by Robert Grant
Abstract
Confusion about how to define and categorize combat reactions for US Forces in Afghanistan and Iraq has resulted in a significant number of traumatized combat veterans falling through the diagnostic cracks. A continuum of stress, Combat Stress and post traumatic stress reactions, along with the need for a holistic and coordinated care delivery, in regard to trauma care will be addressed in this article. Suggestions will be made regarding how to provide combat personnel with preventative education and trauma-care skills prior to deployment, in-theatre support and re-entry protocols. Finally, comments will be made on the impact of military culture on the implementation of trauma-care protocols.
Hoge and his associates published a ground breaking study in the July 2004 edition of The New England Journal of Medicine. The study examined rates of stress, depression and PTSD for troops coming out of Iraq (15.6-17.1%) and Afghanistan (11.2%). The study suggested that one in six experiencing combat (especially in Iraq) exhibited symptoms of a major depression, serious stress or a post-traumatic stress disorder. Data was obtained from a self-administered checklist given to troops as they transitioned out-of-theatre. The statistics do not reflect whether the sampled population considered themselves to be traumatized or not.
Despite the fact that the study initially received a great deal of attention it has left many in the military confused about how many US service personnel are being negatively affected or traumatized by war. This has also raised the question of how many enter combat with pre-existing psychiatric issues (i.e., that predispose them to react in ways that are consistent with PTSD and other forms of psychological distress) (Nishith, 2000). The debate also continues regarding what distinguishes stress from Combat Stress, as well as Combat Stress from PTSD (Selye, 1992, Chrousos & Gold, 1992, Bracken Giller & Sumerfield, 1995). This article attempts to clarify some of these issues.
At the far end of the continuum (whether it is combat stress or not) stress involves being pushed to the limit, i.e., in terms of an individual’s ability to cope. Stressed individuals usually carry a perceived sense of being in control despite dealing with a variety of difficult forces and circumstances.
Stress is known to be a major component in several psychological and physical problems (Schnurr & Jankowski, in press). Resolution usually involves extraction from the stressful situation, a change in attitude, social support and periods of rest and relaxation.
Combat stress is a particularly serious form of stress. It involves actual or potential (Linn, 1986) exposure to combat and thus the possibility of witnessing and/or incurring loss of limb and life. Just knowing that at any moment one could be attacked, witness or experience a serious injury or die typically results in excessive worry, hypervigilance, overwhelming strain and a host of stress-related reactions, e.g., agitation, irritability, panic attacks, sleep disturbances, sleep deprivation and, over time, emotional numbness and/or depression. Many of these PTSD-associated symptoms are the result of trying to survive in the face of recurrent stressors that are highly debilitating, if not, life-threatening.
Combat Stress involves multiple stressors, e.g., hyperalertness, problems concentrating, exhaustion, sleep deprivation, anticipatory anxiety and painful memories. Unresolved Combat Stress can easily turn into mild to moderate post traumatic stress reactions. Mild to moderate PTSD refers to a couple of PTSD symptoms and a diminished sense of health and morale, coupled with feelings of futility and hopelessness.
Being traumatized on the other hand involves being taken over one’s limits, i.e., rendered helpless and powerless. In the case of trauma every traumatic stressor (by definition) threatens the physical integrity and/or life of the individual and/or anyone close to him. Such individuals have been forced to confront their inherent vulnerability and lack of control (i.e., tenuousness and contingent nature of human existence) (Herman, 1994, Grant, 2005).
It is important to bear in mind that not everyone exposed to a traumatic stressor becomes traumatized, i.e., in terms of the full DSM criterion for PTSD. At the same time it does not mean that an individual (who fails to meet the full PTSD criterion) has not been seriously affected or traumatized.
Excessive combat stress often results in mild to moderate forms of traumatization. These forms often present in what the author characterizes as a subclinical presentation of PTSD, i.e., 1-2 of the following PTSD symptoms (nightmares, flashbacks, reliving experiences, panic attacks, phobias, self medicating and/r a sleep disturbance).
