Mapping Trauma and Its Wake

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MAPPINGTRAUMA AND

ITS WAKE

ROUTLEDGE PSYCHOSOCIAL STRESS SERIESCharles R. Figley, Ph.D., Series Editor

1. Stress Disorders among Vietnam Veterans, Edited by Charles R.Figley, Ph.D.

2. Stress and the Family Vol. 1: Coping with Normative Transitions,Edited by Hamilton I. McCubbin, Ph.D. and Charles R. Figley,Ph.D.

3. Stress and the Family Vol. 2: Coping with Catastrophe, Edited byCharles R. Figley, Ph.D., and Hamilton I. McCubbin, Ph.D.

4. Trauma and Its Wake: The Study and Treatment of Post-TraumaticStress Disorder, Edited by Charles R. Figley, Ph.D.

5. Post-Traumatic Stress Disorder and the War Veteran Patient, Editedby William E. Kelly, M.D.

6. The Crime Victims Book, Second Edition, by Morton Bard, Ph.D.,and Dawn Sangrey.

7. Stress and Coping in Time of War: Generalizations from the IsraeliExperience, Edited by Norman A. Milgram, Ph.D.

8. Trauma and Its Wake Vol. 2: Traumatic Stress Theory, Research, andIntervention, Edited by Charles R. Figley, Ph.D.

9. Stress and Addiction, Edited by Edward Gottheil, M.D., Ph.D.,Keith A. Druley, Ph.D., Steven Pashko, Ph.D., and Stephen P.Weinsteinn, Ph.D.

10. Vietnam: A Casebook, by Jacob D. Lindy, M.D., in collaborationwith Bonnie L. Green, Ph.D., Mary C. Grace, M.Ed., M.S., JohnA. MacLeod, M.D., and Louis Spitz, M.D.

11. Post-Traumatic Therapy and Victims of Violence, Edited by FrankM. Ochberg, M.D.

12. Mental Health Response to Mass Emergencies: Theory and Practice,Edited by Mary Lystad, Ph.D.

13. Treating Stress in Families, Edited by Charles R. Figley, Ph.D.14. Trauma, Transformation, and Healing: An Integrative Approach to

Theory, Research, and Post-Traumatic Therapy, by John P. Wilson,Ph.D.

15. Systemic Treatment of Incest: A Therapeutic Handbook, by TerryTrepper, Ph.D., and Mary Jo Barrett, M.S.W.

16. The Crisis of Competence: Transitional Stress and the DisplacedWorker, Edited by Carl A. Maida, Ph.D., Norma S. Gordon,M.A., and Norman L. Farberow, Ph.D.

17. Stress Management: An Integrated Approach to Therapy, by Dor-othy H. G. Cotton, Ph.D.

18. Trauma and the Vietnam War Generation: Report of the Findingsfrom the National Vietnam Veterans Readjustment Study, by Rich-ard A. Kulka, Ph.D., William E. Schlenger, Ph.D., John A. Fair-bank, Ph.D., Richard L. Hough, Ph.D., Kathleen Jordan, Ph.D.,

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Charles R. Marmar, M.D., Daniel S. Weiss, Ph.D., and David A.Grady, Psy.D.

19. Strangers at Home: Vietnam Veterans Since the War, Edited byCharles R. Figley, Ph.D., and Seymour Leventman, Ph.D.

20. The National Vietnam Veterans Readjustment Study: Tables of Find-ings and Technical Appendices, by Richard A. Kulka, Ph.D., Kath-leen Jordan, Ph.D., Charles R. Marmar, M.D., and Daniel S.Weiss, Ph.D.

21. Psychological Trauma and the Adult Survivor: Theory, Therapy, andTransformation, By I. Lisa McCann, Ph.D., and Laurie AnnePearlman, Ph.D.

22. Coping with Infant or Fetal Loss: The Couples Healing Process, byKathleen R. Gilbert, Ph.D., and Laura S. Smart, Ph.D.

23. Compassion Fatigue: Coping with Secondary Traumatic Stress Disor-der in Those Who Treat the Traumatized, Edited by Charles R. Fig-ley, Ph.D.

24. Treating Compassion Fatigue, Edited by Charles R. Figley, Ph.D.25. Handbook of Stress, Trauma and the Family, Edited by Don R.

Catherall, Ph.D.26. The Pain of Helping: Psychological Injury of Helping Professionals,

by Patrick J. Morrissette, Ph.D., RMFT, NCC, CCC 27. Disaster Mental Health Services: A Primer for Practitioners, by

Diane Myers, R.N., M.S.N, and David Wee, M.S.S.W.28. Empathy in the Treatment of Trauma and PTSD, by John P. Wilson,

Ph.D. and Rhiannon B. Thomas, Ph.D.29. Family Stressors: Interventions for Stress and Trauma, Edited by

Don. R. Catherall, Ph. D.30. Handbook of Women, Stress and Trauma, Edited by Kathleen Ken-

dall-Tackett, Ph.D.

EDITORIAL BOARD

Mary Jo Barrett, M.S.W.Betram S. Brown, M.D.Ann W. Burgess, D.N.Sc.Jonathan R. T. Davidson, M.D.Victor J. DeFazio, Ph.D.Bruce P. Dohrenwend, Ph.D.Bonnie Green, Ph.D.Don M. Harsough, Ph.D.Mardi Horowitz, M.D.Terence M. Keane, Ph.D.Rolf Kleber, Ph.D.

Robert Jay Lifton, M.D.Jacob D. Lindy, M.D.Frank M. Ochberg, M.D.Edwin R. Parson, Ph.D.Beverley Raphael, M.D.Charles D. Spielberger, Ph.D.John A. Talbott, M.D.Michael R. Trimble, M.R.C.P.Bessel van der Kolk, M.D.Zahava Solomon, Ph.D.John P. Wilson, Ph.D.

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Autobiographic Essays byPioneer Trauma Scholars

MAPPINGTRAUMA AND

ITS WAKE

Edited by Charles R. Figley

New York London

Published in 2006 byRoutledgeTaylor & Francis Group 270 Madison AvenueNew York, NY 10016

Published in Great Britain byRoutledgeTaylor & Francis Group2 Park SquareMilton Park, AbingdonOxon OX14 4RN

2006 by Taylor & Francis Group, LLCRoutledge is an imprint of Taylor & Francis Group

Printed in the United States of America on acid-free paper10 9 8 7 6 5 4 3 2 1

International Standard Book Number-10: 0-415-95140-2 (Hardcover) International Standard Book Number-13: 978-0-415-95140-1 (Hardcover) Library of Congress Card Number 2005011318

No part of this book may be reprinted, reproduced, transmitted, or utilized in any form by any electronic,mechanical, or other means, now known or hereafter invented, including photocopying, microfilming, andrecording, or in any information storage or retrieval system, without written permission from the publishers.

Trademark Notice: Product or corporate names may be trademarks or registered trademarks, and are used onlyfor identification and explanation without intent to infringe.

Library of Congress Cataloging-in-Publication Data

Mapping trauma and its wake : autobiographic essays by pioneer trauma scholars / Charles R. Figley, editor ; with chapters by the leading pioneers in the study and treatment of trauma, Ann Wolbert Burgess ... [et al.].

p. ; cm. -- (Routledge psychosocial stress series ; 31)Includes bibliographical references and index.ISBN 0-415-95140-2 (hardback : alk. paper)1. Post-traumatic stress disorder--Research. 2. Psychic trauma--Research. 3. Psychiatrists--

Biography. 4. Psychologists--Biography. [DNLM: 1. Stress Disorders, Post-Traumatic--Personal Narratives. 2. Research Personnel--Personal Narratives. WZ 112 M297 2005] I. Figley, Charles R., 1944- II. Series.

RC552.P67M358 2005616.85'21'0922--dc22 2005011318

Visit the Taylor & Francis Web site at http://www.taylorandfrancis.com

and the Routledge Web site at http://www.routledge-ny.com

Taylor & Francis Group is the Academic Division of Informa plc.

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To Joseph Wolpe, MD, the pioneer of trauma treatment theory

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ix

Contents

Series Note xi

Acknowledgments xiii

Introduction 1Charles R. Figley

1. Putting Trauma on the Radar Screen 17Ann Wolbert Burgess

2. It Was Always There 33Yael Danieli

3. From Veterans of War to Veterans of Terrorism: My Maps of Trauma 47

Charles R. Figley

4. Making It Up as I Went Along 61Matthew J. Friedman

5. My Life and Work 77Judith Lewis Herman

6. A Life in but Not Under Stress 85Mardi Horowitz

7. Fully Primed 95Lawrence C. Kolb

8. Psychoanalytic Approaches to Trauma: A Forty-Year Retrospective 111

Henry Krystal

9. Some Reflections 121Robert Jay Lifton

10. There Is Reason in Action 137Frank Ochberg

11. Life, Trauma, and Loss 153Beverley Raphael

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x Contents

12. Choices Made, Promises Kept 169Zahava Solomon

13. Memoirs of a Childhood Trauma Hunter 185Lenore Terr

14. Autobiographical Essay 201Robert J. Ursano

15. The Body Keeps the Score: Brief Autobiography of Bessel van der Kolk 211

Bessel van der Kolk

16. Becoming a Psychotraumatologist 227Lars Weisaeth

17. From Crisis Intervention to Bosnia: The Trauma Maps of John P. Wilson 245

John P. Wilson

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xi

Series Note

The Routledge Psychosocial Stress Book Series is delighted to welcome thisbook about and by the pioneers of trauma to the oldest trauma book series.The series is the first to focus on traumatic stress, the first book havingbeen published in 1978. It is therefore only fitting that a book about andby trauma scholar pioneers be published in this pioneering series.

