By Sandra L. Bloom, MD
CommunityWorks
Philadelphia, Pa., USA

Published in the International Handbook of Human Response to Trauma (2000), New York: Kluwer Academic/Plenum Publishers. Edited by Arieh Y. Shalev, Rachel Yehuda and Alexander C. McFarlane.

The ISTSS is Born

Between November and December, 1983, Charles Figley sent a letter to over 60 internationally known scholars inviting them to form an organization, tentatively titled the Society for Traumatic Stress Studies: I believe that an organization, tentatively titled the Society for Traumatic Stress Studies, would be a useful contribution. Moreover, that the central purpose of this Society would be to sponsor a scholarly publication, tentatively titled, Trauma and Its Wake: The Journal of the Society for Traumatic Stress Studies.

Such a journal would publish important advancements in the field of traumatic and post-traumatic stress. A distinguished Editorial Board is already in place in connection with the book I am editing, with the same primary title, that will be published next year . . . How appropriate is such a society and journal, in particular, and the emergence of a separate field of traumatic or post-traumatic stress in general? (Figley, (1986a).

The response to Figley's letter was positive and enthusiastic. He believed that the formation of such a group was essential if the establishment of a journal to promulgate research findings about traumatic stress was to become a reality. Creating a journal is an expensive proposition that required a subscription base of at least 600 members to get off the ground (Figley, 1998; Meshad, 1997).

Figley recognized that he could use the resources of his organization, the Consortium on Veteran Studies, to provide initial support to start the organization, but a much wider constituency was going to be necessary for a journal to be successful. He sent another memorandum the following year to the people he had previously contacted, and finally, after the birth of his daughter and the completion of Trauma and Its Wake by Brunner/Mazel in 1985, he contacted a group to join him at a meeting in Washington, D.C.

A breakfast meeting was held in Washington on March 2, 1985 and at this meeting the Society for Traumatic Stress Studies (STSS) was formally established. Those who attended comprised most of the Founding Board and their names are recognizable from the previous history: Ann Burgess, Art Blank, Yael Danieli, Bernard Mazel, Frank Ochberg, Robert Rich, Susan Salasin, and Marlene Young. Charles Figley was selected as President, Ann Burgess as Vice-President and Scott Sheely as acting Executive Director. Others subsequently were elected -- John Talbott, Robert Lifton, Bonnie Green, Morton Bard, Peter Erlinder, and John Wilson.

It was agreed that the purpose of the Society would be: "to advance knowledge about the immediate and long-term human consequences of extraordinarily stressful events and to promote effective methods of preventing or ameliorating the unwanted consequences". The objectives of the organization were to 1) recognize achievement in knowledge production; 2) disseminate this knowledge through face-to-face contact with colleagues and 3) through other knowledge transfer media, especially print media.

It was decided to call the group a Society, since the term connotes a small group of like-minded colleagues while the concept of traumatic stress signifies the area that encompasses the entire process of traumatization, including the initial and long-term reactions and recovery (Figley, 1986a,c).

The Founding Meeting was held September 22-23, 1985 in Atlanta with Max Cleland, by then Secretary of State for the Stage of Georgia, welcoming the participants and Robert Lifton delivering the first annual Society keynote address. Over 450 people attended and became members of the Society. Sessions were devoted to research, policy, treatment, assessment, and diagnosis with a wide range of victim populations: rape victims, victims of crime, police officers and emergency workers, combat veterans, families of victims, victims and families of intrafamilial abuse (Figley, 1986a,c).

