
and
circumstances
that
may
be
affected
by
the
exercise
of
human

agency.
34

Aristotle
described
the
enthymeme
as
a
rhetorical
syllogism
used
in
oratorical

practice
(Bitzer,
1959).The
conclusion
of
a
syllogism
results
of
necessity
from
its’
premises.

Aristotle
believed
syllogisms
were
capable
of
producing
scientific
knowledge
since
only
what
is

32

A
link
between
a
specific
stressor
and
disorder
does
appear
in
the
case
of
‘adjustment
disorder,’
but

adjustment
order
is
not
a
distinct
nosological
entity
in
DSM-‐III.
Rather,
it
is
a
residual
criteria
applied

when
there
is
no
better
explanation
for
the
patient’s
symptoms.

33

Autopsis
is
derived
from
the
Greek
word
‘αὐτοψία.’

34

The
Greek
noun
enthymeme
is
derived
from
the
verb
enthymeisthai,
which
means,
on
the
one
hand,

“to
keep
in
mind,”
and
on
the
other,
“to
consider”
or
“reflect
upon”
(Rossolatos,
2014).
The
former

34

The
Greek
noun
enthymeme
is
derived
from
the
verb
enthymeisthai,
which
means,
on
the
one
hand,

“to
keep
in
mind,”
and
on
the
other,
“to
consider”
or
“reflect
upon”
(Rossolatos,
2014).
The
former

refers
to
rote
patterns
of
remembering,
a
passive
state
in
which
men
are
held
captive
to
sensations
and

feelings
about
past
events,
while
the
latter
refers
to
recollection,
an
active
process
that
involves

interpretation,
reason,
and
identifying
patterns
in
the
natural
world
over
time
(Bloch,
2007).

90

necessarily
the
case
can
be
known
scientifically
(Berti,
1978).
35

Whereas
the
syllogism
was

appropriate
for
inferences
about
necessary
matters,
the
enthymeme
was
appropriate
when

reasoning
about
events
that
could
unfold
in
a
number
of
ways.
PTSD
is
enthymematic
because

the
meaning
of
the
disorder
is
ultimately
a
product
of
the
intertextual
relationship
between
the

official
diagnostic
criteria,
the
supplementary
narrative
description,
the
primary
literature

supporting
the
disorder,
the
secondary
literature
clarifying
and
elaborating
the
DSM-‐III

formulation,
and
the
embodied
knowledge
of
practitioners.
In
other
words,
the
underlying

causal
process
connecting
psychopathology
to
the
traumatic
event
takes
on
different
forms

based
on
what
information
practitioners
find
most
persuasive.

Some
clues
from
the
supplementary
text
suggest
the
meaning
of
the
stressor
to
the

individual
plays
a
causal
role
in
PTSD:
“The
disorder
is
apparently
more
severe
and
longer

lasting
when
the
stressor
is
of
human
design
…
Some
stressors
frequently
produce
the
disorder

(e.g.,
torture),
and
others
produce
it
only
occasionally
(e.g.,
natural
disasters
or
car
accidents)”

(American
Psychiatric
Association,
1980,
p.
236).
The
text
seems
to
imply
proportional

relationship
between
the
moral
valence
of
trauma
and
the
intensity,
duration,
and
frequency
of

35

Aristotle
(trans.
1989)
believed
that
if
the
premises
of
a
sullogismos
met
certain
criteria,
they
were

capable
of
producing
knowledge
(episteme)
through
demonstration
(apodeixis;
Prior
Analytics
I.2,

24b18-‐20).
In
contrast,
the
enthymeme
(enthumēma)
could
not
produce
episteme
because
it
was

derived
from
probable
premises
(eikota)
and
signs
(semeia)
[Rhetoric
I.I.3,
11].
The
idea
that
epistemic

knowledge
can
be
produced
through
deduction
survives
in
contemporary
systems
of
knowledge

production.
While
the
process
of
that
the
scientific
method
proceeds
inductively
(observe,
record,

analyze,
explain);
sometimes
the
intersubjective
reasoning
that
animates
that
process
proceeds
in
a

deductive
fashion:
“To
give
a
causal
explanation
of
an
event
means
to
deduce
a
statement
which

describes
it,
using
as
premises
of
the
deduction
one
or
more
universal
laws,
together
with
certain

singular
statements,
the
initial
conditions”
(Popper
[1934]
1959,
pp.
87-‐88).
Scientists
use
empirical

evidence
to
both
revise
outdated
assumptions,
and
to
add
power
their
deductions.
The
end
result
of
this

knowledge
production,
according
Jensen
and
Richter
(2003),
is
“a
set
of
systems
of
statements

organized
deductively”
(p.
211).

91

pathology.
Such
an
explanation
would
be
most
consistent
with
the
cognitive/synthetic
stress

perspectives
espoused
by
Lazarus
(1966).

At
the
same
time,
other
contextual
clues
point
to
an
etiological
signature
that
is

completely
external
to
the
subjective
experience
of
the
patient.
The
DSM-‐III
PTSD
diagnosis

required
the
patient
to
meet
all
of
the
diagnostic
criteria,
while
criterion
A
required
the
patient

be
exposed
to
an
event
“that
would
evoke
significant
symptoms
of
distress
in
most
people”

(American
Psychiatric
Association,
1980,
p.
236).
This
meant
that
reactions
to
certain
stressors

–
floors
and
earthquakes
–
could
be
classified
as
PTSD,
while
identical
behaviors
that
developed

in
response
to
different
stressors
–
business
losses
or
marital
conflict
–
could
not.
This
implied

the
magnitude
of
the
stressor
was
inversely
proportional
to
influence
of
idiosyncratic
cognitive

factors
that
made
individuals
more
or
less
resilient
to
traumatic
stress
reactions.
In
addition
to

textual
evidence
from
the
manual,
external
evidence
supporting
for
the
objective
interpretation

of
the
traumatic
stressor
was
ample.
In
a
textbook
published
the
same
year
APA
released
DSM-‐
III,
Andreasen
(1980)
compared
the
traumatic
stressor’s
role
in
PTSD
to
“the
role
of
force
in

producing
a
broken
leg”:
“It
is
normal
for
a
leg
to
break
if
enough
force
is
applied,
although
a

broken
leg
is
a
pathological
condition”
(p.
1519).
The
assumption
that
stressor
magnitude
can

be
measured
objectively
seems
to
be
more
consistent
the
biological/analytic
perspective

displayed
in
the
work
of
Selye
(1965).

Enthymemes
persuade
because
they
omit
“those
parts
of
the
argument
which
are

known
to
the
audience
and
which
they
can
fill
in
for
themselves”
(Braet,
1999,
p.
108).
The

intertextual
relationship
between
the
premises
constituting
the
PTSD
diagnosis
allowed

researchers
to
fill
in
‘missing
parts’
of
the
argument
(etiology)
with
background
knowledge
and

92

topical
hypotheses
unique
to
their
particular
disciplines
(Hacking,
1992b).
When
these

interlocutors
encountered
audiences
that
might
be
ambivalent
or
hostile
to
what
they
knew

implicitly,
the
explicit
knowledge
contained
in
the
official
diagnostic
criteria
(phenomenological

observations)
came
to
the
fore,
while
tacit
knowledge
receded
into
the
background.
Such

background
knowledge
was
not
forgotten
during
these
moments:
It
simply
lied
dormant
until
it

achieved
circulation
with
another
audience
(Jensen
&
Richter,
2003,
p.
214).

In
sum,
PTSD
is
an
autopic
argument
that
rearranged
associative
networks
of
words,

thoughts,
feelings,
practices,
and
objects
by
temporarily
bridging
different
habits
of
conceiving

and
ordering.
Enthymemes
are
rhetorical
channels
that
permit
advocates
to
navigate
back
and

forth
between
different
streams
of
composition
(Rossolatos,
2014).
PTSD
achieved
this
by

allowing
interlocutors
to
seamlessly
oscillate
back
and
forth
between
different
fields
of

argument
(etiological
vs.
phenomenological;
biological/analytic
vs.
cognitive/synthetic)

characterized
by
particular
concepts,
instruments,
and
values.
Thus
PTSD
made
it
possible
for

the
VVWG
to
inscribe
a
provisional
consensus
regarding
the
gravity
of
certain
traumatic
events,

while
accommodating
dissent
about
the
mechanism
of
the
underlying
pathology.

Conclusion:
The
Initiation
of
a
Shallow
Network
Consensus
(1978-‐1980)

The
energy
driving
the
controversy
over
veterans’
readjustment
dissipated
once
a
term

emerged
in
medico-‐scientific
discourse
that
allowed
veterans’
advocates
to
translate
the
illness

narratives
circulating
in
the
public
culture.
The
official
recognition
of
PTSD
by
the
APA
made
it

possible
for
dynamic
clinicians
to
be
sympathetic
to
the
plight
of
veterans
who
had
committed

unspeakable
deeds
without
being
perceived
as
tender-‐minded.
By
the
same
token,
the
PTSD

93

diagnosis
provided
VA
doctors
a
means
to
distinguish
legitimate
psychiatric
incapacity
from

weak
motivation
or
an
underlying
personality
disorder.

Once
medico-‐scientific
discourse
and
public
culture
were
aligned,
the
presumption
in

favor
of
intervention
on
behalf
of
Vietnam
veterans
shifted
in
the
political
policy
debates
as

well.
Momentum
gathered
behind
legislation
creating
readjustment
counseling
for
Vietnam

veterans
in
the
late
1970s.
Alan
Cranston
had
assumed
the
chair
of
the
Senate
Committee
on

Veterans
Affairs
during
this
period.
In
1977,
President
Jimmy
Carter
appointed
Max
Cleland
the

Administrator
of
Veterans’
Affairs.
Cleland
was
a
disabled
Vietnam
veteran
who
was
sensitive

to
this
groups
unique
psychological
and
practical
needs
(Bloom,
2000).
The
next
year,
the

eleven
Vietnam-‐era
veterans
in
Congress
formed
an
official
caucus,
the
Vietnam
Veterans
in

Congress
(VVC).
Looking
to
build
on
the
momentum
generated
by
the
APA’s
decision
to

recognize
PTSD,
the
VVA
proposed
a
bill
extending
benefits
and
creating
additional
programs
in

the
areas
of
health,
education,
and
employment.
The
bill
included
Cranston’s
proposals
on

readjustment
counseling
as
well
as
drug
and
alcohol
rehabilitation
programs
for
Vietnam

veterans
but
changed
the
language
of
the
bill
to
be
more
consistent
with
the
discourse
of
PTSD

(W.
J.
Scott,
1993).

Unfortunately,
Ray
Roberts
(HCVA
chair)
was
still
hostile
to
the
prospect
of

readjustment
counseling.
He
felt
that
special
programs
for
Vietnam
veterans
were
unnecessary

because
Vietvets
were
a
minority
within
the
veterans’
organizations.
The
VVC
requested
a

formal
hearing
to
discuss
the
VVA
but
Roberts
refused.
The
caucus
tried
to
arrange
a
deal
gave

the
House
and
Senate
committees
on
veterans’
affairs
substantial
say
in
selecting
the
sites
for

future
VA
facilities.
The
deal
effectively
tied
the
fate
of
the
VVA
to
a
larger
package
of
VA
health

94

care
programs.
The
opportunity
for
pork
barrel
funds
made
the
deal
enticing
to
many
in
the

House,
but
Roberts
allowed
the
deal
to
die
in
committee.
Ultimately,
the
deal’s
failure
hurt

older
veterans
as
much
as
it
hurt
Vietnam
veterans
(W.
J.
Scott,
1993).

However,
this
public
failure
created
momentum
for
new
veterans’
legislation
The
VVC

reintroduced
the
package
deal
in
1979
with
renewed
optimism.
According
to
McMichael
(cited

in
Scott,
1993),
legislative
success
was
now
in
the
cards:

I
mean
now
you
had
the
administration
backing
you,
and
Senate
backing
it,
and
you
had

a
changing
attitude
on
the
part
of
veterans’
organizations.
You
had
a
disabled
veteran

heading
the
VA
strongly
urging
its
passage.
At
that
point
is
was
on
track
and
no
one
was

going
to
derail
it.”
(p.
69)

That
year
the
bill
passed
both
houses
and
on
July
13,
1979,
President
Carter
signed
Public
Law

96-‐22
to
establish
the
Vietnam
Veterans’
Outreach
Program
(VVOP)

The
VVOP
authorized
a
national
network
of
Vet
Centers:
VA
facilities
providing

readjustment
counseling
based
off
the
model
established
at
the
Brentwood
facility
under
Shad

Meshad’s
leadership.
Vet
Centers
were
to
be
located
in
the
community
away
from
other
VA

facilities
(Bloom,
2000).
They
provided
individual
counseling,
rap
groups,
in
addition
to
other

services
and
they
were
supposed
to
be
staffed
by
trained
para-‐professionals
(no
higher
level
of

education
than
a
master’s
degree)
rather
than
experts
(psychiatrists
or
psychologists).
The
VA

Department
of
Medicine
and
Surgery
had
authority
of
the
logistical
aspects
of
Vet
Centers
but

exerted
no
control
over
programming
(W.
J.
Scott,
1993).

95

Shortly
after
the
release
of
DSM-‐III
in
1980,
the
VA
established
criteria
for
a
service-‐

connected,
psychiatric
disability
rating
for
PTSD.
By
January
1983,
the
VA
had
established
136

Vet
Centers
around
the
country:

Almost
overnight,
the
Federal
Government
was
pouring
millions
of
dollars
to
establish
a

national
network
of
community
centers
to
treat
Vietnam
War
veterans
and
train
the

professionals
necessary
to
work
in
them.
This
naturally
led
to
a
need
for
institutions
and

systems
to
address
this
new
interest.”
(Figley,
2002,
p.
20)

In
other
words,
a
provisional
consensus
anchored
by
the
concept
of
PTSD
temporarily
brought

controversy
to
closure.
In
the
decades
that
followed,
the
nosopolitics
of
postwar
trauma

stabilized
traumatology
rapidly
matured
as
a
modern
science.
Chapter
three
traces
the

rhetorical
trajectories
of
nosopolitics
as
it
achieved
positive
spiral
and
rendered
PTSD
into

institutions
and
the
everyday
during
the
1980s
and
1990s.

96

CHAPTER
THREE
–
PTSD
(1975-‐1999)
MATURATION:
POSITIVE
SPIRAL
RENDING
AGREEMENT

INTO
INSTITUTIONS
AND
THE
EVERYDAY

The
nosopolitics
of
posttraumatic
stress
is
constituted
by
a
public
culture
of
social

narratives
of
war
and
return,
a
techno-‐medical
public
discourse
that
debates
and
defines

diagnosis,
disability,
treatment
and
rehabilitation,
and
a
political
sphere
that
discusses
the
state

and
civil
society’s
allocation
of
resources
and
the
public’s
just
commitments
to
soldiers.

Together
these
rhetorical
trajectories
exhibit
ways
of
constituting
health
and
illness,
together

with
the
practices
of
intervention,
and
forms
of
subjectivity
and
power
relations
that
inhere
in

such
knowledges
and
relations
between
them.
Over
time,
the
nosopolitics
enacts
social
change

based
on
the
consensual
and
dissensual
meshes
among
rhetorical
network
of
ideas,
words,

things,
data,
and
advocates.
In
the
1960
and
1970s,
Vietnam
veterans
and
their
families

constructed
illness
narratives
that
invited
discussion
in
technical
and
political
forums
about
the

protocol
and
procedures
relating
to
disease
and
disability.
This
period
saw
the
construction
of
a

make-‐do,
weak
network
consensus
marked
by
parallel
developments
in
civil
society
(VVAW
and

the
counter-‐VA),
technical
forums
(APA
recognized
PTSD),
and
the
political
arena
(Congress

authorized
Vet
Centers,
readjustment
counseling,
and
a
service-‐connection
for
PTSD).
These

arrangements
gained
momentum
and
temporarily
stabilized
in
the
decades
that
followed.

