Therapy for PTSD: Whose Search for Meaning? (Part I)
David S. Harrington, LCSW, Washington, DC
Therapists acquainted with the Vietnam veteran and his or her loved ones, know that, while difficult and challenging, clinical work with these veterans can be as enriching and rewarding as any available. That is because, as a group, we, Vietnam veterans, have been touched deeply on emotional, social, political and moral levels by the seminal issues of our times: Vietnam, trauma, stress, feminism, civil and human rights. Each of us has had to question ourselves in a profound way about these issues; and, while our conclusions differ, you will learn a great deal from each of us.
Let me share a personal experience. In 1988, my friend, Emanuel Heard, received his master's degree in Human Services. His wife, Blanche, two stepchildren, and their daughter were there as were my wife, Lucy, and myself. My four stepchildren, nearly grown, were unable to attend but sent Emanuel their best. While unremarkable, perhaps, the components of a healthy therapeutic outcome were present at that graduation. Emanuel is a black veteran who spent many years incarcerated for crimes committed while rageful against America after Vietnam; I am a white veteran who submerged his own feelings while doing social work with others. We met, while Emanuel was still incarcerated, back in 1981. We struggled to understand each other and how our separate searches for meaning had taken us through such varied and difficult paths. Emanuel's progress moved him quickly from client to friend and now colleague. To be sure, because we both struggled with relationships early on, we can acknowledge the important roles Lucy and Blanche and our blended families have played in our ongoing healing from the war.
Our group at the graduation ceremony at Lincoln University represented that therapy with veterans can draw on the truth of the trauma and renew in the Vietnam veteran strength to persevere through adversity, the hope for ourselves and our children and the commitment to make our corner of the world a little better from what we learned as a result of the Vietnam war. This process of healing is one which many Vietnam veterans have also begun or wish to undertake. Hopefully, as clinicians, you will find, reach out and relate to Vietnam veterans and their loved ones. You will grow from the experience.
Who Needs Our Care and Concern?
As a columnist for Vietnam Veterans of America's monthly publication, The Veteran, I have been in the privileged position of hearing directly from Vietnam veterans and their families. Let me share their letters with you.
"Phoenix" Veterans Rising from the Ashes
Wives write often:
For mental health professionals, the needs and concerns of Vietnam veterans are challenging and varied. A short list of issues from these few letters includes:
It is not surprising that many therapists avoid treating Vietnam veterans: none of these issues alone is easy; the composite can be overwhelming. For those therapists willing to rise to the therapeutic challenge, let us reflect on a few assumptions about ourselves as therapists we, too often, bring to our clinical interventions with Vietnam veterans.
Therapists' Assumptions About Vietnam Veterans and Their Loved Ones
Assumption Number One: Trauma is an intellectual concept understood generally by therapists
Have we defined the trauma that was Vietnam? I don't think so. A recent article on the literature of the Holocaust in the New Republic closes with this paragraph:
We are mistaken if we think that the trauma that was the Vietnam war has been explained or understood. Moral culpability for the war has not yet been assigned according to role or responsibility. Tell me of the horrors of two-and-one-half million Vietnamese dead, of the bombs, of Agent Orange and of the ten million refugees we created before 1974. Please let me know why more Americans are informed about the evils of communism and the boat people since 1975 than are informed about the evils of French colonialism and American involvement from 1856-1974?
As therapists we need to understand the trauma in order to treat it. We must ask ourselves, what was the Vietnam war? If we accept responsibility for seeking an answer, then we begin to understand the burden of the Vietnam veteran. At the same time, the inquiry into the Vietnam war as trauma must no be so difficult that it stifles us into silence. Let us recognize that current efforts to popularize the war in Time-Life books or popular videotapes are insufficient to any veteran's search for meaning. Let us proceed with all due haste, tempered by a deep humility, toward an understanding of the Vietnam war as trauma?
Assumption Number Two: Societal context does not matter.
Can the victim of trauma find meaning in a society that denies suffering and death? What is the goal of therapy with Vietnam veterans? We must address the ambivalence of our patients to life in a society that exaggerates the joys of material consumption and ignores the cost of our excesses here and abroad. Too many Vietnam veterans have already offered themselves as undeniable evidence of life's harsher realities through suicide, homelessness, drug and alcohol abuse.
Many more Vietnam veterans will continue to struggle with survival unless and until they see a way to live in America. As therapists, we must ask ourselves whether America today is responsive to those who are suffering? And if not, what is our role in stripping society of its blinders? One friend describes that responsibility as speaking truth to power.
Assumption Number Three: PTSD is sound clinical terminology.
Is PTSD viable terminology? Post-traumatic stress disorder, as a term, serves the mental health community far better than our clients. Why? Because we do not name the incident. The trauma becomes `generic,' is less significant. Our role in it becomes value neutral. We do not have to account for our own feelings about trauma. Nor do we have to accept any responsibility for its aftermath.
Let me elaborate. Was it therapists who called attention to rape as a trauma or was it the woman's movement? For torture, was it therapists or Amnesty International? For Vietnam, who will take responsibility? So far, we therapists have yet to come forward. Yet, if we are to treat veterans of Vietnam, how is it that we acknowledge their trauma? If we were not in Vietnam, where were we? How do we feel about Vietnam and its veterans? And, what are we doing about our feelings?
