The reliving experience in Vietman veterans with posttraumatic stress disorder

The Reliving Experience in Vietnam Veterans With Posttraumatic Stress Disorder Herbert Hendin, Ann Pollinger Haas, Paul Singer, William Schwartz, and Vincent Wallen

Houghton,

Mark

ABSTRACT Among individuals who have been exposed to life-threatening trauma and subsequently develop a posttraumatic stress disorder, a considerable number have episodes in which they suddenly act or feel as if the traumatic event were reoccurring. A lack of well-studied case material has limited our understanding of the psychodynamics of this phenomenon. Work with large numbers of Vietnam combat veterans with posttraumatic stress disorder has provided us with an opportunity to study the reliving experience in greater depth. Case summaries are presented for three such veterans who have had repeated reliving experiences since returning from Vietnam. This material demonstrates how reliving experiences express in dramatic ways aspects of the veterans’ combat experiences which, although usually not consciously recognized, continue to dominate them because they are unresolved. Also shown is the adaptive significance of this behavior. Understanding the origin of veterans’ reliving experiences, the events that trigger them, and the adaptive functions they serve is seen as valuable in treating the posttraumatic stress disorder.

0

NE of the most dramatic manifestations of posttraumatic stress disorders in Vietnam veterans is the reliving experience-the sudden acting or feeling as if traumatic combat events were reoccurring in civilian life. The symptom was considered of sufficient significance that DSM-III listed it, together with recurrent dreams and recurrent intrusive recollections, as evidence of reexperiencing the trauma-one of the criteria which must be present for the diagnosis of posttraumatic stress disorder to be made.’ In reliving experiences the individual is awake but appears to be in a state of altered consciousness and often has subsequent amnesia for what takes place. The experiences last from a few minutes to several hours and can usually be distinguished from startle reactions in response to environmental stimuli that momentarily reinvoke traumatic combat events, in which misperceptions are quickly corrected. Work on posttraumatic stress disorders resulting from exposure to traumatic combat events has given little attention to reliving experiences or their psychodynamics. Several clinicans have reported that dissociative states were frequent among veterans of World War I and II,2-5 and a recent, large-scale survey of Vietnam veterans found that 17% have had combat-related “flashbacks” since returning home. However, neither the behavior nor its functions in terms of postwar adaptation has been elaborated.

H. Hendin. M.D.. A. Pollinger Haas. Ph.D.. P. Singer. M.D.. and W. Houghlon. for Psychosocial Swdies. Veterans Adminisrration Medical Center. Montrose,

Center

the Department from

of Psychiawy,

the Prvchology

Address Veterans

reprint

Service. requests

Administration

New York Medical Vererans Administration to Herbert

Medical

cdl 1984 by Grune & Stratton.

Comprehensive

Center,

Hendin. Montrose.

College;

M. Schwartz.

Medical M.D.,

Center.

Director.

M.D.. j&l New

Ph.D. and C’. Wallen. Monirose,

Center for

the

)_‘ork and Ph.0

New kiwk. Psvchosocial

.(;tudirr.

NY 1054R

Inc. a)l0-44(1X/84/2502-0$Ol.~~/cJ

Psychiatry, Vol. 25, No. 2, (March/April)