The
role
of
public
culture
was
less
salient
in
contestations
and
struggles
of
nosopolitics

during
the
1980s
and
1990s.
Media
representations
of
Vietnam
veterans
and
the
vicissitudes

they
faced
shifted
subtly
over
time,
but
the
popular
conception
of
the
Vietvet
as
a
“spurned,

neglected,
and
troubled
individual”
persisted
throughout
this
period
(Dean,
1997,
p.
21).

Narrative
accounts
of
PTSD
became
ubiquitous
in
news
media,
fiction,
television
programs,
and

97

motion
pictures.
Journalists
invoked
the
disorder
both
as
a
shorthand
description
and
an

explanation
for
the
many
readjustment
issues
like
domestic
violence,
reckless
driving,
and

other
disturbances
veterans
experience
(Hautzinger
&
Scandlyn,
2013).
Most
of
the
action
in

this
middle
episode
was
confined
public
discourse
and
political
policy
debates.
The
1980s
and

1990s
saw
the
scientific
investigation
of
trauma
institutionalized
in
a
single
field
and
the

routinization
of
PTSD
in
bureaucratic
institutions
at
the
national
and
internal
levels.
These

trajectories
are
important
to
understand
because
they
testify
both
to
an
emerging
moral-‐
political-‐scientific
consensus
while
at
the
same
time
generating
vulnerabilities,
forestalled

debates,
and
political
week
spots
that
would
come
under
stress
in
the
21
st

century.
The
chapter

addresses
those
elements
that
render
positive
spiral
of
nosopolitics
visible
in
medico-‐scientific

forums
(expert
nosological
debates)
and
the
public
sphere
(federal
policy
debates).

Autopoiesis:
Self-‐Authentication
of
Scientific
Reasoning
and
Practice

A
growing
body
of
literature
seeks
to
explain
how
and
why
“a
science,
once
in
place,

stays
with
us,
modified
by
not
refuted,
re-‐working
but
persistent,
seldom
acknowledge
but

taken
for
granted”
(Hacking,
1992b,
p.
29).
This
work
seeks
to
explain
how
ideas,
models,
and

concepts
emerge
and
develop
into
knowledge;
how
particular
scientific
communities
discern

what
constitutes
valuable
knowledge;
and
how
social-‐scientific
norms
are
fostered,

perpetuated,
and
institutionalized
into
a
coherent
technical
culture
(Jensen,
Richter,
&
Vendel,

2003;
Margolin,
2012).
Together,
these
activities
constitute
what
might
be
termed
an
argument

culture.
Such
a
culture
features
a
domain
of
practice,
shared
concern,
and
differing
views
on

which
norms
are
primary
and
whose
views
count
(Knorr-‐Cetina,
1999).
An
argument
culture

may
be
analyzed
as
an
autopoetic
entity,
but
only
for
a
while,
since
controversies
rupture
its

98

self-‐reproducing
authority.

Before
proceeding
further,
it
is
necessary
to
explain
exactly
what
is

meant
by
autopoiesis.

Luhmann
(1986)
metaphorically
extended
the
concept
of
autopoiesis
to
explain
the

evolution
of
cultural
systems.
Autopoiesis
is
a
theory
of
biological
systems
based
on
the
idea

that
the
components
and
processes
of
a
living
system
jointly
reproduce
themselves,

establishing
an
autonomous,
self-‐producing
entity
(Mingers,
1991;
Varela,
Maturana,
&
Uribe,

1974).
Such
a
system
perceives
and
constructs
its
own
environments
using
the
means
at
its

disposal.
In
other
words,
the
boundary
dividing
the
system
from
its
environment
is
determined

internally
(Maturana
&
Varela,
1980).
36

Luhmann
(1986)
treated
cultural
systems
as
biological

organisms
that
use
communication
as
“their
particular
mode
of
autopoetic
reproduction”
(p.

174).
It
follows
that
the
production
and
dissemination
of
scientific
research
on
trauma
is
central

to
the
reproduction
of
that
system.

36

The
autopoetic
perspective
stands
counter
to
the
classical
evolutionary
paradigm.
The
latter
is
general

theory
of
change
and
stability
in
which
a
set
of
principles
and
processes
(variation,
selection,
and

retention)
govern
the
conditions
under
which
biological,
social,
and
cultural
chance
occurs
(Aldrich,

1999;
D.
T.
Campbell,
1965;
Hsu
&
Hannan,
2005).
Variation
is
defined
as
intentional
or
unintentional

departure
from
a
routine
or
tradition
(Aldrich
Howard
&
Ruef,
2006).
Selection
refers
to
the

constellation
of
forces
that
differentially
select
and
eliminate
certain
types
of
variations.
These
criteria

are
determined
by
“the
operation
of
market
forces,
competitive
pressures,
the
logic
of
internal

organizational
structuring,
conformity
to
institutionalized
norms,
and
other
forces”
(Aldrich
Howard
&

Ruef,
2006,
p.
21).
Retention
refers
to
processes
in
which
variations
are
preserved,
duplicated
or

otherwise
reproduced
so
that
selected
activities
are
repeated
on
future
occasions.
Through
retention,

organizations
can
capture
value
from
existing
routines
that
have
been
perceived
as
beneficial
by

selectors
(DiMaggio
&
Powell,
1983;
Hannan
&
Freeman,
1984;
Mezias
&
Lant,
1994).
The
classical

perspective
directs
attention
to
the
level
of
the
population
rather
than
the
individual.
In
so
doing,
these

theories
emphasize
the
role
of
the
external
environment
in
shaping
the
future
of
individual
knowledge

systems.
In
contrast,
the
autopoetic
perspective
directs
attention
to
the
autonomy
of
an
individual

system
and
the
ways
in
which
it
shapes
its
own
future
(Mingers,
1989).

99

Technical
cultures
reproduce
identities
that
appear
stable
in
a
number
of
ways.

Proponents
of
the
ANT
approach
have
noted
that
one
source
of
stability
comes
from
the
fact

that
a
scientific
product
is
made
invisible
by
its
own
success.
Latour
(1999)
used
the
term
“black

box”
to
describe
temporary
stabilizations
in
fluid
networks:
“When
a
machine
runs
efficiently,

when
a
matter
of
fact
is
settle,
one
need
focus
only
on
its
inputs
and
outputs
and
not
on
its

internal
complexity.
Thus,
paradoxically,
the
more
science
and
technology
succeed,
the
more

opaque
and
obscure
they
become”
(p.
304).
The
inner
workings
of
the
black
box
are
a
mystery

to
the
practitioners
that
use
it
regularly.
Yet,
such
an
object
is
encoded
with
“preestablished

knowledge
which
is
implicit
in
the
outcome
of
an
experiment”
(Hacking,
1992,
p.
42).
In
some

cases,
“theoretical
assumptions
may
be
built
into
the
apparatus
itself”
(Galison,
1986,
p.
251).
In

this
way,
the
black
box
functions
like
a
vehicle
that
carries
what
is
known
tacitly
out
of
the

laboratory
and
into
the
lifeworld.
Hacking
(1992b)
made
a
slightly
different
argument
about
the

tendency
to
“splendid
anachronism.”
That
is,
the
knowledge
required
to
replicate
experimental

techniques
fades
away
over
time
because
new
instruments
make
those
skills
obsolete.
“We
do

other
things
and
accept
on
faith
most
knowledge
derived
in
the
past”
(p.
41).

Another
source
of
stability
“arises
from
the
fact
that
scientific
practice
is
like
a
rope
with

many
strands”
(Hacking,
1992b,
p.
41).
The
whole
seems
to
persist
unchanged
even
as
single

strands
are
cut
away.
Galison
(1987)
observes
that
different
theoretical
(ideas),
experimental

(practices),
and
instrumental
(things)
traditions
may
be
circulating
within
a
science
at
any

particular
moment.
Scientists
may
abandon
particular
theories
but
continue
to
use
the

experimental
techniques
and
instruments
developed
to
test
said
theory.
Alternatively,

researchers
may
insist
their
work
extends
an
existing
theory
even
in
the
face
of
radical
technical

100

innovation
that
fundamentally
alters
practice.
“The
practice
of
teaching
and
naming”
maintains

the
appearance
of
continuity
even
though
the
meaning
of
concepts
and
the
character
of

practice
mutates
over
time
(Hacking,
1992b,
p.
41).

A
third
source
of
stability
comes
from
the
“self-‐authentication”
and
“self-‐vindication”
of

science.
The
former
to
describes
“the
way
in
which
a
style
of
reasoning
generates
the
truth

conditions
for
the
very
propositions
which
a
reasoned
to
using
that
style,
suggesting
a
curious

type
of
circularity.”
The
latter
is
“a
material
concept,
pertaining
to
the
way
in
which
ideas

[theories],
things,
[types
of
apparatus],
and
marks
[types
of
analysis]
are
mutually
adjusted”

(Hacking,
1992b,
p.
51).
It
is
through
these
autopoetic
processes
that
a
laboratory
science

becomes
a
“closed
system”
in
which
“theories
seem
to
be
susceptible
to
no
improvement
at

all”
(Heisenberg,
1948,
p.
322).

The
argument
culture
of
traumatology
is
an
autopoetic
system
that
stabilized
and

tended
to
reproduce
itself
through
a
combination
of
self-‐authentication
(logic)
and
self-‐
vindication
(practice).
The
culture
is
long
standing
and
not
without
varied
views
and

controversy.
The
scientific
investigation
of
trauma
did
not
begin
in
earnest
until
the
19
th

century
(Evans,
1991;
Pichot,
1991).
During
this
period,
scientific
concepts
began
to
replace
the

mysticism
that
characterized
earlier
discourse
about
trauma
(Ben–Ezra,
2004;
Jebb,
1896;
King,

1993).
Trauma
studies
proceeded
in
piecemeal
fashion
because
interested
practitioners

(psychiatrists,
psychologist,
and
neurologists)
“had
to
justify
their
work
using
the
prevailing
and

limiting
paradigms
of
their
respective
fields”
(Figley,
2002,
p.
18).
This
process
of
self-‐
rationalization
culminated
in
APA’s
recognition
of
PTSD
in
1980.
Trauma
studies
achieved

positive
spiral
during
the
1980s
and
1990s
through
(a)
an
expert
rhetoric
of
self-‐rationalization

101

that
cultivated
the
perception
of
scientific
momentum
while
downplaying
remaining
gaps
in

knowledge
and
(b)
the
creation
of
public
institutions
and
civil
society
organizations
dedicated
to

the
publication,
dissemination,
and
promotion
of
scientific
research
on
trauma.
In
principle,

movements
in
the
technical
realm
and
the
public
sphere
can
be
analyzed
discretely,
but

together
they
unfold
as
a
generative
dynamic
in
which
activity
in
each
realm
reflects
and

reinforce
the
other.

Medico-‐Scientific
Discourse
in
Technical
Forums
(1984-‐1994)

In
the
early
1980s,
the
field
of
traumatic
stress
studies
resembled
what
Hacking
(1995)

has
called
an
“insecure
science”
(p.
352).
A
coalition
composed
of
social
movements
and

sympathetic
experts
had
secured
the
inclusion
of
PTSD
in
official
psychiatric
nomenclature
by

1980,
but
the
mysterious
disappearance
of
the
‘gross
stress
reaction’
listing
from
DSM-‐II
(1975)

served
as
a
reminder
that
this
hard
earned
momentum
could
easily
be
reversed
in
subsequent

revisions
of
the
psychiatrist’s
bible.
The
future
of
PTSD
research
was
uncertain.
However,
by
the

mid-‐1990s
the
nascent
field
of
traumatology
had
matured
into
a
seemingly
stable
science.
This

evolution
depended
on
the
ability
of
PTSD
researchers
to
demonstrate
that
further
study
could

refine
existing
knowledge
in
order
to
optimize
diagnostic
and
therapeutic
practice.

PTSD
in
DSM-‐IV:
Two
Nosological
Controversies

The
stabilization
of
traumatology
in
the
1980s
and
1990s
was
achieved,
not
through

standardization
of
norms
and
practices,
but
rather
through
agreement
on
the
topics
of
autopic

definition.
Expert
debates
about
the
quality
of
PTSD
studies
and
the
credibility
of
their
findings

were
primarily
confined
primarily
to
two
distinct
topics.
The
first
debate
involved
the
diagnostic

criteria
defining
traumatic
stressors
(Criterion
A).
Interlocutors
in
this
debate
addressed
three

102

fundamental
points
of
stasis:
“How
broadly
or
narrowly
should
trauma
be
defined?
Can
trauma

be
measured
reliably
and
validly?
What
is
the
relationship
between
trauma
and
PTSD”

(Weathers
&
Keane,
2007,
pp.
107–108)?
The
second
constellation
of
debates
concerned
a

range
of
issues
related
to
the
phenomenology
of
the
disorder:
Does
the
current
three-‐
dimensional
framework
(Criteria
B,
C,
D)
accurately
describe
PTSD
symptomatology?
Is
PTSD

best
represented
as
a
unitary
construct
or
as
continuum
of
heterogeneous
stress
response

syndromes?
Should
the
diagnostic
criteria
emphasize
symptoms
associated
with
anxiety
(hyper-‐
arousal,
panic
attacks,
phobic
avoidance)
or
dissociation
(flashbacks,
hallucinations,

psychogenic
amnesia)?
Should
PTSD
continue
to
be
classified
as
an
anxiety
disorder
or
should
it

be
placed
into
a
different
category
entirely
(McFarlane,
1991)?

These
nosological
debates
intensified
as
APA
prepared
to
release
DSM-‐III-‐R
(1987)
and

DSM-‐IV
(1994).
The
description
of
the
traumatic
stressor
in
DSM-‐III
had
been
criticized
primarily

for
being
brief
and
vague
(American
Psychiatric
Association,
1991).
The
criterion
language

required
the
existence
of
a
“recognizable
stressor
that
would
evoke
significant
symptoms
of

distress
in
almost
anyone,”
while
the
supplemental
text
revealed
that
such
a
stressor
“would

evoke
significant
symptoms
of
distress
in
most
people”
(American
Psychiatric
Association,
1980,

p.
236).
It
was
alleged
that
neither
the
formal
criterion
nor
the
text
provided
much
practical

guidance
for
identifying
an
event
as
traumatic
(Davidson
&
Foa,
1991).
Aside
from
problems

with
the
description
of
trauma,
critics
claimed
the
numbing
category
(Criteria
C)
contained
only

some
of
the
symptoms
generally
thought
to
make
up
the
second
dimension
of
PTSD
(Brett,

Spitzer,
&
Williams,
1988).

