Intensified interest in the long-term reactions of Vietnam veterans was followed by and partly instrumental in the introduction of Post-Traumatic Stress Disorders into the latest edition of The Diagnostic and Statistical Manual of Mental Disorders. ' This interest also sparked renewed comparison of the pattern of reactions of Vietnam veterans to veterans of Australia, Israel and Afghanistan as well as to POWs, Iranian hostages and victims of rape, fire and a range of other catastrophes.
Clinicians are now more readily recognizing and attending to patterns of stress reactions and rediscovering observations noted at the turn of the century by Janet/ Freud and, thereafter, Lindeman,5 Adler6 and others. Insights into survival guilt, the death imprint and psychic numbing - reactions generated in survivors and clinical observers as well - have enabled clinicians to better understand and develop ameliorating interventions. The rap groups fostered by Shatan,7 Lifton,8 and Pincus, dream groups designed by Wilmer,9'10 guided imagery and behavioral interventions adapted by Keane,11 hypnotic techniques12 and family systems interventions,13 have all enabled victims with powerfully troubling and alienating experience to reach some more peaceful resolution. As clinicians increasingly recognize posttraumatic stress reactions, they are readily recognizing the central symptom patterns and are making attributions about the underlying issues to be resolved in therapy.
Survival guilt has now become commonly accepted and is widely held to be a major factor in reactions following such events as the concrete walkway collapse at the Hyatt Hotel in Kansas City.14 After the event, clinicians readily began to help people deal with their guilt over having survived while others did not. Survival guilt does not explain, however, why equally severe traumatic stress reactions are generated in emergency medical personnel who treat victims of such disasters. It is often commonly assumed that rescue workers and bystanders are simply overwhelmed by the gruesome and horrible sights which they witness.
With some validity, it is recognized that in most disasters, the more deadly and grisly the event, the greater will be the reactions of the normal witness or survivor. Studies of veterans and other survivors15"17 consistently support the common observation that the level of exposure and the intensity of catastrophic experience are the best predictors of the intensity of symptoms of stress reaction. Such field studies have consistently affirmed the finding that stress reactions are precipitated in roughly half the victims of intensely traumatic experience. Many factors have been advanced and explored as contributing to the intensity of reactions.16'"* None of these factors have yet been found, however, to have the predictive power of the intensity and level of exposure to the catastrophic experience itself.
The powerful and often wrenching reactions of clinicians as they begin to listen to the tales of survivors have been explored previously.19'20 Such reactions in clinicians confirm our common assumption that witnessing such horrible deeds and deaths leave extreme residual traumatic effects. These clinical observations have proved to be valuable tools for understanding and treating such reactions. But, the popularization of the notion of survival guilt and the common assumptions about the impact of witnessing deadly catastrophes may obscure recognition of another factor with a potentially more devastating impact on survivors, participants and witnesses. A focus on the intensity and inherent traumatic quality of the events also subtly encourages clinicians to grade the quality of the traumatic event and the reactions U should generate.21 This focus may encourage clinicians to underestimate traumatic stress reactions in other survivors, participants and witnesses whose catastrophic experience is assumed to be considerably less objectively traumatic than others.
In such cases, a lack of survival guilt and the implicit devaluing of apparently lesser traumatic events contribute to the emphasis, too early and too heavily, on character disorder and predisposition, which, for many years, has obscured the recognition of long term stress reactions. A subtle interaction of all of these factors has clouded recognition of this element in stress reactions (JR Smith, unpublished data, 1981). Attention to a further aspect of catastrophic experience may open an avenue for better understanding the relationship between reactions to normal life stresses and reactions to catastrophe.
