Reflections on Vietnam Veterans' Experience—A Guide for Health Care Professionals
Much has been made in recent years of the passing away of the generation that fought World War II. As this generation makes its exit, aging vets from the Vietnam Era are finding themselves in need of health care. Unlike the accolades showered on the previous generation, those who served in Vietnam have often struggled against negative stereotypes, social and cultural ignorance about the combat-related dynamics into which they were thrust, and a lack of acknowledgment or appreciation for the depth of their sacrifice and the sincerity with which they did their duty during an unpopular war.
Any soldier exposed to combat is at risk of developing PTSD and/or moral injury, but various factors can mitigate or intensify the risk. Among these are the responses (real and perceived) of people and groups in leadership positions entrusted to act in soldiers' best interests and the quality of support from one's family and social network after the return home. Did political leaders who sent young men and women to war do so only as a last resort and did they do everything possible to ensure success? Did military leaders set a strategy with clear, obtainable objectives? Did they avoid putting troops in situations that needlessly undermined morale or exacerbated moral distress? Did friends and family provide a safe place to process and heal without being judged?
Memories of Betrayal
The coupling of the dangers and vulnerabilities of war with perceived acts of betrayal is important for health care professionals to bear in mind. Some Vietnam vets may have difficulty trusting those in positions of authority. Some may behave in ways that seem oppositional or disrespectful but which are intended as self-protective. Others may have a fierce need to be in control or an aversion to accepting help. Some may distrust the motives of health care professionals and the large systems in which they work. When the conversation turns to hospice or palliative care they may become suspicious. In the words of one Vietnam vet, "When the doc brought up hospice I figured he was tired of dealing with me and wanted me dead."
Medical settings can be dehumanizing and overwhelming. Relationships with health care providers may be laced with status and power differentials that can be confusing, even threatening. Experiences of pain, immobilization, and threat can trigger unhealed traumatic wounds, defensive patterns, and anxiety. When working with Vietnam vets in such settings professionals may be met with distrust and skepticism. To avoid the trap of responding with negative labels (e.g., oppositional, noncompliant, poor impulse control, or paranoid) it is important for medical personnel to understand some of the reasons this distrust may exist.
It's easy to forget that those who served in Vietnam grew up in a time when politicians were seen as statesmen focused on the common good. Most trusted their leaders when told that war was necessary to stop the spread of communism. Despite stereotypes to the contrary, most volunteered. They were part of a generation raised with stories about how their fathers and uncles had accepted the duties of citizenship and won the Great War.
These soldiers realized quickly that their fathers' war was very different than the one into which they had been led. Their fathers had typically fought as parts of large coordinated forces against a massed enemy, taking and holding territory and attaining measurable strategic objectives, each of which moved them closer to victory. This was not true in Vietnam. Due to geopolitical constraints there would be no invasion of North Vietnam. Rarely would they face a massed force fighting in conventional fashion. In Vietnam, the enemy was often invisible, attacking then slipping away. Though the Army of North Vietnam was a conventional force, the Viet Cong (VC), a guerilla force composed largely of South Vietnamese communists, were often indistinguishable from civilians.
Among the Vietnam vets with whom I've worked there is a widespread belief that the politicians, not the soldiers, lost the war. "We won every battle, took every hill," one told me. "We did everything they asked but the suits back in Washington sold us out." Speaking of politicians, another complained, "They tied our hands because they didn't want to piss off the Russians. Hell, the North Vietnamese were flying Russian fighters, the VC were using Russian machine guns."
It was common for territory to be given up quickly after it was taken. "I lost two buddies," one man said bitterly, "taking a hill that didn't even have a name. The next day we evacuated the hill and the enemy came right back. My buddies died for a useless hill." Chemical toxins such as Agent Orange were used on a wide scale. I've worked with many veterans who believed, often justifiably, that their illnesses were caused by exposure to such toxins.
Other veterans have added an array of situations through which they've felt betrayed. These include inequities in, and feelings of being coerced by, the draft,
An Unwelcome Homecoming
And then there was the betrayal of the homecoming. Though the antiwar movement had broad roots composed of people who genuinely wanted to stop the war, there was a segment openly hostile not just to the war but to the troops who fought it. Returning veterans who had given everything they had and who simply wanted to return home were often met with hostility.
