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THE COMBAT TRAUMA CONTINUUM AND VETERANS Lessons from the Past, Wisdom from the Present, Healing in the Future. Robert J. Caffrey, LPC., J.D.

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Presentation on theme: "THE COMBAT TRAUMA CONTINUUM AND VETERANS Lessons from the Past, Wisdom from the Present, Healing in the Future. Robert J. Caffrey, LPC., J.D."— Presentation transcript:

1 THE COMBAT TRAUMA CONTINUUM AND VETERANS Lessons from the Past, Wisdom from the Present, Healing in the Future. Robert J. Caffrey, LPC., J.D.

2 THE COMBAT TRAUMA CONTINUUM AND VETERANS War and trauma take place on a continuum.War and trauma take place on a continuum. Physical Continuum – Combat Operational Stress Reaction (“COSR”) to Post-Combat Trauma (“PTSD”).Physical Continuum – Combat Operational Stress Reaction (“COSR”) to Post-Combat Trauma (“PTSD”). Narrative Continuum – Trauma is contextual, the warrior and his/her culture give the combat experience its’ meaning.Narrative Continuum – Trauma is contextual, the warrior and his/her culture give the combat experience its’ meaning. Historical continuum – The wounds of war are timeless.Historical continuum – The wounds of war are timeless.

3 Overview The “Paradox” of the Warriors’ World - The Need for Cultural Competence.The “Paradox” of the Warriors’ World - The Need for Cultural Competence. The Physiology of Combat – The Re-wiring of the Warriors’ Nervous and Emotional System.The Physiology of Combat – The Re-wiring of the Warriors’ Nervous and Emotional System. Scars on a Warrior’s Heart – A History of the Impact of Warfare on Soldiers.Scars on a Warrior’s Heart – A History of the Impact of Warfare on Soldiers. Healers and Warriors – A Conversation about Healing Invisible Wounds.Healers and Warriors – A Conversation about Healing Invisible Wounds.

4 A Warrior’s Journey The Bridge Between Worlds

5 THE PARADOXTHE PARADOX

6 The Warrior’s Paradox Soldiers are not as other men...They are those of a world apart, a very ancient world which exists in parallel with the everyday world but does not belong to it...The distance can never be closed, for the culture of the warrior can never be that of civilization itself.Soldiers are not as other men...They are those of a world apart, a very ancient world which exists in parallel with the everyday world but does not belong to it...The distance can never be closed, for the culture of the warrior can never be that of civilization itself. A History of Warfare, John KeeganA History of Warfare, John Keegan

7 The Warrior’s Paradox Operating in a world of chaos Old English “Wyrre” – “to bring into confusion.”

8 The Warrior’s Paradox Combat TruthsCombat Truths War is about combat, combat is about fighting, fighting is about killing, and killing is a traumatic personal experience.War is about combat, combat is about fighting, fighting is about killing, and killing is a traumatic personal experience. Frequency of combat and proximity of killing is directly proportional to the level of combat stress.Frequency of combat and proximity of killing is directly proportional to the level of combat stress. A warrior must be able to psychologically and emotionally distance themselves from the environment, the killing, and the civilian world to win and to survive.A warrior must be able to psychologically and emotionally distance themselves from the environment, the killing, and the civilian world to win and to survive. There is, and always will be a deep and abiding contextual and cultural gap between a combat veteran and a civilian.There is, and always will be a deep and abiding contextual and cultural gap between a combat veteran and a civilian. COL Timothy (“BT”) Hanifen, USMCCOL Timothy (“BT”) Hanifen, USMC

9 The Warrior’s Paradox Warriors - those prepared to kill, or be killed or maimed, to protect another from actual or threatened violence.Warriors - those prepared to kill, or be killed or maimed, to protect another from actual or threatened violence. Victor Davis Hanson – The Western Way of WarVictor Davis Hanson – The Western Way of War The culture of the Western warrior and the Western way of war. The culture of the Western warrior and the Western way of war. “The Knight in a straight up fight!”“The Knight in a straight up fight!”

10 The Warrior’s Paradox “Being a warrior is an inherently self-destructive profession.” Packing Inferno, Tyler E. Boudreau Agreeing to enter a world organized for the specific purpose of annihilating you physically, emotionally, mentally. Agreeing to enter a world organized for the specific purpose of annihilating you physically, emotionally, mentally.

11 The Warrior’s Paradox Warrior’s Narrative – The story of “I” is an individually, culturally, and historically created construct.Warrior’s Narrative – The story of “I” is an individually, culturally, and historically created construct. But the warrior identity can be rewritten by reality:But the warrior identity can be rewritten by reality: –“The enemy has a vote!” –Cousteau’s “food chain” –Nietzsche, “fighting monsters” and “gazing into the abyss” –“John Rambo,” the other guys and “taking names.”

