Combat Veterans: Impressions of an Analytic Observer in a Non-Analytic Setting

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Herbert H. Stein, M.D.

Published in The Journal of The American Academy of Psychoanalysis and Dynamic Psychiatry (2007) vol. 35:4.

 

Abstract: The hallmark presentation of combat trauma – nightmares, waking hallucinations, intrusive traumatic memories and extreme affective reactions to environmental triggers – may best be conceptualized as part of an adaptive mechanism intended to protect the individual against a repetition of trauma.  Combat veterans continuously must cope with the extreme affects that combat induced.  Fear, rage, guilt and grief predominate.  Their mental and emotional life is complicated by a conscience split between war zone and civilian morality and by the special group dynamics of combat.  Optimal clinical understanding of combat-related trauma, whether in a psychoanalytic or general mental health setting, requires an awareness of the interaction of the personal dynamics of each individual with the specific characteristics of their combat situation.

Introduction

 

This paper represents the views of a psychoanalyst who spent more than 20 years working with combat veterans in a clinic that focused on their care. It will delineate impressions and insights gained through thousands of hours of psychiatric interviews, group therapy sessions, ongoing contacts for medication management and discussions with colleagues on a team doing ongoing outpatient work. It delineates the insights of an analytic observer in a non-analytic setting. The primary focus will be the psychodynamic issues that arise with combat veterans. These will be discussed under three general headings:

1. Traumatic repetitions are best conceptualized as part of a warning mechanism against repetition of trauma;

2. The dynamics of combat veterans are complex. They are best understood not in terms of one mechanism but as an ongoing attempt to cope with the extremes of affect that combat trauma induces;

3. Understanding combat veterans involves understanding the personal dynamics of the individual along with the specific circumstances of their combat situation.

1. Traumatic repetitions are best conceptualized as part of a warning mechanism against repetition of trauma.

            Combat veterans regularly experience “repetitions” of their trauma long after the event. These repetitions seem more akin to a fresh experience of the traumatic event, taking place in the here-and-now, than to a remembering. They consist of traumatic dreams, intrusive memories with a strong affective component, usually unbidden and unwanted, “flashbacks” in which the veteran appears to be reliving an incident in waking life and affective reactions to “triggers” in the environment that remind the veteran of some component of the traumatic scene. Traumatic dreams often closely reproduce a real event.  While they sometimes diverge from the original event, with possible clinical relevance (Adams-Silvan and Silvan, 1990; Lansky and Bley, 1995), what makes them unusual is their relatively close following of the script of the original event.

Psychoanalytic thinking about trauma has tended to be very influenced by Freud’s introduction to the subject in “Beyond the Pleasure Principle” (1920). Freud uses the presence of post traumatic dreams to begin to explore the question of repetitions. He first provides a “mastery” model, in which the trauma is repetitively reworked in dreams and symptomatic acts in order to master what had been overwhelming. Eventually, he moves on to propose the “repetition compulsion” as a basic force of human behavior. He proposes an innate function of the human mind to attempt to repeat in memory and action, the circumstances of the trauma. Attempts at mastery of the trauma are secondary.  By linking the traumatic dream with efforts at mastery and the repetition compulsion, Freud set the tone for later theories about the traumatic repetitions of the combat veteran and other traumatized individuals.

I entered this work with a sense that traumatic repetitions are based upon an attempt at mastery. It is my impression that many analysts follow this model, while some adhere to the idea of a fundamental repetition compulsion and others equate the two. Others have argued that the traumatic repetition is an expression of aggression (Wisdom, 1949; Inderbitzen and Levy, 1998) or as disguising (Adams Silvan and Silvan, 1990) or defending against (Lansky and Bley, 1995) other conflictual material.

As I worked with combat veterans, I became increasingly impressed with a feature of the traumatic memory that connects directly to a basic need of someone who has been traumatized—the element of warning. One obvious feature of traumatized people that connects many of their conscious, unconscious and physiological reactions is the attempt to avoid having the same traumatic event occur a second time. In a war zone, combatants develop a sense of hyperalertness that is adaptive. It becomes less adaptive when they continue to react as if severe danger were imminent in civilian life. Their readiness for danger has become automatized (Hartmann, 1939), and is reflected in their physiological reactions (Orr et. al., 2003; Orr et. al., 2002; Wolfe et al. 2000). It seems quite plausible that evolutionary factors supported our learning from trauma, the most highly charged of highly charged affective experiences; that we are constructed to respond rapidly and definitively to avoid repetition of a severe trauma. When that trauma is repeated on almost a daily basis, as it may be in combat, the reaction becomes irreversible.   