Assumption Number Four: The therapeutic community has established a clinical direction for the treatment of PTSD.
Is there an established direction for inquiry into the PTSD in Vietnam veterans? Right now, our search for understanding of PTSD in Vietnam veterans is a muddle. Therapists offer multiple definitions and a veritable menu of therapies. Let's be clear--this definitional confusion has its price. It seems to me that there is an arrogance born of power in all of the probing into veteran's psyches. Many therapists seek catharsis when it may not be part of the solution. The sacred secrets of a Vietnam veterans soul are violated in the prideful name of "therapeutic technique." If this sounds harsh, we must explain the rising interest in "fictitious PTSD!"
As mental health professionals, we must abrogate prerogative and have the humility to acknowledge the limitations of our clinical understanding and our influence on the morality of this society. If we have that humility, I dare say we will reestablish the truth: With PTSD in Vietnam veterans, the constraints on healing are many and the solutions few.
Assumption Number Five: The course of treatment for PTSD is without paradox.
How can we overlook the dilemma: What's harder? Being disenfranchised in America or a soldier in Vietnam?
Hispanic veterans are good examples. I am reminded of the story of the young psychology intern at the Brentwood VA Hospital in Los Angeles who, when interviewing a Mexican-American Vietnam veteran, inquired whether he had flashbacks. "Oh yes," replied the veteran, "I had my first after only two weeks in Vietnam." Noticing the incredulous look on the intern's face, the veteran went on. "We were on patrol in the A Shau Valley when all of a sudden, the setting, the whole place, brought back the time when, as an eleven-year-old, I was working fourteen hour days in the fields of the Central Valley!" You can substitute the Puerto Rican Marine who fought in Hue City and had flashbacks of the South Bronx. In either case, the point is that, for Hispanic Vietnam veterans, survival was not only a childhood experience but an adult fact of life.
There are at least two other paradoxes in the way of any understanding of the Vietnam veteran: Vietnam and coming home. In Vietnam, many veterans had more in common than in conflict with the Vietnamese people. At the same time, many veterans had volunteered for overseas duty for patriotic reasons; and most were well-grounded in the moral principles of Christianity. What questions, unique to their working-class experience, arose in Vietnam for these veterans?
What was it like returning home? These veterans had a clearer sense of all the differences in America and with the Third World. Did they still have hope for their future? Their families and communities were most often very proud of their military service. Were the veterans themselves proud? And when it came time to move on in their lives, how did their families and communities respond to any reluctance to move ahead?
The Cost of Therapists' Denial
First, what is the basis for the change of the Vietnam veteran from pariah to patient? As a social outcast, the Vietnam veteran served America as the "whipping boy" of societal blame for the havoc of Vietnam. Now, as patient, he serves America as a repository for guilt and an object of denial for the larger crimes against the Vietnamese people. In neither case has the therapeutic community altered the course of societal interpretation, i.e., in the pariah days, we were into crisis intervention with sirens and radios; and in today's patient era, we poke and probe with jargon and white coats.
In the particular case of Vietnam veterans, the second question is, "What's new?" For so many years, therapists have been complicit in the denial of America's mistreatment of Vietnam veterans. Whether in hospitals, community clinics or local social service agencies, we have for too long put a big band-aid on a terrible social injustice.
And the third question for us therapists is when do we acknowledge our social responsibility? Let me return to Hispanic veterans and their loved ones. Isn't it difficult to treat Hispanics and ignore the Reagan administration's policy of genocide in South and Central America and right here in the USA? In America, Hispanics are not merely the fastest growing ethnic group but also the fastest growing poor. Joblessness is nearly double that of Anglos and no solutions exist or are sought. As Hispanic families grow in urban areas, how will they resist the pressures of divorce, drug and alcohol abuse and worse without the advantages of jobs and income? How dishonest can our immigration laws be when they exploit Mexican labor on both sides of the border? And how can we deny sanctuary to victims of political upheaval in Central America?
Central and South America represent important frontiers we must cross if we are to treat the Hispanic veteran. In my view, a President who proclaimed he would teach a lesson to the dictator "in green fatigues" and designer glasses is totally insensitive to the Hispanic experience and naive to ex-President Ortega's strength of character. At age sixteen, Daniel Ortega organized Nicaraguan youth to oppose the takeover of small plots of land--including his father's--by large landowners. For this organizing work, he was jailed and tortured by the Somoza National Guard for five years. After his release, he spent ten years in the hills before final victory in 1979. Ronald Reagan was making war movies while millions of Americans were fighting Hitler; Ortega accepted the responsibility for doing something about the horror of the Somoza regime.
When President Reagan threatened the Nicaraguans with the seventh U.S. invasion in this century, did we realize that large numbers of any U.S. force will be Hispanic? That our Hispanic youth would have been used to kill the Hispanic youth of Nicaragua? And did we face the fact that the situation in Central America was not about East-West relations, but about North-South dynamics? Did we admit that the hand of death in Central America--60,000 in El Salvador, 40,000 Indians in Guatemala, and 15,000 Nicaraguans in the contra war--is the American hand? Can we as therapists acknowledge the connections of all these factors to the treatment of Hispanic Vietnam veterans?
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