12 The Warrior’s Paradox I seek to take my enemy’s story from him, and he seeks to take mine!

13 The Warrior’s Paradox The Narrative’s 10 Elements 1.The Transpersonal commitment v. Personal survival 2.Reality v. Mythology “Clean kills exist only in Hollywood”

14 The Warrior’s Paradox 3. Killing and the Gods – The Temple of Mars, Yahweh, “Herem,” and anthropology's insight.3. Killing and the Gods – The Temple of Mars, Yahweh, “Herem,” and anthropology's insight. 4. Skill v. Chance – Von Clausewitz and the “iron dice of fate.” 4. Skill v. Chance – Von Clausewitz and the “iron dice of fate.” 5. Ferocity v. the “Berserker.”5. Ferocity v. the “Berserker.” 6. Brotherhood v. Tribalism – The creation of the “Other.”6. Brotherhood v. Tribalism – The creation of the “Other.”

15 The Warrior’s Paradox 7. The “skill” of killing v. the “taking” of life. 8.Necessary violence v. needless destruction. 9.Obedience v. “toxic” leadership. 10.Loyalty v. Honor.

16 The Warrior’s Paradox The Healer’s Role To help warriors live into rather than solve their paradox, we need to be mindful that:To help warriors live into rather than solve their paradox, we need to be mindful that: 1. A warrior’s effectiveness depends on being internally balanced.1. A warrior’s effectiveness depends on being internally balanced. 2. In war, what you don’t know can and will hurt you.2. In war, what you don’t know can and will hurt you. 3. In war, what you don’t teach often has dreadful consequences.3. In war, what you don’t teach often has dreadful consequences. 4. In the absence of internal and external leadership, there is only chaos!4. In the absence of internal and external leadership, there is only chaos!

17 The Physiology of Combat Re-wiring the Warrior’s Nervous and Emotional System

18 The Physiology of Combat START ME UP!START ME UP! In response to threat, the limbic system releases hormones telling the amygdala to alert the hypothalamus to activate the sympathetic nervous system (SNS) to release neurotransmitters epinephrine (EPI) and norepinephrine (NE) to activate the body for fight/flight/freeze response.In response to threat, the limbic system releases hormones telling the amygdala to alert the hypothalamus to activate the sympathetic nervous system (SNS) to release neurotransmitters epinephrine (EPI) and norepinephrine (NE) to activate the body for fight/flight/freeze response. Respiration and heart rate increase (NE) moving blood to skin and muscles for rapid response.Respiration and heart rate increase (NE) moving blood to skin and muscles for rapid response.

19 The Physiology of Combat SHUT ME DOWN!SHUT ME DOWN! At the same time, the SNS releases corticotrophin- releasing hormone (CRH or CRF).At the same time, the SNS releases corticotrophin- releasing hormone (CRH or CRF). CRH/CRF stimulate the pituitary gland to release adrenocortico-tropic hormone (ACTH) causing adrenals to release hydrocortisone (AKA cortisol).CRH/CRF stimulate the pituitary gland to release adrenocortico-tropic hormone (ACTH) causing adrenals to release hydrocortisone (AKA cortisol). Threat is over, cortisol stops production of EPI and NE.Threat is over, cortisol stops production of EPI and NE.

20 The Physiology of Combat The Inevitability of “Startle/Flinch!”The Inevitability of “Startle/Flinch!”

21 The Physiology of Combat The Survival Stress Reaction (“SSR”) Fear activated heart rate increase = Erosion of combat skills!Fear activated heart rate increase = Erosion of combat skills! Combat – 70 BPM to 220 BPM in ½ secondCombat – 70 BPM to 220 BPM in ½ second High and even moderate levels of stress interfere with fine muscular control & decision making.High and even moderate levels of stress interfere with fine muscular control & decision making. Most life and death confrontations – 145 BPM in tenths of a second!Most life and death confrontations – 145 BPM in tenths of a second!

22 The Physiology of Combat The Survival Stress Reaction (“SSR”) 70 BPM – Normal.70 BPM – Normal. 115 BPM – Fine complex motor skills begin deterioration (Hand-eye co-ordination and some form of digital actions, multi-tasking).115 BPM – Fine complex motor skills begin deterioration (Hand-eye co-ordination and some form of digital actions, multi-tasking) BPM – Optimal survival & combat performance / complex motor skills high functioning ( “The Combat Rush”) BPM – Optimal survival & combat performance / complex motor skills high functioning ( “The Combat Rush”).