The Board of Directors for 1985-1986 was elected at the Founding Meeting by the Founding Board. Charles Figley was elected President, Ann Burgess, Vice President, Bonnie Green, Secretary, and Robert Rich, Treasurer. The Members-At-Large included: Morton Bard, Arthur Blank, Yael Danieli, Calvin Frederick (VAMC, LA), Sarah Haley, Judith Herman, Norman Lourie, Bernard Mazel (of Bruner/Mazel), Irene Melup (United Nations), Frank Ochberg, Erwin Parson (N.Y. Vietnam Veterans Leadership Program), Alvin Poussaint (Judge Baker Guidance Center), Susan Salasin, Chaim Shatan, Joyce Thomas (Children's Hospital, Washington, D.C.), John Wilson, and Marlene Young. Robert Lifton, Martin Symonds (Deputy Chief Surgeon and Head Psychiatrist, New York Police Department) and John Talbott were elected "Distinguished Consultants". Christine Dunning, Jack Lindy, Noach Milgram, Robert Laufer, and Bessel van der Kolk all were active in committee work.

Conscious efforts were made in the early years of the Society to insure that the group would be diverse and a special effort was made to encourage women and members of ethnic minorities to become involved. In an early historical account, Figley recalls that, "it was my major concern and the concern of most of the board that the Society always be by and for the members and avoid elitist concentrations of power and influence in Society affairs among a few" (1988, p.2).

The first edition of the Society newsletter, Stresspoints, came out in Spring, 1986, just after the NASA Space Shuttle disaster. In his opening welcome upon noting this tragedy, Figley commented upon the diversity of opinion expressed in the press after the disaster and hopes that "very soon we can create a national media registry. This would include those most of us would agree are qualified to comment on the psychosocial consequences of traumatic events . . . We hope that by providing the media with a list of qualified experts, the level of public information about human response to catastrophes will be increased substantially (Figley, 1986a, p.1).

At that time, there were specific efforts sponsored by the Society that seemed to be consistent with its mission. These included the development of professional and scholarly institutes; theoretical, methodological, and psychometric innovations; establishment of professional standards for practitioners; and explication of empirically valid diagnostic criteria for PTSD (Figley, 1986c). The first set of bylaws was published in the first edition of Stresspoints.

As Chaim Shatan recalls (1997a), in the early days the stress disorders evident in Vietnam veterans were the primary focus for the society and the first meeting began with a review of the history of the veterans' movement. There was a strong interest in getting people involved who were active in the military and who functioned in the Veterans Administration system.

But this focus quite naturally led to the recognition of the women who had served in Vietnam and the problems they too were suffering. The third early focus was on families of Vietnam vets, a subject Figley took a serious interest in as early as 1983 (Figley & McCubbin, 1983), and this emphasis on families led to the need to look at issues of family violence. A fourth focus was on "VIP" -- veterans in prison, often for perpetrating violence against their families. A study had been released in the early 1980's reporting that 50-60% of incarcerated veterans were Vietnam veterans, and that their needs were not being adequately addressed (Pentland & Rothman, 1982).

From the beginning of the Society, Figley thought it was important to place a particular emphasis on understanding those who are perpetrators, reasoning that unless we could help them, we would never be able to stop victimization (Figley, 1998). Early in the evolution of the Society, Richard Mollica was articulating a concern for victims of torture and refugees from Southeast Asia (Shatan, 1997a).

The men who had served as chaplains in Vietnam were another early focus at attention. Many of them had been influential in the movement to get recognition for stress disorders including William Mahedy. The National Council of Churches had provided significant support in getting the Vietnam veterans' movement off the ground and for the first several meetings, clergy remained actively involved and participated in ecumenical Memorial services that were held during the annual meetings (Danieli, 1997; ISTSS, 1986)

There also was an informal liaison with the American Academy for Psychiatry and the Law through Emanuel Tanay, a Holocaust survivor who had been a contributor to [SLB1]Krystal's Massive Psychic Trauma. He advocated strongly for the recognition of stress disorders in Holocaust survivors and veterans (Shatan, 1997a).

Over the next few years, this interface between practitioners working with victims of trauma and the legal system became increasingly important. As Figley noted in 1986, courts of law, insurance carriers, and agencies disbursing disability benefits (Social Security and Veterans Administration) are encouraging more and more cases of PTSD that require judicious action and thus, require far more precise, reliable and valid diagnosis of PTSD than is currently available (1986c, p.xxvi).