103

The
DSM-‐III-‐R
(1987)
revision
of
PTSD
was
designed
to
remedy
these
problems
while

retaining
the
core
conceptualization
of
the
disorder.
The
alterations
to
stressor
description

were
relatively
minor.
The
criterion
language
and
the
text
were
modified
to
be
more
specific

about
the
quality
of
trauma.
A
list
of
qualifying
events
was
added
to
illustrate
(implicitly)
the

underlying
dimensions
that
make
events
traumatic.
The
list
included
a
new
category
of

qualifying
events
involving
indirect
exposure
such
as
learning
about
a
serious
threat
or
harm
to

a
close
friend
or
relative.
Moreover,
the
text
provided
more
specific
information
regarding
the

type
and
severity
of
the
emotional
response
evoked,
stating
that
event
“is
usually

experienced

with
intense
fear,
terror,
and
helplessness”
(Weathers
and
Keane,
2007,
p.
109).
Perhaps
the

most
significant
change
took
place
in
the
phenomenological
domain.
The
DSM-‐III
symptoms
of

“sleep
disturbance,
hyperalterness
or
exaggerated
startle
response,
and
trouble
concentration”

because
the
nucleus
for
a
separate
criterion
covering
somatic
symptoms
of
arousal.
This
new

category
separated
“hypervigilance”
and
“exaggerated
startle
response”
into
two
discrete

symptoms
and
paired
them
with
two
other
symptoms
–
“irritability
or
outburst
of
anger”
and

“physiological
reactivity”
to
events
[associated]
with
an
aspect
of
the
traumatic
event”
(Brett,

Spitzer,
&
Williams,
1988,
pp.
1232-‐1233).

These
structural
changes
in
the
definition
of
trauma
and
the
description
of
its
associated

pathology
were
caught
up
in
expert
debates
that
intensified
for
an
extended
period
between

the
publication
of
DSM-‐III-‐R
and
DSM-‐IV.
A
selection
of
these
debates
is
reconstructed
from

peer-‐reviewed
journals
and
book
chapters,
as
well
as
editorials
and
commentaries
in
the

psychiatric
institutional
press.
According
to
Shaffer
(1996),
co-‐chair
of
the
DSM-‐IV
Working

Group
on
Infancy,
Child,
and
Adolescent
Disorders,
these
documents
publically
available
to
the

104

because
the
preparations
for
DSM-‐IV
took
place
in
an
era
of
heightened
scrutiny:
“It
was
widely

believed
that
many
of
the
decision
about
DSM-‐III
and
DSM-‐III-‐R
had
been
made
by
a
small

editorial
group
that
had
selectively
taken
advice
from
some
people
in
the
field
but
not
from

others”
(p.
326).
Indeed,
the
DSM
task
force
took
numerous
the
steps
to
make
the
process

more
transparent:

A
series
of
critical
reviews
were
commissioned
for
each
set
of
diagnoses
to
determine

whether
there
were
any
new
empirical
evidence
that
would
warrant
changing

diagnostic
descriptions
and
definitions.
There
were
reviews
to
be
published
openly
in
a

sourcebook,
so
that
the
basis
for
change
would
be
apparent
to
all.
Feasible
proposals

would
be
published
in
an
options
book
that
would
be
widely
circulated.
The
options

book
would
clarify
the
costs
and
benefits
of
proposed
changes,
and
it
was
hoped
that

this
would
stimulate
comment
and
criticism.
(p.
326)

I
compiled
an
initial
list
of
sources
for
analysis
using
the
DSM-‐IV
Options
Book
(1991)
and
two

volumes
of
the
DSM-‐IV
Sourcebook
(Widiger
et
al.,
1996;
Widiger
et
al.,
1994).
A
secondary
list

was
compiled
based
on
the
frequently
cited
references,
influential
authors,
and
major
recurring

topics
that
appeared
in
the
initial
list.
These
additional
items
were
identified
and
retrieved

using
the
Published
International
Literature
on
Traumatic
Stress
(PILOTS)
database,
the
most

comprehensive
international
catalogue
of
publications
on
traumatic
stress
(Banks,
1995;

Ritterbush,
2009).
41

While
these
selections
are
neither
comprehensive
nor
complete,
they
are

representative
of
the
diverse
philosophical
and
disciplinary
commitments
held,
as
well
as

41

The
PILOTS
database
contains
over
22,000
citations
including
all
original
empirical
works,
theoretical

articles,
and
commentaries
on
the
topic
of
traumatic
stress.

105

heterogeneous
instrumentation
and
methodology
employed,
by
those
working
in
the
nascent

field
of
traumatic
stress
studies.
Critical
communication
inquiry
into
nosopolitics
should
reveal

the
evolution,
transformation,
and
mutation
of
the
provisional
network
consensus
undergirding

the
field
from
the
mid-‐1980s
to
the
mid-‐1990s.

Redefining
the
scope
of
trauma:
Two
trajectories

Nosological
controversies
are
never
entirely
technical
because
diagnostic
decisions
are

inevitably
entangled
in
questions
of
access,
relevance,
and
responsibility
for
those
in
need
of

care.
Such
boundaries
and
goals
are
rarely
stated
explicitly,
but
they
always
linger
beneath
the

surface
of
expert
discussions
about
the
scope
of
trauma.
Often,
these
sensationalized
social
and

political
concerns
are
buried
beneath
shallow
and
circular
discussions
of
meta-‐theoretical

disputes
at
the
macro-‐level,
and
complicated
technical
explanations
at
the
micro-‐level.
On
one

side
of
the
debate
were
those
who
argued
that
the
diagnostic
criteria
in
DSM-‐IV
should
be

revised
in
a
way
that
expanded
the
range
of
events
considered
sufficiently
traumatic
to

precipitate
a
diagnosis
of
PTSD.
These
advocates
were
united
by
the
view
that
the
subjective

experience
of
the
individual
(rather
than
supposedly
objective
aspects
of
trauma)
should
be
the

critical
element
in
diagnostic
decisions.
Provisional
networks
developed
between
sociologically

inclined
epidemiologists
and
cognitive
scientists
accustomed
to
working
with
psychiatric

phenomena
derived
in
laboratory
environments.
Opposing
experts
favored
a
trimming

interpretation
of
the
traumatic
stressor.
They
advocates
argued
for
a
wide
diagnostic

understanding
more
consistent
with
the
conceptualization
of
trauma
in
DSM-‐III.
The
opposition

group
consisted
of
weak
alliances
among
behavioristic
psychologists
and
dynamically
inclined

therapists
working
directly
with
particular
traumatized
populations
–
such
as
abused
children,

106

combat
veterans,
disaster
survivors,
and
rape
victims.
Each
network
of
interlocutors
connected

through
different
efforts
at
direct
collaboration,
frequent
and
extensive
citation
in
published

scholarship,
and
informal
acknowledgements
in
manuscripts.

The
positive
trajectory:
The
rationale
in
favor
of
the
stressor
criterion

Proponents
of
the
traumatic
stressor
criterion
advanced
the
argument
that
the

construct
was
clinically
useful
and
socially
valuable
even
if
validity
for
all
of
its
explicit
and

implicit
assumptions
had
yet
to
be
demonstrated.
On
the
one
hand,
advocates
framed
the

stressor
as
heuristic
and
flexible.
On
the
other
hand,
they
argued
this
particular
diagnostic

criterion
served
an
indispensable
‘gate-‐keeper’
function
for
the
PTSD
diagnosis.
The
rationale
in

favor
of
the
quantitative
view
of
trauma
was
composed
of
arguments
backed
by
(a)

behavioristic
psychology
and
(b)
psychodynamic
theories.

the
behavioristic
approach

Many
psychological
approaches
to
the
study
of
trauma
are
purely
behavioristic.

Behaviorism
maintains
that
“all
subjective
terms,
or
names
of
mental
processes,
such
as
ideas,

beliefs,
desires,
wishes,
values,
have
no
place
in
science
except
as
they
may
be
temporarily

tolerated
on
account
of
the
lack
of
objective
terms
for
such
processes”
(Ellwood,
1930,
p.
74).

This
methodological
purity
distinguishes
such
an
approach
from
sociological
disaster
research

that
appeals
to
ideas
and
conscious
values
to
explain
collective
human
behavior.
The
case
for

the
stressor
criterion
grounded
in
behavioristic
psychology
was
clearly
explained
in
the

scholarship
of
John
S.
March
of
the
Department
of
Psychiatry
at
the
University
of
Wisconsin,

Madison.

107

the
dynamic
approach

Psychoanalysts
shared
the
behaviorists’
fundamental
concern
with
the
impact
of

catastrophic
trauma
on
the
life
of
the
individual,
but
psychodynamic
models
explained
the

phenomenology
of
posttraumatic
stress
syndromes
by
referencing
casual
accounts
of

intrapsychic
processes.
This
form
of
top-‐down
reasoning
distinguishes
dynamic
research
from

behavioristic
approaches
that
clearly
distinguished
nosological
concerns
from
etiological

theories.

The
dynamic
rationale
for
the
stressor
criterion
can
be
found
in
scholarship
written
by

clinical
researchers
working
with
particular
traumatized
populations
including
combat
veterans

(Elizabeth
A.
Brett
and
Javier
I.
Escobar),
flood
survivors
(Bonnie
L.
Green,
Jacob
D.
Lindy,
and

Mary
C.
Grace),
and
those
exposed
to
prolonged
and
repeated
trauma
where
victims
are

unable
to
escape
such
as
prisons,
concentration
camps,
and
slave
labor
camps
(Judith
L.

Herman
and
Henry
Krystal).

the
stressor
criterion
as
a
heuristic

The
primary
persuasive
challenge
for
proponents
of
the
stressor
criterion
was
to

accommodate
findings
from
epidemiological
studies
and
clinical
reports
suggesting
that

individuals
exposed
to
less
common
stressors
sometimes
presented
with
the
complete
clinical

picture
of
PTSD.
Advocates
accomplished
this
objective
by
framing
the
DSM-‐III
description
of

the
stressor
criterion
not
as
an
end
in
itself,
but
rather
as
a
heuristic
designed
guide
future

research.
For
example,
Escobar
(1987)
noted
that
“DSM-‐III
was
not
intended
as
a
set
of

unmodifiable
rules,”
while
Lindy,
Green,
and
Grace
(1987)
described
the
stressor
criterion
as
“a

method
of
challenging
the
scientific
community”
to
define
the
concept
empirically
(p.
266;
p.

269).
Thus
stressor
criterion
proponents
broke
the
frame
of
the
debate:
Instead
of
defending

108

the
claim
that
a
traumatic
stressor
“would
evoke
significant
symptoms
of
distress
in
almost

anyone,”
they
argued
studies
only
needed
to
demonstrate
that
dose-‐response
relationship

between
the
objective
intensity
of
a
stressor
and
the
risk
of
pathology
(American
Psychiatric

Association,
1980,
p.
236).

March
(1993)
insisted
that
controlled,
uncontrolled,
and
case-‐controlled
studies
of

extreme
stress
had
repeatedly
shown
the
quantity
of
stress
to
be
one
of
the
best
predictors
of

breakdown.
A
thorough
review
of
PTSD
research
literature
led
him
to
comment:
“The
dominant

conclusion
to
be
drawn
from
these
studies
is
that
stressor
magnitude
is
directly
proportional
to

the
subsequent
risk
developing
PTSD.”
He
found
this
finding
appeared
across
a
variety
of

settings
including:
“natural
disaster,
combat,
prisoner
of
war
(POW)
experiences,
criminal

victimization,
and
accidents”
(p.
40).
The
conceptualization
and
operationalization
of
trauma

varied
substantially,
even
among
studies
with
behavioristic
methods.
One
study
on
survivors
of

the
Mount
St.
Helens
eruption
(1986)
divided
subjects
into
“high
exposure”
and
“low
exposure”

groups
based
on
whether
they
“suffered
at
least
$5000
dollars
in
property
loss
or
whether
they

suffered
the
death
of
a
family
member
or
close
relative”
(Shore,
Tatum,
&
Vollmer,
1986,
p.

591).
Another
study
of
POWs
in
the
Vietnam
divided
subjects
into
“maximal
stress
and
high
but

submaximal
stress
groups”
based
on
whether
they
were
captured
before
or
after
1969
(Ursano,

Boydstun,
&
Wheatley,
1981,
p.
313).

Stephen
Pepper
(1942)
has
distinguished
between
two
complimentary
modes
of

reasoning
scientifically
from
evidence
to
conclusion.
In
multiplication
corroboration,
the

persuasive
force
of
a
claim
is
established
by
data
drawn
from
repeated
testing
and
consensual

observation
of
its
reliability
or
truthfulness.
The
quantitative
science
of
epidemiology
produces

109

knowledge
through
the
process
of
multiplicative
corroboration.
Indeed,
stressor
criterion

proponents
leveraged
the
preponderance
of
favorable
results
to
bolster
their
argument.

However,
the
lack
of
standardized
instruments
and
terminology
between
these
studies
should

be
considered
a
significant
weakness
from
a
multiplicative
perspective.
According
to
this
logic,
a

valid
result
should
be
able
to
replicated
independently
by
scientists
following
the
exact
same

research
protocol.
Thus
the
degree
of
variation
between
protocols
should
be
inversely

proportional
to
persuasive
force
of
the
replicated
result.
Stressor
criterion
proponents
rebutted

this
criticism
by
strategically
pivoting
to
the
logic
of
structural
corroboration,
a
form
of
scientific

reasoning
where
the
“persuasive
force”
of
a
claim
comes
from
“the
massiveness
of
convergent

evidence
upon
the
same
point
of
fact”
(p.
49).

According
to
this
logic,
a
valid
result
should

derive
support
from
qualitatively
different
types
of
proof.
Thus
the
degree
of
variation
between

research
protocols
should
be
directly
proportional
to
the
persuasive
force
of
the
replicated

result.
Since
multiplicative
and
structural
corroboration
are
mutually
supportive
forms
of

scientific
reasoning,
skillful
advocates
can
leverage
both
modes
simultaneously
to
insulate
their

arguments
from
criticism.
March’s
(1990)
claim
that
the
dose-‐response
finding
“transcends

methodological
approach
[sic]”
was
a
prime
example
of
this
rhetorical
strategy
(
p.
40).

Armed
with
powerful
evidence
for
the
role
of
stressor
intensity
in
the
pathogenesis
of

PTSD,
advocates
proposed
multi-‐dimensional
models
of
trauma
that
allowed
researchers
to

account
for
data
that
only
appeared
to
challenge
the
validity
of
the
stressor
criterion.
Krystal’s

(1985)
model
of
catastrophic
traumatization
is
such
a
framework.
The
model
distinguished

between
the
“infantile
type
of
traumatization”
and
the
“adult
(catastrophic)
type
of
psychic

trauma”
(p.
134).
The
former
occurs
when
infants
are
overwhelmed
by
excessively
intense

110

affect.
Infants
cannot
defend
against
trauma
because
(similar
to
non-‐human
animals)
they

experience
affect
as
massive,
undifferentiated,
psychosomatic
reactions
that
cannot
be

articulated
or
sampled
in
small
doses
(Krystal,
1978).
Due
to
developmental
differences,
adults

are
capable
of
distinguishing
nuances
of
feeling
and
separating
feelings
from
purely
somatic

sensations,
they
use
affects
as
signals
to
anticipate
danger.
Once
an
adult
accepts
that
danger
is

unavoidable,
she
can
prevent
herself
from
being
overwhelmed
by
blocking
affects.
The
term

adult
trauma
refers
to
this
state
of
total
helplessness
and
surrender
in
face
of
immanent

danger.
Without
intervention,
the
inhibition
and
constriction
of
affect
can
progress
until
it

broadly
inhibits
cognitive
functioning
and
adaptive
behaviors
(Krystal,
1985).