In this context, post traumatic repetitions are adaptive. What better way to avoid repeating a terrible event than to have the image of that event branded into one’s mind for review at a moment’s notice? It helps guard against complacency that could lead to vulnerability. If we are wary of an attack, sleep puts us into a particularly vulnerable, endangered state. Dreaming that we are back in the danger situation sets off alarms to reestablish the “protective” alertness. Veterans have described dreams in the manifest content of which we can see a struggle between the need to stay asleep and the need to be aroused to avoid danger.

In a therapy group of Vietnam veterans, one man complained of having had a dream in which the Vietnamese were attacking his position, breaking through one barrier after another. Finally they got to him and he woke up, frightened. Another man had a recurrent dream of being under attack and having no bullets in his gun, finally awakening. (Stein, 1995)

These “warnings” may also occur during the waking hours.

A combat veteran is walking down a street with his family when he hears an explosion, a car backfiring, a fire cracker, or maybe a real gunshot. Later he is told that in an altered state of consciousness, he jumped behind a hedge and started yelling orders as if he were in a firefight.

From an adaptational perspective, it makes most sense to think of these traumatic repetitions as part of the hyper-arousal syndrome that follows trauma.

Westen  and Gabbard (2002) have offered a similar argument in their attempt to integrate cognitive science with psychoanalytic theory. They point out the evolutionary advantage of keeping “events relative to survival and reproduction … readily and chronically activated.”  (p. 84)

Unlike Freud’s concept of the repetition compulsion, this proposed warning mechanism is not “beyond the pleasure principle” in that it is part of an overall adaptive mechanism. The need to protect oneself from peril is within the realm of pleasure/unpleasure regulation. Furthermore, this mechanism can become involved in conflict and compromise as Adams-Silvan and Silvan (1990) have demonstrated in their analysis of a traumatic dream that contained elements of a wish-fulfilling nature. Most importantly, the determination of extreme danger, the signification of an event as traumatic, is based upon it’s meaning to the individual rather than to an abstract concept of overcoming and overwhelming the ego’s barriers.  In traumatic situations, individuals are often overwhelmed, but overwhelmed, as we shall see, by events with specific affective meaning usually having to do with fear, rage, guilt or loss.

2. The dynamics of combat veterans are complex, not understandable in terms of one mechanism but as an ongoing attempt to cope with extreme affects that combat trauma induces.

By its nature, combat puts people into situations that evoke intense affective responses. Combat veterans have been subject to something well beyond the “average expectable environment” (Hartmann, 1939) of the patients we usually see in psychoanalytic practice. The arousal, use of and defenses against strong affective responses and their consequences plays a central role in the dynamics of combat veterans. A discussion of affects does not encompass the entirety of their dynamics, but it is central to understanding them. These dynamics are primarily centered around aggression and have to do with fear, rage, grief and guilt. It is impossible to discuss them singly because they present as a complex, with one affect frequently being used to defend against other affects.

Many Vietnam veterans report that upon returning to civilian life they suddenly felt less safe and more frightened in what should have seemed a safer environment than they had felt during deployment. For part or all of a year, they felt that their safety was assured by their weapon and the men who were with them. Without the weapon, without their fellow soldiers or marines, they felt unprotected. Despite the fact that they were manifestly out of the combat zone, they reacted to loud noises with hyperarousal and a defensive posture.  They responded to perceived threats with violence, as if these were life threatening. Sleep was light and short; and they often reacted violently if someone touched them during sleep. Many kept weapons near the bed. To this day, most of the combat veterans I treat sit with their back to the wall, facing the door when in a restaurant or public place.

Attempts to cope with fear are many and complex. The combat veteran lives with both the fear and the mechanisms he has learned to defend against it. Prominent among those defenses is a version of identification with the aggressor. It is best summed up in Patton’s famous comment that the goal of war is not to die for one’s country but to make the enemy die for his country. By seeing oneself as the one who kills, the combatant may bring his fear of being helpless in the face of death under partial control. There is, of course, actual support for this fantasy; but clinical experience indicates that the power of this defense is more psychological than real. It can be effective. Combat veterans commonly use rage to ward off fear. This is particularly apparent in group therapies when material that touches off anxiety soon leads to a group expression of hostility and resentment.