By the start of the second annual meeting September 27-October 1, 1986 held in Denver, membership had grown to 700. At the annual meeting, the Board of Directors elected John Wilson as President-elect, while Joel Brende, Christine Dunning, James Henderson, and Tom Williams became new members of the Board of Directors.

The inadvertent division that had occurred early in the 1980's mentioned earlier between those clinicians with a primary interest in dissociative disorders and those with a primary interest in PTSD, became an area of concern as early as 1986.

In his presidential letter for the second edition of Stresspoints, Figley reported that talks had been initiated between the STSS and the International Society for the Study of Multiple Personality and Dissociation for the purposes of exploring the possibility of joint program activities (Figley, 1986b).

Over the subsequent years, many clinicians participated in the activities of both societies. The third issue of Stresspoints marked the first mention of concern for PTSD in children and youth and organizing efforts were begun to allow people with similar interests to communicate, noting a "lack of data and a need for more systematic study" (ISTSS, 1987, p.3).

By the time Figley stepped down as President and turned over leadership of the organization to John Wilson, the first general election had been held by mail-in ballot instead of at the annual meeting. Yael Danieli was elected as president-elect and new Board Members were Catherine Fine, Robert Laufer, Jacob Lindy, Robert Pynoos, Robert Rich, Chaim Shatan, and Bessel van der Kolk. During her term as President, Danieli commissioned the preparation of a curriculum on traumatic stress that was completed in 1989, representing training curricula in ten specialty areas.

Charles Figley and fifty-two nationally known scholars founded the Journal of Traumatic Stress on July 1, 1986. A contract was signed with Plenum for publication to start January 1988. A call for papers was published in the January, 1988 edition of Stresspoints, setting out what the journal hoped to accomplish, its basic structure, and naming its Editorial Board. The first issue of the journal came out and by April 1988, more than 66 manuscripts had been received and were in the review process.

Internationalization

From the beginning of the Society there was a strong interest in developing liaison relationships with international organizations like the UN, WHO, and the World Psychiatric Group. The International Liaison Committee, chaired by Robert Laufer with Yael Danieli serving as Board Liaison, was one of the original Board committees. Its mission was to "seek out ways to bring groups and persons from other countries into dialogue with the Society and its members around issues of mutual concern" (Figley, 1986b).

By 1986, colleagues were attending the Second Annual Meeting from Australia, Holland, Norway, Japan, and Canada. In the second newsletter, published in Fall, 1986, Figley noted that the British had begun to study Falklands War-related PTSD. Throughout the year there had been correspondence from South Africa and Wales. Ruth Wraith, from Melbourne was already actively recruiting members in Australia.

After the Denver meeting, the executive director noted that there were then 800 members including 18 non-U.S. members. As the organization grew and members from around the world joined, participated, and shared their research findings, the Board of Directors spent a great deal of time trying to figure out how to integrate the international intentions of the organization with the reality that the vast majority of members were still Americans.

At the April, 1990 mid-year meeting of the Board, the much-debated decision was made to change the name of the Society to the International Society for Traumatic Stress Studies (ISTSS), to at least reflect the sincere intentions of the organization (Lindy, 1990b).

In 1988, Roderick Ørner organized the First European Conference on Traumatic Stress (ECOTS), held in Lincoln, England, August 30- September 1. By this time, British attention was focused on the Falklands War, the Bradford fire, the Herald of Free Press sinking, the rampage in Hungerford, and the Kings Cross Station fire.

Charles Figley was a guest speaker at the conference, as well as Shad Meshad and John Wilson. After the Lincoln Conference, Roderick Ørner and Stuart Turner from the U.K., Wolter de Loos from the Netherlands, and Atle Dyregrov from Norway formed the European Network which later became the European Society for Traumatic Stress Studies (ESTSS) and agreed to arrange a European Conference every two years. In 1990, the second ECOTS was held in Amsterdam.

