Psychiatric Annals

The Tattered Ego of Survivors

Chaim F Shatan, MD

Abstract

1. Lindy JD. Grace. Green: Am J Orthopsychiatry 1981; 51:468-478.

2. Amery J; On the necessity and impossibility of being a Jew. New German Critique Spring-Summer 1980, pp 15-29.

3. Kardiner A: The Traumatic Neuroses of War. Psychosomatic Medical Monograph. New York. Paul Hoeber, 1941,

4. Grant JCB: Introduction. A Method of Anatomy. Philadelphia. WB Saunders Co. 1946.

5. Jaynes J: The Origin of Consciousness in the Breakdown of the Bicameral Mind. Boston. Houghton Mifflin Co, 1976.

6. Shatan C: Through the membrane of reality: "Impacted grief" and perceptual dissonance in Vietnam combat veterans. Psychiatric Opinion October 1974.

7. Diagnostic and Statistical Manual of Mental Disorders, ed 3. Washington. American Psychiatric Association. 1980.

8. Shatan C: The guilt and grief of warriors and concentration camp survivors. Presented al the IV International Psychoanalytic Forum, New York. October 2. 1972.

9. Archibald HE, Tuddcnham RD: Persistent stress reaction following combat: A 20 year follow-up. Arch Gen Psychiatry 1965: 12:475-481.

10. Nefzger M: Follow-up stud ics of World War Il and Korean War prisoners. I. Study plan and mortality findings. Am J Epidemiol 1970: 91:123.

11. Shatan C: Bogus manhood, bogus honor: Surrender and transfiguration in the U.S. Marine Corps. Psychoanal Rev 1977; 64:585-610.

12. Shatan C: Special report. The grief of soldiers: Vietnam combat veterans' self-help movement. Am J Orthopsychiatry 1973;43:640-653.

13. Nieder land W: The guilt and grief of Vietnam veterans and concentration camp survivors. Presented at the IV International Psychoanalytic Forum. New York. October 2. 1972.

14. Eitinger LS: Concentration Camp Survivors in Norway & Israel. London. Allan & Unwin, 1972.

15. Haley S: When the patient reports atrocities. Arch Gen Psychiatry 1974; 30:191-196.

16. Shatan C Haley S, Smith J: Johnny comes marching home: The emotional context of combat stress. Presented at the Annual Meeting American Psychiatric Association. Toronto. May 1977.

17. Simenon G: The Family Lie. New York. Harcoiin Brace Jovanovitch. 1978.

18. Suhl Y: Survivor. The New York Times April 13. 1972.

ACKNOWLEDGMENT

The author wishes to express deep appreciation to Ms. Tornar Levine for her editorial assistance.…

"Have you hugged a Vietnam veteran today?" reads the bumper sticker. If you have, you may have been held firmly and dampened by soundless tears, you may have been hugged back, or you may have been brusquely pushed away. Many Vietnam veterans experience serious problems with powerful emotions such as tenderness and intimacy, rage and grief. A 1973 Veterans Administration Memo stated that serious and prolonged readjustment problems "have been markedly greater for Vietnam veterans than for other veterans."

The perforated, even shattered, ego which accompanies massive psychic trauma clothes survivors. The emotional context of catastrophe continues after such trauma seems at an end. This wounded ego has the task of coping with the traumatic reality. To convey the sense of this reality, psychiatry needs a language to confront what was, what is, and what might be again, and to add the control which knowledge brings. These wounds are no less real nor crippling because they are invisible. Thus Newsweek (March 30, 198 1) headlines "The Troubled Vietnam Veteran," a recent paper is entitled "A General Survivors' Reluctance to Utilize Mental Health Resources,"1 and The Houston Post (March 15, 1981) runs the following article:

Man Attacks VA Hospital

WEST LOS ANGELES (AP). A man shouting that Agent Orange had destroyed his brain drove a jeep . . . (into) a VA hospital and opened fire... The man claimed . . . that he was deaf because of Agent Orange, a. . . defoliant used. . . during the Vietnam War.