23 The Physiology of Combat 145 BPM + - Complex motor skills ( 3 + designed to work in unison) deteriorate145 BPM + - Complex motor skills ( 3 + designed to work in unison) deteriorate Brain center for hearing shuts down – “Didn’t hear/couldn’t make sense, understand”Brain center for hearing shuts down – “Didn’t hear/couldn’t make sense, understand”

24 The Physiology of Combat 175 BPM – 185 BPM175 BPM – 185 BPM 1.Cognitive processing deteriorates. 2.“Tunneling” -visual system decreases peripheral info, combatant often retreats from the threat to widen the peripheral field. Pupils dilate to gather more information & depth perception is diminished 3.Perceptual Narrowing occurs (“Coning”) narrowing of visual system slows processing of information, anxiety increases as combatant attempts to direct field of focus to threat. 4.Critical Stress Amnesia – What happened? Who did what? ---

25 The Physiology of Combat BPM – Hyper-vigilance (“Freezing) & Irrational Behavior. “The Dead Zone!” BPM – Hyper-vigilance (“Freezing) & Irrational Behavior. “The Dead Zone!” BPM increases trigger SNS - cerebral cortex is by- passed to large extent as brain stem and amgydala prepare combatant for “flight, fight freeze.”BPM increases trigger SNS - cerebral cortex is by- passed to large extent as brain stem and amgydala prepare combatant for “flight, fight freeze.” Hyperventilation – associated with impairments in memory, concentration and diminished discrimination or perceptual abilities. Men in combat often “square on the target” due to loss of visual focus during stress.Hyperventilation – associated with impairments in memory, concentration and diminished discrimination or perceptual abilities. Men in combat often “square on the target” due to loss of visual focus during stress.

26 The Physiology of Combat Increased heart rates have a catastrophic affect on perceptual skills, cognitive processing skills, reaction time and motor skill performance.Increased heart rates have a catastrophic affect on perceptual skills, cognitive processing skills, reaction time and motor skill performance. Absent proper training in performing needed survival skill, anxiety increases, stress increases, BPM increases, and combatant descends into trauma vortex.Absent proper training in performing needed survival skill, anxiety increases, stress increases, BPM increases, and combatant descends into trauma vortex. Breathing to control BPM is critical to managing stress and trauma.Breathing to control BPM is critical to managing stress and trauma.

27 The Physiology of Combat The Terror of the “Boyd Cycle”The Terror of the “Boyd Cycle” OODAOODA ObserveObserve OrientOrient DecideDecide ActAct Hick’s Law and Its' ConsequencesHick’s Law and Its' Consequences

28 The Impact of Combat Sensory Overload (“Observe & Orient”) – How does the mind respond to the inability to identify danger in a foreign culture?Sensory Overload (“Observe & Orient”) – How does the mind respond to the inability to identify danger in a foreign culture? “THE FIRST TEAM FOOT PATROL IN AL NASARIYHA.” (April, 2003)“THE FIRST TEAM FOOT PATROL IN AL NASARIYHA.” (April, 2003) Uncertainty (“Decide”) – The constant anticipation of being attacked can have a profoundly toxic effect, especially when this stress continues for months and years.Uncertainty (“Decide”) – The constant anticipation of being attacked can have a profoundly toxic effect, especially when this stress continues for months and years. “THE GARBAGE PILE AT CAMP WAR EAGLE.” (February, 2004)“THE GARBAGE PILE AT CAMP WAR EAGLE.” (February, 2004)

29 The Impact of Combat Combat skills and the “Combat Rush” – In combat, the midbrain has learned to bypass logical thought processes and established conditioned reflexes or SNS responses, instantly, without having to be told to do it.Combat skills and the “Combat Rush” – In combat, the midbrain has learned to bypass logical thought processes and established conditioned reflexes or SNS responses, instantly, without having to be told to do it. “The Drunk at Square Town.” ( October, 2003) (“OODA COMPLETED”)“The Drunk at Square Town.” ( October, 2003) (“OODA COMPLETED”)

30 The Physiology of PTSD Combat Frozen in Time – PTSDCombat Frozen in Time – PTSD “The never ending trauma loop”“The never ending trauma loop” PTSD sufferers hypersecrete CRF and have subnormal levels of cortisol.PTSD sufferers hypersecrete CRF and have subnormal levels of cortisol. Result 1 – there is no “shut off valve.” With no ability to halt the body’s alarm reaction, flight/fight/freeze response continues unabated.Result 1 – there is no “shut off valve.” With no ability to halt the body’s alarm reaction, flight/fight/freeze response continues unabated. Hyperarousal and exaggerated startle response may occur.Hyperarousal and exaggerated startle response may occur. Result 2 – The nervous system is “always on high alert.” PTSD sufferers and those exposed to trauma hyper secrete NE.Result 2 – The nervous system is “always on high alert.” PTSD sufferers and those exposed to trauma hyper secrete NE. SNS responds with tachycardia, hypertension, dizziness, increased perspiration.SNS responds with tachycardia, hypertension, dizziness, increased perspiration. Elevated NE believed to play a role in flashback and panic attacks.Elevated NE believed to play a role in flashback and panic attacks.