1984

165

166

HENDIN ET AL

In civilian life the alteration of consciousness seen in fugues and multiple personalities seems to have some similarities to what occurs in combat-related reliving experiences, with the striking difference that the combat veteran usually does not assume another identity during such episodes. Past work on dissociative states among civilians has tended to view the alteration of consciousness either as a defense against conflicted and unacceptable feelings, or as resulting from a failure in the development of the individual’s sense of his own and others’ separateness and an accompanying inability to integrate unpleasant or disparate emotional experiences.7m10 In cases described in such work, traumatic childhoods, often with physical abuse, frequently appear to have been precursors of later episodes of altered consciousness. Several observors have described dissociative states following traumatic experiences during adulthood. Sonnenberg” and Burnstein,12 for example, described hallucinatory experiences or “revisualizations” following such stressful experiences as the traumatic loss of a spouse or a severe accident. Barnes reported the occurrence of partial dissociative reactions resulting from the stress of travel in a foreign country.r3 Jaffer4 and Niederlandi5 described more extreme and persistent dissociative states among former concentration camp inmates, in which traumatic experiences would be reenacted. Jaffe noted that among many concentration camp survivors, precursors of the later dissociative behavior were evident in the altered states of consciousness they experienced during imprisonment as a result of extreme terror and fatigue. Howard’s account of his own experiences in Vietnam similarly suggests that the fatigue and threatening environment encountered by soldiers during combat produced alterations of consciousness and contributed to their subsequent inability to integrate the trauma with the rest of their lives. I6 While such observations suggest factors which may contribute to later reliving experiences, the paucity of welldeveloped case material has limited our understanding of the psychodynamics of this phenomenon. Our work with large numbers of Vietnam veterans evidencing symptoms of posttraumatic stress disorder subsequent to intense combat”-*’ has put us in touch with a sizable subgroup of men with active reliving experiences. Of the more than 100 posttraumatic stress cases with whom we have worked, about 20% have or have had episodes in which they suddenly acted or felt as if traumatic events which they had experienced in Vietnam were recurring. In almost every case such episodes were repetitive across a period of time ranging from a matter of weeks to several years. Access to this population has allowed us an opportunity to begin to explore the psychodynamics and adaptive functions of reliving experiences, about which little is currently known. Presented below are summaries of three combat veterans who have had repeated reliving experiences since returning from Vietnam. Each of these men were participants in our Posttraumatic Stress Evaluation and Treatment Program at the Veterans Administration Medical Center, in Montrose, NY. Following our usual evaluation procedure,22 each veteran completed a life-history questionnaire and a series of five semistructured interviews, prior to being diagnosed as having a posttraumatic stress disorder. Each man was also administered a battery of psychological tests, including the Rorschach, and was subsequently followed in ongoing stress-oriented

POSTTRAUMATIC

STRESS

167

DISORDER

psychotherapy for a minimum of 1 year. As the case summaries illustrate, even though in all three veterans the stress disorder was manifested in periodic reliving experiences, the frequency and duration of these experiences varied considerably. as did their relationship to what the veterans had been through in combat and the ways they tried to cope with this in their postcombat lives. CASE STUDIES Case

1

Mr. M. was a stocky, muscular man in his mid-30’s worked for 14 years for the highway department

who was married,

had four children.

and had

as a bulldozer operator. He had grown up in an intact

farming family and had shown no evidence of social or emotional difficulty prior to his combat experience. He had been in Vietnam in 1966, and had served with various infantry units primarily provinces. His major assignment was as a machine gun operator on an armoured He married soon after his return from Vietnam from

his family.

Vietnam.

in the northern

personnel carrier.

but during the postwar years he gradually

spending more and more time alone in his bedroom

thinking

withdrew

and reading about

In the last few years he had also began to drink heavily. and had increasingly

thought of

taking his own life. Although

he related his combat experiences with a good deal of affect. at times becoming angry and

at other times tearful,

he was vague and claimed

not to remember

any details. Outstanding

recollections were the repulsion he felt at being exposed to dead and mutilated American

in hi\

soldiers whose

bodies he and his comrades often carried back to the base in their vehicle. his awareness that in “free fire zones” they had killed unarmed civilians, and his vague descriptions of sexual involvements Vietnamese

His posttraumatic

stress disorder was characterized

by reliving experiences which he described a\

“weird things I do that I have no memory of.” When initially seen. he had been hospitalized first time after getting drunk at a friend’s house. wrecking furniture. at imaginary

with

prostitutes in which he had been physically abusive.

Vietcong in a nearby field. A few months earlier, also while intoxicated.

in his kitchen. claiming he was burning out Vietcong.

for the

and then running out and shootmg

He was sorrowful

he had set a fire

and upset in diacussmg ttn\

incident. saying he had a lovely family and expressing the fear he might do something to harm them Not all of his reliving experiences took place when he had been drinking.

After he went to \lrep at

night he had often been found by his wife crawling around the house with a gun as though he were back in combat. Once when hunting he felt another hunter was firing at him and started to fire hach but his brother who was with him told him to stop. Several times during sex he had referred to hl\ wlfr as “mama Fan.” During a sexually derogatory

one reliving experience he pointed a gun at her while speaking to her- in

manner.

When not reliving his Vietnam experiences hr avoided talking about them. particularly Yet. the rehving appeared to be a way of communicating

with his wife.

to her and to others things he was unable to

talk about. In therapy he gradually became able to discuss his combat experiences in detail as well as his rcactmn to them. Virtually

all of his reliving experiences turned out to be elaborations of those aspects of comhat

over which he was most troubled.