Increased clinical experience has led me to focus on the role of personal action and responsibility in catastrophic reactions. This may take the form of perceived personal responsibility for individual actions or for failures to act in the midst of catastrophic conditions, leading to tragic and often deadly consequences. Such a factor of personal responsibility interacts in an exponential fashion with the moral and ethical questions of meaning described so well by other writers.22"26
The following case examples illustrate this factor. The first case was related to me by Dr. William Neiderland in a conversation following a New York seminar on the concentration camp syndrome at The New School in April 1976. At the time, while working on the stress disorders proposal for DSM-III, I had been grappling with the paradox over how the victims of a catastrophic experience, such as the concentration camps, could manifest nearly identical reactions as those reactions seen in more active perpetrators of another disaster, such as the veterans of the American war in Vietnam. It was this case, related by Dr. Neiderland, which first drew my attention to the role of personal action.
X, a concentration camp survivor, had been involved for some time in psychotherapy. One day he came to his session with a painting he had recently completed which he gave to the therapist. The painting portrayed a grotesque, demonic figure in a Nazi stòrmtrooper uniform. Something about the painting disturbed the therapist but it was not until a few days later, when glancing at the painting again, that he realized that the face in the painting belonged to the client. At the next session, the therapist shared his observation with the client. At first, baffled and denying the similarity, X suddenly broke down and began sobbing. X then revealed that, during his imprisonment in the concentration camp, six inmates had escaped one night. Following the escape, as was their policy, the guards selected double the number to be executed as an example to the rest. The following morning, X and the other eleven prisoners slated to die, were marched off in the early morning fog to be shot. As the column of inmates passed the long, open slit trench used by the inmates as a latrine, X slipped out of the column and buried himself in the latrine. After many hours covered in excrement, X found his way back to his compound. There, he discovered that two other companions had been selected and executed in his place.
What struck me about this case was the later evidence of overwhelming personal guilt and unconscious selfpunishment which X had carried for so many years, unmitigated in his mind by the circumstances which might have prompted his action for survival.
Lifton19'24 has described survival guilt as guilt over having survived while others perished. In my experience, such guilt is far more powerful when one's survival is bought at the price of another's life.
Billy N. joined the Marines with his best friend from high school. They served in the same combat unit in Vietnam. One day, while crossing a swollen stream, the rifles over their heads, Billy was in danger of being swept away. His buddy, who had reached the opposite bank, stretched out a hand to help Billy. Billy handed his rifle, muzzle forward, to his buddy and while being hauled from the water, his hand slipped, releasing the trigger, killing his buddy with a round through the chest. Later, back home, Billy first sought treatment because of his wife's complaints about the length of time it took for Billy to drive to and from work, only two towns away. Billy explained that he vaguely always wanted to avoid the town next door where he had grown up; so, he drove an elaborate thirty mile route around it, to and from work. Under questioning, he suddenly remembered that his buddy was buried in a cemetery along the route he would normally have driven to work. Later, after considerable work in therapy, Billy drove to the cemetery, sat in front of his buddy's grave, and, in a lengthy conversation with his long dead friend, asked him for forgiveness.
Even when the personal action leading to dreadful consequences seems to be offset by evidence of dozens of successful, even heroic, actions, the impact of the tragic one appears to distort evaluation of the others.
K was a 33-year-old former Marine who was among the first American Marines in Vietnam. After several ambushes and intense battles which marked the first weeks after his arrival, K found himself trusted and relied upon as the point man because of his childhood, backwoods experience in the South. On several occasions, his instincts and sudden caution had saved the platoon from ambushes and booby traps. K, a scrappy and somewhat delinquent kid in school, relished the trust and responsibility relegated to him for the first time in his life. Later in his tour, while leading his platoon on patrol along the railroad tracks near Chu Lai, K noticed cowchips from water buffalo arranged in a regular pattern between the tracks. Immediately questioning such regularity, which was not his experience with cows at home, he suspected that the cowchips might conceal booby-traps. Halting the platoon, he fanned the men out along either side of the roadbed to avoid the possibility of detonating the booby-traps. Unfortunately, as the platoon passed alongside that section of track, a watching North Vietnamese soldier plunged a handmade, remote detonator, exploding a series of mines buried under the cowchips. The explosions immediately killed several of the platoon and wounded several others, including K, ripping the legs off of some men, including an especially beloved black lieutenant.