31 The Physiology of PTSD MEMORIES OF TERROR ARE OUR “GHOSTS IN THE MACHINE”MEMORIES OF TERROR ARE OUR “GHOSTS IN THE MACHINE” PTSD results in the decrease and impairment of hippocampal activity( explicit memory, facts, concepts, ideas, language dependent storage and retrieval of memories).PTSD results in the decrease and impairment of hippocampal activity( explicit memory, facts, concepts, ideas, language dependent storage and retrieval of memories). Amygdala governs implicit memories( based on senses, emotions) and is functioning no matter how high the level of arousal.Amygdala governs implicit memories( based on senses, emotions) and is functioning no matter how high the level of arousal. Hippocampal activity decreases and is impaired by trauma.Hippocampal activity decreases and is impaired by trauma. During trauma, some events maybe stored in the implicit, but not the explicit memory.During trauma, some events maybe stored in the implicit, but not the explicit memory.

32 The Physiology of Combat MEMORIES OF TERROR ARE OUR “GHOSTS IN THE MACHINE” ( continued)MEMORIES OF TERROR ARE OUR “GHOSTS IN THE MACHINE” ( continued) Lack of explicit memory leaves trauma memory devoid of placement in space and time.Lack of explicit memory leaves trauma memory devoid of placement in space and time. Inability to contextualize memories causes flashbacks and experience of reliving trauma.Inability to contextualize memories causes flashbacks and experience of reliving trauma. Serotonin levels decrease due to PTSD in the orbitofrontal cortex (OFC), which processes social and emotional information and plays a role in the emotional processing of affective memories.Serotonin levels decrease due to PTSD in the orbitofrontal cortex (OFC), which processes social and emotional information and plays a role in the emotional processing of affective memories. Decreased serotonin in OFC potentially contributes to misinterpretation on emotional stimuli, impulsivity aggression and inappropriate decision-making.Decreased serotonin in OFC potentially contributes to misinterpretation on emotional stimuli, impulsivity aggression and inappropriate decision-making.

33 COMBAT TRAUMA A Historical Perspective COMBAT TRAUMA A Historical Perspective

34 Scars on a Warrior’s Heart Psychic Trauma and Warfare throughout History Post-combat numbing, nightmares, dissociation, intrusive recollections.Post-combat numbing, nightmares, dissociation, intrusive recollections. Epic of Gilgamesh – (2750 – 2500 B.C.E.) Sumer.Epic of Gilgamesh – (2750 – 2500 B.C.E.) Sumer. Homer’s “Iliad” (850 B.C.E.).Homer’s “Iliad” (850 B.C.E.).

35 Scars on a Warrior’s Heart Psychic Trauma and Warfare throughout History The Civil WarThe Civil War

36 Scars on a Warrior’s Heart Psychic Trauma and Warfare throughout History Civil War (1861 – 1865) “Nostalgia” and “Soldiers’ Heart.”Civil War (1861 – 1865) “Nostalgia” and “Soldiers’ Heart.” Lethargy, fits of hysteria, withdrawal, numbing, extreme emotionality in soldiers from North and South.Lethargy, fits of hysteria, withdrawal, numbing, extreme emotionality in soldiers from North and South.

37 Scars on a Warrior’s Heart Psychic Trauma and Warfare throughout History Two-thirds of those committed to Northern insane asylums after the Civil War were veterans. Two-thirds of those committed to Northern insane asylums after the Civil War were veterans. Virtually all of the 291 veterans in the Indiana State Insane Asylum demonstrated classic symptoms of PTSD- hyper-vigilance, irrational fear of impending danger, resultant paranoia.Virtually all of the 291 veterans in the Indiana State Insane Asylum demonstrated classic symptoms of PTSD- hyper-vigilance, irrational fear of impending danger, resultant paranoia.

38 Scars on a Warrior’s Heart Psychic Trauma and Warfare throughout History World War I

39 Scars on a Warrior’s Heart Psychic Trauma and Warfare throughout History “Shell shock.”“Shell shock.” Artillery bombardment and “intense fear, helplessness, or horror.”Artillery bombardment and “intense fear, helplessness, or horror.” Exaggerated startle response, stupor, traumatic dreams, irritability, trembling.Exaggerated startle response, stupor, traumatic dreams, irritability, trembling. W.H. Rivers – utilized Freud’s “talking therapy” as well as oral and written trauma narratives.W.H. Rivers – utilized Freud’s “talking therapy” as well as oral and written trauma narratives.