James CIa veil, author of Shogun, spoke of the four years he spent in a Japanese prison camp, where 14 out of every 15 prisoners died. For the next 15 years he always carried a can of sardines, and fought the urge to forage for food. And for 1 5 years he told no one.

What of these bizarre troubles that persist for decades or emerge decades later? This reluctant, unresponsive population of survivors often avoids human contact, especially when asked about the atrocities they survived. Professionals may also "turn off," feel uneasy, and find no adequate paradigm within themselves to confront these issues. Staring emptiness and meaninglessness in the face, empathy is all but impossible to achieve. It is impossible to step into the shoes of victimizer or victim.

THE BASIC WOUND OF CATASTROPHIC STRESS

Various syndromes and symptoms have been attributed to these veterans. However, at their core is the fact that an entire culture was rent asunder by manmade, socially sanctioned, destructiveness, not by natural disaster. The manmade nature of this prodigious event determines its intensity, impact and susceptibility to later psychopathology.

Survivors have endured grinding horror as daily reality. Total persecution or total combat overcomes every facet of existence - life now consists of privations, mass deaths, mutilations, killing and being killed - and homecoming does not resolve the horror. Coming home may mean coming home to die, or coming home with the so-called "thousand-mile stare," or a restless, haunted look.

These and many other specific disturbances are best viewed as emblems of a radical personality change - grounded upon the never-ending threat of death at human hands. One type of outcome may be suicidal resignation or murderous rage, without means or opportunity for coping or mastery. More commonly, the outcome is a new, constricted adaptation to life. The chronic disorders which erupt years later stem from the time of the catastrophe, from the intertwining of savagery with desperate anxiety, still unrelieved.

The survivor's tattered garment is unhealed psychic reality - reality that has never been fully restructured. This is his specific wound. His ego remains bent and deformed, and his perceptions still conform to the conditions of the world from which he returned. In that world psychotic reality was the norm, eclipsing the reality of everyday living. Imminent destruction and death had become the new "reality principles." In a concentration camp or in counter-guerrilla combat, a person stood a chance of staying alive only by so distorting his own ego that the new deadly reality became his own. A Vietnam medic, describing an ambush, said "I had to permit my old reality to slide away from me through a membrane." After passing through the "membrane" which separates the two realities, perception of events is transformed and the individual adopts the paranoid posture and mentality necessary for survival in combat. Styles of affect, cognition and action are transfigured. Even when the stress is over, a return to the status quo cannot be expected. Some part of each survivor's inner milieu is permeated with traumatic reality forever. Its malevolence can overwhelm the ordinary reality perception of earlier years.

After the journey through the membrane of reality, the new overriding mentality is paranoid only from the viewpoint of outsiders, outsiders who have never needed to face a ghetto rail line, or needed to kick an opponent in the face to survive. A man's life may be changed forever by one flash of combat. People's haunting experiences are stitched into the tapestry of their lives: there is no deficit in thinking, no ^inappropriate behavior from the vantage point of that other crushing reality.

That other reality meant "to be a dead man on leave, someone to be murdered, who only by chance was not yet where he belonged . . . "" Even now, veterans feel that they are still "condemned to be murdered in due time," perhaps even by those most loudly denouncing the outrage. The survivor finds more wisdom in his Marine dog tag or the number tattooed on his arm than in all the Geneva and genocide conventions.

After re-entry, thesurvivor must penetrate through this torn interface between catastrophic reality and everyday reality again - from the reality of extermination back to daily reality. But the weight of incorporated traumatic reality can easily threaten this return. Usually, we are only in touch with a fraction of the spectrum of possible realities. To know reality as an integrated realm, we dissociate vast territories of experience. In the survivor, however, the two reality perception systems co-exist and overlap, blurring awareness. The clash between these two systems leads to "perceptual dissonance" (PD). After the triumph of survival wears off, "symptoms" may arise. These "symptoms" are actually seething impulses which have had to be restrained, yet press constantly for utterance.

