Presentation on theme: "THE COMBAT TRAUMA CONTINUUM AND VETERANS"— Presentation transcript:
1THE COMBAT TRAUMA CONTINUUM AND VETERANS Lessons from the Past, Wisdom from the Present, Healing in the Future.Robert J. Caffrey, LPC., J.D.
2THE COMBAT TRAUMA CONTINUUM AND VETERANS War and trauma take place on a continuum.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.Historical continuum – The wounds of war are timeless.
3OverviewThe “Paradox” of the Warriors’ World - The Need for Cultural Competence.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.Healers and Warriors – A Conversation about Healing Invisible Wounds.
6A History of Warfare, John Keegan The Warrior’s ParadoxSoldiers 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 Keegan
7Operating in a world of chaos The Warrior’s ParadoxOperating in a world of chaosOld English “Wyrre” – “to bring into confusion.”
8COL Timothy (“BT”) Hanifen, USMC The Warrior’s ParadoxCombat TruthsWar 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.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.COL Timothy (“BT”) Hanifen, USMC
9The Warrior’s ParadoxWarriors - those prepared to kill, or be killed or maimed, to protect another from actual or threatened violence.Victor Davis Hanson – The Western Way of WarThe culture of the Western warrior and the Western way of war.“The Knight in a straight up fight!”
10The Warrior’s Paradox“Being a warrior is an inherently self-destructive profession.” Packing Inferno, Tyler E. BoudreauAgreeing to enter a world organized for the specific purpose of annihilating you physically, emotionally, mentally.
11The Warrior’s ParadoxWarrior’s Narrative – The story of “I” is an individually, culturally, and historically created construct.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.”
12The Warrior’s ParadoxI seek to take my enemy’s story from him, and he seeks to take mine!
13The Warrior’s Paradox The Narrative’s 10 Elements The Transpersonal commitment v. Personal survivalReality v. Mythology“Clean kills exist only in Hollywood”
14The Warrior’s Paradox3. 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.”5. Ferocity v. the “Berserker.”6. Brotherhood v. Tribalism – The creation of the “Other.”
15The Warrior’s Paradox7. The “skill” of killing v. the “taking” of life.Necessary violence v. needless destruction.Obedience v. “toxic” leadership.Loyalty v. Honor.
16The Warrior’s Paradox The Healer’s Role 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.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.4. In the absence of internal and external leadership, there is only chaos!
17The Physiology of Combat Re-wiring the Warrior’s Nervous and Emotional System
18The Physiology of Combat 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.Respiration and heart rate increase (NE) moving blood to skin and muscles for rapid response.
19The Physiology of Combat SHUT ME DOWN!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).Threat is over, cortisol stops production of EPI and NE.
20The Physiology of Combat The Inevitability of “Startle/Flinch!”
21The Physiology of Combat The Survival Stress Reaction (“SSR”) Fear activated heart rate increase = Erosion of combat skills!Combat – 70 BPM to 220 BPM in ½ secondHigh 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!
22The Physiology of Combat The Survival Stress Reaction (“SSR”) 70 BPM – Normal.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”).
23The Physiology of Combat 145 BPM + - Complex motor skills ( 3 + designed to work in unison) deteriorateBrain center for hearing shuts down – “Didn’t hear/couldn’t make sense, understand”
24The Physiology of Combat 175 BPM – 185 BPMCognitive processing deteriorates.“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 diminishedPerceptual Narrowing occurs (“Coning”) narrowing of visual system slows processing of information, anxiety increases as combatant attempts to direct field of focus to threat.Critical Stress Amnesia – What happened? Who did what?---
25The Physiology of Combat 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.”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.
26The Physiology of Combat 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.Breathing to control BPM is critical to managing stress and trauma.
27The Physiology of Combat The Terror of the “Boyd Cycle”OODAObserveOrientDecideActHick’s Law and Its' Consequences
28The Impact of CombatSensory 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)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)
29The Impact of CombatCombat 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”)
30The Physiology of PTSD Combat Frozen in Time – PTSD “The never ending trauma loop”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.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.SNS responds with tachycardia, hypertension, dizziness, increased perspiration.Elevated NE believed to play a role in flashback and panic attacks.
31MEMORIES OF TERROR ARE OUR “GHOSTS IN THE MACHINE” The Physiology of PTSDMEMORIES 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).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.During trauma, some events maybe stored in the implicit, but not the explicit memory.
32The Physiology of Combat MEMORIES OF TERROR ARE OUR “GHOSTS IN THE MACHINE” ( continued)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.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.
34Scars on a Warrior’s Heart Psychic Trauma and Warfare throughout History Post-combat numbing, nightmares, dissociation, intrusive recollections.Epic of Gilgamesh – (2750 – 2500 B.C.E.) Sumer.Homer’s “Iliad” (850 B.C.E.).
35Scars on a Warrior’s Heart Psychic Trauma and Warfare throughout History The Civil War
36Scars on a Warrior’s Heart Psychic Trauma and Warfare throughout History Civil War (1861 – 1865) “Nostalgia” and “Soldiers’ Heart.”Lethargy, fits of hysteria, withdrawal, numbing, extreme emotionality in soldiers from North and South.
37Scars 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.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.
38Scars on a Warrior’s Heart Psychic Trauma and Warfare throughout History World War I
39Scars on a Warrior’s Heart Psychic Trauma and Warfare throughout History “Shell shock.”Artillery bombardment and “intense fear, helplessness, or horror.”Exaggerated startle response, stupor, traumatic dreams, irritability, trembling.W.H. Rivers – utilized Freud’s “talking therapy” as well as oral and written trauma narratives.