A significant number of combat veterans carry a combination of operational stress, combat stress and low grade PTSD. Others experience moderate to full blown PTSD. Still others break down, i.e., have nervous breakdowns or psychotic breaks. The aforementioned responses are typically grounded in the cohesiveness of pre-traumatic identity structures, level of horror and killing experienced in combat and number of tours in a war zone.
The issue should not be whether a war veteran is dealing with stress or trauma reactions but how an individual is holding together, i.e., coping with distressing material that has been acquired in a war zone. In the case of a combat veteran it is whether s/he has been destabilized or not.
The upshot of the above, for psychological professionals and military personnel, is that the DSM criterion for PTSD should no longer be considered the gold standard for whether or not an individual has been traumatized. There are too many other forms of war related distress that occur as a result of being exposed to certain experiences in combat and a war zone that are not picked up on the PTSD radar.
In essence, a continuum of stress and trauma reactions needs to be developed. Professionals need to consider combinations of stress, Combat Stress and trauma that either stand alone or in combination (i.e., due to repeated exposures and/or multiple deployments) to create a spectrum of reactions and disorders that are psychologically and spiritually significant, despite failing to meet the DSM criterion for PTSD. To complicate matters further pre-morbid personality characteristics and pre-war trauma histories of those about to enter combat zones should also be considered when trying to determine why and how certain individuals react to particular stressors and/or situations in the ways that they do. Multiple experiences of pre-war trauma are often triggered or reawakened by a variety of war-related experiences.
In addition to the number of troops that qualified for a diagnosis of PTSD in Hoge’s study, it is possible that a significant percentage (i.e., as many as an additional 20-30% of men and women coming out of Afghanistan and Iraq) are carrying a subclinical version of PTSD.
PTSD is an all or nothing diagnosis. There is no such thing as partial PTSD. One either has PTSD or he doesn’t. Most people, whether involved in combat or not, fail to meet the full DSM criteria for PTSD. A significant number exhibit a syndrome best characterized as debilitating combat stress or a subclinical presentation of PTSD. Their causal histories may differ (i.e., one as a result of the repeated stresses and strains operational tempos and the other due to excessive strain and/or a highly traumatic stressor(s) ).
As a result of failing to understand or diagnose the aforementioned subclinical syndrome a number of health professionals (both in and outside the military) are incorrectly concluding that large numbers of war veterans have come through war and combat relatively unscathed (i.e., in a physical, psychological and spiritual sense) simply because they failed to meet the full DSM Criterion for PTSD. Another reason for this oversight is that the majority of war veterans do not outwardly manifest trauma-related symptoms in a combat zone.
DSM definitions of trauma create additional problems. To qualify for the DSM diagnosis of PTSD one must have experienced a Criterion A Event, i.e., been exposed to an actual threat to the physical integrity of self and/or other. Criterion B-F (which round out the PTSD diagnosis) can not be accessed until a Criterion A Event has been established.
Most people would agree that there are traumatic stressors that pose serious threats to personal integrity, in addition to those that involve a physical threat. These would involve psychological, cultural and spiritual threats. The latter stressors are not only capable of traumatizing an individual but also generating any or all of the symptoms associated with a full presentation of PTSD.
Along the same lines, an overemphasis on DSM guidelines and psychiatric symptomology, frequently causes the Psychological or Psychiatric professional to overlook the more profound effects of combat stress and trauma, i.e., the tectonic shifts that have taken place in a war veteran’s taken-for-granted ways of organizing “self” (Stolorow, 2001; 2002; Grotstein; 1986, 1990) “world” (Bulman, 1992; Decker, 1993a, 1993b; Lifton, 1967; James, 1961) and God (Grant, 1997, 1999a, 1999, 2000, 2002). As a result, often the more serious consequences of war and combat exposure are either minimized or overlooked due to an overemphasis on psychiatric symptomology and threat to physical integrity of self and/or other. In essence, breeches in psychic integrity, generated by a variety of traumatic forces, oblilge individuals to take on more of reality than was previously possible (Grant, 1999; 2004).