In
contrast
to
traditional
psychoanalytic
models
of
symptom
formation
organized

around
early
infantile
conflicts,
the
adult
trauma
paradigm
could
account
for
the
nature
and

severity
of
catastrophic
stressors
as
well
as
the
unique
and
particular
mechanisms
of
pathology

in
those
exposed
(Brett,
1993).
Such
frameworks
allowed
investigators
to
retain
stressor

intensity
as
“the
primary
etiological
factor”
while
simultaneously
accounting
for
the

interrelation
of
personal
factors,
environmental
factors,
and
symbolic/event-‐processing
factors

contributing
to
the
development
of
PTSD
(Green,
Lindy,
&
Grace,
1985,
p.
407).
With
this

framing,
the
stressor
criterion
became
a
heuristic
that
allowed
proponents
to
cast
effectively

their
critics
in
the
role
of
pessimistic
naysayers.
Consider
Lindy,
Green,
and
Grace’s
(1987)
call

for
research
identifying
mediating
variables
that
undermined
Breslau
and
Davis’s
approach:

We
did
not
suspect
that
the
wording
of
the
DSM-‐III
definition
of
PTSD
would
prompt
the

kind
of
dichotomous
thinking
presented
in
the
Breslau/Davis
paper. Clearly
[emphasis

added]
personal
factors
contribute
to
long-‐term
outcome
and
clearly
[emphasis
added]

111

the
recovery
environment
contributes
to
long-‐term
outcome.
We
need
to
be
interested

in
the
interrelationships
among
these
mediating
variables
and
the
stressor
experience

rather
than
use
the
presence
of
their
impact
as
an
argument
against
the
disorder.
(p.

271)

The
authors’
approach
was
conventionally
polite,
but
the
repetition
of
the
word
“clearly”
in

consecutive
sentences
betrayed
the
stakes
of
the
argument
in
its
tone.

the
stressor
criterion
as
gatekeeper

Proponents
also
made
the
case
that
a
decision
to
expand
the
range
of
stressful
events

beyond
those
commonly
associated
with
PTSD
as
defined
in
DSM-‐III-‐R
ran
the
risk
of
trivializing

the
diagnosis.
42

March
(1993)
clearly
championed
maintaining
a
gatekeeper
presumption
in
his

position
paper
on
the
fate
of
PTSD
in
DSM-‐IV:

At
its
extreme,
a
broad
view
would
in
essence
abolish
the
stressor
criterion
through

teleologically
defining
the
stressor
by
its
results.
The
quantitative
or
‘catastrophic’

threshold
for
the
diagnosis
would
be
eliminated
with
preference
given
to
a
purely

subjective
interpretation.
Any
stressor
capable
of
inducing
PTSD
phenomenology
would

qualify….
The
forensic
and
social
policy
repercussions
of
this
result
could
in
themselves

be
catastrophic.
(pp.
48-‐49)

Removing
the
stressor
criterion
would
open
the
diagnostic
floodgates
since
the
other
PTSD

criteria
lacked
sufficient
specificity
to
prevent
false
positives.
Lindy
and
associated
(1987)

42

In
contrast,
this
argument
played
a
relatively
minor
role
in
arguments
advanced
by
researchers

investigating
the
neurobiology
of
trauma
–
presumably
because
this
group
was
convinced
state
of
the

art
assessment
technologies
that
could
accurately
discriminate
between
individuals
with
PTSD
and
those

presenting
symptoms
that
are
not
pathological.

112

speculated
in
their
paper
that
in
lieu
of
a
gatekeeper,
the
entire
diagnosis
might
eventually
be

deleted
from
official
psychiatric
nomenclature.
Such
a
move
would
be
unfortunate
because
“as

a
result
of
the
new
interest
in
PTSD,
patients
with
PTSD
[were]
being
recognized
earlier
and

treated
more
vigorously.”
In
light
of
this
“forward
momentum”
the
authors
considered
the

decision
to
abandon
the
stressor
criterion
to
be
“premature
on
scientific
grounds
and
actively

harmful
on
ethical
grounds”
(p.
271).

Of
course,
proponents
were
not
ignorant
of
the
risks
associated
with
their
position.

March
(1993)
explained
that
the
narrowest
interpretation
of
the
criterion
A
would
exclude

subjective
perception
entirely
and
restrict
the
diagnosis
to
“individuals
who
have
experienced

such
events
as
those
most
commonly
associated
with
PTSD
in
the
research
and
historical

literatures.”
This
would
necessarily
increase
the
risk
that
“persons
symptomatic
after
lower

magnitude
events
will
continue
to
fall
in
the
transitional
and
dimensional
gray
area”
(p.
50).
He

noted
this
would
be
a
significant
problem
from
a
clinical
perspective
since
the
prevalence
of

lower
magnitude
stressors
(workplace
sexual
harassment
or
systemic
racism)
was
likely
to
be

much
greater
than
high
magnitude
events.
But,
in
typical
fashion,
March
(1990)
concluded
the

spectre
of
trivialization
outweighed
the
risk
of
traumatized
patients
falling
through
the
cracks:

“Although
the
resulting
exclusion
of
dimensional
and
transitional
representations
will
prove

bothersome
to
some,
progress
in
understanding
PTSD
will
be
best
served
by
a
narrow
definition

of
the
diagnostic
construct”
(p.
77).
We
might
be
inclined
forgive
this
unfortunate
construction

since
it
appeared
in
a
paper
published
several
years
earlier,
but
the
point
stands.
Proponents
of

the
stressor
criterion
were
generally
forced
to
concede
that
scientific
progress
needed
to
be

113

prioritized
over
the
practical
needs
of
fully
symptomatic
patients
exposed
to
an
‘ordinary’

stressor.

The
negative
trajectory:
The
rationale
against
the
stressor
criterion

Critics
questioned
whether
the
psychiatric
sequelae
resulting
from
exposure
to

traumatic
events
“outside
the
range
of
usual
human
experience”
did
in
fact
differ
from
the

sequelae
resulting
from
exposure
to
more
common
yet
stressful
life
experiences
(American

Psychiatric
Association,
1980,
p.
236).
More
specifically,
these
skeptics
took
issue
with
the
tacit

assumption
that
“the
importance
of
individual
characteristics
as
factors
in
the
stressor-‐disease

connection
is
inversely
related
to
the
magnitude
of
the
stressors”
(Breslau
&
Davis,
1987c,
p.

261).
The
rationale
against
the
stressor
criterion
consisted
arguments
backed
by
two
distinct

argument
fields:
(a)
the
‘sociological
approach’
to
the
epidemiology
of
disaster
and
(b)
the

experimental
research
paradigm
associated
with
the
‘cognitive
approach.’

the
sociological
approach

The
sociological
approach
to
disaster
research
entails
several
disciplinary
assumptions

and
commitments
including,
a
focus
on
behavioral
responses
to
stress,
a
narrow
interpretation

of
psychopathology,
the
assumption
that
social
adaption
is
a
primary
response
to
disaster,
and

an
emphasis
on
disruption
or
maintenance
of
interpersonal
linkages
and
the
use
of
social

support
systems
in
response
and
recovery.
Like
hard
behaviorism,
the
sociology
of
disaster

response,
does
employ
objective
terminology
and
empirical
methods;
however,
its
research

also
attends
to
significant
modifying
factors
consisting
of
intersubjective
phenomena

(communication,
culture,
and
values).
This
approach
stands
in
contrast
to
the
psychological

perspective
on
individual
trauma
that
“still
assumes
that
disaster
victims
respond
primarily
to

114

the
disaster
agent
or
its
immediate
effect.”
Proponents
of
the
sociological
perspective
hold
that

“social
context
is
by
far
the
most
important
factor”
predicting
the
development
of

psychopathology
in
survivors
(Quarantelli,
1979,
p.
21).
This
approach
remained
prominent

among
researchers
trained
initially
as
sociologists
(Naomi
Breslau
and
Robert
S.
Laufer)
as
well

as
those
coming
from
other
disciplines
with
ties
to
the
epidemiological
research
program
that

emerged
out
of
WUSTL
in
the
1970s
and
1980s
(Glorisa
J.
Canino
and
Susan
D.
Solomon).
44

Social
cause
advocates
drew
primarily
on
evidence
derived
from
epidemiological
studies

to
question
the
distinction
between
extraordinary
stressor
and
more
common
stressful
events.

For
example,
using
data
from
independent
studies
of
two
natural
disasters,
Solomon
and

Canino
(1990)
systematically
examined
“the
patterns
of
subclinical
symptomatology
resulting

from
exposure
to
different
kinds
of
disaster”
in
order
to
assess
whether
victims
displayed

sequelae
that
“were
similar
across
disaster
events
from
different
from
[DSM-‐III
criteria]”
(p.

229).
45

Multivariate
analysis
revealed
that
‘common’
stressful
events—
like
moving,
money

problems,
household
illness,
breakups,
involuntarily
increases
in
household
density—related

more
closely
to
PTSD
symptoms
than
did
extraordinary
stressors
such
as
floods,
mudslides,

dioxin
exposure,
or
being
mugged
and
beaten.
Based
on
this
finding,
the
authors
argued
the

decision
to
exclude
more
common
stressors
from
the
PTSD
diagnosis
was
both
arbitrary
and

inappropriate:
In
their
view,
“it
is
more
logical
to
assume
that
stressors
form
a
continuum”
in

44

Breslau
and
Laufer
received
doctorates
of
philosophy
in
sociology,
respectively.
Solomon
and
Canino’s

disaster
research
was
supported
by
a
supplement
to
the
ECA
program
Cooperative
Agreement
No.
UOJ

MH
33883
awarded
to
Principal
Investigators
Lee
Robins
and
John
Helzer
of
WUSTLA
for
research

performed
with
the
NIMH.

45

The
two
data
sets
came
from
victims
of
dioxin
and
flooding
in
St.
Louis
(winter
1982)
and
victims
of

flooding
and
mudslides
in
Puerto
Rico
(fall
1985).

115

which
“some
people
may
be
more
vulnerable
to
less
extreme
events,
and
yet
still
have
full-‐
blown
PTSD”
(p.
235).

Critics
of
the
stressor
criterion
also
emphasized
the
conceptual
ambiguity
inherent
in

the
DSM-‐III
conception
of
trauma.
Breslau
and
Davis
(1987b)
drew
attention
to
the
“tension

between
two
distinct
frameworks:
a)
the
classical
stress
paradigm
in
which
events
are
defined

…
in
terms
of
their
intensity
...

and
b)
the
psychological
(cognitive)
clinical
framework
in
which

events
are
defined
subjectively
in
terms
of
the
meaning
they
have
for
the
individuals
who

experience
them”
(p.
259).
This
line
of
criticism
was
more
difficult
to
disarm
because
it
used
a

methodological
problem
to
explain
the
absence
of
evidence,
rather
than
the
other
way
around:

“Because
the
assumptions
that
underlie
the
stressor
criterion
in
PTSD
are
unsupported,
it
is

questionable
whether
future
research
will
demonstrate
the
kinds
of
validity
beyond
face

validity
that
provisionally
supports
the
DSM-‐III
diagnosis
of
PTSD”
(p.
262).

These
advocates
maintained
that
any
conclusion
about
a
distinct
class
of
traumatic

stressors
“should
be
reached
by
careful
assessment,
rather
than
by
edict”
(Solomon
&
Canino,

1990,
p.
235).
That
is,
researchers
should
first
determine
whether
PTSD
symptoms
emerge
as
a

cluster
and
then
independently
ascertain
what
type
of
stressors
result
in
this
symptom
pattern.

Breslau
and
Davis
(1987b)
argued
that
early
returns
from
epidemiological
research
on
war

veterans
demonstrated
the
etiological
specificity
of
different
types
of
stressors.
The
authors

drew
special
attention
to
quantitative
studies
indicating
that
participating
in
abusive
violence

uniquely
contributed
to
the
diagnosis
of
PTSD
(Breslau
&
Davis,
1987a;
Laufer,
Brett,
&
Gallops,

1985).

116

Laufer,
Brett,
and
Gallops
(1985)
agued

that
exposure
to
particular
kinds
of
battle
stress

(intentionally
harming
civilians)
predicted
distinct
symptom
profiles.
Specifically,
the

researchers
found
that
soldiers
that
reported
participation
in
atrocities
were
less
likely
than

other
combat
veterans
to
experience
unwanted
intrusions
(reenactments
or
nightmares)
and

more
likely
to
present
symptoms
associated
with
avoidance
or
psychic
numbing.
Furthermore,

the
team
found
that
the
effects
of
exposure
to
abusive
violence
differed
in
black
and
white

veterans.
White
soldiers
seemed
to
have
a
greater
risk
of
developing
PTSD
only
if
they
also

participated
in
atrocities,
while
black
soldiers
seemed
to
be
at
risk
from
witnessing
atrocities
as

well.
They
explained
this
difference
by
noting
the
differential
meaning
that
atrocities
had
for

black
and
white
soldiers.
Taken
together,
these
findings
led
the
authors
to
conclude:
“No

summary
concept
and
measure
can
accurately
encapsulate
the
variegated
nature
of
war
stress”

(p.
77).
If
the
subjective
meaning
of
an
experience
moderates
an
individual’s
reaction
to
a

disaster,
then
it
is
all
but
impossible
to
measure
stressors
in
objective
terms.

In
sum,
critics
associated
with
the
sociological
perspective
rejected
as
arbitrary
any

diagnostic
rule
that
defined
trauma
independently
of
information
derived
from
the
specific
life

experiences
and
circumstances
of
the
individual.
While
they
recognized
the
possible
social
and

political
ramifications
of
such
a
move,
Breslau
and
Davis
(1987b)
maintained
patients
would
be

best
served
by
a
tough-‐minded
commitment
to
scientific
rigor:

[Proponents
of
the
stressor
criterion]
suggest
that
in
taking
a
critical
stance
on
the

definition
of
PTSD
we
are
indifferent
to
the
possible
consequence
that
such
criticism

might
have,
that
is,
the
deletion
of
this
category
from
DSM
and
the
subsequent
neglect

of
the
needs
of
victims
of
catastrophes.
We
argue
that
the
path
to
maximizing
therapy
is

117

through
the
scientific
understanding
of
PTSD….
This
is
so
because
a
valid
diagnostic

system
would
ultimately
enable
the
practitioner
to
select
a
disorder-‐specific
treatment,

capable
of
relieving
the
patient's
distress.
(p.
276)

In
contrast
to
researchers
employing
the
behavioristic
approaches
(Lee
Robins
and
John
Helzer)

that
had
been
the
most
vocal
critics
of
PTSD
during
the
1970s,
advocates
critiquing
the
stressor

criterion
critics
refused
to
accept
the
notion
that
constructive
criticism
equated
to
a
rejection
of

the
diagnosis
as
a
whole.
For
these
interlocutors,
a
genuine
appreciation
for
the
devastating

consequences
of
the
disorder
required
a
tough-‐minded
assessment
reliably
differentiating
what

it
was
and
what
it
was
not.

the
cognitive
approach

The
primary
assumption
of
cognitive
approach
is
that
an
understanding
of
internal

mental
processes
is
a
necessary
component
of
any
explanation
for
complex
human
behavior.

Cognitive
scientists
typically
employ
laboratory
experiments
that
allow
indirect
investigation
of

the
acts
and
processes
by
which
knowledge
is
acquired
within
the
mind.
Mardi
Horowitz’
(1976)

research
on
stress
response
syndromes
is
the
exemplar
for
the
cognitive
perspective
on

trauma.
His
experimental
investigation
of
intrusive
and
repetitive
thought
as
a
general
stress

response
tendency
formed
much
of
the
conceptual
basis
behind
the
description
of
PTSD
in

DSM-‐III.

