“What is a ‘tunnel rat’ and why are they important?” are excellent questions. What a wonderful way to begin this article on Sergeant (SGT) R – retired, Vietnam Veteran who has Post Traumatic Stress Disorder. He was treated previously at the VA Hospital and Medical/Behavioral Clinics near his place of residence. Without seeing any progress he was referred to our group by his family physician. You may feel this writer is taking the “long way around” to answer these questions. In a sense she is. After perusing this information the reader will discover the answers to both questions, gaining knowledge in the process.
Before we discuss SGT R’s case the following historic information needs to be shared. Some of this information was relayed by the sergeant, and other individuals involved in group therapy. Permission has been obtained from the individuals involved and changes have been made and approved by these individuals in order to protect their confidentiality and the confidentiality of the therapeutic relationship. The individuals have given their expressed and implied permission for their information to be used as educational/therapeutic treatment tools. Additional information in the form of articles from other military sources and the History Channel have been used. The American Psychiatric Association’s Diagnostic and Statistical Manual has also been used for reference. All materials were used as resources and no information was used verbatim. This is done in order to give interested individuals the history of Vietnam and the United States’ involvement.
The history of Vietnam’s struggles for independence goes back to the last emperor Bao Di and his giving control of the government to the French in 1945. Vietnam had been part of French Indo-China since 1885. An independence and resistance movement began to grow during the early 20th century. In 1941, Japan invaded and conquered French Indo-China. This move precipitated the emergence of the Viet Minh, a communist, nationalist liberation movement led by Ho Chi Minh, seeking independence from France as well as to oppose the Japanese occupation. When the Japanese were defeated in 1945, Ho Chi Minh declared Vietnam independent. France refused to accept the departure of Vietnam from French Indo-China. As a result Vietnam’s war for independence again surfaced until 1954 when a cease fire agreement was made with France and the nation was divided in two sections similar to Korea, thus the creation of North and South Vietnam.
The story of the Cu-Chi tunnels and tunnels in other areas begins during the late 1940’s as the Viet Minh were digging a network of tunnels under the jungle terrain of South Vietnam, in the areas north of Saigon and between Saigon and the Cambodian border. These tunnels were in many cases dug by hand a short distance at a time. The United States became involved in the affairs of Vietnam in the late 1950’s. The United States was concerned about the spread of communism in the region. They initially sent military advisors (mostly Army Special Forces Intelligence Officers). The United States escalated their military presence in Vietnam in support of a non-Communist regime in South Vietnam during the early 1960s. The North Vietnamese Army (NVA) and Viet Cong (VC) gradually expanded the tunnels. At the peak of the Vietnam War, the network of tunnels in the Cu Chi district linked VC support bases over a distance of some 250 kilometers (or 155.34 miles). The tunnels went from the outskirts of Saigon to the Cambodian border.
The Cu Chi district northwest of Saigon was where the majority of these tunnels began. VC and NVA soldiers used these underground routes to house troops, transport communications and supplies, lay booby traps and mount surprise attacks, after which they could disappear underground to safety. To combat these guerrilla tactics, U.S. forces and South Vietnamese forces trained soldiers known as “tunnel rats” to navigate the tunnels. These soldiers, who were usually of small stature, would spend hours navigating the cramped, dark tunnels to detect booby traps and scout for enemy troops.
In January 1966, some 8,000 U.S. and Australian troops attempted to sweep the Cu Chi district in a large-scale program of attacks dubbed Operation Crimp. After B-52 bombers dropped a large amount of explosives onto the jungle region, the troops searched the area for enemy activity but were largely unsuccessful, as most Communist forces had disappeared into the network of underground tunnels. A year later, around 30,000 American troops launched Operation Cedar Falls, attacking the Communist stronghold of Binh Duong province north of Saigon near the Cambodian border (an area known as the Iron Triangle) after hearing reports of a network of enemy tunnels there. After bombing attacks and the defoliation of rice fields and surrounding jungle areas with Agent Orange and other powerful defoliants, the U.S. tanks and bulldozers were able to move in to sweep the tunnels, driving out several thousand residents. NVA and VC slipped back in within months of the sweep, and in early 1968 used the tunnels as a stronghold in the assault on Saigon during the Tet Offensive.