40Scars on a Warrior’s Heart Psychic Trauma and Warfare throughout History 72,000 neuropsychiatric discharges by 1918112,000 receiving benefits by 1922History’s Lesson -Combat stress casualties appear to worsen or become symptomatic with the passage of time.
41Scars on a Warrior’s Heart Psychic Trauma and Warfare throughout History World War II
42Scars on a Warrior’s Heart Psychic Trauma and Warfare throughout History Post - WW I – Theory advanced that certain individuals predisposed to psychic trauma.WW II – 1.6 million men rejected for “psychiatric reasons.”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.”
43Scars 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.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.
44Scars 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.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.
45Scars on a Warrior’s Heart Psychic Trauma and Warfare throughout History History’s Lesson – Front line treatment v. removal from theater, proved more effective.“P.I.E.” – Proximity, immediacy and expectancy.WW II – 60% returned to duty with their division; 90% returned to some duty in theater.
46Scars 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.
47Scars on a Warrior’s Heart Psychic Trauma and Warfare throughout History Korea & Vietnam
48Scars on a Warrior’s Heart Psychic Trauma and Warfare throughout History 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 – 1 year rotation policy initiated.---
49Scars on a Warrior’s Heart Psychic Trauma and Warfare throughout History 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%.2.8 million Vietnam vets – 420,00 and 1.5 million suffered from PTSD at sometime after the conflict.
50Scars on a Warrior’s Heart Psychic Trauma and Warfare throughout History Iraq/Afghanistan – 2.3 million deployed (2011)977,542 deployed more than once107,000 deployed 3 or more times2008 Rand Study – 14% met PTSD and depression criteria1.3 million have left the service711,986 used VA healthcare (2002 – 2011)
51Jesus said, “Thou shalt do no murder.” Matthew 19:18 Scars on a Warrior’s Heart Psychic Trauma and Warfare throughout HistoryTHE IMPACT OF KILLING AND THE RESISTANCE TO KILLINGThou shalt do no murder. Exodus 20:13Jesus said, “Thou shalt do no murder.” Matthew 19:18
52THE IMPACT OF KILLING AND THE RESISTANCE TO KILLING Scars on a Warrior’s Heart Psychic Trauma and Warfare throughout HistoryTHE IMPACT OF KILLING AND THE RESISTANCE TO KILLINGUS murder rate = 6 per 100,000.US aggravated assault = 4 per 1,000.Present day US fire rates estimated at 95% - 98%.What is the psychic cost of being trained to kill?Of actually killing or seeing others killed?
53Scars 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.Changed training doctrine – Human shaped targets, pop –up.Fire ratios – Korea 50%, Vietnam 95%, Iraq – Afghanistan – 95% - 98%.
54Scars on a Warrior’s Heart Psychic Trauma and Warfare throughout History Studies suggest a correlation between post-traumatic stress and killing.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.
55Scars on a Warrior’s Heart Psychic Trauma and Warfare throughout History 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.“After accounting for demographics and general combat exposure, killing was associated with PTSD symptoms, dissociative experiences, functional impairment and violent behavior.”
56Scars 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.
57Scars on a Warrior’s Heart Psychic Trauma and Warfare throughout History Prevalence of PTSD increased with number of firefights.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%.
58Scars on a Warrior’s Heart Psychic Trauma and Warfare throughout History 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.This rate jumps to 30% for soldiers that have been on 3 or more tours.
59Scars on a Warrior’s Heart Psychic Trauma and Warfare throughout History ConclusionsStress 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.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.
61Healers and Warriors – Preparing for a Conversation about Healing Invisible Wounds 1. Become a student of war – To normalize one needs fact based understanding.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. 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.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.
62Healers and Warriors – A Conversation about Healing Invisible Wounds CULTURAL RESISTANCEStoicismRefusal to admit vulnerabilityLoss of cultural statusShame and guiltProtectivenessLoss of warrior identityLanguage deficit
63Healers and WarriorsUltimately, 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.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.
64Normalizing the combat experience Healers and WarriorsNormalizing the combat experience“An abnormal response, to an abnormal situation, is normal behavior.” Victor FranklCombat reflexes will normally decay with time to a greater or lesser degree.Combat establishes neural networks that can be reactivated.“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.Previous training, or the lack thereof, often explains how feelings of fear, helplessness, or horror were minimized, or not.
65Normalizing the combat experience (continued) Healers and WarriorsNormalizing the combat experience (continued)“intense fear, helplessness, or horror.” DSM-IV“Helplessness” – Did you know what to do?“Horror” – Did things happen that you felt unprepared for?“Fear” – What training did you have to manage your fear? Tactical breathing?“Re-experiencing” – Was the soldier ever debriefed about the incident/incidents?
66Healers and WarriorsExposure therapy and Cognitive Processing therapy.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.”
67Healers and WarriorsOpen 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.
69Healers and WarriorsPre-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.
70Healers and WarriorsStudies 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.
71Healers and WarriorsIn helping a veteran, remember the words of SMG William Von Zehle:“Sir, when engaging a target, slow is smooth, and smooth is fast.”
72THE COMBAT TRAUMA CONTINUUM AND VETERANS ResourcesLTC Dave Grossman – “On Killing”; “On Combat”Babette Rothschild – “The Body Remembers”Richard Holmes – “Acts of War”Bruce K. Siddle – “Sharpening the Warrior’s Edge”Daniel Goleman – “Emotional Intelligence”Jonathan Shay, Ph.D. – “Achilles in Vietnam” ; “Odysseus in America”Ben Shepard – “A War of Nerves”Joanna Bourke – “An Intimate History of Killing”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”National Center for PTSD – Veterans Administration
73THE COMBAT TRAUMA CONTINUUM AND VETERANS Bob Caffrey(860)----