THE COMBAT TRAUMA CONTINUUM AND VETERANS

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.
• 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.

3
Overview

• 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.
• Scars on a Warriors Heart A History of the
  Impact of Warfare on Soldiers.
• Healers and Warriors A Conversation about
  Healing Invisible Wounds.

4
A Warriors JourneyThe Bridge Between Worlds
5

• THE PARADOX

6
The Warriors 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.
• A History of Warfare, John Keegan

7
The Warriors Paradox

• Operating in a world of chaos
• Old English Wyrre to bring into confusion.

8
The Warriors Paradox

• Combat Truths
• 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.
• 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

9
The Warriors Paradox

• 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 War
• The culture of the Western warrior and the
  Western way of war.
• The Knight in a straight up fight!

10
The Warriors 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.

11
The Warriors Paradox

• Warriors 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!
• Cousteaus food chain
• Nietzsche, fighting monsters and gazing into
  the abyss
• John Rambo, the other guys and taking names.

12
The Warriors Paradox

• I seek to take my enemys story from him, and he
  seeks to take mine!

13
The Warriors ParadoxThe Narratives 10 Elements

• The Transpersonal commitment v. Personal survival
• Reality v. Mythology
• Clean kills exist only in Hollywood

14
The Warriors Paradox

• 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.
• 5. Ferocity v. the Berserker.
• 6. Brotherhood v. Tribalism The creation of
  the Other.

15
The Warriors Paradox

• 7. The skill of killing v. the taking of
  life.
• Necessary violence v. needless destruction.
• Obedience v. toxic leadership.
• Loyalty v. Honor.

16
The Warriors ParadoxThe Healers Role

• To help warriors live into rather than solve
  their paradox, we need to be mindful that
• 1. A warriors effectiveness depends on being
  internally balanced.
• 2. In war, what you dont know can and will hurt
  you.
• 3. In war, what you dont teach often has
  dreadful consequences.
• 4. In the absence of internal and external
  leadership, there is only chaos!

17
The Physiology of Combat

• Re-wiring the Warriors Nervous and Emotional
  System

18
The 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.

19
The 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.

20
The Physiology of Combat

• The Inevitability of Startle/Flinch!

21
The Physiology of CombatThe Survival Stress
Reaction (SSR)

• Fear activated heart rate increase Erosion of
  combat skills!
• Combat 70 BPM to 220 BPM in ½ second
• 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!

22
The Physiology of CombatThe 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).
• 115-145 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) deteriorate
• Brain center for hearing shuts down Didnt
  hear/couldnt make sense, understand

24
The Physiology of Combat

• 175 BPM 185 BPM
• Cognitive 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
  diminished
• Perceptual 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?
• ---

25
The Physiology of Combat

• 185 - 220 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.

26
The 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.

27
The Physiology of Combat

• The Terror of the Boyd Cycle
• OODA
• Observe
• Orient
• Decide
• Act
• Hicks 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?
• 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)

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.
• The Drunk at Square Town. ( October, 2003)
  (OODA COMPLETED)

30
The 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 bodys 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.

31
The Physiology of PTSD

• 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).
• 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.

32
The 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.

33
COMBAT TRAUMAA Historical Perspective
34
Scars on a Warriors Heart Psychic Trauma and
Warfarethroughout History

• Post-combat numbing, nightmares, dissociation,
  intrusive recollections.
• Epic of Gilgamesh (2750 2500 B.C.E.) Sumer.
• Homers Iliad (850 B.C.E.).

35
Scars on a Warriors Heart Psychic Trauma and
Warfarethroughout History

• The Civil War

36
Scars on a Warriors Heart Psychic Trauma and
Warfarethroughout History

• Civil War (1861 1865) Nostalgia and
  Soldiers Heart.
• Lethargy, fits of hysteria, withdrawal, numbing,
  extreme emotionality in soldiers from North and
  South.

37
Scars on a Warriors Heart Psychic Trauma and
Warfarethroughout 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.

38
Scars on a Warriors Heart Psychic Trauma and
Warfarethroughout History

• World War I

39
Scars on a Warriors Heart Psychic Trauma and
Warfarethroughout History

• Shell shock.
• Artillery bombardment and intense fear,
  helplessness, or horror.
• Exaggerated startle response, stupor, traumatic
  dreams, irritability, trembling.
• W.H. Rivers utilized Freuds talking therapy
  as well as oral and written trauma narratives.

