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Memories of war: how Vietnam-era nurses are coping today.

THE EXCELLENT performance of women who served in the Gulf War highlights the important contributions they have made during times of armed conflict. However, it only has been in the past five or six years that scientific and public attention has been paid to the approximately 11,000 American females who served in Vietnam. The majority functioned in health care positions, primarily as military nurses; additional numbers served as medical technicians or in other roles. Until recently, most people were not aware that a significant amount of women served there and were dealing with the psychological aftermath of these experiences, as were the men who had been involved in the war.

A number of women in the military during the Vietnam War were in the US. Navy on hospital ships off the coast, where they could see and hear the shelling; others were stationed overseas in Guam and Japan. While this article focuses primarily on nurses who served "in-country" in Vietnam, the types of psychological stresses undergone by these other groups were similar. The comments made regarding nurses who served during the Vietnam era are based on my research experience with them.

Clearly, the role of women stationed in Vietnam was quite different from that of the fighting soldier. In primarily medical positions, their major duties were to heal and provide nurturing to severely wounded and/or dying combat soldiers. This function was made more complicated by the fact that the nurses, many of whom were straight out of nursing school, were only a few years older than the wounded they cared for. A number reported that they ended up in a "big sister" role with their patients, providing psychological as well as medical comfort. This fit the societal stereotype of females as nurturers. However, this situation caused the nurses to be emotionally vulnerable. They had to deal with their own feelings in response to the devastating nature of the wounds of many of their patients and the number who died. For some, the only way they could cope with their feelings was to distance themselves psychologically from their patients, provide efficient and skilled medical care, yet not get too involved emotionally. They also avoided thinking about their job when off-duty. For others, coping with the reality of their nursing experiences meant spending extra time talking with their patients, perhaps writing letters to family members, and sharing the emotions they were experiencing with other military friends and associates.

Many reported that the general military message they received was that, as nurses, they were expected to be emotionally strong. Somehow, it was considered a lack of competence if they felt psychologically devastated by particular events or the accumulation of experiences related to the terrible wounds and deaths with which they had to deal. The inability or lack of opportunity to express one's feelings also continued when they returned home. Many nurses indicated after the US. withdrew from Vietnam that their general feeling was one of bitterness and anger. They perceived a tremendous waste of human life and felt that it had all been for nothing. A large proportion reported that they learned very quickly upon returning to the US. that they should not tell others they had served in Vietnam because of the strong hostility directed toward them by the general public. Unfortunately for the returning nurses, this shutting off of feelings and memories generalized to many aspects of their

lives. Some who were married to Vietnam veterans indicated that they never shared their wartime experiences with their spouses, although both would wake up at night in the midst of nightmares. Other nurses who were in psychotherapy for a number of years related that they never told their therapists they had served in Vietnam, nor did they associate their current psychological problems with what happened to them there.

The dedication of the Vietnam Memorial in Washington, D.C., caused an important psychological shift for many male and female veterans. For the first time, the general public became more sympathetic to the plight of those who served there, less hostile, and more openly supportive of the veterans' psychological and medical needs. In a sense, the veterans were given permission to acknowledge that they had been in Vietnam and that many of them were hurting because of their experiences. They also found comfort in talking to and sharing with each other.

At about this same time, the Vietnam Women's Memorial Project was formed in Minneapolis, Minn., with the aim of raising funds to build a memorial in Washington to acknowledge those females who had served during the war. Because of my interests in the study of the ways in which individuals cope with extreme stress, as well as a curiosity about the psychological effects of women functioning in a military setting in a role very different from that of the combat soldier, I decided to contact persons from the Project to gain their cooperation in conducting a study of Vietnam and Vietnam-era nurses. I particularly was interested in examining the relationship between specific patterns of coping while in Vietnam or at other duty stations and current psychological adjustment. With the help of the Vietnam women's organization and through ads in the media soliciting volunteers, our research group was able to interview 36 nurses who served in Vietnam and 32 Vietnam-era nurses--i.e., those who had served at other duty stations during this same period.

Each of those in our study completed a number of psychological tests and also participated in a structured interview during which they were asked questions about their wartime experiences. We also obtained information about their psychological functioning prior to and after their military service. Our general findings showed that the current psychological status of Vietnam and Vietnam-era women was in the normal range, although there were some members of both groups who gave evidence of psychological problems, primarily anxiety and depression. A relatively greater number of the Vietnam, in comparison to Vietnamera, nurses reported that, in the first year after discharge, they experienced greater fear of anger or hostility by spouses or boyfriends. Between the first year after discharge and the present, there was a trend for the Vietnam nurses to report a greater degree of anxiety, depression, sleep disturbances, and difficulties with trust in close relationships. However, there were no differences between groups in the number who sought professional help for these conditions.