The network aimed to foster European developments in clinical research and policy areas and to establish an international database. The group wanted to avoid destructive competition with the ISTSS, to which most of the key members belonged, while still being able to direct regional efforts. Out of these discussions arose the idea of the eventual development of a federal model under which umbrella North American, European, Australian, and potentially other regional societies could find a home (Weisaeth, 1993).

The Founding Meeting of the ESTSS was held in Bergen, Norway in June, 1993, having established an affiliative relationship with the ISTSS (de Loos, 1994). By 1995, the ESTSS represented sixteen European countries. Non-European members represent Israel, United States, Palestine, South Africa and Australia (de Loos, 1995). Colleagues from France established an affiliated society for French-speaking people, the Association de Langue Francaise pour L'Etude du Stress Traumatique (ALFEST).

Melbourne, Australia hosted the Second International Conference on Dealing with Stress and Trauma in Emergency Services. The Australian Society for Traumatic Stress became an incorporated body in November 1992. Beverley Raphael was the founding President and the first national meeting was held in April 1993. The Kuwait Society for Traumatic Stress Studies was approved as an affiliate by the ISTSS Board of Directors in December, 1997.

By 1988, during the Presidency of Yael Danieli, the STSS became an organization member of the World Federation for Mental Health with Danieli as the senior representative to the W.F.M.H. from the U.N.

The Society's formal involvement with the United Nations began in 1989, during Danieli's presidency, when the Society applied for and received consultative status with the United Nations Department of Public Information.

The annual meeting in San Francisco in 1989 was formally opened with greetings from the secretary general of the United Nations (Danieli, 1994). In 1990, Danieli, as Immediate Past President and Chair of the International Liaison Committee of the Board, submitted the newly developed curricula to the Committee on Crime Prevention & Control of the U.N. Crime Prevention & Criminal Justice Branch of the Centre for Social Development on Humanitarian Affairs (Danieli, 1990).

Dr. Danieli was able to enlist the support of Dr. Eugene Brody, Secretary General of the World Federation for Mental Health for the implementation of the curricula as well as Dr. Alfred Freedman, President of the World Psychiatric Association.

The Committee accepted the report into one of its resolutions for deliberation at the U. N. Economic and Social Council (Krystal, 1990). The U. N. General Assembly adopted the ISTSS curricula in 1990. In 1993, the ISTSS was granted the more prestigious consultative status with the United Nations Economic and Social Council (Danieli, 1994).

Into the 90's: The First Five Years

By 1990, Jack Lindy was President. Tragedy struck when both Robert Laufer and Sarah Haley, two people who had been instrumental to the development of the field, both died prematurely. By this time, the Society had nearly 1500 members from over twenty-five countries and five continents with three international board members -- Wybrand Op den Velde from the Netherlands, Noach Milgram from Israel, and Lars Weisaeth from Norway.

In his Spring editorial, President Lindy noted that The Second European Conference on Traumatic Stress is set for the Netherlands and in the call for papers the organizers pointed out that "the Society for Traumatic Stress Studies has been founded as the worldwide umbrella organization for the field" (Lindy, 1990a).

The Ministry of Health in the Soviet Union had announced support for a conference on PTSD and invited a delegation from the ISTSS to be featured speakers. In his Spring, 1990 Presidential letter, Lindy said, "We hope that the model of indigenous "grassroots" regional growth of clinicians and investigators will continue to grow worldwide and that we in the Society as members of an international umbrella organization can foster that growth within the context of a single supportive clinical/scientific body for years to come" (Lindy, 1990a, p.1).

