Personal Responsibility in
Traumatic Stress Reactions (excerpt)

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NAM VET Newsletter, Page 20, Volume 3, Number 6,  June 10, 1989
By John Russell Smith, Reprinted from PSYCHIATRIC ANNALS 12(11):1021-1030, 1982.

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 healing 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 asses 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 refused to look at the past, feeling that if she did, she would start crying and never stop.

Blank <27> 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.

27 Blank AS Jr: The unconscious flashback to the war in Vietnam veterans: Clinical mystery, legal defense, and community  problem. AM J PSYCHIATRY, to be published.

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