Rules of Engagement

Many coalition troops in Afghanistan and Iraq have spent five years alternating between trying to kill and trying not to be killed. Think back to what you were doing five years ago, and what you’ve done since then. Now imagine spending every one of those 2,629,800 minutes wondering whether it was going to be your last.

For more than 5,500 American combat personnel, it was. The 33,000 Americans wounded in action probably thought it was. The rest of the 1.9 million who’ve been deployed have wondered when it would be.

Comprehending the enormity of this life experience is a challenge. A recent study in the American Journal of Psychiatry reports that 58 percent of the men and women in active duty were exposed to dead bodies or body parts; 72 percent were assaulted or ambushed; 73 percent witnessed or experienced an accident causing serious injury or death; 79 percent know someone personally who was seriously wounded or killed; 81 percent came under fire. A study in the New England Journal of Medicine, conducted by Charles Hoge and colleagues in the early years of Operation Iraqi Freedom, found that 86 percent of soldiers and 92 percent of marines had been subjected to shelling and mortar fire. Being exposed to a traumatic event that involves death or serious injury–and therefore meets the criteria for PTSD in the Diagnostic and Statistical Manual (DSM IV-TR)–is part of the everyday environment for these young men and women.

No one knows what this much exposure over that much time does to developing bodies and minds, how it modifies a young person’s identity and outlook, but no one thinks the long-term effects are inconsequential.

Every combat veteran takes home some degree of combat stress. Unfortunately, the term combat stress fails to capture the impact that being in a ground war can have; the term is both a euphemism and a cliché. The civilian use of the word combat conjures up tidy Hollywood moments of bravery and brotherhood, not the calculated viciousness of a surprise attack, the terrifying chaos that ensues, and the blood and body parts that can surround someone suddenly.

Not everyone comes home with PTSD as a result of incidents such as these. Estimates of how many combat veterans are exhibiting symptoms varies from study to study, but it hovers fairly consistently at about 20 percent. These estimates are snapshots of the current situation; in no way do they give us an accurate sense of what lies ahead. There is, after all, a reason it’s called post traumatic stress: measurable symptoms can lie dormant for decades, only to emerge with lethal ferocity.

Accepting the premise that we don’t know how many veterans are going to need care, we can all agree that it’s going to be more than the military medical system can manage, particularly when you add into the equation the spouses and children whose lives are deeply affected by changes in their returning loved ones. So it stands to reason that much of this care is going to have to come from civilian therapists.

Despite good intentions and a desire to ease suffering, civilian therapists working with combat veterans face several challenges. To start with, there’s the challenge of engaging combat veterans in counseling of any kind, especially in-depth therapy. They resist making the decision to set up an appointment with a mental health provider, have difficulty keeping the appointment, and struggle with tolerating more than one session. Civilian therapists across the country have found it tough to engage military clients; they complain of an extremely high no-show rate. So the best-practice approach is to start with the assumption that the first session may afford your only opportunity to ease the suffering of the veterans you encounter, and therefore you have to make every interaction with them count.

By nature and training, most combat veterans are action-oriented, and since action helps reduce their anxiety by increasing their sense of empowerment, capitalize on it. During your first contact, whether or not they make an appointment, give them something to do–a couple of websites to look at or books to check out. Tell them about www.afterdeployment.org, www.iava.org, www.helmetstohardhats.org, and http:// sgtbrandi.com. The Department of the Army’s mental-resiliency programs (http://www.army.mil/csf and www.battlemind.org) are other good resources, as is the Defense Centers of Excellence’s website (http://www.realwarriors.net). Make a point of familiarizing yourself with these and other websites before recommending them.