The United States relied heavily on bombing, hence the NVA and VC went underground in order to survive and continue their guerrilla tactics against the much better-supplied enemy. In heavily bombed areas, people spent much of their life underground, and the Cu Chi tunnels grew to house entire underground villages, in effect, with living quarters, kitchens, ordnance factories, hospitals and bomb shelters. In some areas there were even large theaters and music halls to provide diversion for the troops and their supporters. The tunnels played a key role in the combat operations, including as a base for NVA and VC attacks against nearby Saigon. VC soldiers lurking in the tunnels set numerous booby traps for U.S. and South Vietnamese soldiers, planting trip wires to set off grenades or overturn boxes of scorpions or poisonous snakes onto the heads of our troops.
This is where SGT R comes into the picture. He was one of the operators known as a “tunnel rat.” As a result he experienced flashbacks and periods of blackouts. He began to fear being inside, being in small and/or closed in places, being touched lightly as if by a spider’s web. All of this occurred after his return stateside. He had begun using alcohol to self-medicate, it “assisted with helping me to calm down” (his words). Other behaviors that evidenced PTSD were the “out of control times when I felt the whole house was closing down around me” (his words). During these times of panic he would break anything preventing him from attaining fresh air and sunlight. He had an excellent support group with the other veterans who were members of one of the clubs in town. When one of these incidents occurred, the men would all get together and go to whoever’s home was in need of repair and install things needing to be replaced or complete the demolition and start a new. This is not unusual. Many individuals with PTSD self-medicate with alcohol and other drugs. The Sergeant was unable to continue his responsibilities at the time and was given anti-psychotic medications to treat his “hallucinations”.
Being given an inappropriate medication only exacerbated some of his symptoms which included complaints of depressed mood most of the day, nearly every day; Insomnia nearly every day; psychomotor retardation (which is slowing of the responses and reactions to things happening around him); fatigue; diminished ability to think or concentrate. He also experienced feelings of unreality, what he described as “being back in the tunnels near Cu chi” (his words). He also described the Tet offensive battles in which he was involved. No organic factor initiated or maintained this disturbance. It is not a normal reaction to the death of a loved one. At no time during this disturbance had there been delusions or hallucinations in the absence of prominent mood symptoms. It is not superimposed on Schizophrenia, Schizophreniform Disorder, Delusional (Paranoid) Disorder or Psychotic Disorder, Not otherwise Specified.
At the time of initial contact and therapy with this individual he was 42 years old. He had over twenty years of service and had been stationed many different theaters of operation. He was divorced and rarely saw his family due to the fluctuation of his moods and “mental status”. He had recurrent, intrusive distressing recollections of the events. He made efforts to avoid activities or situations that aroused recollections of the trauma. He felt detached and estranged from others and had become extremely withdrawn. He had a restricted range of affect. He had difficulty falling asleep, hyper-vigilance and an exaggerated startle response. He continued to have periods of memory loss. At the time of initial contact he was willing to be seen by a therapeutic psychiatrist and in individual and group therapy. He agreed to keep a journal, but was uncertain about allowing this therapist to read it. He stated he would “try out the group to see if the guys are for real” and would decide later regarding the journal. That was not a problem for this therapist.
Let me insert here that one may become concerned when they see the term “Negative Reinforcement Behavioral Therapy.” Allow me to demystify this technique and explain it is rarely used with individuals who present a danger to themselves. There is technically not much a rubber band can do that would present critical damage, however, if someone believes they need to punish themselves one could easily loose an arm, hand, any extremity.