We cannot examine a set of affects without taking into account the underlying fantasies. At times, it is apparent that holding a powerful weapon in conditions in which it can be easily used gives the combatant a sense of grandiose power to control life and death. Some veterans experience intense guilt over the fact that they did not merely kill, but came to enjoy it. Fox (1974) found a difference in war zone violence based upon revenge and narcissistic rage (“hostile aggression”) from the violence of regular combat (“adaptive aggression”), the hostile aggression being more conflicted. Pleasure in killing may have many inputs, and many meanings, conscious and unconscious. There may be healthy exhilaration in overcoming fear of death by implementing an identification with the aggressor. Less adaptive is the reaction formation to guilt over murderous impulses seen in veterans who protest, perhaps too loudly, that they have no guilt over killing the enemy, or who even boast of atrocities. Individuals who prior to service struggled with forbidden murderous fantasies may find the combat situation an arena in which these may be gratified. A veteran described killing a woman civilian almost within a breath of describing his intense ambivalence towards his mother.

Aggression may be linked with expressions of sexual desire.

In a group session some years ago, veterans began to talk about the thrill of firing an M 16 rifle. As the session progressed and the level of arousal increased, one man described attacking a man after a traffic argument, feeling larger and more powerful as his face flushed.  In the particular context this could be formulated as an upward displacement of an erection.

Dynamic psychotherapy of some veterans who reported avoiding guns upon return to civilian life revealed that for these men the act of firing a gun was too closely tied in their minds with unacceptable and frankly sexual pleasure.

Clinicians who work with these individuals know that combat veterans use various devices to contain these strong affects and the behavior they induce.  “Psychic numbing” refers to a state of seeming indifference and constriction of affect. In Vietnam, this was put into words, “It don’t mean nothing.” However, psychic numbing is frequently fragile, giving way to overwhelming affects as the veteran talks about his trauma.

Defensive avoidance is used as well, but combat veterans show an ambivalence towards reminders of their war experiencing, avoiding them to protective themselves from their affective reactions, yet often being drawn to them, as well, perhaps to verify their memory or to bring themselves back to a time when they were active and very competent.

Grief

Grief should be understood in the context of its overwhelming nature in a combat zone. People in combat may experience multiple sudden violent deaths of friends and other fellow soldiers.  It would be grossly maladaptive, to grieve properly at the time, since grief requires some degree of respite. When they are out of danger, the sheer amount of accumulated grief work seems overwhelming. That and the defenses against experiencing grief built up during combat create some of the numbing.

I saw a sampling of that grief on trips to the Vietnam War Memorial in Washington. The names on the wall are listed according to the time of death, so those who died in the same battle or firefight are listed together. I saw veterans approaching a spot on the wall for the first time looking for one or two names, but finding names of many more men they knew.  One veteran’s grief momentarily overwhelmed his defenses.  He collapsed on the grass near the monument unable to speak or respond.  Many veterans report having had little feeling when their parents died. They could not let down the defenses against grieving.

Guilt

Combat veterans frequently develop a split in superego functioning. They come to the combat zone with some variant of a “civilian” conscience and ego ideal. That civilian conscience does not allow them to function properly in the combat zone, where morality must focus on survival. It is imperative that the combatant allow himself to kill anyone who may endanger his survival and the survival of his fellow soldiers. People in combat therefore develop an intense interdependence for both their physical and emotional survival. Their security depends upon the small collective of which they are a part; and this group replaces the family that is now not only physically but also psychologically distant from them. Morality now focuses on protecting their new family and upon destroying any threat to its members. This makes them particularly prone to two forms of guilt.

The first is survivor guilt. It gains intensity from the intense interdependence of soldiers in combat and the ideal of protecting one’s comrades that pervades combat morality. It is probably most closely analogous to the attachment to immediate family, and particularly to one’s children, in civilian life. This is the man who is torn by the good fortune that he did not go out on a particular mission on which his replacement died, or the man who says he cannot celebrate Christmas with his family because his friends who died cannot celebrate with theirs. It often takes the form of “If I were there, I could have saved them.”  Men who “walked point,” led the way looking out for signs of danger on the path, often believed that they alone could keep their men alive.  Later they were wracked with guilt when either they failed in this important but almost impossible task or were not present, perhaps having completed their tour of duty, when the men they were protecting were killed.

