Initially, the veterans I work with deny any traumatic symptoms, even though they relate some extremely traumatic events in telling their story. I believe this is because of the numbing detachment they learned that was necessary to survive the war. Therefore, it takes a great deal of time before the therapist can explore the deeper meanings attached to the trauma story: losing the world, spiritual loss, moral pain, killing, and death. In addition, expression of feelings such as anger, fear, and profound sadness takes considerable time to surface and work through in the therapy.
It is important for the clinician to distinguish between vets who are bound tenaciously to the trauma story, almost addicted to it, those "who lie at the bottom," (LB Vets) and those vets who have invested "everything we have" in trying to bury the trauma story and stay "on top of it" (OT Vets). Although both clinical subtypes are detached and fearful of profound emptiness and overwhelming affect, use of imagery differs with each group. In addition, these individuals may medicate themselves with alcohol or marijuana for sleep, requiring either referral to an inpatient Chemical Dependency program or to Alcoholics Anonymous (AA) as an adjunct to outpatient therapy. Because of intrusive dreams, use of short-term, low dose antidepressants may be necessary to promote third stage sleep, or the patient may begin abusing substances again in order to sleep.
The therapeutic model most useful with Vietnam Veterans has been used with Adult Children of Alcoholics (ACA), and those patients who have been physically or sexually abused. I believe all these patients survived life in a combat zone. Therefore, the working phase of therapy with Vietnam veterans is about death and grieving.
Sharing death with someone is the most intimate experience I know. Work with Vietnam veterans is about death: the death of innocence, security, hope, joy, feeling, body parts, closest friends, promises, and the loss of faith in God and non-veterans. These vets are grappling with God at a primordial depth.
Grieving is the process of feeling and expressing the sadness, hurt and anger for the damaging experiences and losses of the past. Often, grieving represents feeling the loss of the fantasy that there is something anyone "out there" can do to "fix it" or "bring me back to the world." Grieving these losses is extremely painful. Many have to face the truth that they have been deprived of an entire period in their youth, often created by things learned in order to survive.
The therapist is often moved to try to comfort or ease the veteran's stress quickly and to prescribe activities designed to help the patient feel good. Although this may be useful for issues of self-esteem and depression, it is not effective to help the patient deal with real grief, that must occur in order to decrease the veterans psychic numbing. In such cases, the therapist's role is to acknowledge the reality of the feelings, and to be open and available while the patient allows the pain to surface. This can be terrifying for the patient and sometimes for the therapist. It is most useful to respect the patient's pace, at least initially. The therapist cannot expect to do this until she has identified her own losses, her own inner death, and addressed her own grieving concerning the Vietnam War.
With both clinical subtypes of Vietnam veterans, those who lie at the bottom (LB Vets), and those who are on top of it (OT Vets), I have found imagery of the Grave Yard, the Grave and its contents most healing. Those vets who have become the trauma story are lying at the bottom of the Grave already. Their task is to observe and encounter the contents of the Grave: what and with whom they have enclosed and entombed themselves, the buried feelings, Grave clothes and cherished relics they wish to preserve forever, and the Talismans they wish to take with them.
These vets must dialogue with the Dead and Walking Dead, as well as with those parts of themselves that they fear have died. These vets need to ask of their dead and of themselves, and perhaps most importantly of God, "Where were you...where are you?" and "What then must we do?" They will then need assistance as they try to stand up, look beyond the Grave, and begin to crawl out. Some Graves are very deep, with earthen walls which cause one to slip back; others are made of concrete, marble, rock, and any may demand special equipment: Special Forces, Marines, LURPS, Seals, Rangers, Airborne, demo experts, medics, or other miraculous heroes to assist in the resurrection. Vets and I have found resurrection hard work. The task is not over once the veteran has risen from the Grave. The next task is to fill the empty space that has been left in the Grave with new material. The vet must choose the material. This takes time and is often revealed in a dream.
At this stage, I usually establish some guidelines for the material, the filling. It must be honorable, kind, gentle, nurturing and compassionate material, for it will nourish and protect a very special part of themselves forever. A ritual then is planned to refill the space. Sometimes talismans, medals, pictures are brought in-not only for this ritual, but throughout the entire therapy. These are surrounded with golden light or an equally healing image elicited from the vet. It is left up to the vet to determine when the Grave is ready to be closed, and how this will be done. Sometimes there is a ritual funeral.
Most often the Grave will not be closed up until the patient has chosen to leave the graveyard, decided on a monument, epitaph, etc. and rehearsed going back to the world with its positive and negative stressors.
Those vets who have done everything they could to distance themselves from the Grave and its contents (those on top of it, OT Vets) have a different task. They must enter the graveyard, dig up the Grave, get down into it and dialogue with contents: parts of themselves, the Walking Dead and the Talismans. They then must proceed with the same tasks as those who lie at the bottom (LB Vets) of the Grave already.
This is sensitive work, and initially it is most effective to allow the patient some distance from the imagery (Bandler, 1985). This is done by using the dissociating these patients have become experts at, such as: having the patient see, feel, and hear himself sitting on a park bench across from the graveyard, and then ?"watching himself, watching himself?" entering the graveyard. In joining the patient's process by offering a three dimensional distance, the therapist allows the patient access to his feelings and his emptiness in a way which will reduce overwhelming anxiety.
This approach also reduces the number of missed appointments and premature terminations. In addition, this teaches the patient to use and internalize the process of moving from dissociation to association and back again as a coping technique for flashback. It is also useful for coping with the feared stressors of everyday living: job stress, the fear of losing control, the fear of anger and destruction; and the fear of intimacy and terrifying dependency needs.
It is important for the therapist to be willing to move beyond a professional detachment and be open to an authentic encounter with the patient and the Vietnam War. One needs to be empathetic without being overwhelmed, which is often difficult, and one needs to be confrontive without being callous. The therapist needs to be comfortable setting boundaries and limits, must be willing to acknowledge and learn from mistakes, and perhaps as important, the therapist needs to model how to redeem and take care of oneีs own lost images and feelings from the Vietnam War Era.
The work of healing for the Vietnam veteran is not a simple linear task. It is a complex primordial journey for both the patient and the therapist. The journey's images are dangerous, empty, painful, joyful, fearful, intense, powerful and sad. It is a journey from estrangement to reconciliation; a journey home-a resurrection journey.