His random shooting in the field was connected to a sense he had

had m the last months of his tour that he was out of control and firing at “anything

that moved ” HI\

setting the fire in his kitchen related to an incident where he had refused to crawl down an underground tunnel

III

pursuit of Vietcong, and had persuaded his sergeant to burn them out instead

Incident in which he almost shot another hunter bore a striking similarity firrflght.

he had killed another American

The huntlng

to a time where. during ;I

whom he had mistaken for a Vietcong. The incident with hl\

wife and the gun bore a direct parallel to hi\ hehavior with a Vietcong

prostitute

whom he had 1111

over the head with his gun after discovering her going through hi5 friend’‘’ wallet. He seemed to feel that his behavior in Vietnam

had been a true reflection of the sort of prr\trn

he

really was. As he became aware of his guilt over his combat behavior and the ways in which he needed to confess and to be punished, he began to make Vietnam

a part of his life over which he had \ome

control. He stopped drinking and became able to share with his Hlfe the details of his combat enperlrncr\ and the emotions he felt with regard to them. In the process he stopped having reliving experience\ After several months his mood lifted considerably,

and he was able to leave the hospital qnd return 1~1

168

his family and his job. He was seen once a week for the next 6 months abatement of his stress symptoms and no return of his reliving experiences.

HENDIN ET AL

and showed

considerable

Case 2 After a distinguished tour as an Army helicopter pilot in Vietnam, for which he received a Presidential Unit Citation, a Valorous Unit Award, 14 air medals, and a Purple Heart, Mr. B. when first seen at the age of 41, was a prison inmate serving a 2 to 6 year term for bank robbery. He had grown up in a warm supportive family in a rural area of New York State. He had done well in school, had a good administrative job, and was happily married with two children when he entered the service in early 1965, hoping to later use service benefits to go to veterinary school. Several particularly traumatic combat experiences played a role in the reliving episodes which were a major feature of the posttraumatic stress disorder he developed after his return from Vietnam. He had once been ordered, along with several other pilots to fly a mission in a storm which resulted in the loss of one of the planes and several of his friends. Caught in the center of the storm, ice formed on the wings of his own helicopter, the rotor stalled several times, and the plane was sucked up and down at the will of the storm. His base was unable to pick him up on radar, his instruments failed, and he thought he would not survive. Finally, he was able to contact a ground unit who fired flares to direct him to a landing. Two of his traumatic combat memories involved women. On one occasion he was shot many times by a Vietcong woman who fired directly at him after his helicopter had landed in a combat assault, and he survived only because of the armor in his flight jacket. During another combat assault into Cambodia he was fired at from point blank range by a woman whose gun contained nails. He escaped injury by ducking behind his seat until someone else was able to kill the woman. The latter incident had occurred on a particularly hot day on which his unit had wiped out an entire village while everyone was taking a mid-day rest. He felt the woman was justified in defending her village and regretted having been part of an assault which he believed should never have taken place. Another of his horrifying memories was of the severed head of an American soldier which he had seen from his plane in the light of exploding artillery shells. The head, which seemed to be frozen in the expression of a scream, was later put in a body bag with the rest of the soldier’s body, and was flown back to the base in Mr. B.‘s helicopter. Although he had been faithful to his wife during his marriage, while in Vietnam Mr. B. used constant sexual involvements with Vietnamese prostitutes to relieve his anxiety. He described himself as having used sex the way other soldiers used drugs or alcohol. On one occasion during his tour of duty he could not be fully aroused to go on a mission. He told the man awakening him to go to hell, went back to sleep, and when he awoke later he had no recollection of what had occurred. The doctor who then spoke with him considered sending him home, but Mr. B. persuaded him not to and the episode was not repeated. He returned home with the intention to pursue his flying through a career in the Army. Almost immediately, however, he began to experience severe insomnia, nightmares, reliving experiences, and an explosive temper that made his functioning in both the Army and in his marriage impossible. He tried to get psychiatric help but was told that “pilots don’t see shrinks.” His promiscuous sexual behavior continued and eventually his involvements with the wives of several officers at the base led to legal difficulties and a less-than-honorable discharge which made him ineligible for veterans benefits. For the next several years, he intermittently worked as a pilot for several small companies, and during this period he became addicted to heroin which he had initially used in order to sleep. Bitter and angry with the government, he joined several other Vietnam veterans in committing a number of bank robberies from 1969 to 1976. The last robbery was done with his second wife who, in the course of their marital breakup in 1980, turned him in to the police in exchange for immunity for herself. The reliving experiences which characterized Mr. B.‘s posttraumatic stress disorder involved several of his combat trauma although the thunderstorm experience and the time he was wounded were predominant. These experiences were frequently set off when he was driving his car and would suddenly begin reexperiencing his helicopter being tossed back and forth in the thunderstorm. Thinking he was actually flying, he had several times driven the car off the road. On other occasions he would relive being shot by the Vietnamese woman and would become so totally swept up in the experience that he would feel the impact of the bullets and fall backward. Periods of insomnia characterized by combat nightmares would make him more prone to reliving

POSTTRAUMATIC

experiences.