We sometimes fail to recognize that survivor guilt is often complicated by other dynamics, particularly delayed grief and anxiety related to bodily destruction. The guilt over having failed to save a fellow soldier may come from a refusal to give up the grandiose notion that they could have saved them. In dealing with such cases, it is very important to keep in mind that we are not dealing with simple guilt. Even if we could somehow make the veteran aware that he was not responsible for his friend’s death, we would still have to deal with his grief and helplessness that he could not save his friend.  It may also be complicated by anxieties associated with loss of bodily integrity. I am thinking of the situation in which a man’s friend is blown up by a rocket or mortar, leaving body parts to be collected. The nightmares have as much to do with anxiety as with guilt and grief.

There is a second form of guilt which, although not unique to combat veterans, is much more common and important for them than for most other victims of trauma. Most trauma survivors, outside of combat, have been the passive victims of outside violence, whether it be from natural forces, as in an earthquake or fire, or from human aggression, as with holocaust survivors or survivors of civilian crime. For many combat veterans, an intrinsic part of the trauma has to do with their own violence against others. That violence may not bring up guilt in the combat zone, where the soldier may well be living up to the necessary morality of protecting himself and his fellow soldiers.  It may, however, evoke intense conflict upon return to the civilian world.

That conflict has to do with the inability to maintain the war zone morality upon return to civilian life, where killing is hardly ever morally acceptable. In order to adapt to civilian life, the veteran must attempt to regain some form of civilian morality; but, by the terms of that morality, he may experience extraordinary guilt over what he has done in the war zone. The returning veteran has a number of unconscious choices: 1. he can maintain the war morality and be anti-social in the eyes of the civilian world; 2. he can embrace his original morality at the cost of enormous self hatred and loathing; 3. he may attempt to embrace both, essentially shifting back and forth from one to the other. There are, of course, no pure types, but some men fall most easily into one of these three “solutions.”

Type one results in someone who is overly aggressive and somewhat paranoid, distrusting most of the people around him who appear to him to be out of touch with the realities of a dangerous world.

One such man, held a job, maintained his family and showed no outward signs of depression. He distrusted everyone outside his family to a degree bordering on paranoia, was violent when he perceived a threat and occasionally was thrown into extended flashbacks in which he acted as if he were in combat under attack. This man displayed no conflict over having killed in the war. Although he was not brought up with war zone values, he was able to adapt to them and to accept that the rest of the world was distorted. He even encouraged his therapist to be more vigilant and ready for trouble.

Such veterans may have difficulty staying out of trouble on their jobs or with the law, but they are probably better protected than those in the other two groups from the ravages of guilt and self destructiveness.

Type two lives with enormous, unrelenting guilt. These men are not without the vigilance and paranoid attitudes of the type 1, but rather than embracing it as a justification for their violence, they may accept it as part of their punishment.

One such man appeared during treatment to be tortured with guilt over villages destroyed and civilians killed. He suffered terrifying nightmares and hallucinations of being under attack and he effectively destroyed his own life by using drugs, and engaging in other self destructive behavior. In the later part of his tour in Vietnam, he had been assigned as the head of a team that lived in a village as protectors. In getting to know the Vietnamese in the village as people, he effectively lost his ability to dehumanize them as a group, and was later horrified at what he had done earlier in the war.

The ability to dehumanize the enemy is almost essential for surviving without incredibly destructive guilt. In such a situation our “humanity” works against us. Empathy in a war zone may not be an ego asset.

Type three may be quite dramatic in it’s full form as a combat veteran lives a Jekyll and Hyde existence.

One such individual, a Vietnam veteran, first entered treatment in what I would call the “Jekyll” mode. He was outwardly cooperative and very guilt ridden, particularly about the enemy soldiers he had killed “on the wire” (the wire fence surrounding the perimeter of the camp).  Over time, he also went through periods in which he was rebellious and engaged in low level criminal activity that usually resulted in his coming to harm. In this “Hyde” existence, he was not verbally demonstrative about his guilt, but appeared to act it out by bringing various forms of punishment upon himself.