CASE REPORT: PERCEPTUAL DISSONANCE

One of the best examples of PD cropped up in a veteran who had been a truckdriver in Vietnam in 1 972. For a year, he stayed alive by driving along Vietnam's Highway One "like a bat out of hell." In I979, he started driving a truck for a copper mine. The narrow, winding dirt road reminded him of Vietnam's Highway One. Within a year, he began to see a split image in his rearview mirror: on one side, the copper mine road, on the other. Highway One. He was aware that one image was from the past, but it was so powerful that he had to fight panic with all his strength to avoid accidents. The anxiety left him trembling, sweating, and exhausted by each day's end. His was one of the first cases the VA agreed to hear as a combat-related stress disorder, despite the fact that symptoms had developed more than two years after discharge.* The congruence between his new job and his military job transported him back to Vietnam as surely as the appearance of North Vietnamese soldiers could have. Why he accepted this job is a question that remains unanswered.

THE DEVELOPMENT OF "NEW" PERMANENT ADAPTIVE LIFESTYLES

Beyond individual differences, sudden re-entry from life in a total institution leaves each returnee with one striking common denominator - a "new" permanent adaptive lifestyle. ?

Impairment of adaptability is the outstanding, overall feature of this "new" adaptive lifestyle. Affect, cognition and action - feeling, thinking and acting - have been radically altered, have acquired tighter parameters and are more hemmed in.

How do combat veterans undergo such basic behavioral changes in only a year or two? The intensity and totality, rather than the duration of the experience, determine the outcome. Uprooting, displacement and relocation have a jarring effect, which renders adolescents, in particular, peculiarly vulnerable and prone to fragmentation. They are taught automatic surrender to authority, and new, rigid styles of reacting. In addition, devoting every waking hour to the repetitive pursuit of a narrow range of activities has a unique imprinting quality. Finally, sudden unannounced shifts - in environment, social group, pace and leadership - promote regressive response patterns. Moreover, when the newcomers are sent into action, they recoil into even more restricted modes of adjustment.

The lightning-like trip back to "the World" (the United States) on the "freedom bird" (plane transporting veterans home after discharge) helps these recently formed traits to set almost with the speed - and the inflexibility - of plaster of Paris. In combat and postcombat adaptation, "the mind is wax to receive impressions, but marble to retain them."4

DIFFERING UNIVERSES OF REALITY PERCEPTION

Biologists conceive of humanity as ushering in the "psychozoic" era, in which the main thrust of human evolution is to be found in mental development. The first concepts of psychic "integration" were voiced in the Eastern Mediterranean less than 2500 years ago.5 Nevertheless, even a scant few centuries ago, the community still included within the pale of normality both hallucinatory experience and the simultaneous perception of several dimensions of reality. Such "unintegrated" or dissonant psychic activity is still to be found in cultural "pockets" in advanced societies, and not only in the Amazon or in Bali.

How is this apparent digression relevant to our concerns? The "new" adaptive lifestyles previously mentioned are not just a product of individual regression. They represent psychological regression of entire social groups. Such regression leads to mental states in which dissociated experiences can come into partial awareness. The individual is fully aware that the dissociated material is an unpleasant intrusion from the past into present-day reality. This is the essence of "flashback." The coppermine truckdriver (case report) represents one of the clearest instances.

How is the ground laid down for such developments? Sudden dramatic shifts in place and time constitute one factor. They do not allow the periods of transition necessary for orderly integration and re-integration of new and old sets of experiential information. Multilayered systems of reality perception from both civilian and military milieux, or from the worlds of persecutory and pre-World War II reality, are stored "alongside" still other reality perception systems of childhood and adult life.6

Let us conceive of the "ego," the psyche, the "G as the seat of the perception of this "reality." This "I" is probably always confronting, not merely a multilayered, but a "multichambered reality." It scans both connections and separations between different segments from the possible spectra of human reality.