STRESS

Sometimes

DISORDER

he would

go from

the nightmares

to the reliving

experiences

with no clearcut

period of wakefulness. For the first 10 years after returning from Vietnam. Mr. B. also had a more prolonged rype of dissociative episode in which he was unable to account for his actlons or whereabouts for periods of several days or even weeks. Sometimes he would find himself with a woman in another city and would not recall ho\\ he got there. He was also amnestic for most of the details of the bank robber&. In \ome cases he could recall planning them; in others he could recall only waking up with a gun and large amounts of money on his bed. In 1978. when he stopped working as a pilot and was able to get off heroin, the dissociative eplhode\ for which he would have amnesia ceased. Since that time he had also galned greater control of hi> reliving experience\. When he would become caught up m reliving combat events. he would have ;I \ense that what was happening was unreal and he would not act on the experience. In time he de\rloprd the ability to recognize that the events “were only taking place in my head.” Gradually he wa, ahlc to tell when the experiences were about to develop and would protect himself by staying ,n hi\ room During once-a-week treatment over the course of a year it was possible to obser\e some of the t’ven~\ that triggered his rehving experiences. The mo\t apparent was the time of the year Around the anniversary of the episode when his helicopter was caught in the storm and that in which a ctmhst assault had co\1 his company many lives and left him with the memory of the severed head. he would prow incrcaslnply apprehensive and have nightmares and reliving experlencra concermng these C‘\~IIIX. ver) hot weather would trigger reliving experience\ of the combat .lssault that was done on a h,Jt da! On several occasmns it was ascertalnable that the relivmg experiences were cauhed tq event\ th;tt were only symbolically associated with the origlnal traumatic experience. When he was turned do\*11 on a parole request. his sense of helplessness and rage triggered reliving experience? conccrmn$ Ihc thunderstorm and the severed head. When a woman was crltlcal (lf hml during a church mrrtlnp held at the pnson. he had a reliving experience in which the Vietnamc\e woman fired the gun cotl~a~n~n~ nail\ at him Hi\ anger toward everyone he felt should have helped him and did not wah prrvaslve 111I~I\III~ hi\ family and rrjhbing banks he had acted on this anger. but hl\ conflict over hi\ fr
3

Mr. R. wa\ a tall. well-built man of 35 who was married. had three children. and worked ;L\ an ambulance driver. He grew up in a small town where his father wa\ a factory worker and his mother wilrkcd night\ as a telephone operator. As a child he was nlckly and strove to make hlmself tough from an cariy ape. He described neither parent as having been very involved with him but related thn factual!!, with no rxprr4on of bitterness or anger toward either of them Although he participated m \ar\ir> athletics and had a number of friends. he said he had always been shy which he attributed to a had ca’rc of acne. 1~ late adolescence he became in\,ol\ed in a gang that trained with kmves and had nume~~~u~ fights. After several years m the Coast Guard he had volunteered for an assignment m Southra\t ASKI. and had \rr\ed from 1965 to 1966 as a member of a covert mtelhgence unit which mainly operated along the ThaICambodian border. After completing this tour, hr was given a statehIde as\ignment m u hich he handled classified material and during thts period he hacame afraid that agent\ from S(lutheaht ,~\!;I were following him ln pursuit of mformation. In the year, after lraving the service he became increasingly Isolated and alienated from his family. hi\ parents and friends, and spent almost all of his time at home and at work obsessed b) image\ and memories of his war experiences. He was perfectionistic with his wife and children and jumpy outslde the home. a\\aulting men on several occasions. He also became a heavy drinker and this. together with hl\ reclusiveness. had led to severe marital problems. He and his wife fought in a tortured way ahout hi‘. lack of mvolvement around the house. Although he had had affairs with other women. he wa\ ~ralous of hl\ wrfe talkmg to other men and thts was a source 01 conflict between them a\ well. Although lmtially he was extremely reluctant to discuss his wdr experiences. he eventually rehealed that he had hilled 26 mdividuals with a knife during the course t>f his combat tour. He explamed that hi\ unit had standing orders to kill anyone who happened to come up to them as they were installing secret signaling devices used to guide American bombers in attacks against enemy positions. Because 01 the need for
170