Looking Beyond Psychiatric Symptoms
Psychiatric symptoms are often the result of being unwilling or unable to integrate the implications of traumatic experience into more comprehensive frames of reference. There are few things more disturbing to a human being than to discover that the ways s/he has been taught to characterize self and/or reality have been radically thrown into question or destroyed by a variety of war experiences. Many discover in the wake of many traumatic events that former ways of characterizing life and making sense are no longer viable and, thus, able to guarantee safety, security, sense or meaning (Frankl, 1959).
Along these lines, it is possible to consider that flashbacks, reliving experiences and nightmares are ways that an awakened psyche’s refuses to be silenced. By throwing traumatic material back into awareness, the psyche in essence, is saying that it will not allow the individual to forget what has been experienced, questioned and concluded (i.e., what the implications of his/her traumatic experience say about being-in-the-world-with-others who are either asleep or in denial).
Military culture plays a significant role in how stress and trauma are experienced and held by service personnel. Inexperienced troops are typically given inaccurate pictures of the psychological and spiritual (Garbarino, 1996) costs associated with participating in any type of combat. The assumption is that by toughening troops, providing realistic training, clarifying roles and instilling the belief in a just war that combat personnel will be able to buffer much of the emotional confusion and ethical toxicity that typically follows in the wake of being in a combat zone.
Military Command has feared for some time that if troops were made aware of the physical, psychological and spiritual costs of war that most would not only freeze under fire but refuse to enter combat and kill. There may be some truth to this concern. Yet whatever the reasons the US Military has for not being more honest with its troops, regarding the emotional consequences of war, the bottom line is that it does not adequately prepare or train its personnel (i.e., in or out of theatre) to process the emotional, spiritual and interpersonal fallout that typically accompanies having been exposed to combat and/or living in a war zone.
Most troops are unprepared for the unsettling dissonance that occurs when what they have been taught collides with what they experience, wonder about and are troubled by. Many discover that foundational values and beliefs, i.e., acquired from home, church, government and military, do not hold up in the face of a variety of combat realities. Military culture provides little in the way of how to process trauma-generated material once it begins to surface and/or undermine the psychological and spiritual integrity of a war veteran.
In practice, the military encourages the suppression of any emotion suggestive of weakness. At the same time, it typically fails to provide self-care protocols for troops that are regularly exposed to a multitude of traumatic stressors. Denying the full impact of trauma is part and parcel of military culture. Troops are taught to keep a stiff upper lip and endure. In order to keep traumatic material suppressed or out of conscious awareness, combat veterans are forced to continually distract themselves through overwork, forms of chemical and emotional anesthesia, high risk activities and overstimulation (e.g., incessant music, video games, DVD’s etc). All of the above are temporary distracters that in no way are capable of working through material that, if left unaddressed, has the potential to cause problems for the rest of a veteran’s life, along with the lives of his family members.
Between the pressures of military culture and the stigmas associated with seeking psychological help (Hoge, 2004) a significant number of combat veterans are left with little recourse but distract, self medicate or seek out the chaplain. Many receive support and care from the chaplain. At the same time those most in need often fail to get help for the existential and spiritual struggles that have been generated from their experiences in a war zone. This is primarily due to the lack of training that military chaplains receive in regard to combat and trauma-based ministries. In addition, most chaplains are ensnared in the same middle class social box as the average military leader and civilian.
As a result of the above, a significant number of combat veterans end up agitated, depressed, existentially displaced, spiritually wounded and socially isolated. As a consequence, they are at risk of performing inadequately at work, developing some form of emotional and/or cognitive impairment, getting divorced, finding themselves unable to relate to anyone but a war veteran, turning towards some form of addiction and/or perpetrating violence on either self or other.