For 16 years, since that incident, K has avoided recollections of that event only to see them emerge in nightmares and daytime flashbacks. Characteristically, his avoidance of that event and its implications for him have been accompanied by the use of alcohol and drugs, emotional numbness, somatic difficulties and social alienation.
Nor is it always action that is the source of the intrusive thoughts. Failure to act may also precipitate later reactions.
Bobby, another former Marine, first came to my attention because of legal difficulties. It was alleged that he had beaten his wife during sexual activities. During the initial interview, Bobby insisted that, while he had indeed hit his wife, the more common occurrence was that she often beat him in the course of sexual intimacy. When Bobby was. asked if he needed to be punished, he replied, "Yes." When asked why, he answered, "Because of Vietnam." When asked if there was a specific incident, Bobby, becoming agitated, spoke of an incident involving a captured female North Vietnamese nurse. Bobby was serving as an advisor to a South Vietnamese Army unit when the prisoner was turned over to them. Bobby stood by while she was raped, tortured, and sodomized, then masturbated, defecated and urinated on. Bobby felt unable to reconcile his failure to act on the impulse to stop the behavior and indicated a secret conflicting impulse to join in.
Conflicting impulses are often at the core of a traumatic episode buried for years.
RD is a 39-year-old former Navy Medical Corpsman. After one tour in Vietnam with the Marines, he was released from active duty into the Reserves and returned to his home town of Baltimore. Due to a shortage of trained corpsmen, he was recalled to active duty where he saw intense action during the Tet offensive in 1968.
Out on an operation five days before the end of this second tour, the corpsman's unit got caught in an ambush. Panicked at all the previous close calls he had survived, he hid behind a rock while hearing the cries for "corpsman." For ten years after his discharge, he was haunted by his act of "cowardice." While never speaking of the experience, he nonetheless spent ten years as a veteran counselor rescuing other veterans in bars and flop houses and creating forums for them to talk. R D's deeplyheld belief that corpsmen and medics risk all for the wounded allowed no room for his conflicting impulse to protect his own life. His belief was bolstered by the high esteem and respect accorded corpsmen and medics for precisely that selflessness.
Quite often, when there is not an initial working through and resolution of traumatic experience, the return to normal functioning forces the working through of the traumatic action to take place at the subconscious level. Thus, in many survivors, the playing out of the traumatic action often takes the form of very concrete undoing, as in the above case. In another case, the clinician may see a veteran who flew aircraft spraying chemical defoliant in Vietnam who denies that the war had any impact on his life, but now works as a chemical safety officer for a major chemical firm. Subconscious undoing of the past "fault," frequently by being intensely involved in directly helping victims similar to those in Vietnam, is a common and effective pattern in medics, corpsmen, doctors, nurses and chaplains for avoiding conscious confrontation with one's own wartime actions. This pattern is especially dramatic in former combat nurses who not only persist in heaUng roles but often find themselves continuing to function in crisis and emergency situations, where the circumstances of their current positions play out concretely the stresses of their own traumatic war experience. These helping professionals will often devote large amounts of time to counseling others even in groups where they are ostensibly members seeking help. Frequently, only a dramatic episode will trigger the recognition that they also have personal experience which needs to be explored.
M, a Boston nurse who had served in Vietnam, described her current difficulties in a recent interview. She was haunted by troubling thoughts of Vietnam and described her inability to stay in bed at night without the light on. Since her return, she indicated that not a week had gone by without recurrent thoughts about the decisions she had made in Vietnam. She gave the example of one night, when, with a short-handed unit, she became the triage officer whose duty it was to assess the gravity of injuries and then select, given the limited treatment resources, those soldiers with salvageable wounds who would receive treatment, leaving those soldiers too severely wounded to die. As ostensibly neutral non-combatants, despite their vigorous objections, the medical staff was required to treat both Americans and any wounded North Vietnamese prisoners. Torn over an oath to care for all the injured, she followed common practice and selected Americans with even minor injury for treatment while leaving North Vietnamese prisoners, with severe but treatable injuries, to die.