HENDIN ET AL

all the killings were strictly within the line of duty, he did admit to having removed gold fillings from the teeth of those he had killed. He claimed to be bothered only by the last killing which he said had involved a woman, something he had not realized until he was searching the body, Mr. R.‘s posttraumatic stress disorder was characterized by recurrent reliving experiences. He had had brief reliving spells at work but his most frequent and prolonged experiences occurred while out in the woods behind his house. He would spend hours there in a dissociated state, dressed in his combat fatigues and carrying his gun and military knife. When he would return to the house following these incidents, he would have only vague memories of what he had been doing, but would often be breathing heavily and perspiring as if he had been running or trying to escape from some unknown threat. On occasion he also awoke from his sleep in the middle of the night and went from one room of his house to another as if he were being pursued and was trying to hide and escape. He reported that the sight of bloody, mangled, or dismembered bodies which hesometimes encountered in the course of his current work triggered episodes in which he thought he was back in combat. Also, when he hunted deer he said he would often think he was back in the jungle stalking the enemy. In the course of skinning and slaughtering deer he had just shot, he described sometimes thinking that he was cutting up human bodies. Once he cut out a deer’s eyes and brains, boiled them in water, and then ate them, to the amazement and horror of his hunting companions. Anger at women in his present life seemed to trigger both nightmares and reliving experiences. In one dream, he began to make love to a woman. realized she was an enemy, and cut her throat. In other dreams, he relived his killing of the woman in Vietnam. The reliving experiences in which Mr. R. was running or escaping turned out to be related to an incident in which he and a companion were hidden from enemy soldiers by the chief of a friendly village. They had watched helplessly as the enemy soldiers hung the chief from his feet. slit open his stomach, and laughed as pigs ate his intestines as they fell to the ground. Mr. R. and his comrade managed to escape from the village but were pursued by the enemy. Mr. R., who was more experienced than his companion, split up with him out of the fear that he would accidentfy give away their whereabouts. From his hiding place in the jungle he heard the other man’s screams and subsequently found his decapitated and mutilated body. Elaboration of the experiences he had had while hunting eventually led him to reveal the frue nature of most of the killing he had done during the war. Only the first eight of his 26 kills had actually occurred in the line of duty: the rest had taken place in the course of his own unauthorized forays into the jungle. During these secret missions he had hid in the bushes and had sprung out and knifed anyone who had walked down the trail. His thought on recent hunting trips that he was slaughtering humans rather than animals was related to his having tortured and butchered a number of those he caught on the trails. He admitted that in some cases he had dismembered his victims while they were still alive. Eating the deer’s eyes and brains was connected to episodes in which he had swallowed handfuls of his victim’s blood, mimicking an Asian ritual in which parts of the corpse was ingested in order to acquire the powers of the dead person. His overall level of functioning at home and at work, and the absence of clinically manifested delusions and hallucinations did not permit a DSM-III diagnosis of schizophrenia. His limited ability to repress traumatic imagery and ideation, and the bizarre nature of his frequent reenactment of experiences from Vietnam, suggested. however, an encapsulated and circumscribed psychotic response to combat, or what might be called a “traumatic psychosis.” Given the fragility of Mr. R.‘s defenses, therapy involved a slow and difficult exploration of his war experiences. He looked to his therapist as a safe person to whom he could express his violent ideas, and an ally in his struggle to control them. In therapy his dreams gradually moved from unemotional killing fo killing with remorse, and he became more aware of the fear and guilt connected with his reliving experiences. Although he has remained obsessed with violent urges, and has maintained considerable rigidity in his personal relationships. he has been successful in controlling his drinking and his reliving experiences have diminished considerably.

DISCUSSION Reliving experiences express in dramatic ways aspects of the veterans’ combat experiences which, although usually not consciously recognized, continue to dominate them because they are so unresolved. The men who have reliving experiences