40
Scars on a Warriors Heart Psychic Trauma and
Warfarethroughout History

• 72,000 neuropsychiatric discharges by 1918
• 112,000 receiving benefits by 1922
• Historys Lesson -Combat stress casualties appear
  to worsen or become symptomatic with the passage
  of time.

41
Scars on a Warriors Heart Psychic Trauma and
Warfarethroughout History

• World War II

42
Scars on a Warriors Heart Psychic Trauma and
Warfarethroughout 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.

43
Scars on a Warriors Heart Psychic Trauma and
Warfarethroughout History

• Historys 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.
• Historys Lesson Critical factors are time in
  combat and intensity of combat.

44
Scars on a Warriors Heart Psychic Trauma and
Warfarethroughout History

• Historys 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.

45
Scars on a Warriors Heart Psychic Trauma and
Warfarethroughout History

• Historys 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.

46
Scars on a Warriors Heart Psychic Trauma and
Warfarethroughout 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.

47
Scars on a Warriors Heart Psychic Trauma and
Warfarethroughout History

• Korea Vietnam

48
Scars on a Warriors Heart Psychic Trauma and
Warfarethroughout 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.
• ---

49
Scars on a Warriors Heart Psychic Trauma and
Warfarethroughout History

• Vietnam Psychiatric casualty rates reported
  between 2 - 5 during combat phase (1965-1975).
• 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.

50
Scars on a Warriors Heart Psychic Trauma and
Warfarethroughout History

• Iraq/Afghanistan 2.3 million deployed (2011)
• 977,542 deployed more than once
• 107,000 deployed 3 or more times
• 2008 Rand Study 14 met PTSD and depression
  criteria
• 1.3 million have left the service
• 711,986 used VA healthcare (2002 2011)

51
Scars on a Warriors Heart Psychic Trauma and
Warfarethroughout History

• THE IMPACT OF KILLING AND THE RESISTANCE TO
  KILLING
• Thou shalt do no murder. Exodus 2013
• Jesus said, Thou shalt do no murder. Matthew
  1918

52
Scars on a Warriors Heart Psychic Trauma and
Warfarethroughout History

• THE IMPACT OF KILLING AND THE RESISTANCE TO
  KILLING
• US 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?

53
Scars on a Warriors Heart Psychic Trauma and
Warfarethroughout 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.

54
Scars on a Warriors Heart Psychic Trauma and
Warfarethroughout 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.

55
Scars on a Warriors Heart Psychic Trauma and
Warfarethroughout 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.

56
Scars on a Warriors Heart Psychic Trauma and
Warfarethroughout 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 Warriors Heart Psychic Trauma and
Warfarethroughout 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.

58
Scars on a Warriors Heart Psychic Trauma and
Warfarethroughout History

• Combat frequency As of 2008 30 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.

59
Scars on a Warriors Heart Psychic Trauma and
Warfarethroughout History

• Conclusions
• 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.
• 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.

60
Healers and Warriors

• INTERVENTIONS

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.
• 2. Assume you are entering a different culture.
• 3. Let each veteran understand that each
  warriors 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.

62
Healers and Warriors A Conversation about
Healing Invisible Wounds

• CULTURAL RESISTANCE
• Stoicism
• Refusal to admit vulnerability
• Loss of cultural status
• Shame and guilt
• Protectiveness
• Loss of warrior identity
• Language deficit

63
Healers and Warriors

• 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.
• 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 soldiers
  support network. Family, community, place of
  worship.

64
Healers and Warriors

• Normalizing the combat experience
• 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 establishes neural networks that can be
  reactivated.
• Its a normal reaction. Heres 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.

65
Healers and Warriors

• Normalizing 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?

66
Healers and Warriors

• Exposure 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.

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.
• 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 WOUNDS

69
Healers and Warriors

• 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.

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.
• 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
• Sir, when engaging a target, slow is smooth, and
  smooth is fast.

72
THE COMBAT TRAUMA CONTINUUM AND VETERANS

• Resources
• www.realwarriors
• LTC Dave Grossman On Killing On Combat
• Babette Rothschild The Body Remembers
• Richard Holmes Acts of War
• Bruce K. Siddle Sharpening the Warriors 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

73
THE COMBAT TRAUMA CONTINUUM AND VETERANS

• Bob Caffrey
• www.caffreycounseling.com
• rjcaffrey_at_gmail.com
• [phone]
• ----