The series strives to attract and publish books introducing new areasof inquiry or understanding that immediately or eventually help prevent,cope with, or eliminate unwanted human stress and promote the result-ant benefits. The list of books in the series is available at the front of thisbook.

Several pioneers with chapters in this book have contributed to theseries. Most recently, among these, has been John Wilsons book The Post-traumatic Self. Others who have published either books or chapters inthe series include Ann Wolbert Burgess, Yael Danieli, Charles R. Figley,Matthew J. Friedman, Mardi Horowitz, Robert Jay Lifton, Frank Ochberg,Beverley Raphael, Bessel van der Kolk, and Lars Weisaeth.

Consistent with the aim of the series of contributing to understandingtrauma and its consequences, Mapping Trauma and Its Wake: Autobio-graphic Essays by Pioneer Trauma Scholars advances the field. This collec-tion of personal, autobiographical essays was written by trauma scholarsrecognized for their significant contributions to the field by the Interna-tional Society for Traumatic Stress Studies and the Academy of Trauma-tology. Each scholar was asked to address four fundamental questionsbut remained otherwise free in structuring his or her chapter. The pur-pose of the collection is to recognize the similarities and differencesamong these scholars, punctuate the significance and interrelatedness oftheir contributions, and inspire current and future trauma scholars tostrive to make equally important lifetime contributions to understandingand helping the traumatized. This is a special project of the Academy ofTraumatology with support from the Green Cross Foundation.

Charles R. Figley, Ph.D., EditorRoutledge Psychosocial Stress Book Series

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xiii

Acknowledgments

Among the many people who were instrumental in some way in bringingthis book to fruition are the following: Dr. Patricia L. Johnson (Traumato-logy assistant editor), Dr. Ellisa Benedek (University of Michigan), AllisonStieber (assistant to Dr. Robert Jay Lifton), Michaela Nevin (Dr. Ursanospersonal assistant), Pamela K. Leadbitter-Shaver and Mary K. Estes (assis-tant to and daughters of Lawrence Kolb), Margarite Salinas (administra-tive assistant to Mardi J. Horowitz), Scott Lindstrom (assistant toDr. Lenore Terr), Kathy Letizio (assistant to John Wilson), Dr. Bruce Thyer(Florida State University School of Social Work), the International Societyfor Traumatic Stress Studies, and the Academy of Traumatology staff.I offer a special note of thanks to colleagues who reviewed the submis-sions and provided tactful and supportive editorial suggestions. Theyinclude Frank Ochberg, Matthew Friedman, Lars Weisaeth, Spencer Eth,Dan Weiss, Robert Michels, Craig Van Dyke, Robert Ursano, Carol Fullerton,Rick Kolb (for assistance with the photos of Lawrence Kolb, his father),Annette Berenger (personal assistant to Prof. Beverley Raphael), LynnOchberg (for assisting Frank, as always), Molly Hall, Professor HarryKreisler (UC-Berkeley Institute of International Studies, for providing aportion of the first draft of Dr. Liftons chapter), Ann Norwood, JudyHerman, Sandy McFarlane, Rachel Yehuda, Anne Burgess, FrancineShapiro, John Fairbank, Onno van der Hart, and Roger Pitman. Also, I amgrateful to my family, who tolerated my going on and on about this project;they include Kathy Regan Figley, Laura Figley, Geni Figley, JessicaChynoweth, Mike Chynoweth, Sandy Elliott, Mike Elliott, and AmyElliott. Dana Bliss, Brook Cosby, and George Zimmar of Routledgeworked hard to keep this project on target and on time during the endlesse-mail exchanges. I appreciate their professionalism and patience.

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Contributors

MAPPING TRAUMA AND ITS WAKE:AUTOBIOGRAPHIC ESSAYS BY PIONEER TRAUMA SCHOLARS

Edited byCharles R. Figley

With chapters by the leading pioneers in the study and treatment oftrauma:

Ann Wolbert Burgess, RN, DSciNYael Danieli, Ph.D.

Charles R. Figley, Ph.D.Matthew J. Friedman, M.D., Ph.D.

Judith Lewis Herman, M.D.Mardi Horowitz, M.D.

Lawrence C. Kolb, M.D.Henry Krystal, M.D.

Robert Jay Lifton, M.D.Frank Ochberg, M.D.

Beverley Raphael, M.D.Zahava Solomon, Ph.D.

Lenore Terr, M.D.Robert J. Ursano, M.D.

Bessel van der Kolk, M.D.Lars Weisaeth, M.D.

John P. Wilson, Ph.D.

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1Introduction

CHARLES R. FIGLEY

The idea for this book emerged from my reading of a biography of AlbertEinstein (Folsing, 1997), which noted that the only autobiography writtenby Einstein was in the form of a chapter in a book edited by Paul ArthurSchilpp (1949) as part of his Library of Living Philosophers (LLP). The planof the LLP was to approach a leading philosopher and request an intel-lectual autobiography, or authorized biography, of his or her publica-tions. In the resulting book, this autobiographical work would befollowed by a series of expository chapters and critical essays written bynoted exponents and opponents of the philosophers perspective. TheLLP autobiographies often illuminated how these ideas grew into signifi-cant philosophical movements. Of special interest is how they reflectedtheir originators own special and personal experiences.

This approach to understanding the person behind the perspectivewould, it seemed to me, be relevant to any field of study, including trau-matology. And it seemed to me that just as Einstein was motivated towrite his only autobiography by this approach, the same method mightentice the pioneers of traumatology to do likewise. This, the resultingbook, offers evidence that the enticement worked.

The history of modern traumatology comprises only a few decades.Although traumatology was originally a narrow specialty of surgery, itsscope has become wide, with a focus on the individuals psychosocial,emotional, and psychobiological reactions to traumatic events as well asthe roles of medical injury and mitigation.

The explosion of this information has outpaced our ability to compre-hend its history. Who better to tell that history than the history makers?The Society for Traumatic Stress Studies was established in 1985, amere 5 years after the diagnosis of posttraumatic stress disorder (PTSD)was first presented. Over the years the (now international) society hasserved as the leading organization dedicated to the creation and dissemi-nation of new knowledge in traumatology. Starting in 1988, the society

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2 Mapping Trauma and Its Wake

established the Pioneer Award to represent both the lifetime achievementsof the recipients and their pivotal role as pioneers in the field. In 1995, asa reflection of the growing significance of the field, the Pioneer Awardwas renamed the Lifetime Achievement Award, which remains the topaward given by this learned society. Therefore, what better way to selectthose whose work represents the core and history of the field than tochoose these award-winning scholars?

This is the first of several volumes of autobiographies written by trau-matologists. Several winners of the societys award, including Edna Foaand Robert Pynoos, were unable to contribute to this book but havepromised to do so in the next one. They are founding members of theAcademy of Traumatology, and internationally, recognized pioneers areincluded in this book in addition to those recognized by U.S. society.Others will contribute to future volumes.

ABOUT THE TITLE

The primary title of this book, Mapping Trauma and Its Wake, representstwo important concepts. First, pioneers of a new field, like the explorersof a new land, contribute primarily because they were the first to tellabout their experience and to link what is known with what is unknown.The maps they drew were the initial reports of the traumatized, such asRobert Liftons discussions of Vietnam veterans and the bombings ofJapan; Danielis accounts of the survivors of the Nazi camps and theeffects on their children; and Terrs reports of the traumatized children ofChowchilla. Attention is given also to the trauma of war (Weiseth,Ursano), sexual assault (Burgess), and prolonged abuse (Herman). Themapping of trauma and its wake has also included pioneering laboratoryresearch such as that of Lawrence Kolb, and its biomedical applications,such as those discussed by Friedman. The maps of theory (e.g., van derKolk), constructs (e.g., Figley), context (e.g., Ochberg), and assessment(e.g., Horowitz, Wilson) were needed, too, and these were provided bymost of the pioneers, along with innovative strategies of research (e.g.,Solomon), treatment (e.g., Krystal), and the unique features of grief andloss (e.g., Raphael).

The other meaning of the primary title is associated with the 1985 bookTrauma and Its Wake: The Research and Treatment of Post-Traumatic StressDisorder (Figley, 1985). This was an historic volume that was also pub-lished in book series on psychosocial stress because it was the forerunnerof the Journal of Traumatic Stress (JTS). The third volume of Trauma and ItsWake1 was not published. Rather, its chapters appeared in the first vol-ume of JTS in 1988.

The subtitle Autobiographic Essays by Pioneer Trauma Scholars reflectsmy decision to let those most responsible for drawing the maps oftrauma and its wake relate the fields history through their own personal


Introduction 3

and professional experiences. Just as Schilpp (1949) believed thatautobiographical essays by leading scholars would help tell the historyof the modern philosophy of science, the editor and publisher of thepresent volume were confident that its pioneers would do the same fortraumatology.

ABOUT THE PIONEERS

The pioneers who were selected for this volume represent some butnot all of the scholars who built the field. Those less known or whobecame known for their work more recently are noted throughout thisvolume and will have an opportunity to express their views in futureones.