In April 1990, the Board of Directors met for an intensive strategic planning meeting to construct a vision of the Society for Traumatic Stress for 1995. Together, they envisioned "an international society with 3000 members, mental health workers and other caregivers devoted to clinical research and policy dimensions of trauma, its pathological syndromes, and its patterns of recovery. We would be the primary body worldwide with such a charge. Directors saw computer terminals accessible to all members with information worldwide regarding service delivery, scientific knowledge, treatment techniques, referral sources, and job opportunities. The scientific meeting of 1995 would take place perhaps in Hiroshima, Japan. The JTS would be available in other languages for regions of STSS unable to read English. Our governance would undergo a democratic overhaul to reflect the international scope of the Society. In addition to a revised edition of the 1989 curricula, four additional projects would be completed: a standard of disaster relief; a standard of trauma care; a work disability document; and a document on childhood trauma and its transmission intergenerationally. These visions . . . including involvement with ethnic minorities and urban problems, would be part of a vigorous and scientific and humane Society honoring simultaneously academic excellence and soul" (Lindy, 1990b, p.1).

At the 1990 mid-year meeting in Columbus, Ohio, Governor Dick Celeste addressed the group by saying "the personal is political and politics at its best responds to the personal. In your work you help us to understand the urgency to translate the data (of research) into a human face and from there to a public policy agenda . . . . Share with us the implications of your work and of your study, make them available to those of us who shape public policy, help us develop a constituency of those appraised of the problem so we can allocate resources to those who need them" (Lindy, 1990c).

In 1991, during the early part of the presidency of Bessel van der Kolk, the National Institute for Mental Health announced the creation of a new "Violence and Traumatic Stress Branch", merging the former Emergency Service Branch, the Emergency/Disaster Research Program, and the Antisocial and Violent Behavior Research Branch.

This was a significant event because until that point, it had been extremely difficult for researchers in the field to obtain grants through NIMH for the study of traumatic stress. Commenting on this achievement, Susan Solomon said, "The logic of our new organization to a large extent mirrors that of ISTSS. The Society was also the partial inspiration for our new Branch title: Violence and Traumatic Stress Research Branch, since the membership of ISTSS is our main constituency for one of our programs" (Solomon, 1991, p.4).

The organization also prepared for what were then the unknown outcomes of the Gulf War that was being waged as the January 1991 newsletter went to press. Clear instructions were given for how the members could mobilize to help in the anticipated crisis that would occur if there were massive casualties.

According to President van der Kolk's newsletter column, " Many members of ISTSS in the U.S. and Israel have been very active in organizing a mental health response to the war both on an institutional level, as in the military, the VA or Red Cross, or individually" (Van der Kolk, 1991). A hotline was being established, and literature made available with the ISTSS headquarters designated as the link between mental health professionals providing services to individuals, families, and communities affected by the war.

Observations and Conclusion

It seems appropriate that we leave this historical account in 1991, at the beginning of a new decade, with a new Editor of the Journal for Traumatic Stress, Bonnie Green, a new branch of the National Institute for Mental Health dedicated to the study of traumatic stress, and a new war being played out on the world stage.

As a psychohistorian, I am much too close to the development of the organization to be able to draw any objective conclusions, but I do feel compelled to make some observations about the changes that have occurred over time, if only to provoke further conversation about the nature of organizational growth and change.

In the introduction to their important volume on the state of the field, published in 1993, Wilson and Raphael observed the changes for themselves, To establish some perspective on the rate of growth 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 biological basis of disorders associated with PTSD, and a limited understanding of effective therapeutic approaches (Wilson & Raphael, 1993, p. xxi).

Today, books on the various aspects of traumatic stress fill rooms, not bookshelves. We have, indeed, become a true field of study if we use the criteria that Figley articulated a decade ago. "The criteria for a true field of study must include a body of knowledge and standards of practice that are subsumed within 1) a history, 2) professional organizations, 3) publications, 4) theory, 5) measurement, 6) research methodology, 7) intervention technology, 8) actions affecting policy and the judicial system" (Wilson, Harel & Kahana, 1988, p.ix).

The development of such a field cannot come about without the simultaneous development of supporting organizations that provide the safety, mutual exchange, and collegiality that stimulates individual creativity, while also encouraging and supporting opportunities for group contributions. The ISTSS has provided the leaders in the field of traumatic stress with that kind of an intellectual "home". But, regardless of whether we look at an individual, a family, or an institution, there are inherent and inevitable structural tensions that can be the fuel for creativity or can blow an organization apart.