POSTTRAUMATIC

STRESS

DISORDER

171

have recurrent nightmares of their traumatic experiences as well. Each of the cases here discussed went at times from a sleeping/dreaming state to a somnambulistic state in which they relived combat experiences. The fact that combat events were re-experienced in their waking life suggests a greater permeation of their adaptive processes by the trauma with a lesser ability to repress traumatic recollections and the associated affect. The Rorschach responses of these men provided some confirmation of this permeation. Mr. M. saw periodic explosions in a Vietnam-related context throughout the testing. Mr. B. had frequent Vietnam-related responses and even more frequent sexual responses that reflected his way of dealing with his anxieties associated with combat. He had a brief quasi-reliving experience during the testing when the blood he perceived on one of the cards took him back into a situation in which blood of a man hit by the blade of a helicopter in front of him had been splattered on his windshield. Mr. R., from his second response on, provided nothing but Vietnamrelated material across the entire spectrum of Rorschach cards, with numerous references to tortured and mutilated bodies. That traumatic experiences will bc reflected in Rorschach responses has long been observed,” ?’ but for each of these three individuals, combat was a much more predominant theme than we have observed among the Rorschach records of Vietnam veterans with posttraumatic stress who do not have reliving experiences. The three veterans, like most of those who relive combat events in civilian life. experienced psychic trauma under conditions of terror and fatigue. We have not yet been able to definitively distinguish the role of these particular factors in contributing to subsequent reliving experiences, as others who suffer from posttraumatic stress disorder but do not show this particular symptom have had similarly disorienting combat tours. What is clear from the cases discussed above, however, is that fatigue due to insomnia as well as drug and alcohol abuse in civilian life can trigger reliving experiences in those veterans who are prone to them. Similarly, veterans who have reliving experiences do not appear to be distmguishable from those who do not on the basis of precombat variables. Although some men who have reliving experiences, like Mr. R., came from difficult family situations. as a group we have not found this to be more true of them than of veterans whose posttraumatic stress disorders do not include reliving experiences. Veterans with posttraumatic stress disorders have often been so transformed b) their combat experiences that they have difficulty III reconciling who they bare with what they have become. This dimension of the disorder appears to be particularly acute in those veterans with reliving experiences. Although Mr. M., the first veteran, showed no particular precombat evidence of identity problems or of any vulnerability to dissociative episodes. the stress of combat and his resultant behavior had badly shaken his picture of who he was. His reliving experiences appeared related to a conflict over whether to hide. confess. or even remember actions over which he felt guilty. He responded well to being helped to become aware of his guilt, his conflict between repression and confesslon. and the ways in which he was punishing himself. Mr. B.. the second veteran, came from a warm supportive family and was a wellfunctioning, stable individual prior to his singularly ardous combat experiences. He struggled during the war and subsequently to repress the fear. pain. and loss

HENDIN ET AL

172

he experienced in combat. His reliving experiences were a reflection of his inability to do so. Mr. B. felt no guilt over his combat behavior and was not amnestic for those events or for his reliving experiences. His posttraumatic stress disorder resulted in changed behavior of such magnitude that he was hardly recognizable as the person he had been before, and he did feel the need to block from consciousness the worst of his antisocial behavior. His dissociative episodes and antisocial behavior paralleled in severity his reliving experiences and disappeared when he gained greater control over those experiences. Mr. R., the third veteran, was not in touch with the frustration and anger he must have experienced in regard to his parents. His social adjustment had been poor prior to combat, and in the war he became eager to kill in a way that neither of the other two veterans had. He needed to hide more than to repress both his combat actions and his reliving experiences, and revealed them only after some months in treatment. He mainly feared punishment for his actions, although some remorse developed as his therapy progressed. The reliving experiences appeared to enable him to privately reenact bizarre and destructive combat behavior, without having to assume full responsibility for it. His drinking the blood of the individual he killed in Vietnam and later eating the deer’s brains suggested some wish to merge with his victims. His need to isolate these experiences from the rest of his life resulted in his being removed from family, friends, and co-workers. The other two veterans struggled against what they saw as unwanted changes produced in them by their combat experiences. Mr. R., at least in part, seemed to want to remain what he had become. The reexperiencing of traumatic events in a waking state is not without adaptive value. Mr. M. was able through the reliving experiences to communicate what had happened to him in Vietnam which he could not otherwise do. Even before treatment Mr. B. had gradually gained increased control over his stress disorder, starting with his reliving experiences in which he moved from acting as if they were real to recognizing that what was happening was actually taking place in his head. Mr. R. seemed to need to induce and control the experiences in which he expressed destructive impulses and escaped retaliation. Sharing them in therapy resulted in his feeling less isolated. For a11 of these veterans, understanding the origin of their reliving experiences, the events that triggered them, and the adaptive functions they served was a valuable lever in treating the posttraumatic stress disorder. ACKNOWLEDGMENT Some of the data in case 3 emerged in subsequent kind enough to share the information with us.

treatment

with Dr. Richard Ulman, who was

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