The pioneers who contributed to this book make up a remarkablegroup. Their names are listed on the Contributors page. Yet theirnames and work are well known even to the more casual consumers ofscholarly literature in the field. Their ages range from the late 50s to93a remarkable span. Most are psychiatrists, but psychology, socialwork, and nursing are represented as well. Though most are Americans,their countries of origin include Israel, the Netherlands, and Norway.Most have traveled and lectured throughout the world. Thus, the con-tributors to this historic book and the beginnings of the field are interna-tional and multidisciplinary, spanning age, gender, areas of expertise,and specialty.

ABOUT THE CHAPTERS

The organization of this book is simple. The chapters are arranged byauthor, alphabetically. Authors were free to decide the way they wouldtell their story as long as, along the way, they answered four questions.Some organized their chapters with the questions (e.g., Horowitz). Oth-ers answered the questions at the end, in a separate section (e.g., Lifton).Most, however, answered the questions in the general context of theirchapters.

Chapter 1, Putting Trauma on the Radar Screen, was written by AnnBurgess. Dr. Burgess is the van Ameringen Professor of Psychiatric Men-tal Health Nursing and has received many awards, including the soci-etys 1993 Pioneer Award and the Episteme Award from the Sigma ThetaTau international Honor Society of Nursing. She has played a significantrole in changing beliefs, attitudes, and practices involving the victims ofcrime, particularly the crime of sexual assault. Much of her chapter tellsthe story, which starts in 1972, of her groundbreaking research on the cir-cumstances and consequences of rape. She credits her contributions tothe science and sociology of rape trauma to her friend and colleague



Lynda Lytle Holmstrom. These two, known affectionately as the rapeladies, put rape on the radar screens of science and mental healthpractice.

Chapter 2, It Was Always There, was written by Dr. Yael Danieli, apsychologist and the founder and director of the Group Project for Holo-caust Survivors and Their Children in New York City. She is the 1995winner of the societys Lifetime Achievement Award, its third president,and a cofounder. She starts her chapter with a brief discussion of herchildhood, on a Tel Aviv kibbutz under British mandate prior to Israelsbirth in 1948. Much of her chapter focuses on her many experiences andachievements on behalf of world peace and the United Nations, and withspecial attention to the social psychology of survivorship and secondarytrauma among the children of Holocaust survivors. Part of her chapter isdevoted to her efforts, through the society and on behalf of the society, atthe United Nations.

Chapter 3, From Veterans of War to Veterans of Terrorism: My Mapsof Trauma, was written by Dr. Charles R. Figley, who is currently a pro-fessor at the Florida State University School of Social Work and directorof the Traumatology Institute. He has won numerous awards, includingthe societys last Pioneer Award (1994) and the National Organization forVictim Assistance Shaffer Research Award; he was chosen Family Psy-chologist of the Year by the American Psychological Association in 1996,became a Penn State University Alumni Fellow in 2004, and was recentlyawarded a Fulbright Senior Research Fellowship. His chapter, as the titleimplies, begins with a discussion of his studies of war veterans and endswith a description of his current research on the survivors of terrorism.He combines notes on his personal life with reflections on his career,starting with his service in the Marine Corps and in the Vietnam Warthrough his involvement at the start of both Society for Traumatic StressStudies and the Journal of Traumatic Stress in 1985 as well as the foundingof the Green Cross and the Academy of Traumatology.

Chapter 4, Making It Up as I Went Along, was written by MatthewJ. Friedman, currently a professor of psychiatry at Dartmouth andcofounder and director of the acclaimed National Center for PTSD inWhite River Junction, Vermont. He has won numerous awards, includingthe societys Lifetime Achievement Award. Professor Friedman admits,at the start of his essay, to having had no clear career passion. Althoughhe had experienced anti-Semitism at first hand and was deeply affectedby the Holocaust, it took the traumatic death by suicide of his only sib-ling, his younger brother Dick, to make him become a trauma pioneer.Soon thereafter, Dr. Friedman took a staff psychiatrist position at the Vet-erans Administration Medical Center in White River Junction, Vermont(where, he says, the locale was far more the initial attraction than work-ing with veterans); there, his work ignited a fire that had already beenkindled.


Introduction 5

Chapter 5, My Life and Work, was written by Judith Lewis Herman.Dr. Herman, in addition to being a professor of clinical psychiatry at Har-vard University Medical School, is also director of training at CambridgeHospitals Victims of Violence Program, in the department of psychiatry.Her long and distinguished career emerged from her passion for dissent,initially introduced by her parents, which continued at Harvard. Thewomens liberation movement primed her sensitivity to sexism and, afterfinishing her medical internship, led her to join a womens conscious-ness-raising2 group in 1970. This opened her eyes to the derogation ofwomen in everyday life; also, as a doctor, she was able to be far more sen-sitive to and connected with female patients. As a result and inevitably,she discovered that the incidence of incest was far greater than had beenreported. This led her to team up with Lisa Hirschman, who had just fin-ished her training in psychology. Together, they found the courage tochallenge the current psychiatric establishment and publish their firstpaper in Signs (a womens studies journal) in 1976. This work was basedon 20 cases of incest just from the surrounding community. The rest, andher career, was then history.

Chapter 6, A Life in but Not Under Stress, was written by MardiHorowitz, professor of psychiatry at University of California at San Fran-cisco. He, perhaps more than any other person, conceived of posttrau-matic stress disorder. Dr. Horowitz adopts a rather straightforwardstructure in describing his long and illustrious career. For example, inresponse to the question about how he became interested in the field, henotes that it was associated with stressful events in his life before he was10 years old: being sent away from home to school at age 5, surviving ahemorrhaging tonsillectomy, witnessing the mauling of two children bya dog, and being violently attacked by two older boys. Later on, he alsonearly drowned as a patrolman for the Fish and Wildlife Service. Horo-witz notes that more meaningful than the experiences themselves was hismindfulness about it all. I learned to observe the workings of my ownconsciousness, especially in review of my error in judgment. This mind-fulness provided an important context as he completed his education andentered psychiatry. In the course of his military service, he became inter-ested in studying the imagery of trauma, and a development grant fromthe National Institute of Mental Health enabled him to pursue research inthis area. He began to realize that intrusive thoughts in the form ofimages were frequently derived from perceptions during a traumaticevent. The postcombat and postaccident cases in military settings gaveconcordant observations. They also frequently involved fantasy elabora-tions and distortions of actual perceptions. These initial speculationsgrew into his theory of traumatic stress and his important contributionsto the field.

Chapter 7, Fully Primed, by Lawrence C. Kolb, covers a greater spanof time than any of the other chapters. His photo from 1947, which is



included, illustrates this. Professor Kolb, now retired and living on theGeorgia coast, won the societys first Pioneer Award. In the 1960s, he wasnot only chair of the department of psychiatry at Columbia UniversityMedical School but also, consecutively, president of the American Psy-chological Association and of the American Board of Psychiatry and Neu-rology. He became the first Distinguished Physician in Psychiatry inthe U.S. Department of Veterans Affairs. Among Kolbs numerousachievements was the discovery, from observations in his laboratory,that there is an abnormal physiologic disturbance in the brains of thosewith chronic PTSD. Indeed, it was Kolbs laboratory, along with the workof other pioneers who contributed to this book, that provided most of thedata to justify the diagnosis of PTSD. The recognition of this abnormalityushered in the neurology of traumatology, which went far beyond psy-chiatry and mental health. As a result, the medical management ofpatients with PTSD and other diagnoses linked to war-related psycholog-ical trauma has improved significantly. Nearly every major developmentwithin the Veterans Administration leading to the more appropriatediagnosis, treatment, and management of PTSD, including the emer-gence of the National Center for PTSD, retains the fingerprints of LarryKolb. For this and many other reasons he has won numerous awards,including the societys 1991 Pioneer Award.

Chapter 8, Psychoanalytic Approaches to Trauma: A Forty-Year Ret-rospective, was written by Henry Krystal. Dr. Krystal, Michigan StateUniversity Professor Emeritus of Psychiatry, explains in the opening ofhis chapter that his family once resided in Sosnowiec, Poland; a deadlychildhood condition and 3-month hospitalization was his first trauma,which he survived thanks to his mothers devoted care. This experience,he explains, led to a number of important insights. He notes that pri-mary childhood narcissismthe feeling that one is loved and lovable,resulting from the programming of the child in a state of secure attach-ment to the motherwas the most important single asset promoting thesurvival of Holocaust victims. His journey to the United States and hismedical and analytic training in Michigan provided important tools forwhat was to become an extraordinary and distinguished career. Hisscholarly contributions to the psychoanalysis of trauma and, in particu-lar, the horror of the Holocaust and its survivors are recognized interna-tionally. As a result, he has won many awards, including the societysPioneer Award in 1992 and the International Psychoanalytic Associa-tions Hayman Prize for his paper on resilience in 1999.

