THE COMBAT TRAUMA CONTINUUM AND VETERANS

THE COMBAT THE COMBAT TRAUMA TRAUMA

CONTINUUM AND CONTINUUM AND VETERANSVETERANS

Lessons from the Past, Lessons from the Past, Wisdom from the Present, Wisdom from the Present,

Healing in the Future.Healing in the Future.

Robert J. Caffrey, LPC., J.D.Robert J. Caffrey, LPC., J.D.

THE COMBAT TRAUMA THE COMBAT TRAUMA CONTINUUM AND CONTINUUM AND

VETERANSVETERANS• War and trauma take place on a War and trauma take place on a

continuum.continuum.• Physical ContinuumPhysical Continuum – Combat – Combat

Operational Stress Reaction (“COSR”) to Operational Stress Reaction (“COSR”) to Post-Combat Trauma (“PTSD”).Post-Combat Trauma (“PTSD”).

• Narrative Continuum Narrative Continuum – Trauma is – Trauma is contextual, the warrior and his/her contextual, the warrior and his/her

culture give the combat experience its’ culture give the combat experience its’ meaning.meaning.

• Historical continuum Historical continuum – The wounds of – The wounds of war are timeless.war are timeless.

OverviewOverview

• The “Paradox” of the Warriors’ WorldThe “Paradox” of the Warriors’ World - - The Need for Cultural Competence.The Need for Cultural Competence.

• The Physiology of CombatThe Physiology of Combat – The Re- – The Re-wiring of the Warriors’ Nervous and wiring of the Warriors’ Nervous and Emotional System.Emotional System.

• Scars on a Warrior’s HeartScars on a Warrior’s Heart – A History – A History of the Impact of Warfare on Soldiers.of the Impact of Warfare on Soldiers.

• Healers and WarriorsHealers and Warriors – A Conversation – A Conversation about Healing Invisible Wounds.about Healing Invisible Wounds.

A Warrior’s JourneyA Warrior’s JourneyThe Bridge Between WorldsThe Bridge Between Worlds

•THE PARADOXTHE PARADOX

The Warrior’s ParadoxThe Warrior’s Paradox

• Soldiers are not as other men . . .They Soldiers are not as other men . . .They are those of a world apart, a very are those of a world apart, a very

ancient world which exists in parallel ancient world which exists in parallel with the everyday world but does not with the everyday world but does not

belong to it . . .The distance can never belong to it . . .The distance can never be closed, for the culture of the warrior be closed, for the culture of the warrior can never be that of civilization itself.can never be that of civilization itself.

• A History of WarfareA History of Warfare, John Keegan, John Keegan


Operating in a world of chaosOperating in a world of chaos

Old English “Wyrre” – “to bring into Old English “Wyrre” – “to bring into confusion.”confusion.”

The Warrior’s ParadoxThe Warrior’s Paradox• Combat TruthsCombat Truths

• War is about combat, combat is about fighting, War is about combat, combat is about fighting, fighting is about killing, and killing is a traumatic fighting is about killing, and killing is a traumatic personal experience.personal experience.

• Frequency of combat and proximity of killing is Frequency of combat and proximity of killing is directly proportional to the level of combat stress.directly proportional to the level of combat stress.

• A warrior must be able to psychologically and A warrior must be able to psychologically and emotionally distance themselves from the emotionally distance themselves from the environment, the killing, and the civilian world to win environment, the killing, and the civilian world to win and to survive.and to survive.

• There is, and always will be a deep and abiding There is, and always will be a deep and abiding contextual and cultural gap between a combat contextual and cultural gap between a combat veteran and a civilian.veteran and a civilian.

• COL Timothy (“BT”) Hanifen, USMCCOL Timothy (“BT”) Hanifen, USMC


• WarriorsWarriors - those prepared to kill, or - those prepared to kill, or be killed or maimed, to protect be killed or maimed, to protect another from actual or threatened another from actual or threatened violence.violence.

• Victor Davis Hanson – Victor Davis Hanson – The Western The Western Way ofWay of WarWar

• The culture of the Western warrior The culture of the Western warrior and the Western way of war.and the Western way of war.

• ““The Knight in a straight up fight!”The Knight in a straight up fight!”


““Being a warrior is an inherently self-Being a warrior is an inherently self-destructive profession.” destructive profession.” Packing Packing InfernoInferno, Tyler E. Boudreau, Tyler E. Boudreau

Agreeing to enter a world organized Agreeing to enter a world organized for the specific purpose of for the specific purpose of annihilating you physically, annihilating you physically, emotionally, mentally.emotionally, mentally.