Plan of Treatment for “The Sergeant”:
|Presenting Problem||Date Met||Mode of Treatment||Frequency|
|Major Depressive Episode & PTSD||Individual therapy||initially once a week for 1 hour decreasing to bi-monthly decreasing to once a month additional sessions as needed|
|Group therapy||once a week for 1 ½ hours|
|Discuss medication options|
|Journal||a minimum of once a day regarding thoughts, actions, and feelings|
|Systematic Desensitization||Instruction during individual sessions; Document sessions outside of appointments; use during his regular daily activities when used.|
|Negative Reinforcement Behavioral Response Therapy||To be determined|
Individual therapy is one of the primary treatments for PSTD. During these sessions the individual is encouraged to share what is on their heart and mind. They are also encouraged to share important episodes from the journal. If the individual is open to using medication, it should be chosen wisely by a therapeutic psychiatrist with extensive experience in working with individuals who have major depression and PTSD. From this writer’s personal and professional experience, it is not wise to use an anti-psychotic drug for treatment of PTSD. These medications tend to increase depressive symptoms and slow reaction and response time. It also slows thinking.
SGT R. attended individual therapy consistently and kept journals for the first several years of treatment. During therapy there were times when he would have flashbacks, in other words act as if the trauma was occurring in the here and now. During these times he was reminded these were only memories, they could not harm him, he had survived the original event. This became his “mantra” or self talk when he would have prodromal sensations prior to an episode. He began to gain control over of these sensations through the self talk and has subsequently experienced a significant decrease in the number of full blown flashbacks.
Systematic desensitization was also used. During one of the sessions he was instructed to hold the remote control as a taped news program regarding the type of work in which he formerly participated played on the television. When he began to experience the prodromal stage prior to the flashback, he was instructed to either hit the pause or the stop button. As he practiced this initially during his sessions he began to experience a heightened sense of anxiety and would quickly hit the stop button. While using the self talk and maintaining control of the remote he experienced less and less symptoms and was able to practice this technique at home and at other places when the prodromal effects began. He became able to exercise control without having to use the actual remote, simply visualizing himself pressing the pause or stop button. During the most recent session of individual therapy SGT R indicated the flashbacks had essential subsided. While he did intermittently experience the prodromal stage at times, this also had significantly decreased.
SGT R attended group therapy on a regular basis once a week. The other members of the group also experienced symptoms common to PTSD. During these sessions the group members would ventilate feelings of anger, frustration, anxiety, and eventually fear. During the process of sharing their personal stories he discovered he was not alone in his experiences. They were very similar to the other members of the group. There were times when confrontations were appropriate and encouraged to engage other members to participate. At times the group took on the structure of and Alcoholics Anonymous (AA) meeting where one individual would share their story with the group. The meeting where SGT R participated in this manner was extremely cathartic (his words). He expressed he was hesitant to participate in “Sharing my issues with the group,” however he was glad he had been encouraged to participate in this fashion. He expressed he “felt as if I was ready to graduate when I was able to describe the events surrounding my life and not flash out”.
After conferring with his psychiatrist it was decided he had progressed to the point where he was able to graduate from the group and only continue with individual therapy at a frequency of once a month. He continues to require medication due to a change in neurobiological chemistry and the lack of uptake of the neurotransmitters serotonin, norepinephrine and dopamine. Occasionally, he continues to require antianxiety medication to prevent panic attacks. Overall he is much improved with it having been several years since an occurrence of a flashback.
We see here a case of an active duty soldier who needed assistance initially from the Military physicians and when he retired from the Veteran’s Administration. He received services however, it does not appear they were tailored for the sergeant’s individual needs, thus prolonging the severity and interfering with his active thought processes. When appropriate medical and psychological/behavioral interventions were applied the Sergeant improved greatly and has been stable and functioning normally within his community. All it takes is TIME, UNDERSTANDING, WISDOM AND WILLINGNESS TO TRY SOMETHING NOT TRADITIONAL! There is always an answer out there somewhere, we just have to find it.