Advocates
associated
with
the
cognitive
approach
are
critical
of
the
stressor
criterion

because
experimental
studies
demonstrate
the
same
type
of
mental
processes
are
involved
in

psychological
responses
to
both
common
and
catastrophic
events.
Horowitz,
Wilner,
Kaltreider

and
Alvarez
(1980)
found
little
difference
in
scores
between
groups
meeting
the
PTSD
stressor

118

criterion
on
the
Impact
of
Event
scale
(IES)
and
those
of
groups
exposed
to
more
common

stressors.
The
IES
is
a
psychometric
assessment
tool
used
to
measure
subjective
distress
with

subscales
based
on
lists
of
items
consisting
of
commonly
reported
experiences
of
intrusion
and

avoidance
(Horowitz,
Wilner,
&
Alvarez,
1979).
Based
on
these
experimental
results,
Horowitz,

Weiss,
and
Marmar
(1987)
argued
that,
“reactions
to
such
high-‐impact
stressors
are
not

uniquely
different
from
responses
to
less
extreme
events
that
may
nonetheless
be
quite

traumatic
for
an
individual
because
of
special
meanings
and
vulnerabilities.”
For
this
reason,

the
authors
cautioned
clinicians
against
being
“overly
swayed
by
the
emphasis
on
an
‘unusual’

event
put
forward
by
the
DSM-‐III
criteria”
and
encouraged
them
to
assess
the
degree
to
which

the
supposed
stressor
was
“shocking
to
the
individual”
(p.
268).
Indeed,
cognitive
scientists

often
argued
that
an
experience
as
common
as
bereavement
over
the
loss
of
a
loved
one
may

be
sufficiently
shocking
to
precipitate
a
PTSD
diagnosis
(Horowitz,
1993).

Cognitive
scientists
were
critical
of
rigid
adherence
to
the
stressor
criterion,
but
their

criticism
did
not
extend
to
the
rest
of
the
diagnostic
construct.
They
acknowledged
the

significant
risk
that
weakening
the
stressor
criterion
might
contribute
to
false
positive

diagnoses,
but
dismissed
misdiagnosis
as
an
unavoidable
part
of
medicine.
Horowitz
and

associates
(1987)
explained
that
neurologists
also
struggled
to
determine
when
common

problems
like
intermittent
headaches
reached
the
criteria
for
diagnosis
as
a
“headache

disorder.”
In
contrast
to
cognitive
science,
diagnostic
decisions
in
medicine
rested
on
“a
clinical

algorithm”
that
considered
a
number
of
factors
in
a
subjective
way
(p.
267).
Perhaps
the

willingness
of
cognitive
psychologists
to
accommodate
the
practical
realities
of
clinical
practice

explains
why
Horowitz
supported
the
VVWG’s
efforts
to
secure
the
inclusion
of
PTSD
in
DSM-‐III

119

in
spite
of
the
fact
that
the
organizing
principle
of
the
disorder
(the
distinction
between

common
and
extraordinary
stressors)
was
unsupported
in
experimental
studies
(Horowitz
&

Wilner,
1976).
In
other
words,
the
demands
of
the
moment
required
compromises
that
may

have
been
unpalatable
in
different
circumstances.

Comparative
analysis
revealed
a
similar
pattern
in
the
nosological
debates
regarding

DSM-‐IV.
While
adherents
to
the
“individual
perspective”
made
temporary
associations
with

researchers
with
the
“epidemiological
perspective,”
those
alliances
were
always
precarious

because
of
significant
disciplinary/methodological
differences
between
these
camps

(Horowitz,

1993,
p.
55).
Many
of
the
methodologies
employed
in
sociological
approaches
to
epidemiology

of
disaster
were
derived
from
behaviorism.
For
this
reason,
the
sociological
perspective
was

fundamentally
incompatible
with
approaches
grounded
in
cognitive
science.

The
classification
of
PTSD:
Two
trajectories

Nosological
debates
are
also
controversial
because
different
diagnostic
schemes
have

significant
and
differing
implications
for
treatment,
and
therefore,
social
and
political

implications
for
researchers
and
clinicians
alike.
A
second
set
of
debates
turned
on
the
question

of
whether
DSM-‐IV
should
classify
PTSD
as
an
anxiety
disorder,
as
it
had
been
previously

classified
in
DSM-‐III
and
DSM-‐III-‐R,
or
whether
it
should
be
placed
in
a
different
category.

On
one
side
of
the
debate
were
advocates
who
felt
PTSD
was
best
conceptualized
as
a

conditioned
response
to
trauma.
This
camp
included
behaviorist
psychologists
as
well
as

experimental
scientists
investigating
the
neurobiology
of
stress
response.
These
individuals

were
united
by
the
belief
that
social
learning
theory
provided
the
most
useful
conceptual

framework
for
understanding
the
disorder.
Opposing
them
were
those
who
felt

120

the
‘hallmark’
of
PTSD
(flashbacks,
nightmares,
hallucinations
and
other
intrusive
symptoms

commonly
associated
with
dissociation)
should
have
more
bearing
on
its
classification.
In

general,
this
group
included
cognitive
scientists
and
psychodynamically
oriented
theorists.

The
negative
trajectory:
the
rationale
against
reclassification

General
agreement
over
the
natural
history
of
PTSD
facilitated
a
natural
alliance

between
(a)
behaviorist
psychologists
and
(a)
experimental
scientists
investigating
the

neurobiology
of
stress
response.
March
(1990)
described
the
longitudinal
course
of
the

disorder:

PTSD
follows
as
a
reflexive
or
conditioned
response
to
the
traumatic
event.
Avoidance
in

the
service
of
arousal
reduction
soon
follows.
The
trauma-‐specific
fear
of
these
patients

remains
unbearable,
their
submission
absolute.
This
is
true
phobic
anxiety
and
is
what

differentiates
PTSD
from
responses
to
psychic
trauma
not
involving
fear
conditioning.
In

this
sense,
PTSD
is
a
disorder
of
failed
in
vivo
habituation.
(p.
77)

Behavioristic
and
biomedical
approaches
to
trauma
research
granted
fear
a
central
role
in
the

etiology
and
symptomatology
of
the
disorder.

the
behavioristic
approach

Behavioristic
psychologists
studied
PTSD
using
a
social
learning
theory
approach
that

described
PTSD
using
a
two-‐factor
(classical
and
operant)
conditioning
model.
According
to
the

model,
an
event
that
entails
the
threat
of
death
and/or
physical
injury
serves
as
an

unconditioned
stimulus
that
elicits
a
fear
response/autonomic
arousal
in
the
survivor.
Any

stimuli
present
during
the
experience
can
become
associated
with
the
trauma
through
the

process
of
classical
conditioning.
Cognitive
cues
become
conditioned
stimuli
that
can
evoke
the

121

same
response
(intrusive
imagery,
nightmares,
flashbacks,
and
symptoms
of
autonomic

hyperarousal)
in
different
contexts.
The
progression
of
PTSD
is
described
via
operant

conditioning.
That
is,
traumatized
individuals
learn
by
trial
and
error
to
reduce
symptoms
by

avoiding
conditioned
stimuli.
While
avoidance
(behavioral
and
cognitive
avoidance,

interpersonal
detachment,
and
restricted
affect)
does
reduce
fear/anxiety,
it
also
decreases
the

likelihood
that
the
conditioned
fear
reaction
will
dissipate
over
time
and
may
facilitate
the

generalization
of
this
fear
response
to
other
settings
(March,
1990).

According
to
behaviorists,
most
empirical
models
of
trauma
implicitly
if
not
explicitly

followed
a
social
learning
theory
framework,
“at
least
in
part
because
it
is
easily

operationalized”
(March,
1990,
p.
66).
Indeed,
results
from
prospective
epidemiological
studies

(the
Vietnam
Experience
Study,
the
Epidemiological
Catchment
Area
general
population
survey,

and
an
investigation
of
sites
varying
in
exposure
to
the
Mt.
St.
Helen’s
volcanic
eruption)

indicated
that
exposure
to
life
threatening
situations
was
the
primary
risk
factor
for
developing

PTSD.
In
addition,
hyperarousal
and
avoidance
behaviors
were
the
most
prevalent
symptoms

reported
in
most
studies
(Centers
for
Disease
Control,
1989;
Helzer,
Robins,
&
McEvoy,
1987;

Shore
et
al.,
1986).
Behaviorists
believed
finding
such
as
these
documented
“the
importance
of

fear
conditioning
in
the
development
and
maintenance
of
PTSD”
(March,
1990,
p.
69).

“Dynamic
theories,
while
contributing
to
understanding
the
cognitive
aspects
of
PTSD,
do
not

adequately
capture
the
fear
conditioning
inherent
in
the
disorder”
(p.
77).

From
a
rhetorical
perspective,
the
behavioristic
rationale
consisted
of
a
synecdochal

substitution
of
a
part
(anxiety/autonomic
arousal)
for
the
whole
(the
phenomenology
of
PTSD).

The
primary
benefits
of
this
rhetorical
strategy
were
logical
and
ethotic.
Since
social
learning

122

approaches
form
a
practical
framework
around
which
instruments
can
be
designed
to
measure

variables
of
interest,
the
conditioning
perspective
is
“intrinsically
descriptive
rather
than

etiologic
in
orientation.”
For
this
reason,
the
validity
for
PTSD
was
drawn
almost
exclusively

from
arguments
based
in
social
learning
theory
(March,
1990,
p.
65).
In
contrast,
arguments

drawn
from
dynamic
theories
or
cognitive
and
biological
models
lacked
the
empirical
rigor
to
be

nosologically
useful.
At
the
same
time,
the
social
learning
theory
approaches
stood
to
benefit

from
incorporating
support
from
biomedical
approaches
since
it
was
not
yet
possible
to
“to

define
a
class
of
stressors
that
reliably
result
in
PTSD”
(p.
73).
Because
of
this
methodological

problem,
findings
from
epidemiological
studies
–
the
gold
standard
in
the

behavioristic/psychological
paradigm
–
could
never
provide
anything
more
than
strong

provisional
support
for
the
fear-‐conditioning
model.

the
biomedical
approach

In
general,
medical
doctors,
neurologists,
and
physiologists
conducted
PTSD
research

using
a
biomedical
approach.
Biological
models
of
the
disorder
can
be
traced
back
to
the
work

of
a
distinguished
VA
psychiatrist
named
Lawrence
C.
Kolb.
Consistent
with
social
learning

models
of
trauma,
Kolb
(1989)
believed
that
that
all
intense,
life
threatening,
traumatic

experiences
were
“perceived
by
the
individuals
exposed
to
them
as
mortal
danger
associated

with
fear/terror
emotional
responses.”
The
novelty
lies
in
his
idea
that
the
central
nervous

system
“translates
both
the
meaning
of
the
percept
and
its
intensity
into
electrochemical

signals.”
Kolb
hypothesized
that
“often-‐repeated,
high-‐intensity
signals
lead
to
neural
change,

which
induces
hypersensitivity
and
impairment
of
habituation
learning”
(p.
811).

123

Biomedical
approaches
were
grounded
almost
exclusively
in
experimental
research

utilizing
animal
models
to
identify
specific
neurotransmitter
systems
involved
in
the
disorder.

Sometimes
researchers
made
observations
of
animal
behavior
and
predicted
similar
responses

in
humans.
For
example,
van
de
Kolk,
Greenberg,
Boyd,
and
Krystal
(1985)
proposed
an

“inescapable
shock”
model
of
PTSD
based
on
the
studies
showing
that
laboratory
animals

exposed
to
inescapable
aversive
events
exhibited
marked
behavioral
and
biochemical

abnormalities
such
as
endogenous
noradrenaline
depletion
and
opioid
dysregulation.
The

model
predicted
that
similar
alterations
occurred
in
people
with
PTSD.
Other
times
this
pattern

was
reversed
and
researchers
started
with
observations
on
humans
and
then
extrapolated

them
to
animal
models.
Several
studies
demonstrated
that
American
combat
veterans
who
met

diagnostic
criteria
for
PTSD
exhibited
more
abnormal
behavior
and
physiological
arousal
than

control
subjects,
when
exposed
to
meaningful
stimuli
reminiscent
of
combat
(audiotapes
of

combat
sounds,
slides
of
combat
scenes,
and
autobiographical
vignettes
about
combat

exposure)
in
a
laboratory
setting
(Blanchard,
Kolb,
Pallmeyer,
&
Gerardi,
1982;
Gerardi,

Blanchard,
&
Kolb,
1989).
Researchers
interpreted
these
findings
using
animal
models
showing

cortical
neuronal
and
synaptic
changes
in
response
to
intense
stress.
At
any
rate,
with
very
few

exceptions,
biological
theories
of
trauma
functioned
by
analogizing
phenomena
observed
in

human
activity
to
behaviors
observed
in
animals.
From
this
perspective,
it
is
clear
that
the

biomedical
rationale
against
reclassification
also
relied
on
a
form
of
metonymy.
The
key

difference
is
that
advocates
involved
in
biological
research
substituted
an
adjunct

(neuroendocrine
abnormalities)
for
the
thing
itself
(the
phenomenology
of
PTSD).

124

The
primary
advantage
of
this
strategy
over
synecdoche
is
that
it
was
possible
for
the

former
(by
virtue
of
substituting
an
adjunct)
to
add
some
measure
of
external
validity
to
the

diagnostic
construct
that
the
latter
(because
it
elevates
a
part
of
the
thing
it
itself)
cannot.
For

example,
Friedman
(1991)
argued
current
advances
in
biological
research
on
PTSD
could
be

combined
with
psychometric
techniques
to
“achieve
greater
precision”
and
ultimately

distinguish
PTSD
from
the
affective
(major
depressive
disorder)
and
anxiety
(panic
disorder)

entities
with
which
PTSD
was
most
likely
to
be
confounded
(p.
68).
Friedman
(1989)
also
noted

that
clinical
reports
of
uncontrolled
trials
generally
indicated
that
any
“pharmacological
agent

which
dampens
sympathetic
hyperarousal
usually
reduces
PTSD
symptomatology”
(p.
231).
This

provisional
finding
was
consistent
the
prevailing
view
that
“humans
exposed
to
catastrophic

stressors
utilize
the
same
neurobiological
mechanisms
that
are
activated
following
exposure
to

a
less
severe
‘normal’
stressor”
(Friedman,
1995,
p.
1).
This
anecdotal
evidence
“fostered
a

growing
conviction
among
many
clinicians
that
pharmacotherapy
is
sometimes
useful
in

reversing
the
biological
abnormalities
associated
with
PTSD”
and
that
that
it
was
“only
a
matter

of
time”
before
an
effective
pharmacological
approach
would
be
demonstrated
(Friedman,

1993,
pp.
785–788).

One
disadvantage
of
the
rhetorical
strategy
employed
by
advocates
of
biomedical

approaches
is
that
no
matter
how
reasonable
they
may
have
seemed,
experimental
studies
had

yet
to
produce
sufficient
empirical
support
for
biological
models
of
trauma.
According
to
March

(1990),
“there
is
no
lack
of
hypothesizing
about
possible
biological
contributions
to
PTSD”
even

though
biological
approaches
“have
so
far
contributed
little
of
value
to
the
reliable

discrimination
of
PTSD
from
other
psychiatric
disorders”
(p.
70).
Even
proponents
were
careful

125

to
explain
methodological
concerns
that
limited
the
generalizability
of
current
data
on
the

pathophysiology
of
PTSD.
These
concerns
included
“the
small
amount
of
published
research

findings,”
“the
lack
of
standardized
protocols,”
and
“failure
to
control
for
different
diagnoses
…

frequently
associated
with
PTSD”
(Friedman,
1993,
p.
791).
For
this
reason,
the
persuasive
force

of
the
biomedical
rationale
depended
greatly
on
pro
hominem
associations
derived
from
the

alliances
forged
between
neurobiologists
and
with
behavioristic
psychologists.