Despite objections, American and North Vietnamese patients were often placed on the same ward. The nursing staff. loyal to their American charges, were often reluctant to care for the Vietnamese. One evening, M volunteered to change dressings on a severely burned Vietnamese for whom no one else would care. As she was changing his bandages and cleaning the wounds, the prisoner suddenly grabbed a pair of scissors and lunged at her. Narrowly escaping, she called for a pair of military guards to "take care of him. The military guards quickly hustled him off the ward. A short while later, they returned to assure her that he would no longer bother her and that he had been taken care of. She has a recurrent nightmare about this incident.
Because of a recent flashback experience she no longer carries scissors. On this particular day in the operating room, a fellow nurse announced that she was reaching into the pocket of M's uniform for a pair of scissors. As the nurse did so. M panicked, turned and struck the other nurse.
Until her interview, she had never spoken with anyone about the earlier incident. Though highly regarded by her peers, she feels ashamed and inadequate about her performance as a nurse in Vietnam. Afraid to look into the future, she refuses to look at the past, feeling that if she did. she would start crying and never stop.
Blank2 has noted that such personal traumatic episodes, repressed and unexamined for years, yet still powerfully charged affectively, may result later in an unconscious re-enactment of the episode in vivid concrete detail. Such later recapitulations and undoing of the past personal action in a traumatic incident may be the key to recapturing an integrity which opens a channel to recovery.
T was a 26-year-old former Army infantryman who begged to be permitted to join an ongoing rap group. At his first session, he poured out a terrible tale. T, the squad leader, had stopped the squad's armoured personnel carrier ( APC ) while they broke for lunch. While T and the others ate outside. T had the radioman stay inside the vehicle at the radio. Suddenly, the squad came under attack and the APC was hit with an RPG - rocket powered grenade. T dashed to rescue the radioman but was unable to pry open the door, warped shut by the heat. T was now agonizing in the group over the terrible screams of the dying radioman and his impotence in doing something about it.
In the following weeks, the group learned that T was under pressure at the advertising agency where he worked as a production manager. T was dragging his feet on getting out an airline's ad on their jet fleet. In discussions with the group, it emerged that the entire jet fleet of this airline was composed of a type of plane which had, in the past few years, been involved in a series of crashes resulting from a faulty latch on a cargo door, thereby killing several hundred people. T was unsure whether the expensive modifications recommended by the airplane's manufacturer had been performed on this airline's fleet. The group helped T to finally realize that his reluctance to participate in an ad campaign which might induce people to ride in a potentially unsafe aircraft might be connected to the incident in Vietnam. The group then helped T find a course of action which, with a minimum of confrontation, would lead to the assurance that the modifications had been performed.
While in T's case, exploration of the current situation and of a past action of perceived responsibility led to significant improvement in the quality of T's life, long years of denial can result in serious pathology.
LR was a thirty-three year old former Marine. At the time of interview, he was hospitalized with his forty second admission in a large east coast VA psychiatric facility. The staff suspected a case of multiple personality since LR referred to himself as Karl and frequently spoke in German on the ward. He had been a particularly troublesome, aggravating and intractable patient, disruptive on the ward and often signing himself out abruptly only to end up at another VA facility somewhere across the country to then be transferred back to the hospital. The staff knew little about LR's military history except that he had been in Vietnam and had read the book. The Spy Who Came In From The Cold, on the plane on his way over to Vietnam. During the interview with a consulting psychologist, it was revealed that LR had been a forward observer tasked with calling in artillery fire on enemy positions. After the interview, the consultant read the book. The Spy, and realized that the central character was responsible for an ally's fleeing across the no man's land at the Berlin Wall where he was shot. The consultant suggested to the ward staff that LR be placed in a rap group where the possibility be explored that LR might have called in artillery fire on some of his own troops. Fourteen months later, LR broke down in the rap group and revealed that he had mistakenly misdirected artillery fire on an American unit killing and wounding ninety men.