The tattered ego of the survivor is unprepared for such tasks of bridging and separating. It will be seen that the new adaptive lifestyle is "designed" to protect this now delicate organization, the survivor's self. Although not fully intact, the tattered garment defends the veteran as well as it can. It protects the individual from sudden onslaughts of what was, in a previous milieu, at the center of perceived reality. However, since this way of life is inflexible, there can be "breakthroughs" ("flashbacks") of previous life events, or "breakdowns" (syndromes)7 to previous ways of life - despite orientation in current time and space. Because of this rigidity and imprinting, it is difficult to use one's inner resources to relieve the inner tension. As a result, the average veteran may reach a state close to desperation upon re-entry after being "in country," or in, or near, combat.7

COMMON FEATURES OF MANMADE STRESS

The notion that Vietnam veterans and K-Z (concentration camp), or death camp, survivors have common traits still meets with disbelief. Yet, this idea was introduced in 1972, not on theoretical grounds, but because of similar clinical features and symptoms.8 One group was considered armed victimizers and the other destined for the ovens, but this is less of a gap than might be expected.

Both groups were plucked from their peacetime environments, relocated and de-individuated. Both were repeatedly dispersed and eventually referred to by numbers. Both felt surrounded, like fish in a hostile sea of foes - with death, crippling and starvation everywhere. Drugs, from amphetamines to heroin (and alcohol), were heavily used to lower GIs' resistance to commands. Besides being blown away by booby traps, snipers and "friendly fire," grunts were shot down by some officers for refusing to go into action ( Personal Communication from S.T.J. , a Vietnam combat veteran). Terror (and counterterror) were each day's diet for veterans and K-Zs alike.

Extremes of climate were a mutual experience. The few escapees, in deadly danger, roamed the forests or jungles, sometimes in small groups, and offered what resistance they could to all comers.1*'10 Computerized rest and relaxation was not only a hollow mockery, but the torture of Tantalus, a brief interlude in hair-raising "reality." Less-than-honorable discharges or "SPN" (spin) numbers, often inflicted by vindictive non-coms, pursue 600,000 to 1,000,000 veterans. This legacy of "bad paper" is fraught with unemployability. So is the legacy of the camps for some people.

MANMADE STRESS AND "DELAYED STRESSORS"

What is the quality of manmade stress that it induces such protean manifestations? How does it differ from random natural disaster? The effects of manmade "injury," even an urban ambush (a mugging), are much more persistent and disabling than those following a sudden "act of God."

When someone loses all of his combat unit or his whole town, he becomes "unplugged" from his communal relationship network. This unplugging is the source of the delayed stress disorder triggered - years or decades later - by traumatic triggering factors. At first, these "delayed stressors" appear autonomous, but they are actually recognizable fragments or symbols of an appalling reality - the original stress-related or combat related stimuli. They act upon people who are in a state of latent autonomic and endocrine hyper-arousal. This hyperalertness exists side by side with a state of unfinished mourning - persistent effects of unexpressed loss which may be called "impacted grief." The startle reactions, the recurrent nightmares, the irritability have all been catalogued and summarized in DSM-III.7 They are much more persistent and severe in survivors of combat and persecution than in non-combat veterans or survivors of earthquakes and hurricanes. Twenty-five years later, combat veterans still show baseline pulse, respiration, and EEG readings significantly higher than those of noncombat veterans or non- veterans.

POST-COMBAT LIFESTYLE AND RELATED POST-TRAUMATIC ADAPTATIONS

The post-traumatic adaptation under discussion - especially that which follows counter-guerilla warfare or holocaust - is essentially a post-war continuation of the death factory or jungle position: the paranoid stance, ceaselessly vigilant as under threat of death, yet ill at ease in the absence of enemies. When there is friction between "ordinary life" and readiness for action, "warparticipation syndromes" or symptoms may appear (E. Tanay, personal communication, 1979).