Vets often say things such as, "We were spat on, called baby killers, treated like dirt when we arrived back home." Others remember subtle hostility: "I was afraid to wear my uniform in public because of the looks I'd get." Many contrast their experience with an earlier generation. "Those World War II guys got parades and ticker tape; we got stabbed in the back."
In the private sphere most had loved ones eager to welcome them home but with emotions so intense and divisive, family gatherings could easily conflate with generational or political tensions. Some felt pushed and pulled by loved ones. "My Dad was a big Nixon man and he held me up to my little brother who was smoking weed and carrying antiwar signs," one vet said. "Neither wanted to hear the truth about what I'd been through. They just wanted to use me to prove some kind of point."
The pain and distrust that can grow out of such experiences can last a lifetime. Even among those who have healed or learned to cope with such things, illness may trigger painful memories, sensations, and emotions. In the case of Vietnam veterans, traumatic material may combine with the psychic imprint of core betrayals and manifest in defensive patterns that can frustrate medical staff. Patterns include hypervigilance, distrust, argumentativeness, catastrophic thoughts about the future, cynicism, intense suspicion, disrespect for authority figures, attempts to intimidate, sensitivity to differentials in power, emotional flooding, withdrawal, and rage.
Because the wounds of combat-related betrayal can fuel and exacerbate PTSD, it is easy to simply label veterans exhibiting such responses as having (clinical or subclinical) PTSD without being sensitive to possible underlying breaches of trust, or considering that this, rather than PTSD, may be at the core. When these vets arrive amidst the vulnerabilities of a serious illness, special care should be taken to do whatever can be done to create a sense of safety.
In Vietnam, a special code, "broken arrow," was the signal to divert all available resources to optimize support for ground troops under potentially devastating fire. As this generation ages and enters the decontextualized, dehumanizing terrain of modern health care, and as they face challenges related to illness and mortality, those of us in health care need to call our own version of this code.
Recommendations to health care professionals serving these men and women include the following:
• Learn the history of the Vietnam War, rejecting superficial or simplistic narratives and embracing awareness of its confusing complexities.
• Resist negative stereotypes. Though tempting when we are frustrated, these are the kiss of death when it comes to establishing trust and cloud our ability to serve with compassion.
• Enhance our understanding about psychological trauma and its intersection with the end of life and the ways unhealed traumatic wounds can become reactivated as health declines.
• Be sensitive to the longstanding psychological and moral injury that can occur when, as young soldiers, trust was betrayed during the danger, vulnerability, and grief of war.
• Learn about suicide risk assessment and prevention. The statistics on suicide among Vietnam War vets are, and will likely continue to be, horrendous.
• Where possible, hire veterans for professional staff positions and/or recruit them as volunteers.
• Think seriously about ways to create physical environments that avoid trauma triggers and enhance a sense of safety and control.
• Developing some type of veterans' recognition protocol can be helpful as long as vets are given the choice to participate.
• Emphasize an interdisciplinary approach to care where social workers, chaplains, practitioners of complementary therapies, and personal care staff all have input and are available to any veteran seeking care.
• Health care professionals in the habit of quickly reaching for their flag pins and reciting the mantra, "Thank you for your service" whenever learning a patient is a veteran might want to move more slowly. Though such gestures may indeed be appreciated and meaningful, for some they can come across as trite and insincere if offered reflexively. This is not to suggest such expressions be withheld, but doing so automatically may unintentionally convey a desire to push a preconceived narrative onto a veteran, rather than convey a willingness to listen without judgment as they tell their own stories.
• We must invite the sharing of stories and memories without pressuring vets do so, while establishing a safe context for such sharing. If a veteran chooses not to speak we should respect this choice. For those who venture forth, we must be worthy of the trust.
--J. Scott Janssen, MSW, LCSW, is a social worker with the Hospice and Palliative Care Center of Alamance-Caswell in Burlington, NC, and an editorial advisor for Social Work Today.