Not all traumas connected to a war or catastrophe happen just to the participants. Lesser trau mas can have a great impact even far from the front, and will be connected only later when the participant realizes the import of his actions.
P was a black Army officer in charge of returnees from Vietnam reassigned to Germany. He was responsible for mustering out, with administrative discharges, those Vietnam veterans with poor attitudes who failed to adapt to the regimentation and boredom of non-combat garrison life by using drugs, talking back or having general "bad attitudes." After his release from the service, even with his excellent education and record, P found himself unable to "get his life together" until he "happened" to find a job where he counseled veterans with less than honorable discharges and helped them to upgrade those discharges and get a fresh start. Though P repeatedly remarked on how satisfying and meaningful he found his work for the first time, it was some time before he recognized the connection to his military experience.
Another example of a minor earlier decision having later impact is illustrated in the demonstration videotape of a sodium amytal interview by Dr. Lawrence KoIb.28 X, a black Vietnam veteran is sedated with amytal. At first quiet, he becomes agitated, enraged and tearful as a painful memory of a Vietnam attack is triggered by the playing of a tape of combat sounds. X recounts how a hometown buddy died in his arms after being hit in the attack. Under questioning by Dr. KoIb while crying and angry, X repeats his blame for the death because the admiring buddy followed him into the service despite X's protests.
Having made the observation of the apparent role of personal action and responsibility in war and other major catastrophes, I have come to see it frequently in other situations. I suspect that the consequences of personal choice and action may be part of the reason why we see stress reactions among rescue workers and emergency medical technicians. As these workers race to the aid of victims, as in the Hyatt Regency walkway collapse in Kansas City (1 98 1), these rescue workers make choices about whom to treat first or about moving a steel beam which, in retrospect, may have had tragic consequences for another victim. In a similar way, victims themselves make choices. After grabbing the hand of a spouse and dashing to the left, where a beam collapses on that spouse, the victim will often agonize over wishing he had made the choice to go to the right instead. Furthermore, victims may distort the blame so that they appear to hold themselves more responsible for the death than the accident itself.
In some cases, a distorted notion of personal responsibility may sometimes lead rape victims to blame themselves in a caricature of the old myth of "asking for it."
MP, a 26-year-old Mid westerner, worked for an antipoverty agency in Tucson. Returning home from work one evening, she was walking the dimly lit streets between the bus stop and her home. Tired from a long day, she neglected to cross to the other side of the street, as she normally did, when she saw a strange man approaching as she passed by a wooded area. When the man grabbed and attacked her, she found herself screaming internally but was stunned to realize that no words came from her mouth. Though she finally managed to wiggle free and escape in terror, four years later she appears to blame and in subtle ways punish herself for the incident, with greater focus on her role than on the rapist's role.
In many victims of catastrophe, the assertion of personal responsibility is an attempt to overcome overwhelming feelings of powerlessness and helplessness in the face of the disaster. Such assertions of responsibility and control, while serving positive ends, may also contain seeds of future turmoil.
Distorted perceptions of responsibility can haunt even families caught in a common traffic accident.
WS, a surgeon, had been away on one of his frequent professional trips. On his return, he wanted to relieve M, his wife, of the responsibility of watching over their four year old daughter, R, so he planned to spend time with R shopping at a local toy store. En route to the store, WS asked R which of the two popular toy stores she wanted to visit. R chose the further store because it had a greater selection of toys. As the two drove on, WS was reflecting on pressing issues about his work. The car in front stopped short to turn left without signaling and WS's car plowed into the rear, crushing the gas tank and bursting into flames. Despite partially crushing his own skull against the windshield, WS managed to unbuckle, grab his daughter and dash out the passenger side before both cars burned. The driver of the other car escaped but WS was left with head injuries and several cracked ribs. In the hospital, WS worked over his responsibility and what he could have done differently. Meanwhile, his wife was agonizing over the brief spat that they had just before the trip and her guilt over how relieved she had felt "to be rid of the two of them for a time.