One
disadvantage
of
the
biomedical
rationale
is
that
metonymy
is
always
vulnerable
to

arguments
that
questioned
the
proximity
between
the
adjunct
(neuroendocrine
disruptions)

and
the
thing
itself
(the
phenomenology
of
PTSD).
The
history
of
trauma
studies
is
replete
with

instances
in
which
cognitive
scientists
and
dynamically
oriented
theorists
employed
this

rebuttal
in
arguments
with
behaviorists
and
physiologists.
Indeed,
Lazarus
(1966)
had
critiqued

Selye’s
quantitative
stress
paradigm
for
exactly
this
reason:
“In
order
to
a
have
a
general
theory

of
psychological
stress
for
all
animals,
the
associationist
tends
to
eliminate
categories
which
are

prime
theoretical
tools
for
understanding
the
person”
(p.
15).
But
in
order
for
such
a
rebuttal
to

be
effective,
proponents
of
reclassification
would
need
to
demonstrate
the
value
of
concepts

excluded
by
behavioristic
and
biological
models
of
trauma.

The
positive
trajectory:
the
rationale
for
reclassification

Those
who
favored
reclassification
were
generally
split
between
two
different

proposals.
One
faction
argued
that
PTSD
should
be
categorized
as
dissociative
disorder.
The

other
group
argued
the
disorder
should
be
moved
into
a
new
category
containing
a
spectrum
of

stress
syndromes.
The
common
thread
between
these
proposals
was
a
conception
of
anxiety
as

a
secondary
manifestation
of
intrapsychic
defense
mechanisms,
rather
than
the
primary
motive

126

force
in
the
disorder.
Taken
together,
the
rationale
for
reclassification
encompassed
two
major

strategies:
(a)
pushing
for
a
nosological
system
that
classified
some
disorders
in
terms
of

function
and

(a)
blocking
the
tropological
associations
between
anxiety,
stress,
and
trauma.
In

general,
proponents
of
reclassification
were
trained
either
as
psychoanalysts
or
cognitive

scientists.

a
functional
nomenclature

Proponents
of
reclassification
wanted
to
move
towards
a
nosological
system
that
was

functional
rather
than
merely
descriptive.
While
some
focused
on
changes
at
the
top

(classification),
others
focused
on
changes
at
the
bottom
(diagnostic
criteria).
Horowitz
and

colleagues
(1987)
argued
that
the
authors
of
DSM-‐IV
should
take
PTSD
out
of
the
anxiety

disorder
category
and
place
it
in
a
separate
category
where
it
could
fall
along
a
continuum
with

other
“stress
response
syndromes”
(p.
268).
According
to
Herman
(1992)
this
continuum
would

range
from
single
acute
trauma
to
simple
PTSD,
to
a
complex
disorder
of
extreme
stress
not

otherwise
specified
(DESNOS)
that
results
from
prolonged
exposure
to
repeated
trauma.

Horowitz
(1993)
believed
such
a
move
would
naturally
facilitate
“an
etiologic
or
causality
based

nomenclature
rather
than
one
that
is
purely
descriptive”
(p.
56).

Brett
and
Ostroff
(1985)
proposed
a
reconceptualization
of
DSM-‐III
criteria
based
on
a

two-‐dimensional
framework
for
the
disorder.
The
authors
claimed
that
dividing
the
symptom

profile
into
two
clusters
relating
to
re-‐experiencing
(repetition
of
the
trauma
in
images,

affective
and
somatic
states,
and
action)
and
defensive
functioning
(psychogenic
amnesia,

emotional
numbing,
and
avoidant
behavior)
would
“remedy
diagnostic
and
clinical
confusion”

and
“point
to
a
more
fruitful
and
systematic
research
perspective”
(p.
417).
This
approach
may

127

have
lacked
diagnostic
specificity
in
practice,
but
this
was
irrelevant
since
the
“core

psychopathology”
of
PTSD
related
to
“intrusive
phenomena
or
re-‐experiencing
of
the
trauma

and
the
specific
forms
of
psychic
numbing
and
phobic
avoidance
used
to
deny
their
impact”

(Lindy,
Green,
&
Grace,
1987,
p.
270).
Different
people
may
behave
in
different
ways
when

faced
with
the
failure
to
process
traumatic
memories,
but
these
are
merely
ego-‐specific

adaptions.
Indeed,
even
symptoms
in
the
DSM-‐III-‐R
anxiety
cluster
(hyper
arousal
and

avoidance)
could
be
explained
as
intrapsychic
defenses
in
response
to
intrusions
(Brett,
1993;

Brett
et
al.,
1985).

Green
and
associates
(1985)
argued
that
PTSD
should
be
defined
by
its’
hallmark:

“The

most
unique
aspect
of
the
PTSD
diagnosis
appears
to
be
the
intrusive
symptoms,
including

intrusive
images
and
recurrent
dreams
and
nightmares.”
While
social
learning
theories
implied

intrusive
imagery
constituted
a
“direct
recapitulation”
of
the
traumatic
event,
psychoanalysts

believed
these
images
were
often
presented
in
a
“partially
disguised
form”
(p.
409).
The

authors
lamented
the
fact
that
individuals
studying
the
impact
of
trauma
on
the
human
mind

had
paid
so
little
attention
to
the
manifest
and
latent
content
of
these
images.
That
is,

behavioristic
assessment
technologies
identified
the
phenomenon
of
re-‐experiencing,
but
rarely

explored
the
phenomenology
of
re-‐experiencing
with
the
patient.
According
to
Lindy
and

colleagues
(1987),
“if
one
considers
seriously
the
diagnosis,
and
together
with
the
patient
can

translate
current
symptoms
into
disavowed
traumatic
memories,
both
clinician
and
patient
will

gain
a
compelling
respect
for
the
disorder”
(p.
272).

128

blocking
tropological
associations

Proponents
of
reclassification
attempted
to
block
the
metonymical
associations

between
anxiety,
fear,
and
trauma
employed
by
behavioristic
psychologists
and

neurobiologists.
Sometimes
this
was
achieved
by
drawing
attention
to
interactions
between

extreme
stressors,
mental
states,
and
environment
that
were
not
usefully
described
by
the

fear-‐conditioning
model.
For
example,
Rachel
Herman’s
(1992)
description
of
DESNOS
was

based
on
a
review
literature
on
survivors
of
prolonged
domestic,
sexual,
or
political

victimization.
She
directed
particular
attention
towards
“observations
that
did
not
fit
readily

into
the
existing
criteria
for
PTSD.”

Clinical
observations
identify
three
broad
areas
of
disturbance
which
transcend
simple

PTSD.
The
first
is
symptomatic:
the
symptom
picture
[including
somatization,

dissociation,
and
affect
changes]
in
survivors
of
prolonged
trauma
often
appears
to
be

more
complex,
diffuse,
and
tenacious
than
in
simple
PTSD.
The
second
is

characterological:
survivors
of
prolonged
abuse
develop
characteristic
personality

changes,
including
deformations
of
relatedness
and
identify.
The
third
area
involves
the

survivor’s
vulnerability
to
repeated
harm,
both
self-‐inflicted
and
at
the
hands
of
others.”

(pp.
378-‐379)

Other
times,
these
advocates
pointed
out
serious
conceptual
and
methodological
shortcomings

with
attempts
to
define
PTSD
as
a
conditioned
response
to
trauma.
Green
(1990)
cautioned

that
“only
careful
research
delineating
both
stressor
dimensions
and
specific
outcomes
will

allow
the
most
appropriate
and
useful
decision
to
be
made
about
classification
and
treatment

implications”
(p.
1639).

129

As
a
first
step
in
this
direction,
the
Green
(1990)
suggested
a
variety
of
“generic

experiences”
that
potentially
occur
within
different
types
of
extreme
events
(p.
1634).
The
goal

was
to
develop
a
consensus
such
that
a
variety
of
events
could
be
reliably
described
along

independent
dimensions.
The
paper
proposed
eight
initial
dimensions
including:
(1)
threat
to

bodily
integrity,
(2)
severe
physical
harm
or
injury,
(3)
recipient
of
intentional
injury/harm,
(4)

exposure
to
the
grotesque,
(5)
violent/sudden
loss
of
a
loved
one,
(6)
witnessing
or
learning
of

violence
to
a
loved
one,
(7)
learning
of
exposure
to
a
noxious
agent,
and
(8)
causing
death
or

severe
harm
to
another.
In
dimensions
1-‐7,
the
patient
plays
the
role
of
a
passive
victim
or
a

bystander
observing
or
hearing
about
events.
However,
in
the
final
dimension
(causing
death
or

severe
harm
to
another)
the
patient
is
involved
as
the
agent
of
her
own
stressor
experience.

Green
(1990)
defended
the
inclusion
of
the
final
dimension
in
spite
of
the
obvious

inconsistency:
“It
could
be
argued
that
the
agent
role
does
not
fit
with
the
more
passive

categories
at
all.
However,
it
seems
important
that
this
type
of
stressor
should
be

acknowledged
as
it
is
part
and
parcel
of
stressors
that
are
duty-‐related
(e.g.,
combat,
police,

etc.)”
(p.
1638).
In
other
words,
the
decision
to
include
dimension
8
was
actually
consistent

with
Green’s
selection
criteria
because
clinicians
and
researchers
had
historically
considered
it

an
important
factor
in
the
development
of
PTSD.
Moreover,
the
perception
of
superficial
of

inconsistency
was
tolerable
because
Green’s
goal
was
never
to
reduce
each
dimension
into

some
common
substrate,
but
rather
to
appreciate
each
dimension
on
its
own
terms.

This
last
point
illustrates
the
primary
difference
between
interlocutors
using
social

learning
frameworks
and
those
using
a
dimensional
approach.
The
former
group
tried
to
bolster

their
credibility
by
demonstrating
propositions
that
“transcend
methodological
approach”

130

(March,
1993,
p.
40;
sic).
Consider
March’s
review
of
research
literature
on
event-‐specific

stressor
dimensions:

In
any
case,
the
dimensions
of
threat
to
life,
severe
physical
harm
of
injury,
exposure
to

grotesque
death,
and
loss
and/or
injury
of
a
loved
one
are
at
least
modestly
correlated

to
the
likelihood
of
developing
PTSD.…
it
is
likely
that
increasing
prevalence
of
these

constituent
elements
is
proportional
to
an
increased
risk
of
intensity
as
well
as
to
the

shape
of
subsequent
symptom
pattern
[read:
anxiety
symptoms].
(p.
46)

It
is
clear
the
author
tried
to
incorporate
Green’s
(1990)
taxonomy
of
generic
experiences
into

the
social
learning
framework.
It
is
hardly
a
coincidence,
however,
that
dimension
8
is
not

mentioned
in
the
passage
above.
Upon
closer
examination,
it
appears
“causing
death
or
severe

harm
to
another”
is
the
only
one
of
the
stressor
dimensions
that
cannot
be
usefully
described

by
a
fear
conditioning
model
(p.
1638).
While
proponents
of
the
social
learning
approach
to

trauma
aim
at
analytical
simplicity
(via
fear
conditioning),
proponents
of
the
dimensional

approach
aim
for
precision
by
emphasizing
context:
“Instruments
that
address
each
construct

as
independently
as
possible
will
help
most
in
contributing
to
our
precision
in
this
matter”

(Green,
1986,
p.
715).

The
Contingency
of
Rhetorical
Networks

Descriptive
analysis
of
each
nosological
debate
reveals
that
discussions
developed
into

controversy
because
interlocutors
were
drawing
on
different
institutional
contexts
(dynamic,

sociological,
biological,
and
psychological)
as
the
backings
for
their
inferences.
The
range
of

oppositional
pairings
observed
are
the
same
that
documented
in
the
1960s/1970s
iteration
of

131

the
controversy
including:
cognition/behavior;
psyche/soma;
description/explanation;

subjective/objective;
method/theory;
laboratory/nature;
nomothetic/ideographic.

Comparative
analysis
provided
a
glimpse
of
an
autopoetic
argument
system
in
motion.

Between
the
early
1980s
and
the
mid-‐1990s,
the
scientific
investigation
of
trauma
matured
by

incorporating
researchers
from
increasingly
diverse
different
disciplinary
and
theoretical

backgrounds.
The
infusion
of
diverse
perspectives
produced
friction
between
investigators
from

different
sub-‐disciplines.
This
friction
intensified
as
advocates
were
entangled
in
debates
about

over
DSM
revisions.

Because
these
nosological
debates
were
accessible
all
and
because
any

major
changes
would
need
to
be
backed
by
diverse
factions
within
APA
membership,

interlocutors
were
sometimes
caught
in
dilemmas
that
forced
them
to
prioritize
either

methodological/theoretical
purity
(personal
disciplinary
identity)
or
the
influence
of
their
sub-‐
discipline
within
the
broader
field
(the
identity
of
traumatology).
Different
proposals

concerning
the
scope
of
trauma,
the
classification
of
PTSD,
and
the
description
of
its

phenomenology
had
tangible
and
significant
implications
for
researchers
(institutional

capital/financial
support)
and
patients
(efficacious
treatment/public
recognition).
Due
to
these

high
stakes,
provisional
alliances
observed
in
the
earlier
iteration
of
this
controversy.
For

example,
the
behaviorist/biomedical
rationale
against
reclassification
depended
heavily
on
the

validity
of
the
stressor
criterion.
Since
dynamic
oriented
theorists
chose
to
concede
the
value
of

the
stressor
criterion
for
their
own
reasons,
their
available
means
of
persuasion
in
debates

about
reclassification
were
limited.
In
general,
positions
had
to
be
tweaked,
muted,
or
omitted

in
order
to
maintain
consistency
as
interlocutors
moved
between
controversies.

132

This
raises
the
question:
which
alliances/strategies
were
more
effective?

In
the
end,
the

revision
of
PTSD
diagnostic
criteria
in
DSM-‐IV
(1994)
did
constitute
a
significant
departure
from

earlier
approaches.
The
committee
opted
to
keep
the
controversial
stressor
criterion,
with
a

few
modifications.
The
most
obvious
change
was
the
partitioning
of
the
stressor
criterion
in
A1

and
A2.
The
former
specified
the
type
of
exposure
(“experienced,
witnessed,
or
was
confronted

with”)
and
the
nature
of
the
event
(“actual
or
threatened
death
or
serious
injury,
or
a
threat
to

the
physical
integrity
of
self
or
others”),
while
the
latter
specified
the
response
of
the
individual

exposed
(“intense
fear,
helplessness,
or
horror”)
(pp.
424-‐427).
With
respect
to
the
etiology,

the
committee
opted
to
retain
the
anxiety
disorder
classification
and
to
reject
the
inclusion
of

DESNOS
or
“complex
PTSD.”
Finally,
they
committee
functionally
narrowed
the
concept
of
PTSD

by
introducing
“Acute
Stress
Disorder”
(ASD),
a
new
diagnosis
used
describe
acute
stress

reactions
that
may
precede
PTSD
(p.
429).
Taken
together,
these
changes
indicate
the

behaviorist/biomedical
alliance
produced
a
network
of
motives
that
was
more
persuasive
than

the
competition.

To
be
sure,
cognitive
scientists
and
dynamic
theorists
did
secure
some
marginal

concessions.
For
one
thing,
the
addition
of
criterion
A2
represented
an
important
“conceptual

modification”
in
the
understanding
of
PTSD
(Weathers
&
Keane,
2007,
p.
111).
The

conceptualization
of
trauma
in
DSM-‐III
(1980)
was
essentially
objective
–
that
is,
based
on
an

apriori
assumption
that
relationship
between
the
magnitude
of
stress
and
the
development
of

pathology,
irrespective
of
factors
particular
to
the
individual.
In
contrast,
the
conceptualization

of
trauma
in
DSM-‐IV
(1994)
emphasized
the
objective
elements
of
the
stressor
as
well
as
the

subjective
reaction
of
the
individual.
Additionally,
the
description
of
Criterion
A1
was
written
in

133

such
a
way
that
non-‐violent
sexual
childhood
sexual
molestation
was
included
as
a
threat
to

“the
physical
integrity
of
self
”
(p.
424).