Chapter 9, Some Reflections was written by Robert Jay Lifton, cur-rently Harvard University Visiting Professor of Psychiatry. Dr. Lifton isamong the best-known and highly celebrated of the trauma pioneers fea-tured in this book and was the first winner of the Pioneer Award in 1985.Lifton notes that his interest in trauma began with his early years in Japan,while serving in the military. This resulted in the first of many books that


Introduction 7

focused on the nature and consequences of trauma. He notes that he has,since childhood, been fascinated by imagery (especially in sports), history,and social justice. This explains to some degree his many contributions tothe elucidation of trauma in so many different contexts. His earliest work,on thought reform, or brainwashing, led to his study of Hiroshima andmarked the beginning of his approach to psychology and history. Henotes at the end of his chapter that Hiroshima . . . was a major turningpoint because it combined everything I had become concerned with: alarge and historical event, and advocacy in confronting and combatingnuclear weapons. Yet perhaps his greatest contributions are associatedwith his work on Nazi doctorstwo books and two personal immersions.Certainly his concepts will live on: psychic numbing, doubling, and thesymbolization of immortality.

Chapter 10, There Is Reason in Action, was written by FrankOchberg. Dr. Ochberg, Michigan State University Clinical Professor ofPsychiatry and Adjunct Professor of Criminal Justice, is chairman emeri-tus of the Dart Center for Journalism and Trauma. He is also the formerassociate director of the National Institute of Mental Health, former direc-tor of the Michigan Department of Mental Health, and the 2003 winner ofthe societys Lifetime Achievement Award. His chapter is a highly per-sonal recollection of his distinguished and colorful career, which began1968, when he was 28 years old and halfway through a psychiatry resi-dency at Stanford. With encouragement from his wife, Lynn, and theguidance of faculty, he helped to establish the Stanford Committee onViolence and Aggression. Dr. Ochberg and his Stanford colleagues wrotehis first book, Violence and the Struggle for Existence. He was then acceptedinto an elite group, the Mental Health Career Development Program, andby 1973 had moved up the ranks to become director of the Services Divi-sion of the NIMH. Once in this position, he was asked to serve on the U.S.Attorney Generals National Task Force on Terrorism and Disorder. Itwas the beginning of a long-term relationship between, as he puts it,cops and shrinks. This led to a 1976 assignment to the work-study pro-gram at The Maudsley, Londons premier psychiatric teaching hospital. Itwas during this period that he made one of his more famous discoveries,which became known as the Stockholm syndrome, defined as an unex-pected bond that forms between captor and captive. Although he did notname this syndrome, he defined it. As associate director for Crisis Man-agement of NIMH he undertook a year-long study of the U.S. Secret Ser-vice. Among his other efforts, he served as the only male member of theCommittee on Women of the American Psychiatric Association (APA),which is credited with having kept Hysterical Personality Disorder out ofthe Diagnostic and Statistical Manual (DSM). He and his colleagues alsopaid close attention to the concerns of victimized women, among otherthings picketing APA meetings until the APA trustees agreed to boycottstates that refused to ratify the Equal Rights Amendment.



Another chapter in Dr. Ochbergs distinguished career comprised hisservice as Director of the Michigan Department of Mental Health.Though the position did not last long, it opened the door to establishingthe first residential treatment facility for trauma victims in America,called the Dimondale Stress Reduction Center. The Dart Foundation wasso impressed with his efforts that they helped him to cocreate the Michi-gan Victim Alliance, the Dart Center for Journalism and Trauma, theCritical Incident Analysis Group, the National Center for Critical Inci-dent Analysis, and Gift from Within. Dr. Ochberg notes that his most sig-nificant achievements in the trauma field may lie in the seeding andnourishing of these networks.

Chapter 11, Life, Trauma and Loss, was written by Beverley Raphael,the third winner (1987) of the Lifetime Achievement Award. Dr. Raphaelis director of the Centre for Mental Health for New South Wales andemeritus professor in psychiatry from the University of Queensland.Professor Raphael is a fellow of the Australian Academy of Social Sciences.She organized her chapter by the four primary questions. The events thatshaped her life included, first, surviving World War II as a child in Aus-tralia. She started out as a general practitioner with no particular interestin trauma until she became interested in the many war veterans shetreated; the labels inadequate personality or anxiety neurosis led herto learn something of their ways of dealing with what had happened inthe war, as well as the strong cultural prescription of the time. Thiseventually led to her training in psychiatry in 1964, with a special interestin Caplans model of preventive intervention, or crisis intervention,that she quickly extended to other life crises, including hysterectomy,first pregnancy, and later in studies of response to accidental injury andnatural disasters (starting with Cyclone Tracey of Christmas Eve, 1974).

Dr. Raphaels significant achievements include her research on bereave-ment as a stressorand its psychological, social, and mental health con-comitantswith the aim of developing appropriate mental healthresponses. In her work she has differentiated the phenomena of bereave-ment reactions and traumatic stress reactions and developed evidence-based guidelines for responses to disaster and terrorism. She notes inthe latter part of her chapter that there is much to do in the field and isespecially interested in improving the research and understanding ofresilience in populations affected by disasters and terrorism. She alsonotes that it is important to further develop interventional strategies forthose bereaved and traumatized by exposure to disaster or terrorism andhas pointed out another half dozen areas that are ripe for research.

Chapter 12, Choices Made, Promises Kept, was written by ZahavaSolomon, who is a distinguished professor of social work and formerdean of the Bob Shapel School of Social Work at the University of TelAviv, Israel. She is the 1997 winner of the Robert S. Laufer MemorialAward for Outstanding Scientific Achievement. This award is given to an


Introduction 9

individual or group responsible for an outstanding contribution toresearch in the PTSD field. She is full professor and director of the AdlerResearch Center at Tel Aviv University. Like some of the other authors,she has organized her chapter around the four standard questions. As tothe emergence of her interest in trauma, she notes that all Israelis areinfluenced by the struggle to establish and protect the Jewish state. Israel,therefore, has become a virtual laboratory of stress. Dr. Raphael empha-sizes the important role played by the Israeli army in our collective andindividual existence, as well asthe high toll that the ongoing strife cantakeon fighters, their families, and other civilians. As a daughter andniece of Holocaust survivors, she was constantly reminded of its long-lasting horrors. As she notes, trauma study is not merely an academicbut [a] deeply personal matter. She describes surviving the Sinai cam-paign of 1956 as a child and being in the 11th grade during the Six-DayWar, which erupted in June 1967. Only 3 kilometers separated her fam-ilys home from the Arab forces. She vividly remember her motherwhohad spent her adolescence in the Auschwitz death camp and livedthrough the Israeli War of Independence as well as the Sinai cam-paignwhispering quietly to herself, Till when? How many more warsdo I have to go through in my lifetime? Then came the Yom Kippur Warin October 1973. It was now Zahavas turn as wife and mother to worry.She saw in her husband, on his return from the Syrian front, what shewould later describe as combat stress reactions.

The turning point of her career came with the 1982 Lebanon War,shortly after her return from the United States with a doctorate in psychi-atric epidemiology. As a member of the research branch of the IsraeliDefense Force Mental Health Department, she was instrumental in trans-forming the department into the first major research facility focusing oncombat stress. She set up a casualty file to record the number and charac-teristics of all casualties, examined the clinical features for common pat-terns, and looked at data on predisposition and types of treatmentinterventions. By the time the first Gulf War broke out in 1991, she was amature scholar, well recognized in her field. Her expertise would beneeded, because civilians were the targets. These circumstances offeredProfessor Solomon another opportunity to study the psychological reac-tions of people under stress. The El-Aqsa intifada, which continues at thiswriting (though there are hopeful signs of peace), has caused hundredsof deaths and injuries to Israelis from all walks of life and demographiccategories.

Professor Solomon counts among her greatest achievements her quan-titative research on the stress of combat as it affected not only soldiers aswell as prisoners of war and their families but also civilians exposed toviolence. Her studies have resulted in the publication of six books and 50book chapters, more than a dozen monographs, and more than 200 arti-cles in scientific journals in several languages. She has brought early and



significant attention to secondary trauma, starting with combat stress butalso including many other traumatic circumstances. Furthermore, she hasnoted vulnerability and resilience factors, including personality traitsand social and cultural factors; societal attitudes to traumatized individu-als; and issues of counter transference.

Dr. Solomon ends her chapter with a plea for more attention to severalareas of research. First she notes the need to understand the specialnature of vulnerability and resilience. Professor Solomon also empha-sizes the importance of assessing acute stress as a risk factor for PTSD.She believes that it is imperative to devise effective evidence-based inter-ventions for the treatment of PTSD that specifically focus on blocking orarresting the crystallization of acute stress reactions into chronic PTSD,inhibiting development of the disorder before it occurs, and interruptingor slowing its progression. She also urges more attention to understand-ing the prolonged and repeated trauma that so frequently occurs inIsrael, Northern Ireland, the inner cities, and war zones. She also urgesfar more attention to understanding traumatized children and victims ofsecondary traumatization. Finally, she urges more cross-disciplinaryresearch focusing on the issues outlined above.