As demonstrated by this history, the organization began as a grassroots, multidisciplinary, activist, war-biased but multi-interest group. For many reasons, some perhaps inevitable, the grass-roots nature of the organization has diminished over time and as a result, many of the original voices have faded from the ongoing life of the group. This shift came about as a result of a need to professionalize and thereby legitimize, the field of traumatic stress so that the accumulated evidence about the effects of trauma could be recognized by and influence social policy makers, i.e. lawyers, judges, legislators, health care administrators, etc.

Over time, academic standards for participation in the annual meetings and for the submission and acceptance of articles to the journal rose as the field defined and refined itself. Academic research grew as a central concern of the organization and as a result, extremely respected highly qualified academicians and researchers became involved and active in the Society. Because of the academic focus on publications, their names often held high recognition value.

As the organization grew in size and became less based on personal acquaintance, the highly published members tended to also be the members most likely to get elected to positions of leadership, fueling rumblings of "elitism" from the constituency that had, in fact, elected them.

An internal split occurred in the organization in the early 1990's, unrecorded in the sparse institutional publications that contain the institutional memory.

Many of the grassroots organizers and workers, many clinicians, law enforcement personnel, chaplains, emergency workers and others formed a separate organization now known as the ATSS -- the Association for Traumatic Stress Specialists (Meshad, 1997). There were many reasons for the split. Some felt that the ISTSS had become far too academically-oriented.

Others believed that given the overwhelming interest in research, the ISTSS could no longer meet the needs of in-the-trenches clinicians. Some felt the price of ISTSS membership was too high. Others wanted to move in directions that the ISTSS Board did not want to go, towards credentialing and training for example. It is estimated that about 50% of the ATSS remain active in the ISTSS, in fact the current President, Mary Beth Williams is also an ISTSS Board Member, so that the split was fortunately not one so filled with rancor that all bridges were burned.

Nonetheless, the result for some members of the ISTSS has been expressed as a feeling that "we have lost our soul".

Even with this internal split, the tension between clinicians and researchers has not gone away. Despite the fact that 60-70% of the members are still primarily clinicians, the Board of Directors is dominated by researchers, most of whom hold academic positions.

The inherent organizational skills of academically-minded people has played a significant role in helping the organization achieve stability, credibility, and recognition. And unlike some other academic organizations, in reality, most of those who consider themselves primarily researchers are also engaged in clinical practice. Nonetheless, the leadership of the organization can occasionally be vulnerable to losing track of the organizational and political needs of clinicians working in the fields.

Likewise, international representatives can easily become puzzled or irritated by a focus on issues that may be dominant in the United States but are of less concern elsewhere, while feeling that their own pressing issues are not being addressed.

For instance, the "false memory" controversy became a serious concern of clinicians in the United States, and to some extent, the United Kingdom, in the mid-90's, while researchers initially attempted to address it as an academic, not a political and forensic controversy, and international representatives were a bit perplexed by the importance the issue was given in organizational discussion.

At the same time, many European countries have pressing and serious problems with highly traumatized refugee populations, an issue that is easily overlooked by the American members who see fewer of these cases.

Another theme, unresolved and running throughout the history of the organization is that of trying to achieve a truly diverse membership. Unlike many professional organizations, from its inceptions the ISTSS has been multidisciplinary and bi-gendered, with psychiatric and psychological colleagues, male and female, inadvertently alternating presidencies on a fairly regular basis, and other disciplines represented as Board Members. But the organization has not yet been able to achieve significant racial integration, despite repeated organizational attempts - and an expressed desire -- to do so.

Victims have largely been the focus of interest in the ISTSS, although the issue of victim/perpetrator has been a recurrent theme. Early in the evolution of the group, the problem of Vietnam veterans in prison was a serious concern.