Upon closer inspection, these symptoms and syndromes are obviously intensifications of the wartime personality which persists in the peacetime milieu. However, no two people have the same "breaking point" under stress. Accordingly, it is possible to live a lifetime without revealing one's new-found way of life. People simply know that a man is "different," that he is permanently "changed," that "he's not the same person."

Both vets and survivors experience early interludes of triumph, but these feelings usually subside. They are replaced by: feeling scapegoated; feelings of guilt, rage and violence; impulsivity and grief; problems with secretiveness, security, intimacy and work; and a pervasive hyper-alertness with startle reactions, intrusive fears and flashbacks.1,6,8

Focusing on the post-Vietnam combat survivor, we meet with constant vigilance. The reflex startle reaction to any sudden environmental change is an automatic tactical response. But it is a failure in peacetime adaptation, as if the veteran feels ambushed by the sudden change. Elaborate precautions are taken to avoid being startled: being against a wall to protect one's rear, aware of the difference between a leaf shaken by a squirrel or swayed by a breeze, walking on the inside of a park path. ("Anyone who's been on patrol knows that you're less visible to hostiles.")

Sleeping with a weapon at hand (machete, knife or pistol) is no guarantee against nightmares. Nor is sleeping on the floor to be below the window line, because one may be awakened by the sudden silence which presages an attack. (In Nam, all animal, insect and bird sounds would vanish before a nighttime attack - a deathly stillness.) Or a sudden hot, humid spell - like jungle weather - may trigger nightmares, as does cold for the K-Z survivor (S. Rustin, Ph.D., personal communication, 1 973).

Combat nightmares may lead to wives or sweethearts being hit, or worse, with no waking memory on the part of the veteran. When a veteran has a child, the child may appear in his combat nightmares: "I dreamt 1 was near Dakto and trying to save my kid who was being chased by a bunch of guys in black pajamas." A woman, who was born in a ghetto in 1939, gave birth and began to dream that her child was with her in the K-Z camps.

Grief and intimacy are the most anti-martial of sentiments. Basic combat training actively discourages them, while attempting to maximize fury and hate." Nor was it wise to display feeling in Nazi slave camps if one hoped to survive.

For both groups, certainly for combat survivors, the result is a guarded attitude toward showing and feeling emotion. Strict military bearing is the preferred mode at the funeral of a parent, not public mourning. Tenderness toward women and children is to be avoided. Warriors' women say "we just couldn't get close." Some add, "it frightened the baby to see him beating me." One veteran said "I wish 1 could learn to love as much as I learned to hate in Vietnam. And I sure hated, man. But love's a pretty heavy thing." Yet combat vets - survivors of so many "separations" - feel that even brief separations from their wives are excruciating.

Moving to the next block or to another state is quite stressful. Anxiety increases as do hyper-arousal, flashback, and security measures. Frequently, one is told something like: "you just don't know what to expect in the new locale. It makes you feel threatened, so you become threatening, just like you became in the Nam." Moving is one more case of uprooting, dislocating and transplanting.

International crises are likely to precipitate acute anxiety or withdrawal, a retreat to "mental foxholes." The 1975 helicopter evacuation from the top of the U.S. embassy in Saigon evoked flashbacks, among Holocaust survivors, of small, ancient rescue ships off the Rumanian coast in 1944. The 1982 Anglo- Argent ine Falklands war caused a rash of phone calls from Vietnam veterans. They were both frightened and fascinated.

On the other hand, both types of survivors have also acquired some new positive values. Many K-Z survivors value children highly, and in a concerned, not always over- protective, way. Many a Vietnam veteran feels a deep, though often unspoken, sense of comradeship with other veterans, in spite of the computerized nature of the war. They have also adopted the Vietnamese sense of being a part of nature and animal life. Seeds and apple cores are not rubbish, but are left where they drop to feed birds and other small animals.