But
in
the
end,
these
small
victories
weakened
the
strategic
position
of
the

dynamic/cognitive
alliance.
First,
the
introduction
of
A2
was
one
step
forward
and
two
steps

back.
If
a
person
failed
to
experience
intense
fear,
helplessness,
or
horror
during
the
trauma,

then
the
diagnosis
could
not
be
applied.
This
stipulation
effectively
barred
anyone
who

dissociated
(defensively
blocked
affects)
during
trauma
from
being
diagnosed
with
PTSD.

Second,
and
somewhat
ironically,
the
addition
of
ASD
in
DSM-‐IV
functionally
placed
PTSD
a

continuum
of
anxiety
disorders
by
introducing
ASD
and
describing
it
as
a
risk
factor
for

developing
PTSD.
Third,
diagnostic
changes
that
granted
access
to
therapy
and
support
services

to
previously
excluded
populations
also
blunted
the
moral
force
of
critique.
In
the
long
run,

these
advocates
would
need
to
develop
new
rhetorical
strategies
if
they
were
going
to
retain

their
place
in
the
budding
field
of
traumatology.

After
the
publication
of
DSM-‐IV,
it
seems
that
dynamic
researchers
generally
opted
to
hitch

their
wagons
to
the
behaviorist/biomedical
alliance,
and
to
distance
themselves
even
further

from
cognitive
approaches.
This
strategy
is
evident
from
two
trends
observed
between
the
mid-‐
1990s
and
early
2000s.
The
first
trend
is
an
increase
in
studies
and
commentaries
authored
by

dynamic
theorists
embracing
a
shift
from
information
processing
models
(Type
A)
that

described
PTSD
an
oscillation
between
two-‐states
–
re-‐experiencing
and
defensive
avoidance
–

to
models
of
massive
adaptive
failure
(Type
B)
that
described
PTSD
as
a
unilateral
progression

of
a
single
state
(Horowitz,
1986;
Krystal,
1985).
Horowitz
had
popularized
Type
A
models
using

methods
and
theories
derived
from
cognitive
science.
According
to
Brett
(1993),
the
dynamic

134

affinity
for
information
processing
models
is
due
to
the
latter’s
similarity
between
gradual

information
processing
and
Freud’s
concept
of
repetitive
intrusion.
Type
B
models
such
as

Krystal’s
theory
of
catastrophic
adult
trauma
can
be
traced
back
to
seen
Freud’s
stimulus

barrier.

This
leads
directly
into
the
second
trend
–
the
incorporation
of
dynamic
concepts
and

theories
into
biological
models
of
PTSD.
For
example,
after
joining
the
VA’s
newly
minted
PTSD

research
center,
John
Krystal
participated
in
a
number
of
studies
and
reviews
exploring
the

neurobiology
of
PTSD.
His
chapter
in
the
International
Handbook
of
Traumatic
Stress
Syndromes

(1993)
outlined
a
research
agenda
bridging
his
theory
of
adult
trauma
and
van
der
Kolk’s
(1985)

inescapable
shock
model
of
PTSD.
These
dynamic/biomedical
associations
were
also

advantageous
for
neurophysiologists.
Biomedical
theories
carried
the
freight,
but
dynamic

theories
provided
a
critical
rhetorical
resource
that
scientists
exploited
when
they
encountered

unexpected
difficulties.
Popper
(1981)
famously
assigned
falsifiability
as
the
criterion
for

demarcating
science
from
pseudoscience.
But
Duhem
(1906)
observed
that,
in
practice,
a

theory
inconsistent
with
an
observation
could
always
be
rescued
from
falsification
by
modifying

an
auxiliary
hypothesis
-‐-‐
typically
a
hypothesis
about
the
working
of
an
instrument.
Hacking’s

(1992)
formulation
of
a
self-‐vindicating
science
is
an
materialist
extension
of
Duhem’s
doctrine

in
the
sense
that
“any
test
of
theory
is
against
apparatus
that
have
evolved
with
it
–
and
in

conjunction
with
modes
of
data
analysis.
Conversely,
the
criteria
for
the
working
of
the

apparatus
and
for
the
correctness
of
analyses
is
precisely
the
fit
with
theory”
(p.
30).
Taking

Duhem’s
doctrine
as
his
point
of
departure,
Alan
Young
(1995)
argued
dynamic
theories
were

incorporated
in
neurobiological
studies
of
PTSD
as
ancillary
hypotheses
to
unsupported

135

biological
models
from
unexpected
experimental
results.
This
comparison
of
iterative

nosological
controversies
concerning
the
invention
and
optimization
of
PTSD
provided
a

glimpse
into
the
process
through
which
the
shape
of
nosopolitics
changed
over
time.

Medico-‐Scientific
Discourse
in
the
Public
Sphere
(1974-‐1995)

The
more
PTSD
was
refined,
the
more
difficult
it
became
to
sustain
a
provisional
consensus

regarding
the
gravity
of
certain
events
and
the
appropriate
orientation
toward
survivors.
Nancy

Andreasen
(2014),
who
served
as
the
chair
of
the
DSM
committee
on
reactive
disorders,

disagreed
with
APA’s
decision
to
broaden
the
concept
of
PTSD
in
DSM-‐III-‐R
and
DSM-‐IV
by

dropping
the
“stringent
requirement”
that
stressors
be
outside
the
range
of
normal
human

experience:
“In
my
view,
this
broadening
should
be
reconsidered.
Giving
the
same
diagnosis
to

death
camp
survivors
and
someone
who
has
been
in
a
motor
vehicle
accident
diminishes
the

magnitude
of
the
stressor
and
the
significance
of
PTSD”
(p.
1322).
Paradoxically,
as
the
theories

supporting
the
PTSD
were
refined
in
the
technical
realm,
advocates
had
to
develop
new

strategies
to
maintain
its
utility
in
public
discourse.
A
prominent
approached
combined

arguments
that
leveraged
the
perception
of
epistemic
momentum
with
those
that
downplayed

the
reflexive
character
of
trauma
studies
in
extra-‐scientific
forums.
In
the
preface
to
the

International
Handbook
of
Traumatic
Stress
Syndromes
(1993),
John
Wilson
commented
on
the

relationship
between
the
public
sphere
and
the
exponential
expansion
of
PTSD
research
from

1980
to
1993:

To
establish
some
perspective
on
the
growth
rate
of
the
field,
one
only
has
to
recognize

that
a
decade
ago
there
were
no
reference
books
on
traumatic
stress
syndromes,
few

standardized
psychological
measures
of
the
disorder,
little
knowledge
about
the

136

biological
basis
of
behaviors
associated
with
PTSD,
and
a
limited
understanding
of

effective
therapeutic
approaches.
Today,
in
contrast,
there
are
over
40
books
on
trauma

and
victimization,
a
Journal
of
Traumatic
Stress,
and
hundreds
of
scientific
articles
in

major
professional
journals.
Furthermore,
in
the
United
States,
there
is
now
the

National
Center
for
Post-‐Traumatic
Stress
Disorder,
which
has
five
specialized
divisions

at
different
Veterans
Administration
hospital
locations.
It
is
clear
from
these
and
other

indicators
that
the
field
has
come
a
long
way
in
a
short
amount
of
time
and
will
continue

to
grow
rapidly
across
national
boundaries.
(xxi)

Indeed,
civil
society
organizations
emerged
in
the
role
of
scientific
associations
and
societies

dedicated
to
the
publication,
dissemination,
and
promotion
of
scientific
research
on
trauma

and
public
institutions.
Congress
and
the
VA
supported
federal
research
centers.
Together,

public
institutions
played
an
instrumental
role
in
the
maturation
of
traumatology.

ISTSS
(1974-‐
1993)

The
International
Society
for
Traumatic
Stress
Studies
(ISTSS)
was
and
remains
the

premier
society
for
the
exchange
of
professional
knowledge
and
expertise
about
trauma
among

global
audiences—
including
the
scientists,
clinicians,
government
organizations,
and
the
lay

public.
It
was
one
of
the
primary
actants
driving
the
perceived
continuity
of
trauma
studies
that

PTSD
advocates
leveraged
in
expert
debates
and
public
arguments.
The
term
actants
is
used
to

denote
human
and
non-‐human
actors
in
the
actor-‐network
approach.
In
either
case,
actants
in

a
network
take
the
shape
that
they
do
by
virtue
of
their
relations
with
one
another
(Law,
1992;

Law
&
Callon,
1988).
The
actants
of
nosopolitics
include
institutionally
sanctioned
operations

137

that
bid
for
state
of
the
art
authority
as
well
as
means
of
translating
research
into
practical

techniques
and
operations
(gathering
data,
analyzing
it,
and
making
changes).

The
most
prominent
institutional
biographies
of
ISTSS
give
the
impression
that
the
birth

of
such
a
society
was
organic
and
inevitable:
In
light
of
“major
social
movement
and
shifts
in

social
policy
and
psychiatric
diagnosis,
efforts
to
bring
these
[social
movements
associated
with

traumatized
groups]
together
was
a
matter
of
when
and
how,
not
if”
(Figley,
2002,
p.
25).
The

origin
of
the
society
“cannot
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
multiopinioned”

(Bloom,
2000,
p.
28).
There
is
undoubtedly
a
great
deal
of
truth
in
these
narratives,
but
they

may
undersell
the
contingency
of
these
arrangements.
ISTSS
was
built
upon
a
precarious
web
of

translations
that
relates,
defines,
and
orders
a
range
of
objects.
If
that
web
had
taken
a

different
shape,
if
one
of
those
translations
had
failed,
things
might
have
turned
out
differently.

In
this
section,
a
rhetorical
history
of
ISTSS
is
reconstructed
from
biographies
of
persons
and

organizations;
and
books,
journal
articles,
and
reference
material
on
traumatic
stress
studies

for
specialized
and
general
audiences.
Attention
is
drawn
to
events
from
1974
–
1980

(precursors)
and
from
1980
–
1999
(early
history).
49

49

This
timeframe
partially
overlaps
with
the
period
in
which
a
network
consensus
developed
around
the

concept
of
PTSD,
but
nosopolitics
does
not
always
follow
a
linear
path.
Tracing
the
intermediate
arch
in

this
controversy
necessitates
mapping
the
process
through
which
institutions
transformed
from
minor

to
major
parts
of
a
discourse
formation.

138

ISTSS
precursors
(1974-‐1980)

Charles
Figley
(ISTSS
founding
president;
1985-‐1987)
was
a
U.S.
Marine
Corp
veteran

and
an
active
participant
in
VVAW.
He
participated
in
a
number
of
demonstrations
during
his

graduate
studies.
Eventually
Figely
(2002)

became
frustrated
with
the
limitations
of
protest

and
decided
to
adopt
a
different
tactic
–
he
would
practice
“social
action
research”
by

demonstrating
the
toll
of
the
war
went
far
beyond
the
battlefield”
(p.
19).
As
a
faculty
member

at
Bowling
Green
State
University,
he
formed
a
clinical
support
group
that
helped
student

veterans
cope
with
post-‐war
readjustment
difficulties.
Figley
also
compiled
“a
bibliography
of

war-‐related
posttraumatic
stress
disorder”
during
his
doctoral
studies
at
Penn
State
University.

This
bibliography
was
later
published
in
the
Congressional
Record
within
a
committee
print

titled,
“Source
Material
on
the
Vietnam
era
Veteran”
(1974).

The
term
PTSD
does
not
appear
in
Figley’s
(1974)
bibliography
because
that
particular

entity
did
not
exist
until
1980.
The
list
of
references
was
not
designed
to
be
comprehensive,
but

to
“stimulate
and
facilitate
research
into
the
area
of
interpersonal
adjustment
and
family
life

among
Vietnam
veterans
towards
greater
understanding
of
and
solutions
to
adjustment

problems
among
veterans”
(p.
2).
The
document
carved
out
a
field
of
inquiry
by
networking

knowledge
from
the
technical,
public,
and
social
realms
and
bringing
them
to
bear
on
the

experience
of
the
Vietnam
veteran.
It
contained
almost
300
entries
including
peer-‐reviewed

journals
articles,
conference
papers,
popular
books,
press
narratives,
and
public
documents.

Figley
(1974)
claimed
“the
bibliography
attempts
to
bring
together
references
from
the

behavioral
sciences
which
focus
on
the
Vietnam
veteran
experience”
(p.
2).
Critical
examination

reveals
it
did
so
by
connecting
five
distinct
bodies
of
knowledge:
(a)
a
1940s-‐1950s
literature

139

examining
the
development
and
maintenance
of
intimate
relationships
during
and
after

military
service;
and
1960s-‐1970s
literature
examining
(b)
the
relationship
between
combat

experience
and
interpersonal
competence,
as
well
as
(c)
the
relationship
between
the
American

family
system
and
interpersonal
violence.
In
addition,
the
list
embeds
this
technical
discourse
in

(d)
press
narratives
portraying
Vietnam
veterans
as
unknowing
and
unwilling
pawns
in

America’s
chess
game;
and
(e)
moral-‐political
discourse
about
America’s
obligations
to

returning
Vietnam
veterans.
By
networking
technical,
social,
and
public
knowledge
in
this
way,

the
list
invited
inquiry
into
a
theoretical
construct
that
can
be
traced
back
to
the
postwar
era;
it

gained
attention
by
introducing
novelty
in
the
form
contextual
factors
specific
to
the
Vietnam

War.

The
knowledge
the
list
omitted
was
just
as
important
as
the
discourse
it
included.
It
is

the
rare
bibliography
that
completely
excludes
literature
posing
critical
questions
and

contradictory
findings.
This
omission
is
particularly
striking
because
research
literature
was

replete
with
studies
questioning
the
link
between
combat
exposure
and
prolonged

interpersonal
conflict.
For
example,
the
list
includes
Archibald
and
Tuddenham’s
(1965)
paper

finding
evidence
of
a
chronic
combat
syndrome
in
veterans
20
years
after
the
conclusion
of
the

war.
The
authors
used
these
findings
to
argue
against
the
conventional
wisdom
that
post-‐war

combat
syndrome
was
a
transient
condition
that
improved
with
time.
But
the
list
does
not

include
the
NRC’s
(1956)
earlier
study
on
WWII
veterans,
the
paper
to
which
the
authors
were

responding.
One
could
easily
argue
the
results
from
the
more
recent
paper
contained
the
most

up-‐to-‐date
information
about
the
long-‐term
course
of
readjustment.
But
this
argument
falls
flat

when
methodological
rigor
is
taken
into
account.
The
NRC
(1956)
study
relied
on
large
samples

140

drawn
from
a
relatively
random
selection
of
ex-‐servicemen.
The
scope
of
the
investigation
was

much
broader
and
systematic.
52

The
bibliography
itself
became
tool
that
embedded
a
particular
history
of
trauma

studies
in
a
much
larger
social
network.
Senator
Vance
Hartke
(SCVA
chair)
had
the
list

published
in
the
Congressional
Record
(1974).
Hartke
is
best
known
for
his
vocal
opposition
to

the
Vietnam
War
(Figley,
2002;
Saxon,
2003).
As
a
consequence,
the
list
was
made
available
in

nearly
every
library
in
the
country.
Afterwards,
Figley
received
“an
extraordinary
number
of

requests
for
reprints
and
general
inquiries
about
sharing
resources”
(p.
19).
He
reasoned
it

would
be
easier
to
meet
these
requests
with
the
support
of
a
dedicated
research
organization.