Once combat veterans are actually in your office, plan for the following points during your time with them:

Expect angry reactions. Intense anger is a predictable side effect of having been “down range.” It’s often the reason combat veterans seek care. There are two key reasons for this. First, of the three self-preserving responses hardwired into the human brain (fight, flight, freeze), combat training is all about habituating “fight” as the automatic response to any threat, and eliminating the “flight” and “freeze” responses. Once that’s ingrained, every perceived threat, regardless of context, is likely to be met with the anger that encourages the fight response—which can create a host of problems in civilian life. Second, combat veterans whose job in theater had anything to do with being in a convoy or on a patrol have almost certainly experienced the destructiveness of roadside bombs (improvised explosive devices, IEDs), detonated by an unseen enemy who has no uniform, no distinguishing demographics, and no rules, and, therefore, offers no focus for a natural drive for revenge. In a cauldron of war-induced stress, feelings of injustice, helplessness, and a profound desire to retaliate come to a rapid boil.

In assessing these clients, help them identify the ways in which their anger is compromising them in civilian life or detracting from their quality of life (frightening their children, hurting their spouse, alienating friends, decreasing commanders’ trust, affecting their job security), not protecting them as it did in combat.

This is an opportunity to help them regain emotional control. After explaining how breathing can help slow down both the bodily reactions that come with rage and the impulsive thinking that can escalate emotions, teach them a breathing technique known as “tactical breathing”: breathe in slowly for 4 counts, hold for 2, out for 4, hold for 2, repeat. To mitigate their belief that this might make them look silly or dumb (a threat to their warrior image), you might explain that this breathing technique is what snipers use to calm their nerves and steady their hands. This kind of military-oriented information will assure them that you’re invested in what’s most important to them—maintaining their identity as warriors. Encourage them to use self-regulating techniques like tactical breathing, counting to three, and walking away anytime, including during therapy.

Since their physiological arousal state remains highly activated long after deployment (if they’ve been deployed multiple times, they’ll consciously keep it intact until discharged out of the military), you can expect anger to be a staple of therapy. They’re likely to list people, experiences, and issues that are angering them. Interspersing meaningful psychoeducation will help them focus on changing the things they can control and not merely venting about the things they can’t control.

Focus on emotional pain. Assess how much emotional pain your military clients are experiencing at the beginning of the session, perhaps by using a 0-10 scale. It helps them acknowledge how much pain they’re really in—something they avoid doing. At the end of the session, ask that they again attach a numerical value to their emotional pain level. This helps them acknowledge that they can feel better, instilling hope, and that the things you did together in the session worked—which has the additional bonus of increasing their trust in you and in the therapeutic process.

Conduct a sleep assessment. Because sleep is critical to coping, be sure to assess their sleep quality and quantity, and then focus on getting that in line. If it’s way off, find out how much caffeine and alcohol they’re consuming. According to the DSM IV-TR, caffeine intoxication (one of four psychiatric conditions related specifically to caffeine) occurs when 250 mg of caffeine is ingested in a short time. Consuming a couple of energy drinks can easily surpass that amount. Many young people have no idea they’re consuming high quantities of caffeine, or that it could be the source of their anxiety, nightmares, sleeplessness, irritability, and shakiness. Teach them about the effects of caffeine, and then suggest a slow decrease to wean them from it, to see whether their symptoms lessen.

Ask what losses they suffered. Unrecognized, and hence unresolved, grief is a huge component of soldiers’ pain. Emphasize the importance of “honoring the fallen and their sacrifices”—that every fallen soldier deserves to be wept over and missed by his brothers and sisters in arms. Explain that their grief may be part of what’s making them feel so bad so much of the time.

Never ask a combat veteran, “Did you kill anyone?” This is an incredibly intimate question, the answer to which a civilian will never truly understand, because the context of war is unique. Every single combat veteran to whom I’ve spoken has been asked this question at some point, and they’ve all told me it either angered or upset them. If they offer the information, recognize the sacredness of the trust they’re sharing, but don’t press them for details.