Chapter 13, Memoirs of a Childhood Trauma Hunter, was writtenby Lenore Terr. Dr. Terr is a clinical professor of psychiatry at theLangley Porter Psychiatric Institute at the University of California, SanFrancisco. The first among her many awards was the NIMHs CareerTeacher award. She is also a winner of the Blanche Ittleson Award for herresearch on childhood trauma. Terr begins her chapter with a descriptionof her first psychiatric patient in 1962, months after Terr gave birth, andher confrontation with child abuse. This led to her documenting similarcases in each department of her hospital. And, she reports, she washooked. Dr. Terr noted that in the early sixties, psychological traumawas fragmented into such areas as battle fatigue, rape, incest,accident, torture, civilian casualties of war, and battered childsyndrome. So she chose the last until she almost single-handedly estab-lished the field of child trauma. A large section of her chapter is devotedto her classic investigation of the Chowchilla kidnapping, which startedon July 15, 1976, when 26 summer-school children from the Californiatown of Chowchilla disappeared, along with their school bus and driver.Fortunately, the children and driver were able to escape after beingimprisoned in an underground pit. Their captors were found; they con-fessed and served long jail sentences. Her years of investigation ledto numerous publications and the identification of some lasting conceptsusing the core symptoms and signs found at Chowchilla: mentalmechanisms, such as omen formation, future foreshortening, perceptualdistortion, fears of the mundane, specific trauma-related fears, posttrau-matic play, reenactment, characteristics of traumatic memory, how trau-matic childhood dreams are expressed and changed over time, and


Introduction 11

posttraumatic thought patterns. These found their way into the APAsdescription of PTSD in children. The next section of her chapter focuseson the range of childhood trauma that could be considered normal; shenotes that small traumatic events may affect taste, preferences, and inter-ests as well as fears. The rest of the chapter is a review of her variousprojects, many of which have resulted in booksa pattern similar to thatof Robert Liftons career. Dr. Terr ends her chapter with a series of ques-tions for current and future child traumatologists.

Chapter 14, Autobiographical Essay, by Robert J. Ursano, is orga-nized around the four primary questions. Dr. Ursano is professor andchairman of the Department of Psychiatry, Uniformed Services Univer-sity of the Health Sciences, E. Edward Hebert School of Medicine inBethesda, Maryland, and director of the Center for the Study of Trau-matic Stress. Winner of the societys Lifetime Achievement Award in1999, he became, in that same year, editor in chief of the venerable jour-nal Psychiatry. Professor Ursano began his career with his work at theU.S. Air Force School of Aerospace Medicine, which included his firststudies of trauma in the late 1970s; these focused on repatriated prisonersof the Vietnam War. This work led to changes in the Uniform Code ofMilitary Conduct and to disability payments for the repatriated prison-ers. He also discusses his later association with the Gander, Newfound-land, air disaster, the largest peacetime loss the Army had ever suffered.Since that time, in the past 20 years, he has had contact with nearly everymajor disaster our nation has faced, through consultation, education, orresearch. These events have included plane crashes in New York City andaround the nation; earthquakes in California and Armenia (then part of theUSSR); hurricanes in Florida and typhoons in Hawaii; the Khobar Towersbombing; USS Cole attack; embassy bombings in Kenya; wars in Iraq; peace-keeping in Somalia; and extensive involvement following the 9/11 terroristattack, the anthrax attacks, and sniper attacks in Washington, DC. Dr.Ursano has held many leadership positions, including the first chair of theAmerican Psychiatric Associations Committee on Psychiatric Aspects ofDisaster and also chair of the first task force of the APA to develop thetreatment guidelines for PTSD and ASD. He ends his chapter by suggest-ing that PTSD may be the first preventable psychiatric disorder and notesthat the establishment of an extreme-stress brain bank will facilitate thisgoal and our neurobiological understanding of this and other eventrelated disorders.

Chapter 15, The Body Keeps the Score, is a brief autobiography byBessel van der Kolk. The title comes from a well-known phrase thatappears in several of his papers and represents the essence of his impor-tant contributions to traumatology. He is currently professor of psychia-try at Boston University Medical School and Clinical Director of theTrauma Center at HRI Hospital in Brookline, Massachusetts. Like otherpioneers, he has been both president of the society and winner of the



societys Lifetime Achievement Award. His interest in traumatologybegan with one of his first patients, a Vietnam War combat veteran whowanted to be free from his painful symptoms, later known as PTSD. Pro-fessor van der Kolks work integrates developmental, biological, psycho-dynamic, and interpersonal aspects of the impact of trauma and itstreatment. Because of his multidisciplinary approach and personal curi-osity he has, perhaps more than any other modern traumatologists,helped to stimulate creativity among practitioners. This has led to impor-tant innovations in the assessment, treatment, and prevention ofunwanted consequences from traumatic events.

Chapter 16, Becoming a Psychotraumatologist, was written by LarsWeisaeth. Like other chapter authors in this volume, Professor Weisaethwas profoundly affected by World War II. He notes early in his chapterthat he was born during the Nazi occupation of his homeland of Norway;virtually all my memories from those [early] years are war-related, thevast majority of them involving some kind of danger. He credits theseminor or moderately stressful experiences with his specializationwithin the field. Equally important, it appears, was his military serviceprior to medical school. This provided access to the culture of the mili-tary at home and abroad that enabled him to work later as a military psy-chiatrist and with war veterans. He credits his experiences in teachingand practicing at the University of Oslos department of psychiatry aspart of the medical faculty and work with Professor Arne Sund, M.D. asthe deciding factors of his specialization in psychotraumatology statingin 1975. The rest of the chapter is a useful review of the history of thestudy of trauma in Norway with special emphasis on and credit to LeoEitinger, whom Professor Weisaeth credits as the father of Norwegianpsychiatry related to stress, the military, and disaster. Starting with his1976 paper at the Nordic Psychiatric Conference in Finland on the trau-matic anxiety syndrome, Professor Weisaeth was poised for a definingevent in his professional life. This event was the September 15, 1976 San-defjord petrochemical plant explosion. His research led to a series of pub-lications including a two-volume monograph. The rest of the chapterdiscusses his work among peacekeepers with PTSD, the 1980 Oil-RigDisaster: PTSS-10 in the North Sea, and various other studies and activi-ties. These activities included his international collaborations. The finalsection of the chapter includes his discussion of his current position at theNational Centre for Violence and Traumatic Stress Studies. He ends thechapter with an optimistic view that the field is the most promising forprevention in psychiatry. But what is lacking, he asserts, is convincingand compelling evidence of the value of our treatment efforts.

The final chapter is entitled From Crisis Intervention to Bosnia: TheTrauma Maps of John P. Wilson. Dr. John Wilson is currently a profes-sor of psychology at Cleveland State University. Though trained as adevelopment and personality psychologist, Dr. Wilson became interested


Introduction 13

in traumatized war veterans very early in his career and, by 1978, hadcompleted one of the first comprehensive studies of Vietnam War veter-ans for the Disabled Americans Veterans. Cofounder of the society andits second president, Professor Wilson is a recent Fulbright Fellow andDistinguished Visiting Professor of Psychology at the University ofCroatia Medical School, where he drew upon his 9 books, 20 monographsand many dozens of journal articles, including such topics as the traumaof war, countertransference and the assessment and treatment of PTSD.These achievements are well represented in his chapter. He traces thebeginning of his career to his initial encounter with a Vietnam vet whowas a student in one of his classes and was instrumental in acquiring thegrant from the Disabled American Veterans that made Dr. Wilsons For-gotten Warrior Project possible. Having described his many achieve-ments and challenges, Dr. Wilson ends, as his title suggests, with thestory of his work in Bosnia.

ABOUT JOSEPH WOLPE

As editor, the dedication of this book is my choice. In the past, I havededicated my books to family members. I dedicate this book to JosephWolpe because I see him as one of the first pioneer traumatologists(Figley, 2002). Although we were not friends or even acquaintances, Iflew from Tallahassee to Los Angeles to attend his funeral and meet hiswife, Anna, and his children. I had that much respect for Dr. Wolpe andhis work. He first became interested in trauma as a young South Africanpsychiatrist in the 1940s, when he was responsible for treating combatveterans returning from the battlefields of Europe and North Africa inWorld War II. He immediately recognized that traditional theories ofpsychiatry would not do and appreciated the emerging social learningtheory and its originators. With more of an interest in research than prac-tice, he began to replicate the studies of Pavlov and others.

More than sixty years ago, in his paper Reciprocal Inhibition as theMain Basis of Psychotherapeutic Effects, Wolpe (1954) asserted that thesuccessful treatment of anxiety disorders was due to what he calledreciprocal inhibition. Wolpe suggested that reciprocal inhibition, firstapplied outside psychology, was the active ingredient in desensitization(i.e., complete or partial suppression of anxiety responses). Wolpes the-ory suggested that stress reactions or fear can be eliminated when thesufferer is exposed to both the source of the fear and anything that wasphysiologically antagonistic to fear reactions. This implied a techniquethat would condition a new response to the originally feared stimulus.Originally, in animal studies, food was the physiologic antagonist, usedfirst by Pavlov with dogs and then by Wolpe with cats. Food and associ-ated cues counteracted the fear conditioning. With his technique ofsystematic desensitization, Wolpe substituted food-related cues with



evocation of the relaxation reflex to counteract conditioned fear in humanbeings. The rest is history; but, with some exceptions (Heriot & Pritchard,2002; Wolpe & Plaud, 1995; Poppen, 1995), Wolpes treatment and experi-mental methods were adopted and improved upon by behaviorists overthe next 60 years, with little credit to him or the reciprocal inhibition the-ory. This is why Joseph Wolpe was the first inductee to the Academy ofTraumatology and winner of the first Golden Award.