• Warrior’s NarrativeWarrior’s Narrative – The story of “I” is an – The story of “I” is an individually, culturally, and historically individually, culturally, and historically created construct.created construct.

• But the warrior identity can be rewritten by But the warrior identity can be rewritten by reality: reality: – ““The enemy has a vote!”The enemy has a vote!”– Cousteau’s “food chain”Cousteau’s “food chain”– Nietzsche, “fighting monsters” and “gazing into Nietzsche, “fighting monsters” and “gazing into

the abyss” the abyss” – ““John Rambo,” the other guys and “taking names.”John Rambo,” the other guys and “taking names.”


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

The Warrior’s ParadoxThe Warrior’s ParadoxThe Narrative’s 10 The Narrative’s 10

ElementsElements

1.1. The Transpersonal commitment v. The Transpersonal commitment v. Personal survivalPersonal survival

2.2. Reality v. MythologyReality v. Mythology

““Clean kills exist only in Clean kills exist only in Hollywood”Hollywood”


• 3. 3. Killing and the GodsKilling and the Gods – The – The Temple of Mars, Yahweh, “Herem,” Temple of Mars, Yahweh, “Herem,” and anthropology's insight.and anthropology's insight.

• 4. 4. Skill v. ChanceSkill v. Chance – Von Clausewitz – Von Clausewitz and the “iron dice of fate.”and the “iron dice of fate.”

• 5. 5. Ferocity v. the “Berserker.”Ferocity v. the “Berserker.”• 6. 6. Brotherhood v. TribalismBrotherhood v. Tribalism – The – The

creation of the “Other.”creation of the “Other.”


7. 7. The “skill” of killing v. the “taking” The “skill” of killing v. the “taking” of lifeof life..

8.8. Necessary violence v. needless Necessary violence v. needless destructiondestruction..

9.9. Obedience v. “toxic” leadershipObedience v. “toxic” leadership..

10.10.Loyalty v. HonorLoyalty v. Honor..

The Warrior’s ParadoxThe Warrior’s ParadoxThe Healer’s Role The Healer’s Role

• To help warriors live into rather than solve To help warriors live into rather than solve their paradox, we need to be mindful that:their paradox, we need to be mindful that:

• 1. A warrior’s effectiveness depends on 1. A warrior’s effectiveness depends on being internally balanced.being internally balanced.

• 2. In war, what you don’t know can and will 2. In war, what you don’t know can and will hurt you.hurt you.

• 3. In war, what you don’t teach often has 3. In war, what you don’t teach often has dreadful consequences.dreadful consequences.

• 4. In the absence of internal and external 4. In the absence of internal and external leadership, there is only chaos!leadership, there is only chaos!

The Physiology of The Physiology of CombatCombat

Re-wiring the Warrior’s Re-wiring the Warrior’s Nervous and Emotional Nervous and Emotional

SystemSystem

The Physiology of CombatThe Physiology of Combat

• START ME UP!START ME UP!• In response to threat, the limbic system In response to threat, the limbic system

releases hormones telling the amygdala to releases hormones telling the amygdala to alert the hypothalamus to activate the alert the hypothalamus to activate the sympathetic nervous system (SNS) to release sympathetic nervous system (SNS) to release neurotransmitters epinephrine (EPI) and neurotransmitters epinephrine (EPI) and norepinephrine (NE) to activate the body for norepinephrine (NE) to activate the body for fight/flight/freeze response.fight/flight/freeze response.

• Respiration and heart rate increase (NE) Respiration and heart rate increase (NE) moving blood to skin and muscles for rapid moving blood to skin and muscles for rapid response.response.

The Physiology of CombatThe Physiology of Combat

• SHUT ME DOWN!SHUT ME DOWN!• At the same time, the SNS releases At the same time, the SNS releases

corticotrophin-releasing hormone (CRH or corticotrophin-releasing hormone (CRH or CRF).CRF).

• CRH/CRF stimulate the pituitary gland to CRH/CRF stimulate the pituitary gland to release adrenocortico-tropic hormone release adrenocortico-tropic hormone (ACTH) causing adrenals to release (ACTH) causing adrenals to release hydrocortisone (AKA cortisol).hydrocortisone (AKA cortisol).

• Threat is over, cortisol stops production of Threat is over, cortisol stops production of EPI and NE.EPI and NE.


•The Inevitability of The Inevitability of “Startle/Flinch!”“Startle/Flinch!”

The Physiology of CombatThe Physiology of CombatThe Survival Stress The Survival Stress Reaction (“SSR”)Reaction (“SSR”)

• Fear activated heart rate increase = Fear activated heart rate increase = Erosion of combat skills!Erosion of combat skills!