Depathologize their feelings, experiences, and thoughts. This can be one of the most powerful interventions in your arsenal. I’ve seen incredible improvements in soldiers who were tormenting themselves over their belief that they were weak. The phrase “You’re having a normal reaction to an abnormal experience” may sound canned, but these men and women still appreciate hearing it. They want to be reassured that they aren’t “crazy.” We just need to make sure, as Navy psychiatrist Bill Nash likes to point out, that in normalizing their reactions, we don’t unintentionally communicate that they don’t need treatment and care. A serious burn on your hand might be a “normal reaction to an abnormal experience,” but that doesn’t mean it isn’t an injury needing competent intervention and attention.

Create action plans. As I alluded to earlier, talking doesn’t feel like action to most veterans, so having a plan to carry out between sessions is both functionally helpful and emotionally soothing. Start your sessions by assessing their current problems and then helping them create a plan that’ll move toward relieving their symptoms. Ask them what the single most disturbing or bothersome symptom is, and work on that. Reducing their emotional pain and instilling a sense of hope requires active, ongoing assessment of symptoms and in-office interventions during each session. Before they leave a session, write down the specific, customized plan the two of you have developed that addresses their issues in concrete terms.

Be aware of suicidal tendencies. Always assessing a client’s suicidality is sound practice, but never more so than with combat veterans; however, be prepared for the likelihood of suicidal thoughts, because most veterans who’ve endured numerous combat missions entertain the idea of suicide fairly frequently. Because combat experiences desensitize them to pain and death, the notion of their own death creates none of the usual alarm responses, and according to Thomas Joiner’s book Why People Die by Suicide, this puts them at unusually high risk. Since most of them own guns and many of them carry their weapons in civilian life, you should take the risk of suicide or homicide seriously.

They may also be covertly suicidal. A soldier who volunteers for his fifth mission may be hoping that the enemy will end his pain and preserve his and his family’s honor by allowing him to come home as a hero in a flag-draped coffin. Addressing this desire to die in battle frankly, calmly, and without judgment is the best intervention with this particular group.

Overprepare. Read blogs written by deployed veterans and look at some of the HBO documentaries and movies that capture a tiny portion of the war experience. Watch The War Tapes, Fighting for Life, The Messenger, and Taking Chance. Each film beautifully examines a different piece of this enormous, messy puzzle. Talk to friends and colleagues who are former military or combat veterans themselves, or have family members who are currently serving, and listen to their stories. Go online and become familiar with “military-speak” so that you don’t waste time in therapy having the vet explain that a FOB is a Forward Operating Base, not a keychain decoration. They’ll feel more trusting if you and your office are orderly in appearance. Expect them to call you doc, doctor, miss, mister, ma’am, or sir, and not to refer to you by your first name, no matter how many times you say they may do so. Then “gear up,” get yourself “squared away,” “watch your six,” and get ready for the most dynamic—and extraordinarily rewarding—work of your career.

Resources

Grieger, Thomas A., Stephen J. Cozza, Robert J. Ursano, et al. “Posttraumatic Stress Disorder and Depression in Battle-Injured Soldiers.” American Journal of Psychiatry 163, no. 10 (October 2006):1777-83.

Hoge, Charles W., Carl A. Castro, Stephen C. Messer, et al. “Combat Duty in Iraq and Afghanistan, Mental Health Problems, and Barriers to Care.” New England Journal of Medicine 351 (July 1, 2004): 13-22.

Joiner, Thomas. Why People Die by Suicide. Cambridge, Mass.: Harvard University Press, 2007.

Testimony by Terri Tanielian, “Assessing Combat Exposure and Post-Traumatic Stress Disorder in Troops and Estimating the Costs to Society: Implications,” submitted on May 24, 2009, to the Subcommittee on Disability Assistance and Memorial Affairs of the House Veterans’ Affairs Committee. Taken from the RAND Corporation’s research brief Invisible Wounds of War: Psychological and Cognitive Injuries, Their Consequences, and Services to Assist Recovery, ed. Terri Tanielian, Lisa H. Jaycox, et al. (http://www.rand.org/pubs/ research_briefs/ RB9336/index1.html).