Let us hope that this book helps us to remember the important contri-butions that have already been made, to build on them and go beyondthem. As Chaim Shatan, another pioneer, has noted:

I propose that [we] . . . go beyond the treatment of new trauma popula-tions: the long-range cure of war-related trauma requires prevention oftraumatic stress. We traumatologists can continue to provide first aid asstretcher bearers of the social order, sophisticated, compassionate, withgrowing scientific knowledge, but picking up the wounded rather than pre-venting them from being wounded. Or we can try to eliminate the sourcesof PTSD in the social order, to dismantle the army-and-enemy system, ahuman invention, an institutionalized manhunt . . . . Otherwise, PTSDanoutgrowth of war and persecutionwill remain with us unchanged, underwhatever name, from shell shock to K.Z. syndrome, from DSM-III to DSM-X(Shatan, 1992, p. 20; cited in Bloom, 2000).

Far from being the final statement on the pioneers of trauma, thisbook, we hope, will provide steppingstones to preventing the unwantedand promoting the wanted consequences of trauma. At the very least, wehope that this book will offer some degree of understanding and appreci-ation of the living pioneers explanations in mapping trauma and itswake and how they differentiated the steppingstones of trauma workfrom stumbling blocks in the field of traumatology.

REFERENCES

Bloom, S. L. (2000). Our hearts and our hopes are turned to peace: origins of the InternationalSociety for Traumatic Stress Studies. In A. Y. Shalev, R. Yehuda, & A. C. McFarlane(Eds.), International handbook of human response to trauma pp. 2750. New York: KluwerAcademic/Plenum Publishers.

Figley, C. R. (2002). Theory-driven and research-informed brief treatments. In C. R. Figley(Ed.), Brief Treatments for the traumatized (pp. 328). Westport, CT: Greenwood Press.

Folsing, A. (1997). Albert Einstein: A biography. New York: Penguin Books.Roberts, S., Weaver, A.J., Flannelly, K. J., & Figley, C. R. (2003). Compassion fatigue among

chaplains and other clergy after September 11th. Journal of Nervous and Mental Disease,191,11, 756758.

Poppen, R. (1995). Joseph Wolpe. London: Sage.Reyna, L. (1998). Joseph Wolpepioneer: A personal remembrance. Journal of Behavior Ther-

apy and Experimental Psychiatry, 29, 187188.Schilpp, P. A. (1949). Albert Einstein: Philosopher-scientist. Evanston, IL: Living Philosophers,

Inc.


Introduction 15

Shatan, C. (1992, June). Enemies, armies, and PTSD: Divided consciousness and warournext assignment. Paper presented at the First World Conference of the ISTSS, Amsterdam,Netherlands.

Sherrington, C. S. (1906). The integrative action of the nervous system. New Haven, CT: YaleUniversity Press.

Wendt, G. R. (1936). An interpretation of inhibition of conditioned reflexes as competitionbetween reaction systems. Psychological Review, 43, 258281.

Wolpe, J. (1954). Reciprocal inhibition as the main basis of psychotherapeutic effects. Ameri-can Medical Association Archives of Neurology and Psychiatry, 72, 204226.

Wolpe, J. (1958). Psychotherapy by reciprocal inhibition. Stanford, CA: Stanford UniversityPress.

Wolpe, J. (1993). Commentary: The cognitivist oversell and comments on symposium con-tributions. Journal of Behavior Therapy and Experimental Psychiatry, 24, 141147.

Wolpe, J., & Plaud, J. J. (1995). Pavlovs contribution to behavior therapy: The obvious andthe not so obvious. American Psychologist, 52, 966972.

ENDNOTES

1. Volume 2 was published in 1986 (Figley, 1986).2. The term consciousness raising was invented by her friend and Harvard classmate

Kathie Sarachild, of the New York Red Stockings.


17

1Putting Trauma on the Radar Screen

ANN WOLBERT BURGESS

GETTING STARTED: THE HISTORY OF RAPE TRAUMA RESEARCH

My work on rape trauma started as a research project. Credit for any ofmy contributions to the science and sociology of rape trauma mustinclude my colleague, Lynda Lytle Holmstrom. Without her, I neverwould have started the study. Both of us were newly hired at BostonCollege. Holmstrom had just finished a research project on two-careerfamilies and was searching for a topic that was relevant to womens livesand to the relationship between men and women. She had heard manyreports by women at consciousness-raising groups in the late 1960s aboutphysical assaults that had been made on them by men. And yet, itseemed that despite the common occurrence of assault against womenand its strong impact on the people involved, researchers seldom pickedup on this behavior as a research topic. Thinking about this disparity ledHolmstrom to the idea, initially only vaguely formulated, of studyingrape and especially rape victims. Her next step was to meet with me(Burgess), with whom she had done some interdisciplinary teaching atBoston College, to discuss how one might go about such a study. As Ilistened, I did a memory search on what I knew about rape and its vic-tims. I came up with a blank. Having been educated in Boston, I hadlearned mainly the psychoanalytic theories, so nothing Holmstrom was

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saying about rape matched what I was taughtwhich piqued mycuriosity. It led me to tell her that if she wanted to add a clinical or coun-seling component to the study, I would be interested in collaboratingwith her. We then discussed how an interdisciplinary approach might bean especially fruitful way to deal with the problem, and how the aca-demic expertise of a sociologist and the clinical expertise of a psychiatricnurse complemented each other. We became a team (Holmstrom &Burgess, 1978).

In venturing forward in the spring of 1972, the first thing we discov-ered was that rape victims were hard to find. Our initial inquiries werenot successful. First, we tried locating victims through the courts, only tobe confronted with innumerable delays and also to learn that only a verysmall percentage of cases made it through the system.

We then asked some criminologists for advice and made somecontacts in the criminal justice system. Although people were polite to us,they were not very helpful in terms of locating victims. Third, we triedcontacting the police. That proved totally impossible, as our calls werenever returned. So we then turned to the medical hierarchy of a largemunicipal hospitalBoston City Hospitalwhere a large percentage ofvictims were taken. A colleague in the department of psychiatry referredus to medical personnel on the emergency services; again, people werepolite but also thought of many reasons why we could not begin ourstudy. After trying these four entry points into the system, we were stillnot getting very far. No one had refused us, but neither was anyone help-ing us or moving very fast.

Impatient with delays, we tried a fifth approach: the nursing hierarchyat Boston City Hospital. And they moved with utmost speed. Anne G.Hargreaves, Executive Director of Nursing Services and Nursing Educa-tion, told us that the emergency department saw many rape victims and,to her knowledge, no psychological services were being provided.Hargreaves put us in touch with the assistant director of nursing foremergency services, who met with us. She then arranged for us to meet atonce with the three shifts of staff nurses, the people who would be mostin contact with us as we worked. She introduced us as interested in doingsome clinical work. The research aspect was noted but not emphasized.We exchanged ideas. The staff nurses expressed polite interest, madesome inquiries, explained what they had done with rape victims in thepast, and told us some of the obstacles they thought we might faceforexample, that the police were often in a hurry and might rush us.But most important, they agreed to telephone us each time a rape victimwas admitted. Two days later, a rape victim was brought to the hospitaland the nurses called us promptly at 1:40 a.m. And they, as well as theadministrative staff, continued to call us for an entire year. Their tremen-dous and conscientious help was essential to the success of the project.


Ann Wolbert Burgess 19

Access to the hospital was the first step. We also needed the cooperationof the individual victims. The nurse or physician on duty typically toldthe victims about us. Their explanations varied, depending on their per-ceptions of us. Some emphasized that we did counseling, others said wewere doing a study. Because victims were often in great distress when wemet them, we provided a handout repeating the information that theVictim Counseling Program had two aims: (1) to provide counselingthrough an initial visit at the hospital and by telephone for follow-up and(2) to study the problems the victim experienced as a result of beingassaulted. This same information was also posted on the wall of theexamination room. All victims met with us and agreed to telephonefollow-up calls.

A part of our study was also to observe what happened at court. Wewould accompany the victim and occasionally would be asked aboutwhy we wanted to stay. We answered that we were from the hospital,provided counseling services to rape victims, and studied rape victimsproblems. Upon hearing that explanation, the judges ruled that we had adirect interest in the case and could stay.

At Boston City Hospital, over a 1-year period, we interviewed allpersons (n = 146) admitted through the emergency department with acomplaint of rape, provided crisis counseling, and accompanied themthrough the court process. We called the victims trauma response rapetrauma syndrome and published the resulting paper in the AmericanJournal of Psychiatry in 1974. The study was twofold, having a clinicalfocus on victim response to rape and an institutional focus. The studymade clear that rape does not end with the assailants departure; rather,the profound suffering of the victim can be diminished or heightened bythe response of those who staff the police stations, hospitals, and court-houses. Ironically, the institutions that society has designated to helpvictims may in fact cause further damage (Holmstrom & Burgess, 1978).

How We Were Perceived

The staff nicknamed us the rape ladies. For the most part they went outof their way to help us, so we assumed that our presence had some legit-imacy in their eyes. Perhaps the thing that established us most was ourwillingness to be on 24-hour call to the hospital. The staff subjected us togood-natured teasing about whether we had the stamina to last a year.

The physicians who examined the victims accepted our presence onthe emergency ward. We were careful to explain to the physicians ourcredentials and what we were doing, but still they often misperceived us.One physician thought we were from the hospitals Social Services andsometimes entered that on the patients medical record. Anotherassumed we were nuns because we taught at Boston College; he told us,



laughing, of this misperception one night after suddenly realizing thatone of us was very pregnant. And still another thought we did this kindof work to earn a little extra money on the side.