Dealing with stress

With regard to the relationship between coping patterns while in the military and current adjustment, the same trends were evident for both groups. Relatively more favorable current functioning was associated with coping with stresses through developing close friendships, openly expressing one's feelings when off duty, the use of humor, altruistic behavior (helping patients during off-duty time, volunteering for work at orphanages or with Vietnamese civilians), and looking for a meaning in the events they were experiencing. Relatively poorer current adjustment was associated with military duty coping patterns of self-blame ("It's my fault I'm in this situation"), withdrawal from contact with others, thus spending off-duty time by oneself, and anxious thoughts (fear for one's safety, worry about others).

These findings point to the important role of social support in coping with the extreme stressors of the situations in which the nurses were functioning. While clearly impacted by their experiences, those who had the psychological skills as well as the opportunity to seek out other people with whom to share their feelings tended to exhibit relatively better psychological adjustment some 15 years after their military duty was completed. Having available one or more supportive persons with whom to talk was a significant factor in getting through this difficult situation. Other studies with Vietnam and Israeli combat soldiers also have shown how vital social support is in coping with combat situations.

The use of humor as a means of defusing the very strong emotions that occur in stressful circumstances over which one has little control has been demonstrated in television series such as "M*A*S*H." Further, the therapeutic importance of finding some meaning in the situations one is experiencing has been documented in other settings such as concentration camps. A number of the nurses indicated that the meaning they found in their traumatic experiences was in knowing that they had provided help and comfort to the best of their abilities to those who were in pain and badly needed their help. In a related manner, altruistic activities benefiting the Vietnamese population were a way for some to provide additional meaning to their roles there.

The coping patterns related to relatively poorer current psychological adjustment are all mechanisms involving negative thoughts about oneself and withdrawal from contact with others. These behaviors are quite different from those engaged in by nurses exhibiting good current adjustment. We concluded from our findings that social support has a protective function in traumatic situations such as the ones nurses underwent in caring for the wounded and dying in Vietnam.

Research with males in combat situations has revealed another important factor affecting psychological functioning after military service. The amount of exposure to combat consistently has been demonstrated to have an independent effect on later adjustment, irrespective of pre-service life experiences, prior psychological adjustment, and particular ways of coping. The nurses in Vietnam were not in active combat, but many were stationed in field hospitals that received regular shelling, while others served in hospitals to which helicopters brought the wounded directly from the battlefield. Even nurses in places such as Guam, and certainly Navy nurses serving on hospital ships off the coast of Vietnam, can be considered to have been close to the combat zone because they were treating fresh casualties or wounded who had been stabilized for a day or two and then sent out of the country.

A number of nurses stationed in the US. reported that the psychological stresses they experienced were somewhat different, but difficult nonetheless, and also had a significant impact on them. They indicated that they had the opportunity really to get to know their patients because the wounded were in long-term rehabilitative care. The stressful aspect was the traumatic nature of the wounds these young men had suffered and the nurses' recognition that the long-term prospects for many with regard to the quality of their future lives was quite poor.

While our findings point to the importance of emotional support and sharing of feelings, we are not able to say whether some individuals, on the basis of personality factors and psychological adjustment before going into military service, had an easier time establishing close friendships, sharing feelings with others, and thus coping. There is no way to tease out the links in these relationships without more comprehensive information on pre-service adjustment.

It is clear that the vast majority of persons who served in Vietnam and elsewhere were affected emotionally by their experiences. However, this is different from concluding that, because of having served at this time, persons came out of the conflict psychologically disturbed. While some continue to suffer psychologically from their Vietnam experiences, others have been able to overcome them. The tremendous societal stigma of having served in Vietnam seems to have receded significantly with the dedication of the memorial wall and subsequent interest in and sympathy with veterans of that war, both men and women. The development of peer counseling groups led by Vietnam veterans and the establishment of Veterans Administration mental health services specifically targeted for them also have been quite helpful in reaching out to those in need.

The Gulf War again drew attention to the role of women in war. Many of the females in that brief conflict served in support capacities in and out of combat zones, in addition to those in nursing and other medical functions. A major difference from Vietnam in the attitudes of the general population was the strong support for the combat operation, the quick end to the fighting, and the extremely few American casualties. Since the acute combat situation was quite short, this most likely lowered significantly the numbers of individuals currently suffering from post-traumatic stress disorder, in comparison to the veterans of the Vietnam War. Nonetheless, many military and civilian personnel were affected by the buildup to warfare, the combat itself, and its aftermath. The results of our study with Vietnam nurses would lead to the presumption that the types of mechanisms found helpful in dealing with the stresses in Vietnam also should prove a benefit in adaptively coping with the stresses of those men and women who participated in the Gulf War.
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Author:Leon, Gloria R.
Publication:USA Today (Magazine)
Date:Mar 1, 1993
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