He
established
the
Consortium
on
Veterans
Studies
in
1975.
The
Consortium
was
an
informal

network
of
like-‐minded
scholars
interested
in
investigating
the
mental
health
consequences
of

the
Vietnam
War
through
sessions
at
national
and
international
societies
(p.
20).

From
1976-‐1980,
the
Consortium
organized
panels
and
presentations
on
veterans’

readjustment
at
most
major,
relevant
associations
including
the
AOA,
APA,
ApA,
ASA,
and
the

National
Council
on
Family
Relations
(NCFR).
It
was
during
one
such
panel
at
the
1975
ASA

annual
conference
where
Figley
networked
with
Shatan,
Lifton
and
their
colleagues
in
the

VVWG
(Bloom,
2000,
p.
37).
They
began
collaborating
on
an
edited
volume
–
Stress
Disorders

52

The
study
was
rigorous
and
comprehensive.
Results
were
based
on
representative
samples
from
Air

Force,
Army,
and
Navy
admissions
for
psychoneurotic
disorders
during
1944.
The
list
of
conditions

examined
includes:
“hysteria;
anxiety
state
(including
hypochondriasis);
neurasthenia;
neurocirculatory

asthenia;
obsessive
compulsive
(psychasthenia);
mixed
(including
phobias);
reactive
depression;

psychoneurosis,
other,
unqualified,
unspecified,
including
combat
exhaustion”
(p.3).
Psychiatric

examinations
were
conducted
for
the
entire
clinical
sample.
The
vast
majority
of
these
were
performed

by
trained
psychiatrists
with
a
history
of
military
service.
The
design
was
limited
by
“inconsistencies
in

psychiatric
approach,
orientation,
and
technique”
and
the
commonly
accepted
premise
that
any
study

of
veterans
is
“bound
to
be
influenced
by
considerations
of
compensation”
(Brill
&
Beebe,
1956,
p.
8).

141

among
Vietnam
Veterans
(1978).
This
seminal
work
was
“devoted
to
expanding
the
knowledge-‐
base
of
combat
related
stress
disorders
in
particular
and
the
psychosocial
adjustment
of

veterans
in
general
…
to
advance
the
field
of
veterans
studies
and
to
provide
useful
resources

for
others
to
build
upon”
(Bourne,
1978,
p.
xv).
The
trauma
studies
bibliography,
the
Veterans

Consortium,
Stress
Disorders
among
Vietnam
Veterans,
and
the
individuals
that
produced
them

played
pivotal
roles
in
crafting
a
practical
and
historical
foundation
for
ISTSS.

Early
history
of
ISTSS
(1980
–
1988)

By
the
early
1980s,
the
environment
seemed
ripe
for
the
development
of
an

international
scientific
organization
dedicated
to
the
study
of
psychological
trauma.
Between

1979
and
1980,
Congress
established
the
Vietnam
Veterans
Readjustment
Counseling
program,

APA
officially
recognized
PTSD,
the
VA
established
criteria
for
a
service-‐connected
psychiatric

disability
rating
for
PTSD,
and
opened
the
first
Vet
Centers.
This
shift
in
social
policy
led
to
the

development
of
institutions
and
systems
to
address
this
new
interest.
So
Figley
(2000)
wrote
to

a
number
of
“like-‐minded
colleagues”
proposing
the
formation
of
a
society
for
traumatic
stress

studies
in
1983
(p.
27).
Such
an
organization
would
“recognize
achievement
in
knowledge

production;
disseminate
this
knowledge
through
face-‐to-‐face
contact
with
colleagues;
and

make
this
information
available
through
other
knowledge
transfer
media,
especially
print

media
…
unifying
theories,
concepts,
and
assessment
tools,
and
treatment
approaches
would

evolve
quickly”
under
the
umbrella
of
a
single
organization
(p.
26).
ISTSS
was
formally

established
during
a
meeting
in
Washington
D.C.
on
March
2,
1985
(Bloom,
2000).

The
next
step
was
to
establish
a
scientific
journal
that
would
function
as
an
outlet
to

studies
on
the
immediate
and
long-‐term
psychosocial
consequences
of
highly
stressful
and

142

traumatic
events
(Bloom,
2000;
Figley,
2002).
A
traumatology
journal
would
allow
ISTSS
to

disseminate
knowledge
to
new
audiences
and
ultimately
influence
practice
and
policy.
Figley

(2002)
worked
to
broaden
the
tent
beyond
those
interested
in
veterans’
studies
because

previous
experiences
taught
him
that
publishers
would
not
be
interested
unless
there
was
a

substantial
subscription
base
(p.
26).
The
founding
board
of
directors
included
practitioners

working
with
different
traumatized
populations
including
returning
veterans
(Figley);
victims
of

sexual
assault
and
domestic
abuse
(Marlene
Young
and
Ann
Burgess)
concentration
camp

survivors
(Yael
Danieli);
and
young
children
(Robert
Rich;
Bloom,
2000).
A
diverse
board
made

ISTSS
more
likely
to
draw
interest
from
practitioners
in
a
variety
of
disciplines.

Figley
(1988)
penned
an
editorial
in
the
inaugural
issue
of
the
Journal
of
Traumatic

Stress
(JTS)
that
urged
readers
to
submit
their
own
manuscripts.
Studies
published
in
the
official

journal
of
ISTSS
“will
be
read
not
only
by
members…
but
also
by
other
processionals
in

academic,
industry,
government,
and
clinical
settings.”
The
success
of
JTS
would
ultimately

determine
whether
traumatology
developed
into
“an
intriguing
but
temporary
area
of
interest”

or
“a
dynamic
and
important
field
of
study”
(p.
1).
It
appears
that
his
call
was
well
received.

There
were
495
articles
published
in
JST
between
1988
and
2001.
Additionally,
13,865
trauma

articles
published
between
1987
and
2001
were
identified
using
the
PILOTS
database.

In
sum,
the
field
of
traumatology
developed
in
parallel
with
and
because
of
civil
society

organizations
formed
by
like-‐minded
scholars
interested
in
the
psychosocial
impacts
of
trauma.

The
Veterans
Consortium
and
ISTSS
built
momentum
by
disseminating
existing
studies
and

laying
the
foundation
for
the
production
of
new
knowledge.
First,
these
organizations

facilitated
intragroup
ties
between
experts
with
tacit
knowledge
about
the
impact
of
trauma

143

and
different
traumatized
populations
and
intergroup
associations
between
PTSD
researchers

and
other
practitioners
in
other
fields.
The
cross-‐pollination
of
subject-‐matter
expertise
with

technical
know-‐how
produced
unifying
theories,
assessment
tools,
and
therapies
that
were

mutually
adjusted
to
each
other.
Second,
these
organizations
codified
that
background

knowledge
in
the
form
of
scholarly
publications
designed
for
the
consumption
by
practitioners,

government
agencies,
and
the
lay-‐public.
By
examining
the
history
of
these
organizations,
this

analysis
provides
a
window
into
the
process
of
self-‐authentication
and
self-‐vindication
that

rendered
traumatology
into
a
mature
science
by
the
end
of
the
20
th

century.

The
brief
history
just
sketched
has
obvious
limitations.
A
comprehensive
list
of

individuals,
ideas,
things,
and
marks
involved
in
the
early
history
of
ISTSS
is
beyond
the
scope
of

this
chapter.
Attention
was
drawn
to
elements
that
rendered
the
autopoetic
reproduction
of

trauma
studies
visible.
PTSD
was
transformed
from
a
once
contested
hypothesis
into
an

accepted
fact,
and
eventually
into
a
black
box
through
successful
scientific
practice
in
the
1980s

and
1990s.
Figley’s
trauma
studies
bibliography
is
an
example
of
an
object
that
PTSD
advocates

used
to
speed
up
this
process.
By
crafting
a
particular
history
of
trauma
studies,
one
that

suppressed
criticisms,
doubts,
and
shortcomings,
the
list
communicated
a
particular
narrative

about
the
degree
of
progress
as
well
as
the
continuity
of
theory
and
practice
in
the
scientific

investigation
of
trauma.
PTSD
advocates
used
this
list
to
generate
attention
and
secure

additional
resources
because
parallel
developments
in
the
public
sphere
allowed
the
latter
to

achieve
circulation
in
a
wider
social
network.

144

Political
Policy
Debates:
Federal
Hearings
and
Debates
(1983
–
1995)

Congress
voted
to
extend
eligibility
for
Post-‐Vietnam
readjustment
counseling
three

times
over
the
course
of
the
1980s.
During
this
period,
the
SCVA
and
HCVA
conducted
a
series

of
oversight
hearings
assessing
the
biopolitics
of
postwar
trauma.
Witness
testimony
addressed

several
major
questions
including:
what
was
the
prevalence
of
combat
related
PTSD
among

Vietnam
veterans
and
veterans
of
earlier
wars;
were
veterans
with
PTSD
getting
the
best

available
treatment
from
the
VA;
were
qualified
mental
health
professionals
diagnosing

veterans
accurately;
were
the
VA
officials
responsible
for
assigning
disability
ratings
acting

performing
their
duties
fairly
and
efficiently;
did
research
into
PTSD
treatment
receive
the

priority
it
should;
to
what
extent
was
there
an
unmet
need
for
additional
services?
Special

attention
is
given
to
a
political/technical
epidemiological
debate
concerning
the
prevalence
of

PTSD
in
Vietnam
veterans.
The
second
case
consists
of
testimony
from
a
special
VA
taskforce
on

PTSD.
This
debate
is
important
to
explore
because
it
provides
a
window
into
the
practices
of

self-‐vindication
involved
in
the
epidemiology
of
trauma
as
well
as
the
rhetoric
of
self-‐
rationalization
and
employed
by
PTSD
researchers
in
public
forums.

The
Prevalence
of
PTSD
in
Vietnam
Veterans:
An
Epidemiological
Controversy

In
1983,
Bob
Edgar
(HCVA
chair)
proposed
legislation
authorizing
the
VA
to
conduct
a

major
study
of
the
Vietnam-‐era
veteran
population.
According
to
Edgar,
the
study
would

determine
the
VA’s
ability
to
provide
for
continuing
readjustment
and
health
needs
of
Vietnam

veterans
and
to
provide
“an
assessment
of
the
readjustment,
economic,
social,
and
health

status
of
the
population.”
With
these
results
in
hand,
Congress
would
“have
the
tools
to
gauge

the
strengths
and
weaknesses
of
the
Vietnam-‐era
veteran
population
(Readjustment
Counseling

145

Oversight,
1983,
pp.
1-‐2).
Congress
eventually
awarded
the
study
contract
to
the
Research

Triangle
Institute
(RTI)
in
1985.
This
RTI
study
was
one
of
two
major
epidemiological
studies

examining
the
Vietnam
War’s
long-‐term
influence
on
veterans’
health.
While
both
studies

confirmed
that
Vietnam
veterans
returned
with
more
psychological
disturbances
than
non-‐
veterans,
they
gave
conflicting
accounts
on
the
scale
of
the
problem.

The
VES
and
NVVRS:
Two
trajectories

The
Centers
for
Disease
Control

(CDC)
Vietnam
Experience
Study
(VES)
was
a

multidimensional
assessment
of
the
health
of
Vietnam
veterans
(Destefano,
1988).
Researchers

conducted
telephone
interviews
and
comprehensive
health
examinations
on
men
drawn
from
a

random
sample
of
GIs
who
entered
the
U.S.
Army
from
1965
to
1971.
The
VES
found
that

certain
psychological
problems
were
more
common
among
veterans
that
served
in
Vietnam.

These
problems
included
depression,
anxiety,
and
PTSD.
However,
the
VES
found
that:

“Vietnam
veterans
seem
to
be
functioning
socially
and
economically
in
a
manner
similar
to

army
veterans
who
did
not
serve
in
Vietnam”
(p.
2705).
Moreover,
the
VES
data
belied
claims

about
the
long-‐term
psychological
complications
of
combat
service
in
Vietnam.
Although
over

15
percent
Vietnam
veterans
had
met
the
diagnostic
criteria
for
PTSD
at
some
point
during
or

after
service,
only
2
percent
would
receive
that
diagnosis.

RTI’s
National
Vietnam
Veterans
Readjustment
Study
(NVVRS)
was
a
congressionally

mandated
study
exploring
the
on-‐going
effects
of
the
Vietnam
War
on
its
veterans
(Kulka
et
al.,

1990).
This
study
was
similar
to
the
VES
in
terms
of
the
questions
it
asked
and
the
sample
is

used,
but
it
produced
very
different
results
(Young,
1997,
p.
131).
The
NVVRS
found
that
nearly

31
percent
of
all
men
who
served
in
Vietnam
developed
PTSD,
and
an
additional
23
percent

146

developed
clinically
significant
symptoms
that
fell
just
short
of
the
diagnostic
threshold
(Kulka,

1988,
p.
53).
Moreover,
the
results
revealed
that
the
disorder
persisted
in
about
half
of
these

veterans
in
the
late
1980s.

Given
the
fact
that
experts
agreed
both
the
NVVRS
and
VES
estimates
were
based
on
a

large
sample
of
Vietnam
veterans
and
conducted
according
to
high
scientific
standards;
the

discrepancy
in
the
estimates
of
the
magnitude
found
was
cause
for
considerable
concern.
In

1988,
research
teams
from
both
studies
were
invited
to
prepare
testimony
for
the
SCVA
to

explain
the
reasons
from
the
conflicting
data.
Representatives
from
each
team
testified
about

the
background
for
their
project;
the
methods
and
criteria
used
to
assess
PTSD;
the
estimates

of
the
prevalence
of
PTSD
based
on
those
methods;
and
the
data
discrepancy.
According
to

RTI’s
report:
“analysis
of
the
factors
that
could
account
for
differences
in
the
prevalence
rates

between
the
CDC
and
the
NVVRS
studies
suggests
the
difference
is
primarily
the
result
of

differences
in
the
measures
used
to
assess
PTSD”
(Kulka,
1988,
p.
38).
CDC
testimony
presented

an
identical
conclusion.

VES
methodology:
The
DIS

In
order
to
assess
the
prevalence
of
PTSD,
VES
exclusively
used
the
PTSD
module
of

Version
IIIA
of
the
Diagnostic
Interview
Schedule
(DIS)
(Robins,
Helzer,
Croughan,
&
Ratcliff,

1981).
DIS
was
a
psychiatric
diagnostic
tool
developed
by
researchers
from
the
Department
of

Psychiatry
at
the
University
of
Washington
in
St.
Louis
(WUSTL).
The
National
Institutes
for

Mental
Health
(NIMH)
requested
that
WUSTL
produce
an
instrument
for
use
in
the
large-‐scale

Epidemiological
Catchment
Area
(ECA)
project
(Regier
et
al.,
1984).
The
major
objective
of
the

ECA
program
was
to
obtain
prevalence
rates
of
specific
mental
disorders
as
defined
by
DSM-‐III.

147

Researchers
believed:
“epidemiologically
derived
data
on
correlates
of
disorders
should

improve
the
usefulness
or
validity
of
the
currently
defined
diagnostic
categories
by

demonstrating
if
disorders
are
concentrated
in
the
population
groups
previously
thought
to
be

at
higher
risk
for
certain
conditions”
(p.
938).

The
ECA
project
was
comprised
by
four
different
psychiatric
epidemiological
surveys
in

different
geographic
sites
with
over
4000
total
subjects.
Given
the
scale
of
the
project,
NIMH

would
need
to
rely
on
laypersons
with
little
to
no
clinical
experience
to
produce
diagnoses
both

reliably
and
validly.
The
project
necessitated
a
user-‐friendly
instrument
that
required
minimal

clinical
judgment
on