Victims saw us as part of the hospital system. Despite our carefulexplanation, our exact training and position were not always understood.Victims called us, or asked us if we were, social workers, workers, psy-chiatrists, shrinks, doctors, counselors, or religious women. Severalinquired if we were rape victims ourselves.

The Experience of Interdisciplinary Research

Could a sociologist and a psychiatric nurse work together? In the begin-ning, we did not know. We had very different backgrounds. Holmstrombrought to the project training in sociology and anthropology, researchexperience analyzing the careers of professional couples, an interest inthe sociology of the professions and medical sociology, knowledge offeminist literature, and experience in the womens movement. I, incontrast, brought training in nursing and psychiatric care, previous workwith a wide range of emotional problems, and experience in many hospi-tals, private practice, and the training of other clinicians. Through mutualeducation we each expanded our range of skills and conceptual frame-work. And through countless discussions, we came to make analyticsense out of our data. The resulting conceptualizations were very much ajoint product.

DUAL MOTIVATION FOR THE STUDY: THE WOMENS MOVEMENT

Lynda Holmstrom was influenced to initiate a study of rape victimsbecause of her understanding of the womens movement, and I was influ-enced because of my nursing education and experience. Both are key tounderstanding our purpose in studying rape victims. As background, thewomens rights movement had enjoyed a number of births, phases, andrebirths since the beginning of the 19th century. Initially, the movementconcerned itself with legal recognition of women to secure their rights tovote, to own and control property, and to participate in public affairs. Themovement in the 20th century focused on educational opportunities,equal employment, and the impact of sexism on womens lives. For agrowing number of women, this freedom meant more than a choice ofnontraditional roles, jobs, and lifestyles; for many it meant confrontingrestrictions on womens personal lives. Analysis of these restrictionsbegan to emerge from the dialogue of consciousness raising (CR)groups, a new organizing tool of the womens movement wherebywomen discussed their experiences and problems of being female in amodern society. Frequently viewed by men as hotbeds of radical feminism,



the reality was simply that attending such a discussion group was themost assertive action many of the women of that day were capable of tak-ing. But it was within the supportive environment of the CR groups thatwomen found the courage to share private experiences never beforeshared, such as incest and rape (Largen, 1985).

These disclosures of former victims had a profound effect on theirlisteners. The revelations represented an unprecedented breakthrough ofthe silence that had surrounded the topic of rape for centuries. The act ofrape has been an inherent part of womens lives throughout recorded his-torya theme of literature, poetry, theater, art, and war; it is an act that apre-1970 society tended to view more through the mocking eyes of Play-boy magazine. At best, it was a subject considered too delicate to raise, asnoted by Largen (1985); at worst, it was a subject that generated derision,blame, or distrust of the victim.

In the early 1970s, when police departments and rape crisis centersfirst began to address the crime of rape, little was known about rape vic-tims or sex offenders. The issue of rape was just beginning to be raised byfeminist groups, and the 1971 New York Speak-Out on Rape had beenheld. Contemporary feminists who raised the issue early were SusanGriffin, in her now classic article on rape as the all-American crime;and Germaine Greer, in her essay on grand rapes (legalisticallydefined) and petty rapes (everyday sexual ripoffs). Susan Brownmillerwrote the history of rape and urged people to deny its future. The gen-eral public was not particularly concerned about rape victims; very fewacademic publications or special services existed; funding agencies didnot see the topic as important; and health policy was almost nonexistent.

The antirape movement began to attract women from all walks of lifeand political persuasions. Various strategies began to emerge, one ofthem being the self-help program now widely known as the rape crisiscenter. One of the first such centers was founded in Berkeley, California,in early 1972, known as Bay Area Women Against Rape (BAWAR).Within months of the opening of the Berkeley center, similar centers wereestablished in Ann Arbor, Michigan; Washington D.C.; and Philadelphia.Lynda Holmstrom and I founded a hospital-based rape counseling ser-vice at Boston City Hospital, and in Minneapolis, Linda Ledray, RN, PhD,founded a similar service. Centers soon were replicated and servicesflourished. Although volunteer ranks tended to be composed of a largenumber of university students and instructors, they also included home-makers and working women. The volunteer makeup usually reflectedevery age, race, socioeconomic class, sexual preference, and level ofpolitical consciousness. Volunteers were, however, exclusively women.Among the women, the most common denominators were a commitmentto aiding victims and to bringing about social change (Largen, 1985).As Susan Brownmiller noted, the amazing aspect of the proliferationof the grass-roots womens groups was that such an approach to the



problem of rape had never been suggested by men: That women shouldorganize to combat rape was an invention of the womens movement.

In retrospect, the history of the rape crisis centers in the United Stateshas been one of enormous struggle. The struggle was to overcome indif-ference, apathy, changing social trends, and lack of stable resources, yet itwas willingly engaged in from the belief in the rightness of the causeacause that, despite the struggles, had its share of successes. Feministsidentified a social need and a way of responding to it. Centers, begunwithout role models, became role models themselves for other crime vic-tims, specifically for battered women and their children. Though neverhaving reached the ultimate goal of eradicating rape through socialchange, they nonetheless were the instigators of social change essential tothe rights of women (Largen, 1985).

CONTRIBUTIONS AND ACHIEVEMENTS

Rape, until the 1970s, thrived on prudery, misunderstanding, and silence.It was not until the 1980s that academic and scientific publications on thesubject multiplied. A review of articles on the psychological effects ofrape and interventions for rape victims in the posttraumatic periodlocated 78 references between 1965 and 1976, with 36 on the effects ofrape and 42 on intervention. Two of the papers were coauthored byBurgess and Holmstrom in 1973 and 1974.

But studying the lot of the victim was only half of the equation in rape.To fully appreciate the impact of rape on a victim, it was necessary tounderstand the assailant.

Holmstrom and I had met A. Nicholas Groth at a tiny (about 15 peopleattended) conference on rape in 1973, where we informally talked aboutrape victims coming into an emergency ward. Groth (one of the featuredspeakers) impressed us for several reasons. First, he talked of his inter-views with rapists at the Massachusetts Treatment Center, where he wasa clinical psychologist. Some of what he said matched what we had heardfrom victims, but other parts, of course, did not. Second, after the confer-ence he (as he had promised) sent us material; and third, he was inter-ested in collaborating with us on a paper on motivational intent of issuesrelated to power, anger, and sexuality rather than primarily sex, citingthe amount of sexual dysfunction during rape. Child sexual abuse vic-tims told us (and we wrote) of the pressure, sex, and secrecy used in theact, and the child molesters told of how they pressured children for sexusing attention and material goods as the exchange (Burgess, 2002).

Funding opportunities for further research to expand on these find-ings became available to Burgess as the problem of child sexual abuseand child pornography became more visible. Serial murderers and therole of physical abuse, child sexual abuse, and lack of supportive and/orblaming parents provided key variables to understanding a possible



transition from victim to victimizer (Ressler, Burgess, & Douglas, 1988).Another key colleague was research psychologist Robert Prentky, whowas director of research at the Massachusetts Treatment Center and hadextensive data and understanding of serial sex offenders. Our first papertogether focused on prevention and analyzed victim response by rapisttype (Prentky & Burgess, 2000). The collaboration has continued onissues such as the presumptive role of fantasy in serial sexual homicide,the cost-benefit analysis of the rehabilitation of child molesters, childmolesters who abduct, and the new research opportunities on the devel-opmental antecedents of sexual violence, including the most extremeform of sexual violence: serial homicide.

Financial help for funding research and services came from Congressin the 1970s. In response to a growing crime rate and concern over theproblem of rape, Sen. Charles Mathias of Maryland had introduced a billin September 1973 to establish the National Center for the Prevention andControl of Rape (NCPCR). The purpose of the bill was to provide a focalpoint within the National Institutes of Health from which a comprehen-sive national effort could be undertaken to do research, develop pro-grams, and provide information leading to aid for victims and theirfamilies, to rehabilitation for offenders, and, ultimately, to the curtail-ment of rape crimes. The bill was passed by overwhelming vote in the93rd Congress, vetoed by President Ford, and successfully reintroduced.The NCPCR was established through Public Law 94-63 in July 1975 andBurgess was the chair for the first advisory committee to the new center.However, by the late 1980s, momentum for the study of rape had signifi-cantly diminished and the NCPCR was closed. It was not until 1994 thatfunding again became available when Congress passed the ViolenceAgainst Women Act (VAWA) as part of the Violent Crime Control andLaw Enforcement Act, and an Office on Violence Against Women in theU.S. Department of Justice was established. With funding, many othervulnerable target populations for sexual assaultchildren, adolescents,the developmentally delayed, and patients with physical and/or mentalimpairmentshave been the subject of varying degrees of clinical andempirical scrutiny. Like the elderly, when any of these populations residein an institutional setting, the risk for abuse increases simply as a func-tion of their dependence on staff for safety, protection, and care.