• Combat – 70 BPM to 220 BPM in ½ Combat – 70 BPM to 220 BPM in ½ secondsecond

• High and even moderate levels of High and even moderate levels of stress interfere with fine muscular stress interfere with fine muscular control & decision making.control & decision making.

• Most life and death confrontations Most life and death confrontations – 145 BPM in tenths of a second!– 145 BPM in tenths of a second!

The Physiology of CombatThe Physiology of CombatThe Survival Stress The Survival Stress Reaction (“SSR”)Reaction (“SSR”)

• 70 BPM70 BPM – Normal. – Normal. • 115 BPM115 BPM – Fine complex motor skills – Fine complex motor skills

begin deterioration (Hand-eye co-begin deterioration (Hand-eye co-ordination and some form of digital ordination and some form of digital actions, multi-tasking).actions, multi-tasking).

• 115-145 BPM115-145 BPM – Optimal survival & – Optimal survival & combat performance / complex motor combat performance / complex motor skills high functioning ( “The Combat skills high functioning ( “The Combat Rush”).Rush”).


• 145 BPM +145 BPM + - Complex motor skills ( - Complex motor skills ( 3 + designed to work in unison) 3 + designed to work in unison) deteriorate deteriorate

• Brain center for hearing shuts down Brain center for hearing shuts down – – “Didn’t hear/couldn’t make sense, “Didn’t hear/couldn’t make sense, understand”understand”


• 175 BPM – 185 BPM175 BPM – 185 BPM 1.1. Cognitive processing deterioratesCognitive processing deteriorates. . 2.2. ““Tunneling”Tunneling” -visual system decreases peripheral info, -visual system decreases peripheral info,

combatant often retreats from the threat to widen combatant often retreats from the threat to widen the peripheral field. Pupils dilate to gather more the peripheral field. Pupils dilate to gather more information & depth perception is diminished information & depth perception is diminished

3.3. Perceptual Narrowing occurs (“Coning”)Perceptual Narrowing occurs (“Coning”) narrowing narrowing of visual system slows processing of information, of visual system slows processing of information, anxiety increases as combatant attempts to direct anxiety increases as combatant attempts to direct field of focus to threat.field of focus to threat.

4.4. Critical Stress AmnesiaCritical Stress Amnesia – – What happened? Who did What happened? Who did what?what?

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• 185 - 220 BPM185 - 220 BPM – Hyper-vigilance (“Freezing) – Hyper-vigilance (“Freezing) & Irrational Behavior. “The Dead Zone!”& Irrational Behavior. “The Dead Zone!”

• BPM increases trigger SNS - cerebral cortex is BPM increases trigger SNS - cerebral cortex is by-passed to large extent as brain stem and by-passed to large extent as brain stem and amgydala prepare combatant for amgydala prepare combatant for “flight, fight “flight, fight freeze.”freeze.”

• HyperventilationHyperventilation – associated with impairments – associated with impairments in memory, concentration and diminished in memory, concentration and diminished discrimination or perceptual abilities. Men in discrimination or perceptual abilities. Men in combat often “square on the target” due to loss combat often “square on the target” due to loss of visual focus during stress.of visual focus during stress.


• Increased heart rates have a Increased heart rates have a catastrophic affect on perceptual skills, catastrophic affect on perceptual skills, cognitive processing skills, reaction time cognitive processing skills, reaction time and motor skill performance.and motor skill performance.

• Absent proper training in performing Absent proper training in performing needed survival skill, anxiety increases, needed survival skill, anxiety increases, stress increases, BPM increases, and stress increases, BPM increases, and combatant descends into trauma vortex.combatant descends into trauma vortex.

• Breathing to control BPM is critical to Breathing to control BPM is critical to managing stress and trauma.managing stress and trauma.


• 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

The Impact of CombatThe Impact of Combat• Sensory OverloadSensory Overload (“Observe & Orient”)(“Observe & Orient”) – How – How

does the mind respond to the inability to identify does the mind respond to the inability to identify danger in a foreign culture?danger in a foreign culture?

• ““THE FIRST TEAM FOOT PATROL IN AL NASARIYHATHE FIRST TEAM FOOT PATROL IN AL NASARIYHA.” (April, 2003).” (April, 2003)

• UncertaintyUncertainty (“Decide”)(“Decide”) – The constant – The constant anticipation of being attacked can have a anticipation of being attacked can have a profoundly toxic effect, especially when this stress profoundly toxic effect, especially when this stress continues for months and years.continues for months and years.