R, appeared to be little affected by the accident, the sight of her father bleeding by the side of the road and the tension and bustle of the hospital emergency room. However, she later revealed, during a play session, how she was responsible for the accident. On questioning, she said she had been dreaming and thinking about the fact that if only she had chosen to go to the closer store, the accident would never have happened.
Even more ordinary events of everyday life may lead to rumination about personal responsibility and to the pattern of intrusive thought characteristic of stress reactions.
"I was very upset because, essentially, a guard (Indiana's Isiah Thomas) beat us and that's my position," UNC guard Jimmy Black said of the Tar Heels* championship game loss to Indiana last season. "I felt like I had let the team down and that's what probably bothered me the most. Then I realized it was a team effort and we can't put the blame on anyone.
"I know I couldn't sleep for about a week afterwards, thinking about what we could have done," Black added, "1 want to get my rest this year."
(Durham Morning Herald, March 25, 1982) In later interviews, Jimmy revealed that in the weeks following the basketball loss to Indiana, he had been obsessed by nightmares and daytime intrusive images of Isiah Thomas' various fakes and moves during which he had scored crucial baskets. Jimmy was haunted by selfblame until chats with his teammates convinced him that the team and coaches together bore responsibility rather than he alone.
Another well-known dramatization of the troubling sequelae to perceived personal responsibility for tragedy is the recent book and film Ordinary People.29 The resolution of the son's traumatic stress reaction comes only when, triggered by news of a friend's death, he experiences a flashback and then he and his therapist face his self-blame. Beyond the grief for the loss, he has blamed and punished himself for the drowning even though it was the older brother who let go of their hands clasped across the hull of their capsized boat.
Too great an emphasis on the survival aspects of catastrophic experience may obscure the actions and choices involved in survival. A focus simply on the intensity of stress invariably leads to a grading and evaluation of catastrophic experience which also obscures the painful consequences of action and the subtle choices made under such stressful conditions. While the severity and intensity of stress may be the best predictor of the symptoms of stress reaction, more powerful, longer lasting stresses may just provide more occasion and opportunity for the types of painful choices illustrated in the cases above.
Such expectations about survival and severity of stress and its reactions also contribute to a falsification of experience on the part of the victim. Victims will sometimes fabricate or distort their traumatic experience in order to bring it into line with expectations of the type of stressful encounter which will generate the sympathy and empathetic response they desire.
Consider the following example.
W is a German, Jewish psychologist from the Southwest. During WWII, she spent her early adolescence fleeing and hiding from Nazi persecutors who had shipped her parents to a concentration camp in Poland. Still at large at the end of the war, she found her way to the U.S. with a group of other orphaned Jewish children. Later, when she learned that her parents had survived, W found herself the only one among her peers who had surviving parents. Consumed and confused by the years of panic and trauma, she nonetheless felt guilty and petty about her experience next to her peers who had lost their entire families. Judging her own trauma to be negligible, but jealous of the warmth and care tendered to her orphaned peers, she distorted and exaggerated her own haunted experience to gain the equality of suffering she needed for that sympathy. Only later did she realize the extent to which that compromise had rendered the sympathy counterfeit, when she found herself repeatedly obsessed with tracking the authenticity of the tales of her combat veteran clients.
The extent of the personal blame victims accord themselves and the quality of the moral judgments they pass on their actions influence the course of the recovery process they will follow far more than the objective severity of the stress which individuals undergo. Unexpressed expectations of the judgments others will make (often confirming their own secret and lacerating evaluations) frequently render unexplained and powerful incidents subconscious, emerging only obliquely to wreak havoc with their current lives. Awareness of and openness to exploration of this theme of personal responsibility in traumatic stress may further the resolution of catastrophic reactions as well as open a path of intersection with the mechanisms underlying intense reactions to more common life stresses.
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