Indeed, the decade of the 1990s catapulted sexual assault from relativeobscurity to high profile in the legal and public health arenas (Prentky &Burgess, 2000). Despite the considerable attention given to the diversityand ubiquity of sexual assault, it is all the more noteworthy that one ofthe most vulnerable groups of victims, the residents of nursing homes(estimated to be 1.5 million persons in 1997), remain in obscurity. It isinteresting that the NCPCR funded the first research on elderly victims ofsexual assault in October 1975, but by 2000 there was still less than scantliterature on the topic. Although the reasons for our failure to tackle



forthrightly the problem of sexual abuse of the elderly and nursing homeresidents are unclear, we can certainly posit two explanations: (1) theincomprehensibility, and hence rejection, of claims of sexual assault onnursing home residents and, perhaps most important, (2) ageismorgeneralized negative attitudes, if not outright hostility, toward older andcognitively impaired people (Burgess, 2002). With that as background, apilot study of 20 sexually abused nursing home residents identified barri-ers to effective health care interventions. First, delayed reporting of thesexual abuse resulted in failure to obtain timely medical evidentiaryexaminations, delayed treatment for injuries and infection, and anabsence of medical or psychological follow-up care. Second, there wasdifficulty in performing evidentiary rape examinations due to leg con-tractures and cognition/memory problems. Indeed, in a number of thevictims, the fetal position and muscular rigidity made examinationimpossible. Third, there was evidence of wide variations in the eviden-tiary examination for sexual assault, such as the lack of colposcopic pho-tographs. And fourth, the offenders (who were arrested) were eitheremployees of the nursing homes or residents and, without prompt victimidentification, were suspected to have abused more than one victim(Burgess, 2002).

PEOPLE WHO INFLUENCED AND SIGNIFICANTLY ASSISTED MY RESEARCH

I have already identified Lynda Lytle Holmstrom as the most influentialcolleague contributing to my work with trauma victims and have men-tioned other colleagues who have collaborated with their own researchand mine. But here are a few more influential people.

Anne G. Hargreaves was my professor in psychiatric nursing as anundergraduate at Boston University. She continued to be my mentor andin 1972 was Executive Director of Nursing Services and Nursing Educa-tion for the Department of Health and Hospitals, City of Boston. Sheopened a door to the rape study by giving permission for my colleagueLynda Holmstrom and me to begin our research with rape victims whowere being admitted to Boston City Hospitals emergency department.We had approached all nursing directors of large emergency depart-ments in the Boston area and all except Anne Hargreaves said we wouldneed the approval of medicine. Hargreaves told us that providing crisisintervention for rape victims was the domain of nursing and we neededno further approval. In 1974, she wrote the foreword to our first book onrape and said, Rape is a total public policy issue. . . . This book shouldbe especially helpful to those involved in the immediate crisis situation,the hospital staff and the police, who are most often the first on the scene.. . . Readers of this book, hopefully, may find a change in their attitudestoward the victims of rape.



Anne Hargreaves is legendary for her no-nonsense approach to healthcare. She was a consummate Renaissance woman who fought long hardbattles for nursing. She has significantly influenced many students in herlong career in nursing.

The Power of Publication

The study that began in the emergency department at Boston City Hospi-tal in 1972 sought to document the career of the rape victim throughthe institutional systems of law enforcement, the hospital, and the court.And while clinical research of this type was not funded in those days(Lynda Holmstrom and I wrote unsuccessful grant proposals to threeagencies), the important act that opened the door to begin to educatenursing and law enforcement specifically about rape was the publicationof our very first article in the 1973 American Journal of Nursing, titled TheRape Victim in the Emergency Ward. That article described rape ashaving a traumatic aftermath and supported the idea of nursing inter-vention being effective as a first step in reducing the consequences of thisviolent act.

The fact that rape occurs and is an act of conquest is documented inthe Bible as well as in war annals. It is endemic to humankind and wasundoubtedly practiced by cavemen. But in 1972, when Lynda Holmstromand I launched our research, there were very few clinically based articlesthat dealt with the incidence of rape or the impact of rape on the victimand/or family. And there was little information on the offender. Whilethe violent acts and the suffering they caused had been noted sincethe origins of humanity, few considered these events from a healthstandpoint.

My choice of the American Journal of Nursing (AJN) for the firstdescriptive article on the rape victim was instrumental for my collabo-ration with research and training with the special agents of the Behav-ioral Science Unit at the FBI Academy in Quantico, Virginia. And theFBI sought me out because of a nurse whom I did not even know atthe time.

As background, in 1973, the FBI Training Division had been assignedto instruct in the area of rape and sexual assault victimology. None of theagents were so trained. Roy Hazelwood, Supervisory Special Agentassigned to Quantico, was conducting a training on homicide investigationwith the Los Angeles Police Department (LAPD). He mentioned his newassignment to the class. Rita Knecht, a detective with the LAPD who wasalso a registered nurse working part-time in the emergency departmenton weekends, told Hazelwood of the AJN article on rape victims. Knechtsuggested that Hazelwood contact me, which he did. With that, I begantraining FBI special agents at Quantico on rape victims and offenders.



The association with the FBI agentsespecially Bob Ressler, JohnDouglas, Roy Hazelwood, and Ken Lanningled to several researchprojects on serial offenders and profiling, now called criminal investiga-tive analysis. I later sought out Rita Knecht at a training academysession specifically to thank her for the major role she had played inmy career.

Sometimes being invited to speak at a conference opens a door toother researchers studying similar issues. One such conference was the1979 Purdue University conference, to which I was invited as a speakerby Charles Figley. As I listened to Figleys account of his work on combatstress, it became clear to me that similar dynamics were involved in pro-longed trauma situations such as sexual abuse suffered by children andwomen. Discussions around these issues led to a valued friendship aswell as an opportunity to be part of Figleys conference on Iranianhostages.

Another important influence on my work is my colleague andfriend Carol R. Hartman, RN, DNSc., an expert nurse-therapist whosignificantly influenced me specifically in the area of conceptualizingthe practice of trauma therapy. Hartman was a classmate of mine dur-ing my doctoral study at Boston University School of Nursing.Together we studied under June Mellow, who directed the program toprepare nurses as nurse-psychotherapists. Two factors prompted meto seek out Hartman as a collaborator. In my clinical practice withrape victims, I was finding that a significant percentage were movingon with their lives but were still suffering from the rape trauma. Ineeded someone to help analyze the problem. Second, the interviewswith serial sex offenders were coming in from the FBI agents and Ineeded some help in analyzing the motivational intent. Our worktogether was critical in efforts to develop theories of the neurobiologyof trauma. Before we learned of the influence of neuroscience andtrauma, we believed certain changes occurred in the victims that werenot readily amenable to extinction. As best we tried, there were justsome behaviors that did not respond to existing treatment methods.Something had changed profoundly in these victims whole neuro-logic systems. The only model we knew of at that time that led to suchchanges was imprinting. Our work with victims led to our descriptionof a trauma modelthat is, the neurobiology of trauma. As researchcame along to back up the observations, in the 1990s, the changeswere to be observed through brain imaging. The implications of thatmodel were to look at intervention in a more eclectic manner.We realized we had to tailor interventions to the specific responses ofindividuals to their trauma. This is where the use of hypnotherapy,support systems, safety, and ego support became primary beyondmerely uncovering the trauma. In fact, releasing memories of the eventcould be damaging if the victim were not strong enough psychologically



to deal with them. These findings led to some principles involved insetting up therapy. The work on the problems of memory has beendebated. Nevertheless, these are early clinical observations and mustbe understood in that context. Critical to this phase of study was ourwork with very young, preverbal children.

Another phase of study was our work with sexual killers. The work ofBrittain and MacCulloch and colleagues (cited in Ressler, Burgess, &Douglas, 1988) served as a foundation for our hypothesis that the motiva-tion for sexual murder is based on fantasy. We began to look at theimpact of fantasy on personality and reviewed with the FBI agents all oftheir interviews with killers and the role of fantasy in the lives of peoplewho could not make a connection with other people. These killers empa-thy was used for narcissistic gain rather than to connect with others. Fan-tasy was their dominant emotional experience and its acting out becamean important part in the escalation and triggering of a violent response.Out of that work came the model for profiling serial offenders (Ressler,Burgess, & Douglas 1988).

EVENTS IN MY LIFE LEADING TO MY INTEREST IN TRAUMA

I came to the trauma field as a result of having been invited to collabo-rate on a research project with Lynda Holmstrom rather than becausethere were any specific events that sparked my interest. However,I stayed in the field and made it a focus of research and practice. AsI pondered how to answer why, I realized that my experiences as anursing student and as a nurse prepared me for work with traumavictims.

I had been music major in high school and had dreams of becoming aconcert pianist. My only sibling, a brother, was very talented, playingjazz piano in a band. I thought I might follow in his footsteps. But mymothers Swiss background led her to urge me to have steady work(such as that of a teacher or nurse), and my fathers physician brothersalso encouraged me to enter the health field. Medicine did not interestme, but nursing seemed a second best to music. Even in college I wasable to choreograph a production to raise money for a student nursingfund.

I was admitted to Boston University, a 4-year school that would grantme a BS degree and make me eligible to take my RN exam. However, myearly experience of hospital nursing opened my eyes to the kind ofoppression women experienced in the workplace. I saw that nurses weretaught to give up their seats to doctors and to eat in separate diningrooms. If a patient problem developed, the nurse was looked to first.There was a complete devaluation of nurses work. Nurses were not evenallowed to describe blood as blood; we had to call it red fluid. Doctorsdominated the work setting; nurses were seen as the handmaidens.



Fortunately, there was a developing group of nursing leaders who stakedtheir reputations on asserting themselves. Nursing leaders who keptpushing nursing forwardAnne Hargreaves,

Documents

Mapping Trauma and Its Wake