40 Scars on a Warrior’s Heart Psychic Trauma and Warfare throughout History 72,000 neuropsychiatric discharges by ,000 neuropsychiatric discharges by ,000 receiving benefits by ,000 receiving benefits by 1922 History’s Lesson -Combat stress casualties appear to worsen or become symptomatic with the passage of time.History’s Lesson -Combat stress casualties appear to worsen or become symptomatic with the passage of time.

41 Scars on a Warrior’s Heart Psychic Trauma and Warfare throughout History World War IIWorld War II

42 Scars on a Warrior’s Heart Psychic Trauma and Warfare throughout History Post - WW I – Theory advanced that certain individuals predisposed to psychic trauma.Post - WW I – Theory advanced that certain individuals predisposed to psychic trauma. WW II – 1.6 million men rejected for “psychiatric reasons.”WW II – 1.6 million men rejected for “psychiatric reasons.” U.S. lost 504,000 men (50 divisions) due to psychiatric collapse.U.S. lost 504,000 men (50 divisions) due to psychiatric collapse. Army recognizes that any individual will succumb to trauma at personal “breaking point.”Army recognizes that any individual will succumb to trauma at personal “breaking point.”

43 Scars on a Warrior’s Heart Psychic Trauma and Warfare throughout History History’s Lesson – Longer the exposure to combat, greater the likelihood of psychic injury.History’s Lesson – Longer the exposure to combat, greater the likelihood of psychic injury. WW II after 60 days of continuous combat 98% of surviving soldiers will be some kind of psychiatric casualty.WW II after 60 days of continuous combat 98% of surviving soldiers will be some kind of psychiatric casualty. History’s Lesson – Critical factors are time in combat and intensity of combat.History’s Lesson – Critical factors are time in combat and intensity of combat.

44 Scars on a Warrior’s Heart Psychic Trauma and Warfare throughout History History’s Lesson – Support troops not involved in direct combat are also susceptible to becoming psychiatric casualties.History’s Lesson – Support troops not involved in direct combat are also susceptible to becoming psychiatric casualties. Pre-existing trauma history, attachment issues play a greater role for these individuals.Pre-existing trauma history, attachment issues play a greater role for these individuals. Stressors include separation from home and friends, social and physical deprivations, boredom, lower unit cohesion.Stressors include separation from home and friends, social and physical deprivations, boredom, lower unit cohesion.

45 Scars on a Warrior’s Heart Psychic Trauma and Warfare throughout History History’s Lesson – Front line treatment v. removal from theater, proved more effective.History’s Lesson – Front line treatment v. removal from theater, proved more effective. “P.I.E.” – Proximity, immediacy and expectancy.“P.I.E.” – Proximity, immediacy and expectancy. WW II – 60% returned to duty with their division; 90% returned to some duty in theater.WW II – 60% returned to duty with their division; 90% returned to some duty in theater.

46 Scars on a Warrior’s Heart Psychic Trauma and Warfare throughout History Despite frontline treatment, after 4 years of war of the 800,000 U.S. soldiers that saw ground combat 37.5% became such serious psychiatric casualties that they were permanently lost from the war effort.Despite frontline treatment, after 4 years of war of the 800,000 U.S. soldiers that saw ground combat 37.5% became such serious psychiatric casualties that they were permanently lost from the war effort.

47 Scars on a Warrior’s Heart Psychic Trauma and Warfare throughout History Korea & VietnamKorea & Vietnam

48 Scars on a Warrior’s Heart Psychic Trauma and Warfare throughout History Korea 24% of U.S. soldiers became serious psychiatric casualties during tour.Korea 24% of U.S. soldiers became serious psychiatric casualties during tour. Korea – Of these 88% returned to duty with division; 97% some duty in theater.Korea – Of these 88% returned to duty with division; 97% some duty in theater. Korea – 1 year rotation policy initiated.Korea – 1 year rotation policy initiated.---

49 Scars on a Warrior’s Heart Psychic Trauma and Warfare throughout History Vietnam – Psychiatric casualty rates reported between 2% - 5% during combat phase ( ).Vietnam – Psychiatric casualty rates reported between 2% - 5% during combat phase ( ). Post – Vietnam – VA estimate was 15% of vets suffered from PTSD. Figures of other groups range from 18% - 54%.Post – Vietnam – VA estimate was 15% of vets suffered from PTSD. Figures of other groups range from 18% - 54%. 2.8 million Vietnam vets – 420,00 and 1.5 million suffered from PTSD at sometime after the conflict.2.8 million Vietnam vets – 420,00 and 1.5 million suffered from PTSD at sometime after the conflict.