In psychoanalytic work, we customarily deal with guilt that is based on unconscious fantasies, childhood relationships and intentions that have not been acted upon; but, with these patients, the guilt is based upon the veteran having done something that breaks severely with his conscience. We cannot usually “analyze it away” and we cannot reassure. Support and acceptance may be helpful, but reassurance is hollow. In most cases the patient knows that what he did was destructive. He knows, for instance, that he has taken a life and destroyed others. The goal may have to be for the veteran to accept and live with his guilt, perhaps repairing some of the internal damage by doing something that will benefit others.

3. Understanding combat veterans involves understanding the personal dynamics of the individual along with the specific circumstances of the combat situation.

One of the most important questions concerning combat trauma, or, for that matter, any adult trauma, is the relationship between the traumatic event and the dynamics that the individual brings to it.

Post traumatic reactions are closely related to the specific events of the trauma, both those that are central to the traumatic experience and those that are incidentally associated with it. This is true of those concomitants that signal danger—explosions, hostility directed at them, the sight of blood, images of combat in film or elsewhere—those that signal safety—the weapon or absence of it, the small group that offers protection, having someone on “guard duty” while they sleep—and those that are related by chance to a greater or lesser degree—anniversaries of the time of the trauma, hearing the enemy’s language spoken or odors associated with the combat zone. The characteristics of each specific traumatic combat situation takes on meaning for each individual combatant in ways that may be both unique and shared.

Soldiers who were in a base camp which was attacked by rockets or other incoming fire were essentially passive victims of attack. There was always the question of survival, which depended a great deal on luck. In such situations, there was a natural turn to magical thinking, to a belief that survival can be controlled by one’s thoughts or behavior to a greater extent than is actually possible. In addition to being reactive to loud noises and to having dreams of explosions, such individuals frequently develop phobic symptoms and generalized anxiety or panic.  They may need to stay in motion, as if being in one place too long might make them a target or, more magically, as if the spot they are in may not be safe, so they’d best move on.  Many veterans say that they avoid crowds, not only because of the need for hypervigilance, for which crowds create difficulties, but because groups of people may be targets for attack. The terrorist attack on 9/11 reinforced such fears and behaviors.

“Tunnel rats” were sent into narrow tunnels to pursue the enemy. It was obviously dangerous since they could not know what they would encounter in the darkness of the tunnel. Some of these men become claustrophobic.  A clinician who worked with a number of tunnel rats noted that many of them become obese, as if to make themselves unsuitable to enter tunnels.

Similarly, we often see agoraphobic symptoms in sniper victims. The reaction to a sniper may be complex, involving not only fear of attack, but also helplessness and shame at being at the mercy of an unseen assailant. The concomitant rage projected onto the sniper reinforces the sense of danger. I have seen wounding from sniper fire that leads to episodes of uncontrollable rage directed at others, at times consciously marked by the frustration of having no means of avenging oneself on the unseen attacker.

The circumstances of combat may also affect attitudes toward authority. This can be a complicated issue for men who were sent into danger during late adolescence or young adulthood. We may see evidence of unconscious attitudes towards parental figures who failed to protect them. Trust takes on special meaning when life and death is involved.  The behavior and perceived behavior of officers and non-commissioned officers in intense combat situations may have a lasting effect on attitudes towards those in authority. Shay (1994) argues that the betrayal of trust is the core pathogenic experience in combat stress disorders. 

Issues of guilt may take on meaning specific to the trauma. Men who have killed children or seen them killed are sensitized when they have children of their own, in some cases fearing some form of magical retribution upon their children as well as fearing their own aggression. 

Group Ties

Most of the veterans with whom I have worked appear to have been less motivated by duty and honor to their country and the military and more concerned with their devotion to the small group of men, often only two or three, with whom they faced death. This distinction is particularly prominent amongst the Vietnam veterans who actually saw themselves as initially deceived by the more abstract duty to the larger unit or cause. But even those who do not claim such disillusionment describe themselves in specific situations as being motivated primarily by their own survival and the survival of the one or two men with whom they were close.

The evidence points to a transference to this small group that replaces familial attachments. This is particularly true of veterans who were in direct combat, “in the bush” in Vietnam, as opposed to those who were stationed in a base camp. The importance of this bonding is apparent in a number of ways: in the affection with which veterans speak of the men with whom they were close in combat, sometimes holding on to the illusion that their dead buddy is still with them, even hearing their voice or seeing them in the absence of other hallucinations; in the descriptions of complete breakdown of ego functions and controls after the death of a close buddy in combat; in the description of difficulty feeling the same degree of affection and bonding with wives, children and other family members that they had felt with their comrades in war; and, in the apparent restorative powers of bonding to a new small group in a therapeutic setting. The intense need to protect the small group in the combat zone often carries into civilian life in the form of pathological protectiveness of the veteran’s family against dangers both real and imagined.