Despite the fact that a large number of active personnel are carrying significant impact from Iraq and Afghanistan, Military Command, (at every level), continues to remain uncertain about how to characterize and/or react to the effects of combat stress and trauma as they manifest themselves in their personnel. The Trauma Brief continues to remain unpopular and unclear. It continues to be passed through the military system without any sector of the Armed Forces willing to make it its own.
Overall, progress has been made in getting more trauma-related information out to the troops. The OSCAR and Warrior Transition Programs have been fortified and better resourced. Despite raised awareness and the aforementioned improvements, the problem of combat stress/subclinical PTSD has yet to be properly conceptualized or addressed by Military Leadership. Mostly likely, the failure to properly address the needs of war veterans (in regard to combat stress and trauma) is due to a variety of economic and political reasons that have nothing to do with the current state of trauma knowledge in the Field of Psychology (i.e., which is quite capable of providing appropriate self care protocols to military personnel are struggling with the effects of Combat Stress and Trauma).
Turf issues in military systems further complicate the matter. Navy Medicine has worked diligently to avoid becoming locked into the role of psychiatric provider. Along the same lines, Navy Chaplains have struggled for years to gain credibility as line officers and are reluctant to see their job descriptions reduced to those of pastoral counselor (especially in regard to victims of combat stress and trauma). Lastly, military psychotherapists have been routinely overworked and understaffed. Historically they have been tasked to address marital and family matters rather than issues related to combat stress or trauma.
Marines coming back from Iraq often have to wait weeks or months to see a psychotherapist on base. Many seeking counseling are referred outside of the military to EAP systems or OneSource counselors who often have little to no training in the areas of combat stress and trauma.
The aforementioned divisions within the military fail to provide a coordinated system of care to either victims of combat stress/trauma or their families.
Regardless of more progressive voices in the military or what is written in procedural manuals or military literature, a diagnosis of PTSD can still seriously affect one’s career and restrict his/her security clearance. These realities work against seeking care (even if available) and more importantly against disseminating trauma awareness throughout every facet of military life and training.
Military pride also makes it difficult for leadership to bring in outside experts from the mental health sector. Strategic planning, on matters related to trauma and coordinated-care delivery, needs the involvement of civilian experts (many of whom have spent their entire careers working with the medical, psychological and spiritual effects of trauma).
Other than brochures and pamphlets dealing with preventative education and self-care, there is almost nothing built into the training of troops that teaches them how to do psychological first aid and self-care in the field (i.e., in the aftermath of having been exposed to a combat or traumatic stressor).
As mentioned earlier, many fear that if a soldier, marine, airman or sailor is given realistic information about the impact of war and trauma then s/he will become too frighten to go into battle or work in a medical field facility. This mindset implicitly supports after-care at the expense of prevention and self care. A considerable decrease in traumatic impact could be obtained if trauma awareness and coping skills were integrated into every facet of military training. Sadly, after-care usually means once an individual is out of the military and, thus, becomes part of the Veterans Administration. After-care should mean: after traumatic exposure, after leaving theatre (i.e., transitioning home) and after getting back home.
The problems mentioned above are compounded when Reserves and National Guard (who are frequently without the holding capacity of a military community or the spirit d’corps that holds many combat veterans together in the field) are considered. Multiple deployments, individual augments and shorter turn around times end up creating environments in which combat veterans are afraid to take off their emotional “packs.” In these cases, it is just a matter of time before suppressed material gets compounded to the point where it bursts forth with a range of consequences that, not only affect the individual combat veteran and his/her family but also the entire US Military and American people.
In this day and age with all the knowledge about traumatic stress that has been gained from war veterans; especially those coming out of Vietnam (Rosenbeck & Fontana, 1996, Figley, 85, 86, 96) and Israel (Solomon, 1987, 1989), it is essential that US Combat Forces be taught how to address the psychological and spiritual effects of war (i.e., from boot camp to the rest of their career) on their own and/or in small groups.