50 Scars on a Warrior’s Heart Psychic Trauma and Warfare throughout History Iraq/Afghanistan – 2.3 million deployed (2011)Iraq/Afghanistan – 2.3 million deployed (2011) 977,542 deployed more than once977,542 deployed more than once 107,000 deployed 3 or more times107,000 deployed 3 or more times 2008 Rand Study – 14% met PTSD and depression criteria2008 Rand Study – 14% met PTSD and depression criteria 1.3 million have left the service1.3 million have left the service 711,986 used VA healthcare (2002 – 2011)711,986 used VA healthcare (2002 – 2011)

51 Scars on a Warrior’s Heart Psychic Trauma and Warfare throughout History THE IMPACT OF KILLING AND THE RESISTANCE TO KILLINGTHE IMPACT OF KILLING AND THE RESISTANCE TO KILLING Thou shalt do no murder. Exodus 20:13 Jesus said, “Thou shalt do no murder.” Matthew 19:18

52 Scars on a Warrior’s Heart Psychic Trauma and Warfare throughout History THE IMPACT OF KILLING AND THE RESISTANCE TO KILLINGTHE IMPACT OF KILLING AND THE RESISTANCE TO KILLING US murder rate = 6 per 100,000.US murder rate = 6 per 100,000. US aggravated assault = 4 per 1,000.US aggravated assault = 4 per 1,000. Present day US fire rates estimated at 95% - 98%.Present day US fire rates estimated at 95% - 98%. What is the psychic cost of being trained to kill?What is the psychic cost of being trained to kill? Of actually killing or seeing others killed?Of actually killing or seeing others killed?

53 Scars on a Warrior’s Heart Psychic Trauma and Warfare throughout History S.L.A. Marshall – “Men Against Fire” and the WW II 15% - 25% fire rate.S.L.A. Marshall – “Men Against Fire” and the WW II 15% - 25% fire rate. Changed training doctrine – Human shaped targets, pop –up.Changed training doctrine – Human shaped targets, pop –up. Fire ratios – Korea 50%, Vietnam 95%, Iraq – Afghanistan – 95% - 98%.Fire ratios – Korea 50%, Vietnam 95%, Iraq – Afghanistan – 95% - 98%.

54 Scars on a Warrior’s Heart Psychic Trauma and Warfare throughout History Studies suggest a correlation between post- traumatic stress and killing.Studies suggest a correlation between post- traumatic stress and killing – Research by Stellman and Stellman found a correlation between intensity and frequency of combat experience and PTSD in Vietnam veterans, yet “great majority” seeking mental health services were never asked about combat experience.1988 – Research by Stellman and Stellman found a correlation between intensity and frequency of combat experience and PTSD in Vietnam veterans, yet “great majority” seeking mental health services were never asked about combat experience.

55 Scars on a Warrior’s Heart Psychic Trauma and Warfare throughout History The Impact of Killing Study – S. Maugen, et al.The Impact of Killing Study – S. Maugen, et al. Study of Vietnam vets 47% reported killing or believing they killed a combatant, 13% a non- combatant.Study of Vietnam vets 47% reported killing or believing they killed a combatant, 13% a non- combatant. “After accounting for demographics and general combat exposure, killing was associated with PTSD symptoms, dissociative experiences, functional impairment and violent behavior.”“After accounting for demographics and general combat exposure, killing was associated with PTSD symptoms, dissociative experiences, functional impairment and violent behavior.”

56 Scars on a Warrior’s Heart Psychic Trauma and Warfare throughout History OIF 2004 NEJM study by C.W. Hoge, et al. – 48%-65 % reported being responsible for the death of an enemy combatant, 14-28% for death of a noncombatant. OIF – 90% reported having been shot at. OIF – 71% to 86% reported engagement in firefight with 5 being the median number. OEF – 36% reported participating in a firefight with 2 being the median number in Afghanistan.

57 Scars on a Warrior’s Heart Psychic Trauma and Warfare throughout History Prevalence of PTSD increased with number of firefights.Prevalence of PTSD increased with number of firefights. OIF – 0 = 4.5%; 1-2 = 9.3%; 3 -5 = 12.7%; 5+ =19.3%.OIF – 0 = 4.5%; 1-2 = 9.3%; 3 -5 = 12.7%; 5+ =19.3%. OEF – 0 = 4.5%; 1-2 = 8.2%; 3-5 = 8.3%; 5+ = 18.9%.OEF – 0 = 4.5%; 1-2 = 8.2%; 3-5 = 8.3%; 5+ = 18.9%.