Preexisting Dynamics and Pathogenesis

Each individual approaches the traumatic situation with his own personal history and psychology, which give the trauma its specific meaning. Pathogenesis may be understood as a process of compromise formation involving the interaction of the traumatic situation with the prior experiences and dynamics of the individual.

There has been debate in the psychoanalytic literature about the pathogenesis of traumatic reactions, and, in effect, the nature of trauma. Does trauma destroy internal representations (Auerhahn and Laub, 1984; Laub and Lee, 2003) or create a “catatonoid” state through hopelessness and helplessness (Krystal, 1978)? Those working with holocaust survivors are impressed with the death instinct and “beyond the pleasure principle” theories. For the most part, combat veterans did not experience themselves as totally helpless at the time of trauma. Are the traumatic experiences of combat simply traumatic because they overwhelm the defenses (Kardiner and Spiegel, 1947; Moses (1978 and in Geerts and Rechardt, 1978) or is their effect based in whole or in part upon specific pre-existing dynamics? (Hendin and Haas, 1984; Dane, 1927) Are some people more disposed to traumatic reactions than others? (Moses, 1978) Is an event traumatic because of the way it impinges on pre-existing conflicts? (Brenner, 1986)  The problem with this last question is that conflict is ubiquitous, as are fantasies of aggression and danger.  Trauma always occurs in the context of conflict, but that does not necessarily explain its effect. (Blum, 2003).

Certainly, a given event may be more traumatic for one individual than for another, and individuals will respond differently to the same stressor. There are, on the other hand, some events to which a great many people will react similarly. Just as there are so called “universal fantasies” there are likely universal overwhelming traumata, particularly during war. A recent study pointed to the importance of perceiving a threat to one’s life as a determinant to the development of post traumatic stress disorder. (Voges and Romney, 2003)

The life and death occurrences of war almost certainly influence core fantasies involving aggression and fear of aggression. The soldier who kills someone may be enacting fantasies of patricide, fratricide or matricide; witnessing an atrocity may reawaken the childhood trauma of witnessing spousal abuse; the death of a close buddy may replicate earlier traumatic loss of a parent.

A Vietnam veteran shocked a group of battle hardened veterans when he talked about an incident in which he deliberately called in an air strike on a group of Vietnamese children. Even he seemed baffled at what he had done, able to say only that he had the thought, “Why should they be happy?” He was the oldest in his family, with an acknowledged resentment of his younger siblings, for whom he was often held responsible by his mother. In time, it came out that the dynamics of this act concerned loss. His mother had died suddenly when he was a young adolescent, leaving him bereft. Shortly before the incident with the children, he suffered another sudden loss, of his best buddy in a battle so fierce that they could not retrieve the body. That loss proved overwhelming. He was in a state that could best be described as severe depression with dissociation. It was in that state, affected by the repetition of sudden overwhelming loss, that he killed the children, leaving himself a permanent wound of guilt. We can see the inevitable interaction of the traumatic event and individual dynamics

This is further illustrated by Phillips (1991) in his paper on an interrupted  analysis of a Vietnam veteran. Phillips’s patient had experienced ambivalence towards his own aggression from childhood. Early in the analysis, the patient described an ambush in Vietnam in which two adolescent North Vietnamese soldiers were killed, their bodies steaming and with gaping holes. He soon recalled a childhood incident in which his father volunteered him to shoot two pigeons under the roof with his BB gun. He did it, but was very disturbed and put aside the gun after that. Phillips argues that the combat experiences would have certainly been traumatic without the pigeon incident, but it would have taken a different form.

My experience has led me to a complex model of response to combat, one that reflects an interrelation between infantile and adult trauma, an understanding of the dynamics of combat veterans from an adaptational perspective that encompasses some factors that appear to be universal—including some mechanism of alarm after a traumatic event as well as dynamic aspects involving guilt and grief that affect all of us—as well as factors that are specific to the life history and dynamics of the individual and factors that come from the particular nature of the trauma and the context in which it occurred. Borrowing from Isaiah Berlin (1953), we should be “foxes”, looking for complexity and diversity, rather than “hedgehogs”, straining for a single explanation.

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