However, this interest faded away and the organization has largely not been able to attract or keep members whose interests lie in understanding, working with, or researching men and women who are perpetrators. In this way, the organization can be seen as reflecting the attitudes of the wider society, which, if it focuses on the subject at all, would far rather turn the spotlight of understanding and sympathy on the victims then the victimizers. But, as many have pointed out, including the Founding President, Figley, the only way to stop victimization is to stop the victimizers.

There have also been recurrent tensions in the Society about the role that child trauma should play in the formulation of what the Society should focus its attention on. The original focus, of course, was on adult veterans of war, although Figley and Shatan early on, expressed the need to understand child trauma.

Many of the early members were working exclusively with adult veterans in VA settings and had little clinical or academic exposure to the problems of children. This tension was fueled by the influx of clinicians in the late 1980's and early 1990's whose work centered on adult victims of child abuse and some child abuse specialists.

One former President, Bob Pynoos, is a respected child psychiatrist in the field. But many of the child specialists have organizational allegiances to other groups, including the American Professional Society on the Abuse of Children (APSAC). These tensions have proven to be largely creative ones, as those clinicians working with adult victims of war, Holocaust and disaster have been informed by the work of those focusing on victims of child abuse. Similarly, the latter have found support and endorsement of their perception and experience by witnessing similar phenomena in adult victims of other kinds of trauma.

The willingness or ambivalence of the Society to place the child at center stage appears to parallel the larger society within which the ISTSS has a place, as we listen to, and then deny, the voice of the child.

International integration has also presented recurrent challenges, although the ISTSS has been more successful than many organizations, at achieving internationalization in membership and at the level of the Board from its inception. The actual structure of the organization continues to evolve over time to reflect these changes.

Early in the life of the organization there was consideration of a federal structure, with the ISTSS as the overarching umbrella for regional societies. But the actual implementation of such an idea has had to wait on the development of sufficient international regionalization to support such organizational development. Meanwhile, most of the financial support continues to come from the United States' members.

If the field continues to thrive, and African, Asian, Latin American, Middle Eastern, and other societies develop and become self-supporting, the federal structure may indeed become a reality for the twenty-first century.

Finally, there has been one other theme that has pervaded the history of the organization and that can be best summed up as isolationism vs. advocacy. As this account has demonstrated, the ISTSS was founded only as a result of the most profound social activism, and that is the existential heart of the organization.

As Art Blank has recently pointed out, "There is no trauma field without advocacy" (1997). But there has also always been a desire in the Society, to remain small, intimate, and quiet.

Many of us have pointed out that the ISTSS is one of the best-kept secrets around. Unless you are a member of the group, it is quite likely that you have never even heard of it, despite the fact that the members of the organization have been instrumental in creating such a widely influential social movement. There have been few attempts made over the years to interface directly with the media or to attract media or public attention.

The organization has done little to try and market itself or widely expand membership. This may largely be explained by a desire to maintain the intimacy that can characterize a smaller group. But it is also a desire for safety. The daily exposure to the overwhelming effects of victimization has left many members with a desire for a safe place, away from the "madding crowd", where the horror of trauma can be intellectually and emotionally cordoned off, contained, and even, perhaps, safely transformed.

The dilemma, of course, is that all safety is relative. Just as the early workers in the field had to be concerned about personal and professional safety, the danger has not really passed. As the results of traumatic experience become more widely known and accepted, the need to deny these results - and their implications - becomes simultaneously more frantic.

Perhaps it is only a coincidence that as we gain the knowledge we require to treat, and perhaps even, prevent, post-traumatic stress disorders, funding for mental health services in the United States is minimized or cut-off entirely. Perhaps it was only a coincidence that at the height of the TET offensive, the psychiatric establishment dropped "gross stress reactions".

But it is logic and experience, not coincidence, that tells us, as Blank has pointed out (1997b), that organizations that stand to lose financially by paying compensation or damages have a vested interest in denying the profound and long-term effects of trauma. Perpetrators of assault and abuse have a highly vested interest in finding protection from exposure and criminal penalties by continuing to "blame the victim" as they have always done. The larger society will continue to deny the magnitude of the problem, not only because of the emotional arousal exposure causes, but also because it is becoming increasingly clear that fixing the problems and actually preventing trauma, will cost a great deal.