• ““THE GARBAGE PILE AT CAMP WAR EAGLETHE GARBAGE PILE AT CAMP WAR EAGLE.” (February, 2004).” (February, 2004)

The Impact of CombatThe Impact of Combat

• Combat skills and the “Combat RushCombat skills and the “Combat Rush” ” – In combat, the midbrain has learned – In combat, the midbrain has learned to bypass logical thought processes to bypass logical thought processes and established conditioned reflexes and established conditioned reflexes or SNS responses, instantly, without or SNS responses, instantly, without having to be told to do it.having to be told to do it.

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

The Physiology of PTSDThe 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 PTSD sufferers hypersecrete CRF and have subnormal levels of cortisol.cortisol.

• Result 1Result 1 – there is no “shut off valve.” With no ability to halt the – there is no “shut off valve.” With no ability to halt the body’s alarm reaction, flight/fight/freeze response continues body’s alarm reaction, flight/fight/freeze response continues unabated.unabated.

• Hyperarousal and exaggerated startle response may occur.Hyperarousal and exaggerated startle response may occur.• Result 2Result 2 – The nervous system is “ – The nervous system is “always on high alertalways on high alert.” PTSD .” PTSD

sufferers and those exposed to trauma hyper secrete NE.sufferers and those exposed to trauma hyper secrete NE.• SNS responds with tachycardia, hypertension, dizziness, SNS responds with tachycardia, hypertension, dizziness,

increased perspiration.increased perspiration.• Elevated NE believed to play a role in flashback and panic Elevated NE believed to play a role in flashback and panic

attacks.attacks.

The Physiology of PTSD The Physiology of PTSD

• MEMORIES OF TERROR ARE OUR “GHOSTS IN THE MEMORIES OF TERROR ARE OUR “GHOSTS IN THE MACHINE”MACHINE”

• PTSDPTSD results in the decrease and results in the decrease and impairment of impairment of hippocampalhippocampal activityactivity( explicit memory, facts, ( explicit memory, facts, concepts, ideas, language dependent storage and concepts, ideas, language dependent storage and retrieval of memories).retrieval of memories).

• Amygdala governs implicit memories( based on senses, Amygdala governs implicit memories( based on senses, emotions) and is functioning no matter how high the emotions) and is functioning no matter how high the level of arousal.level of arousal.

• Hippocampal activity decreases and is impaired by Hippocampal activity decreases and is impaired by trauma.trauma.

• During trauma, some events maybe stored in the During trauma, some events maybe stored in the implicit, but not the explicit memoryimplicit, but not the explicit memory..


• MEMORIES OF TERROR ARE OUR “GHOSTS IN THE MEMORIES OF TERROR ARE OUR “GHOSTS IN THE MACHINE” ( continued)MACHINE” ( continued)

• Lack of explicit memory leaves trauma memory devoid of Lack of explicit memory leaves trauma memory devoid of placement in space and time.placement in space and time.

• Inability to contextualize memories causes flashbacks and Inability to contextualize memories causes flashbacks and experience of reliving trauma.experience of reliving trauma.

• SerotoninSerotonin levels levels decreasedecrease due to PTSD in the due to PTSD in the orbitofrontal cortex (OFC), which orbitofrontal cortex (OFC), which processes social and processes social and emotional informationemotional information and plays a role in the emotional and plays a role in the emotional processing of affective memories.processing of affective memories.

• Decreased serotonin in OFC potentially contributes Decreased serotonin in OFC potentially contributes to misinterpretation on emotional stimuli, impulsivity to misinterpretation on emotional stimuli, impulsivity aggression and inappropriate decision-making.aggression and inappropriate decision-making.

COMBAT TRAUMACOMBAT TRAUMAA Historical PerspectiveA Historical Perspective

Scars on a Warrior’s HeartScars on a Warrior’s Heart Psychic Trauma and Psychic Trauma and

WarfareWarfarethroughout Historythroughout History

• Post-combat numbing, nightmares, Post-combat numbing, nightmares, dissociation, intrusive recollections. dissociation, intrusive recollections.

• Epic of Gilgamesh – (2750 – 2500 Epic of Gilgamesh – (2750 – 2500 B.C.E.) Sumer.B.C.E.) Sumer.

• Homer’s “Iliad” (850 B.C.E.).Homer’s “Iliad” (850 B.C.E.).



•The Civil WarThe Civil War



• Civil War (1861 – 1865) “Nostalgia” Civil War (1861 – 1865) “Nostalgia” and “Soldiers’ Heart.”and “Soldiers’ Heart.”

• Lethargy, fits of hysteria, Lethargy, fits of hysteria, withdrawal, numbing, extreme withdrawal, numbing, extreme emotionality in soldiers from North emotionality in soldiers from North and South.and South.