Marine fire teams, for example, could be taught throughout their training (including the Crucible) how to properly assess and process traumatic material together, i.e., when it affects a particular member or the entire team. Marines, like all combat troops, would continue to receive in-field support (e.g., from chaplains, corpsman and psychological/medical professionals) if unable to resolve matters on their own. Psychiatrists would then take on personnel that have been severely affected (i.e., those that qualify for a full DSM diagnosis of PTSD or a more psychologically disorganizing reaction). Finally all troops would have access to a variety of re-entry protocols (e.g., when transitioning back home and at 30, 60, 90, 180 days post deployment). This would involve various forms of self care and emotional and spiritual detoxification.
It is important to remember that many fail to exhibit reactions to combat stress and/or trauma until they feel safe enough (which usually means once they have gotten home to a safe and predictable routine). In many instances, delayed reactions do not appear until months after a final deployment has been completed.
Health care professionals need better training in the assessment and treatment of combat stress and trauma, especially in regard to the various sub-clinical expressions of PTSD that were mentioned in earlier sections.
Family volunteers need more training and input in regard to policy development. They are not only an invaluable source of information in regard to family members that have been traumatized but they are also able to offer a great deal of support and care to returning combat veterans (if properly trained).
Troops need to be taught a variety of combat stress and trauma self-care protocols that can be effectively and efficiently implemented in-theatre without interfering in operational effectiveness or group cohesiveness.
Trauma Briefs, at all levels, need to be upgraded. Less time should be spent on psychiatric diagnoses and symptom management than on what the symptoms signify (i.e., changes in the way a war veteran views self, others, world and God). Lastly, war veterans must be taught how to resolve and integrate war-related material that, if left unaddressed, often results in a wide-range of PTSD like-symptoms and interpersonal problems.
The Military can deal with the effects of trauma now or it can deal with them later. The financial and social costs (to both the Military and the American people) will be enormous, if many of issues surrounding combat stress and trauma are not addressed in a more comprehensive fashion. The Iraq situation has the potential to be far worse than what transpired after Vietnam. Combat conditions are quite severe in many parts of Iraq. In addition, CNN, the Internet and cell phones have provided information to troops that no other army in history has ever had access to. This influx of information increases the chance of cognitive dissonance and uncertainty amongst combat personnel (i.e., in terms of receiving contradictory information about the war from Command, the Media and people at home).
More research is needed on what troops are actually experiencing in Iraq and Afghanistan, as well as what factors contribute to both a positive or negative resolution of such experience. Information needs to be gathered from combat veterans in terms of what they have experienced and how they are dealing with stress and trauma-based exposures, i.e., both in-theatre and when returning home.
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"http://web14.epnet.com/searchpost.asp?tb=1&_ug=sid+96B83F44%2DC351%2D44DC%2D8CC8%2D0A88E136C3F2%40sessionmgr4+dbs+pdh+cp+1+8C91&_us=sel+False+frn+1+hd+False+hs+False+or+Date+mdbs+pdh+fh+False+ss+SO+sm+ES+sl+%2D1+dstb+ES+mh+1+ri+KAAACBWB00045696+860E&_uso=hd+False+tg%5B2+%2D+tg%5B1+%2D+tg%5B0+%2D+st%5B2+%2D+st%5B1+%2Danticipation+st%5B0+%2Dstress+db%5B0+%2Dpdh+op%5B2+%2DAnd+op%5B1+%2DAnd+op%5B0+%2D+DB9F&ss=AR%20%22Linn%2C%20Margaret%20W%2E%22&fscan=Sub&lfr=Lateral&" \o "Linn, Margaret W." Linn, M.W. (1986). Modifiers and perceived stress scale.
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Chaplains are usually also co-opted into the “culture of denial.” Most chaplains know that if they don’t play ball with the powers that be they will not be promoted and, thus, be mustered out of the military (along with the many benefits and pay that cannot be found in the civilian world for a church minister).