DELAYED TRAUMATIC STRESS DISORDERS AFTER RE-ENTRY ("LATENCY")

Manmade stress, new styles of adaptation, perceptual dissonance, and a permanent change in self-definition all form the substrate for "delayed" traumatic stress disorders12 following the "symptom-free incubation period." Such disturbances may be neither transient nor reversible. The harrowing processes of adaptation to survival lead to the creation of the "new" personality which harbors predispositions to delayed stress disorder.

Long-term followups of World War II veterans?'10 survivors13'14 and Vietnam combat veterans12 all come to the same conclusion: perceptual dissonance may not become manifest as disorder until years or decades after the original stress. Is this due to "permanent psychological implants" whose damage is not apparent until they work their way to the surface like shrapnel?

However inadequate such concepts are, it is our responsibility to alleviate suffering. To do so, we must grasp the twofold context of the sufferer. First we must specify that the stress was due to "social" catastrophe, not "natural" disaster. This notion of manmade stress centers on the torn fabric of human trust. Secondly, the stress affects entire social or cultural groups whose members have shared monumental disruption of community - loss of communality.

In the presence of massive stress, pre-existing psychiatric disorder is irrelevant. The specific stress itself is the crucial predisposition and is generally predictive of the nature and degree of morbidity and symptoms.

The so-called "latent" period in manmade posttraumatic stress disorders is a time of chronic susceptibility. In contrast, natural disaster is usually followed by early acute emotional reactions and relatively rapid repair after rescue and rebuilding. There has been no human agency, no chronic threat and no coercion. Witness the rapid recovery of Darwin, Australia after its 1975 tidal wave. Once disorder emerges we can see that it comes from the blossoming of earlier adaptive traits into symptoms and the burgeoning of adaptive ways of life into syndromes. Time does not heal all wounds.

COMBAT VETERANS AND SURVIVORS IN PSYCHOTHERAPY

All too often, a military history is never taken from a veteran, nor is the story of his persecution obtained from the survivor.'5 Without this foundation it is not possible to talk of treatment or "cure." Therapy requires a multiaxial framework, with catastrophic life events as the defining axis, and symptoms and course as the other two axes.1" With this approach we will eventually hear stories of war and persecution, for veterans and survivors need to repair their torn fabric of faith in other human beings.

Victims and certain victimizers are two groups which are/ will be deeply connected.* Additional case reports illustrate cure. These demonstrate both the facts of manmade disaster and the need to excavate buried material.

CASE 1

HS, a survivor of the Warsaw Ghetto, came for treatment of suicidal depression. A physician, he was Chief of Pathology in a major Connecticut hospital. He had fallen afoul of the administrator, who wanted him dismissed. His terror was due to his conviction that he would be blackballed and that "no one in the state would want to touch him." Suicide seemed the only alternative to unemployment - a rather extreme solution.

Reluctantly, he spoke about life in the death factories, and selections between those who should live and those who should die." It became clear that his depression was based on the dread of becoming unemployable, a criterion for instant extermination in the death camps. When this was analyzed, his depression slowly lifted. He was soon in demand at three other hospitals, and was elected vice-president of the state society of pathologists. His other disturbances now fell into place.

For instance, he had loathed his son's college (one of the foremost in the East) since his first glimpse of it. He recognized that what had hit him were the railroad tracks nearby. They had precipitated an instant flashback, later repressed, to the rail lines which transported the Ghetto population to the "East."

In the Ghetto, the misperception that the hospital was a safe haven endured. His ill aunt was in the hospital. News came of an impending S.S. raid. The family immediately packed off the grandfather, two infant cousins and a baby brother to the hospital. Imagine their horror when the S.S. invaded the Ghetto, headed straight for the hospital, and slaughtered all the patients. For his first ten years in the U.S., this doctor insisted on working only in rundown "ghetto" hospitals.

After a survivors' rap group session, he had a recurrent nightmare. He was being observed in a performance, which would "have a bearing on his future." (Association: the observers were "like S.S. men making 'selections.'") His task was to re-assemble an old laboratory machine, but "he could never find the important missing parts." His "frantic search prevented an orderly performance." AU such dreams have ended in frustration.