58 Scars on a Warrior’s Heart Psychic Trauma and Warfare throughout History Combat frequency – As of % of OIF OEF soldiers were on their THIRD TOUR!Combat frequency – As of % of OIF OEF soldiers were on their THIRD TOUR! 15% to 20% of all soldiers fighting in Iraq and Afghanistan at that time, were then showing signs of depression or PTSD.15% to 20% of all soldiers fighting in Iraq and Afghanistan at that time, were then showing signs of depression or PTSD. This rate jumps to 30% for soldiers that have been on 3 or more tours.This rate jumps to 30% for soldiers that have been on 3 or more tours.

59 Scars on a Warrior’s Heart Psychic Trauma and Warfare throughout History ConclusionsConclusions Stress of combat operations ultimately effects all warriors, some more than others.Stress of combat operations ultimately effects all warriors, some more than others. Duration of tour and intensity of combat appears to be causally connected to post-combat trauma.Duration of tour and intensity of combat appears to be causally connected to post-combat trauma. Killing in and of itself may be a causal ingredient in the development of combat related PTSD beyond general combat experiences.Killing in and of itself may be a causal ingredient in the development of combat related PTSD beyond general combat experiences. OIF/OEF veterans are engaged in an unprecedented operational tempo and combat cycle.OIF/OEF veterans are engaged in an unprecedented operational tempo and combat cycle.

60 Healers and Warriors INTERVENTIONSINTERVENTIONS

61 Healers and Warriors – Preparing for a Conversation about Healing Invisible Wounds 1. Become a student of war – To normalize one needs fact based understanding.1. Become a student of war – To normalize one needs fact based understanding. 2. Assume you are entering a different culture.2. Assume you are entering a different culture. 3. Let each veteran understand that each warrior’s journey is unique and each story fits in the narrative of their life.3. Let each veteran understand that each warrior’s journey is unique and each story fits in the narrative of their life. 3. Expect it to be worse than you anticipate.3. Expect it to be worse than you anticipate. 4. “The mind leads the body and the body leads the mind.” – The need for “Awareness” based intervention.4. “The mind leads the body and the body leads the mind.” – The need for “Awareness” based intervention. 5. Combat history, frequency, and severity is of critical importance.5. Combat history, frequency, and severity is of critical importance. 6. Unit integrity, morale and leadership quality play a critical role in resilience needed to ward off combat stress and PTSD.6. Unit integrity, morale and leadership quality play a critical role in resilience needed to ward off combat stress and PTSD.

62 Healers and Warriors – A Conversation about Healing Invisible Wounds CULTURAL RESISTANCE StoicismStoicism Refusal to admit vulnerabilityRefusal to admit vulnerability Loss of cultural statusLoss of cultural status Shame and guiltShame and guilt ProtectivenessProtectiveness Loss of warrior identityLoss of warrior identity Language deficitLanguage deficit

63 Healers and Warriors Ultimately, combat trauma is a normal reaction to an external threat rather than an illness.Ultimately, combat trauma is a normal reaction to an external threat rather than an illness. Try to hear past the words to the statement of emotional need underneath it.Try to hear past the words to the statement of emotional need underneath it. Affirmation – The war and the warrior are separate and distinct. Whether we oppose the war or not, we trained them, we sent them, they went for us, they deserve our respect and need our reassurance.Affirmation – The war and the warrior are separate and distinct. Whether we oppose the war or not, we trained them, we sent them, they went for us, they deserve our respect and need our reassurance. Support – Identify and involve the soldier’s support network. Family, community, place of worship.Support – Identify and involve the soldier’s support network. Family, community, place of worship.

64 Healers and Warriors Normalizing the combat experienceNormalizing the combat experience “An abnormal response, to an abnormal situation, is normal behavior.” Victor Frankl“An abnormal response, to an abnormal situation, is normal behavior.” Victor Frankl Combat reflexes will normally decay with time to a greater or lesser degree.Combat reflexes will normally decay with time to a greater or lesser degree. Combat establishes neural networks that can be reactivated.Combat establishes neural networks that can be reactivated. “It’s a normal reaction. Here’s what to do when it happens.”“It’s a normal reaction. Here’s what to do when it happens.” Combat stress and trauma is simply how the veteran is manifesting their experience of the war.Combat stress and trauma is simply how the veteran is manifesting their experience of the war. Previous training, or the lack thereof, often explains how feelings of fear, helplessness, or horror were minimized, or not.Previous training, or the lack thereof, often explains how feelings of fear, helplessness, or horror were minimized, or not.