New England Journal of Medicine (Vol. 351, No. 1-, pages. 13-22) (July ,2004) Anticipation of these losses can stress some to the point of becoming overwhelmed and emotionally destabilized. Peer pressure, training and unit cohesiveness can temporarily contain such fears and emotions. As a result, many combat troops fail to manifest trauma-related symptoms until they leave the stressful environment and return to a more normal and safe routine at home. Delayed reactions are more rule than the exception. One of society’s main functions is to provide the illusion that people are safe, secure and not in immediate danger of death or injury, along with a host of other myths regarding interpersonal civility, justice, right and wrong and the sanctity of life. These estimates are based on USMC (1-MEF) personnel whom I had access to from Nov. 2003 - June 2005 at Camp Pendleton. Many had already done one or two tours of duty in Iraq of Afghanistan. Esprit d’corps, role clarity, pressures to believe in a just war, highly structured routines, exhaustion and close personal friendships tend to keep the majority of war veterans stabilized and contained while in-theatre. There is currently no room in DSM for an anticipated or imagined threat. It would be important for professionals to recognize psychologically that one’s sense of self is not only destabilized but in many cases irreparably damaged as a result of combat exposure. Existentially, many war veterans become acutely aware that they are inherently not in control of any aspect of their life. In essence, they come to see that they are limited and finite (i.e., can’t cover all of life’s contingencies, can be seriously wounded or killed at any moment - whether in a war zone or not). Many also learn that war and, especially combat exposure, rendered their former ways of characterizing life meaningless and, thus, left them without purpose or direction. Spiritually, the war experiences of many end up contradicting or destroying any image of God that they may have held in the past. Traumatic material, in addition to the implications it holds for former ways of organizing internal and external reality, also contains considerable affect (i.e., particularly in regard to anxiety and depression). Anxiety frequently represents awareness of their inherent vulnerability which has been exposed, in and through a variety of war-related experience and, which in an ultimate sense, demonstrates that they are unable to guarantee the safety of self and/or others. A by-product of this realization is that life often ends up being without any sense of meaning; especially in regard to the sleepwalking masses). Depression, on the other hand, is frequently is linked to some form of loss (i.e., a specific person but more specifically a particular version of life). Stuffing and enduring makes sense, to some degree, in a “hot zone.” Yet it does not make sense to keep such material suppressed indefinitely. As an overall approach, in or out of combat, it seriously impairs an individual’s ability to accurately perceive, judge and react to a variety of stressful and dangerous stimuli. Unresolved traumatic stress is a major factor in subpar performance, poor judgment, a lack of sensitivity in the face of threat and, thus, an increased chance of putting others in harms way. Hoge goes on in his article to state that only 23-40% of the personnel that claimed to have qualified for a diagnosis of PTSD actually sought psychological care. He attributed this to the powerful stigmas that are associated with seeking psychological counseling in almost all military settings. Navy Chaplains have been trained to address the psychological and spiritual impact of trauma over the last ten years. The problem is that a great many chaplains have trouble transitioning from an office and church-based ministry to ones that are field-based or combat-oriented (i.e., which emphasize combat exposure and the need for depth work in the areas of emotion, belief, ethical values and God imagery). Chaplains, like their medical counterparts, have turf issues and a vision of how the profession should be represented and expressed. Many, in leadership, feel that it is less attractive to help an individual reconstitute a tattered belief system than to hold a religious service or advise military leadership.CREDO was originally and still is (depending on who is leading the retreat) a place where Navy and Marine Chaplains help personnel and their families sort out the emotional and spiritual damage they sustained as a result of war. Chaplains have also become the unofficial counseling service of the military. Visits to the chaplain, unlike the psychologist, do not end up in a personnel file. Underground therapy often takes place at the chaplain’s office, although often without the chaplain being able to provide the kind of care that could help the combat veteran work through the effects of war (Jaffe, 1985). Again they often do not manifest themselves in terms of PTSD symptomology but in terms of domestic violence, high risk activity, substance abuse, work related accidents and suicide. Common consequences are substance abuse, violent assault, health problems, domestic violence, child abuse, divorce, training accidents, suicide and murder.
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