Working in "ghetto" hospitals is not only an attempt at restitution. It is a "frantic search for a safe hiding place." He is hunting for the "missing parts," the relatives who vanished in the ghetto hospital. Without them, he cannot reconstitute the family machine. At work, however competent he may appear outwardly, inwardly he feels "very disorganized in the eyes of observers." Yet he manages to be a brilliant pathologist - at tremendous psychic cost.

CASE 2

Thirteen years after leaving Vietnam, John Brennan, a former medic, started experiencing flashbacks when friends and relatives began to get pregnant. Later, he would become anxious the day before visiting someone with children. Just before the visit, he would go into an acute anxiety attack, and his agitation would mount enroute. Once he saw that the children were intact and had all four limbs, a wave of relief would sweep over him. He counted the arms and legs of any child in the street, and would lean over the seat of a car to verify the presence of limbs that were hidden from view. Although he did not recall taking part in any atrocities, he insists that "my eyes must have seen what my hands have done."

Hyper-vigilance was second nature, so much so that he thought of dropping pre-med studies to "become a cop like many vets do." His muscles would jump at the sound of firecrackers, especially on Memorial Day. Eleven years after coming home, he insisted on taking a vacation in Northern Ireland, although he would have preferred Vietnam. This trip only strengthened his siege mentality and "en garde" poise. He said "I take a different route each time I come to your office just as I did in Belfast where I was avoiding both the posts of the Orangemen and the posts of the Catholics." He typed a detailed biographical sketch, in which the only references to Vietnam were two instances of relatives being hospitalized while he was there.

No evidence of atrocities against children ever emerged. The children were symbolic, literally ("the Vietnamese all looked like small kids") and figuratively ("kids are so vulnerable, such an easy target, that I have trouble keeping my violent impulses under control because I want to take action to protect the kids"). He found, as have other veterans, that the random violence of male toddlers was especially provoking: "they make me feel like hitting out indiscriminately. . .except at kids."

Following these insights, he began to sleep better, felt better about holding children, and stopped counting their arms and legs. When he found that he had a fertility problem, perhaps due to Agent Orange, he perceived this as "one more punishment" for taking part in the Vietnam War. Paradoxically, this increased his guilt feelings: he felt it was a "mark of Cain," confirming his criminality. "On my first day in Saigon, I saw hundreds of kids missing arms and legs. It was like a sock in the stomach. I knew I shouldn't be there." Despite this, he achieved a deep feeling of acceptance and support in an analytic group.

Flashbacks decreased in frequency, intensity, and length. When he knew he would be leaving for medical school in the Midwest, and would be without a group or therapist for a while, he feared that flashbacks might return in full force. An attempt to control flashbacks through hypnosis failed, even though he was very hypnotizable and had learned to master certain anxieties through self-hypnosis. We found that he missed his flashbacks, and wanted to keep them'. "During a flashback, the feelings are pure hell, but they give me relief afterward." Perhaps, repetition of the massive psychic trauma permitted some "working through," as is the case with more circumscribed, acutely stressful events. We concluded that "progress could not be pushed" and arranged for him to visit an "Operation Outreach"* center on a preliminary trip to his new state.

TREATMENT - A CULTURAL PROCESS

Former counter-guerrilla warriors should be approached as "combat survivors." As with other survivors, "the talking cure" involves repeated retelling and remembering of every aspect of the cataclysm, to someone who truly listens. However, talk is not enough. Gathering together the remnants that are left is the other facet of cure. To mend the broken ties, mutual support systems, composed of peers, restructure or build anew social equivalents of ruined cultural or military groups. A Vietnam Veterans Against the War( VV AW)** rapgroup, the June 198 1 meeting of survivors in Jerusalem, and the American Legion, can each serve as recreations of the shattered symbiotic units. These can originate social and political action on their own behalf, and play a part in determining their future.