There is a moral danger inherent in our work, perhaps best thought of as the medicalization and privatization of what is a socially determined problem (Bloom, 1995). If we fail to provide evidence-based treatment for our patients who suffer from the chronic disorders related to exposure to traumatic experiences, we fail as healers.

But, when we focus our attention exclusively on deciphering the complex brain processes that lead to the symptoms of post-traumatic stress, we may ignore the social context within which the traumatic stress originally occurred. A senior army officer and Vietnam veteran nurse points out, "It's the government and the country at large that suffer from PTSD: anger, guilt, shame, denial, mistrust, and all the rest. We've been saying that for years. It's good politics to blame the victims.

Then America avoids the consequences of its own actions and condemns the veterans to pay the price" (Davis, 1994, p. 134). This is the same charge that has been leveled at mental health professionals from the women's movement as well, "Psychiatry and psychology on either side, believing or disbelieving women and children, defuses the issue by medicalizing it. That, in removing it from the political sphere to that of individual pathology, it is an excellent vehicle for problem management rather than for social change" (Armstrong, 1994, p. 183).

It is a discourse that pervades those who work in the field of human rights abuses, "In a context of human rights violations, this problem must also be related to the political context. To be on a survivor's mission in Chile was not only a question of one's own survival but also of the survival of democracy and human dignity . . . It appeared that therapists were exposed to the same kinds of trauma as their patients. . . . Their work, which helped the enemies of the regime, was fraught with danger and could bring on traumatization by direct actions from the regime. . . . The work could, however, also be experienced as healing for therapists because of the commitment to a higher goal, the struggle for prosocial change and human rights" (Agger & Jensen, 1994, p. 284 & 285).

We are mental health professionals, trained to diagnose and treat mental illness. We are not as well-trained - or even comfortable with - social activism. However, the ISTSS was created as an organization clearly directed at mobilizing the power of scientific knowledge in the service of social change and we forget - or neglect - this heritage at our peril.

Our work is far from over. It has only just begun. Ahead, for the organization, lie the same challenges that we pose for our traumatized patients. Can we continue to balance conflicting needs without disintegrating into chaos? Can we contain overwhelming affect and manage the anxiety of change and lack of predictability without becoming destructive? Can we ultimately find ways to successfully integrate conflicting desires, needs, points of view, and agendas into a creative, dynamic whole? Can we hold onto our memories of what we have learned, defying the every-present tendency to deny and forget the effects of trauma?

Zahava Solomon urges us to "constitute a professional system that will retain information so that lessons, once learned, shall not be forgotten . . . I believe that it is our duty as the International Society for Traumatic Stress Studies to chip away, however slowly, at these denial tendencies, at professional blindness, and at the tendency of the establishment to refuse responsibility for the treatment and rehabilitation of casualties and their families" (Solomon, 1995d, p. 281).

We still have the opportunity to decide if we, as individual clinicians and as part of a larger whole, are going to ultimately become a part of the problem or a part of the solution. As Chaim Shatan summed it up, "I propose that our next professional assignment is to go beyond the treatment of new trauma populations: the long-range cure of war-related trauma requires prevention of traumatic stress. We traumatologists can continue to provide first aid as "stretcher bearers of the social order", sophisticated, compassionate, with growing scientific knowledge, but picking up the wounded rather than preventing them from being wounded. Or we can try to eliminate the sources of PTSD in the social order, to dismantle the army-and-enemy system, a human invention, an institutionalized manhunt . . . Otherwise, PTSD - an outgrowth of war and persecution - will remain with us unchanged - under whatever name from shellshock to K.Z. syndrome, from DSM-III to DSM-X (Shatan, 1992, p.20).

Dedication

This chapter is dedicated to all those who have played a critical role in transforming trauma into wisdom, particularly those I have neglected to mention in this brief, and by necessity, incomplete historical summary. So much to be said and so little time.

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