65 Healers and Warriors Normalizing the combat experience (continued)Normalizing the combat experience (continued) “intense fear, helplessness, or horror.” DSM-IV“intense fear, helplessness, or horror.” DSM-IV “Helplessness” – Did you know what to do?“Helplessness” – Did you know what to do? “Horror” – Did things happen that you felt unprepared for?“Horror” – Did things happen that you felt unprepared for? “Fear” – What training did you have to manage your fear? Tactical breathing?“Fear” – What training did you have to manage your fear? Tactical breathing? “Re-experiencing” – Was the soldier ever debriefed about the incident/incidents?“Re-experiencing” – Was the soldier ever debriefed about the incident/incidents?

66 Healers and Warriors Exposure therapy and Cognitive Processing therapy.Exposure therapy and Cognitive Processing therapy. Body centered modalities – EMDR, Somatic Experiencing, autogenic breathing, open awareness exercises.Body centered modalities – EMDR, Somatic Experiencing, autogenic breathing, open awareness exercises. Reconstruction of the narrative – Post-traumatic growth and the distinction between “brooding” and “reflective pondering.”Reconstruction of the narrative – Post-traumatic growth and the distinction between “brooding” and “reflective pondering.”

67 Healers and Warriors Open focus exercise – Both PTSD and combat can create experience of “coning.” Stress of not being able to fully visualize environment can accelerate stress response.Open focus exercise – Both PTSD and combat can create experience of “coning.” Stress of not being able to fully visualize environment can accelerate stress response. To break out of tunnel vision having combatants scan and breathe - After taking a shot, by physically turning the head and scanning the battlefield after engagement seems to cause tunnel vision to diminish.To break out of tunnel vision having combatants scan and breathe - After taking a shot, by physically turning the head and scanning the battlefield after engagement seems to cause tunnel vision to diminish.

68 Healers and Warriors PRE-EXISTING WOUNDSPRE-EXISTING WOUNDS

69 Healers and Warriors Pre-existing trauma history can play a huge role in predisposing individuals to PTSD.Pre-existing trauma history can play a huge role in predisposing individuals to PTSD. In 2007 study, 69.1% of women veterans suffering from PTSD reported pre-enlistment sexual assault. 73% reported sexual trauma such as sexual assault or rape while serving in the military.In 2007 study, 69.1% of women veterans suffering from PTSD reported pre-enlistment sexual assault. 73% reported sexual trauma such as sexual assault or rape while serving in the military.

70 Healers and Warriors Studies suggest securely attached individuals, with a history of high quality caregiver relationships were less likely to develop PTSD than their less securely attached counterparts.Studies suggest securely attached individuals, with a history of high quality caregiver relationships were less likely to develop PTSD than their less securely attached counterparts. Low cognitive function prior to exposure strongly influenced measured vulnerability to developing PTSD.Low cognitive function prior to exposure strongly influenced measured vulnerability to developing PTSD.

71 Healers and Warriors In helping a veteran, remember the words of SMG William Von Zehle:In helping a veteran, remember the words of SMG William Von Zehle: “Sir, when engaging a target, slow is smooth, and smooth is fast.”“Sir, when engaging a target, slow is smooth, and smooth is fast.”

72 THE COMBAT TRAUMA CONTINUUM AND VETERANS ResourcesResources LTC Dave Grossman – “On Killing”; “On Combat”LTC Dave Grossman – “On Killing”; “On Combat” Babette Rothschild – “The Body Remembers”Babette Rothschild – “The Body Remembers” Richard Holmes – “Acts of War”Richard Holmes – “Acts of War” Bruce K. Siddle – “Sharpening the Warrior’s Edge”Bruce K. Siddle – “Sharpening the Warrior’s Edge” Daniel Goleman – “Emotional Intelligence”Daniel Goleman – “Emotional Intelligence” Jonathan Shay, Ph.D. – “Achilles in Vietnam” ; “Odysseus in America”Jonathan Shay, Ph.D. – “Achilles in Vietnam” ; “Odysseus in America” Ben Shepard – “A War of Nerves”Ben Shepard – “A War of Nerves” Joanna Bourke – “An Intimate History of Killing”Joanna Bourke – “An Intimate History of Killing” John Keegan – “The Face of Battle”; “A History of Warfare”John Keegan – “The Face of Battle”; “A History of Warfare” M.S. Micale & P. Lerner (Eds.) – “Traumatic Pasts: History, Psychiatry and Trauma in the Modern Ager, 1870 – 1930”M.S. Micale & P. Lerner (Eds.) – “Traumatic Pasts: History, Psychiatry and Trauma in the Modern Ager, 1870 – 1930” National Center for PTSD – Veterans AdministrationNational Center for PTSD – Veterans Administration

73 THE COMBAT TRAUMA CONTINUUM AND VETERANS Bob CaffreyBob Caffrey (860) (860)


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