Both facets of this cultural treatment process combine to relieve the shame and guilt feelings of being alive when others have died, as well as the "impacted grief.12

A veteran's fear of unpredictable and uncontrollable rage and violence can be "stepped down" in small increments. As a rule, in fantasy, he sees no middle ground between withdrawal and physical violence. In session, he is asked to add an additional alternative between these two extremes, eg, hitting a wall or a punching bag, imagining hitting a wall, etc. This "basic training in reverse" is quite effective, and can be carried over into daily life.

As for duration of treatment, it took the pathologist two years to learn the meaning of the college railroad tracks and four years for John Brennan to realize that he was returning to Vietnam via Northern Ireland. Many veterans and survivors suffer privately, reluctant to communicate their pain. Perhaps only poets and writers can speak for them.

A patient used to his illness... a sick person subject to acute crises that. . .may seize him at any moment, lives prudently, walks gingerly . . . ready to withdraw into himself. . . The pain is there somewhere; he doesn't know how it will pounce on him. and so he's ... on his guard, feeling his way... hoping to cheat fate."17

Memory is the enemy now,

Again and again his first wife dies

In his second wife's embrace.

The chase is still on.

He hides behind the busyness of days

And is captured each night

When the enemy moves on with

The slippery ease of dreams.18

The unendingness of persecution, the unexpectedness of ambush, equipped their survivors with another system for interpreting reality, a frame of reference which does not fit everyday psychosocial frameworks - a system in close touch with dark timeless depths. The slightest echo from that encapsulated past - a helicopter on TV or Nazi emblems - can easily explode into Tet 1968 or Auschwitz 1944, where there is no present, no past and no future.

Yesterday's tragedy - be it booby-trap or death factory - is today's inner oppression, "a catastrophe that occurred yesterday and cannot be ruled out for tomorrow,"2 a fear that, but for historical accident, may afflict any of us. Trust in the human world must be rebuilt each day and may be lost each day. Each day, these people fear that their essential sense of identity is threatened. They are not deranged, and were not deranged, but rather the disorders which may engulf them exist as historical events. These events were on TV as they occurred. But, for many ex-soldiers seen on TV, "the awareness of catastrophe . . . remains the dominant force of (their) existence."2 Recently, several World War II and Korean War veterans have contacted me, hoping to find an outreach program or a rap group to help them cope with continuing or delayed symptoms from their wars.

Concentration camp survivors, however badly off, have fared better than Vietnam combat veterans due to the early support of the United Nations Relief and Rehabilitation Administration (UNRRA), German reparations, the support of world Jewry, and the support of Israel. The hostages who recently returned from Iran, and their families, were treated along lines similar to those adopted in 1970 in the volunteer "rap group" program and recommended long ago to the VA, Congress and the Pentagon. They are now being adopted in "Operation Outreach."

Data from the VA hospital system on the high suicide rate among Vietnam veterans and data from penal systems on the high percentage of Vietnam veterans in jail, are only the most ominous yardsticks. They impose upon us the need to recognize and define combat survivors appropriately so that we may intervene responsibly.

To some, they may appear unfit - physically, psychically, socially. But perhaps they are better able to recognize the inner and outer dimensions of true reality. We dare not turn away from them and their unique knowledge. Otherwise, tomorrow we may walk in their footsteps.

REFERENCES

1. Lindy JD. Grace. Green: Am J Orthopsychiatry 1981; 51:468-478.

2. Amery J; On the necessity and impossibility of being a Jew. New German Critique Spring-Summer 1980, pp 15-29.

3. Kardiner A: The Traumatic Neuroses of War. Psychosomatic Medical Monograph. New York. Paul Hoeber, 1941,

4. Grant JCB: Introduction. A Method of Anatomy. Philadelphia. WB Saunders Co. 1946.

5. Jaynes J: The Origin of Consciousness in the Breakdown of the Bicameral Mind. Boston. Houghton Mifflin Co, 1976.

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ACKNOWLEDGMENT

The author wishes to express deep appreciation to Ms. Tornar Levine for her editorial assistance.

10.3928/0048-5713-19821101-12

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