Two-thirds of those committed to Two-thirds of those committed to Northern insane asylums after the Civil Northern insane asylums after the Civil War were veterans.War were veterans.

• Virtually all of the 291 veterans in the Virtually all of the 291 veterans in the Indiana State Insane Asylum Indiana State Insane Asylum demonstrated classic symptoms of PTSD- demonstrated classic symptoms of PTSD- hyper-vigilance, irrational fear of hyper-vigilance, irrational fear of impending danger, resultant paranoia.impending danger, resultant paranoia.



World War IWorld War I



• ““Shell shock.”Shell shock.”• Artillery bombardment and “intense Artillery bombardment and “intense

fear, helplessness, or horror.”fear, helplessness, or horror.”• Exaggerated startle response, stupor, Exaggerated startle response, stupor,

traumatic dreams, irritability, traumatic dreams, irritability, trembling.trembling.

• W.H. Rivers – utilized Freud’s “talking W.H. Rivers – utilized Freud’s “talking therapy” as well as oral and written therapy” as well as oral and written trauma narratives.trauma narratives.



• 72,000 neuropsychiatric discharges by 72,000 neuropsychiatric discharges by 19181918

• 112,000 receiving benefits by 1922112,000 receiving benefits by 1922

• History’s LessonHistory’s Lesson - -Combat stress Combat stress casualties appear to worsen or become casualties appear to worsen or become symptomatic with the passage of time.symptomatic with the passage of time.



•World War IIWorld War II


WarfareWarfarethroughout Historythroughout History• Post - WW I – Theory advanced that Post - WW I – Theory advanced that

certain individuals predisposed to psychic certain individuals predisposed to psychic trauma.trauma.

• WW II – 1.6 million men rejected for WW II – 1.6 million men rejected for “psychiatric reasons.”“psychiatric reasons.”

• U.S. lost 504,000 men (50 divisions) due U.S. lost 504,000 men (50 divisions) due to psychiatric collapse.to psychiatric collapse.

• Army recognizes that any individual will Army recognizes that any individual will succumb to trauma at personal “breaking succumb to trauma at personal “breaking point.”point.”



• History’s LessonHistory’s Lesson – – Longer the Longer the exposure to combat, greater the exposure to combat, greater the likelihood of psychic injury.likelihood of psychic injury.

• WW II after WW II after 60 days60 days of continuous of continuous combat combat 98%98% of surviving soldiers will of surviving soldiers will be some kind of psychiatric casualty.be some kind of psychiatric casualty.

• History’s LessonHistory’s Lesson – – Critical factors Critical factors are time in combat and intensity of are time in combat and intensity of combat.combat.


WarfareWarfarethroughout Historythroughout History• History’s LessonHistory’s Lesson – – Support troops not Support troops not

involved in direct combat are also involved in direct combat are also susceptible to becoming psychiatric susceptible to becoming psychiatric casualties.casualties.

• Pre-existing trauma history, attachment Pre-existing trauma history, attachment issues play a greater role for these issues play a greater role for these individuals.individuals.

• Stressors include separation from home Stressors include separation from home and friends, social and physical and friends, social and physical deprivations, boredom, lower unit deprivations, boredom, lower unit cohesion.cohesion.



• History’s LessonHistory’s Lesson – – Front line Front line treatment v. removal from theater, treatment v. removal from theater, proved more effective.proved more effective.

• ““P.I.E.” – Proximity, immediacy and P.I.E.” – Proximity, immediacy and expectancy.expectancy.

• WW II – 60% returned to duty with WW II – 60% returned to duty with their division; 90% returned to some their division; 90% returned to some duty in theater.duty in theater.



• Despite frontline treatment, after 4 Despite frontline treatment, after 4 years of war of the 800,000 U.S. years of war of the 800,000 U.S. soldiers that saw ground combat soldiers that saw ground combat 37.5% became such serious 37.5% became such serious psychiatric casualties that they were psychiatric casualties that they were permanently lost from the war effort.permanently lost from the war effort.



•Korea & VietnamKorea & Vietnam



• Korea 24% of U.S. soldiers became Korea 24% of U.S. soldiers became serious psychiatric casualties during tour.serious psychiatric casualties during tour.

• Korea – Of these 88% returned to duty Korea – Of these 88% returned to duty with division; 97% some duty in theater.with division; 97% some duty in theater.

• Korea – 1 year rotation policy initiated.Korea – 1 year rotation policy initiated.

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WarfareWarfarethroughout Historythroughout History• Vietnam – Psychiatric casualty rates Vietnam – Psychiatric casualty rates

reported between 2% - 5% during reported between 2% - 5% during combat phase (1965-1975).combat phase (1965-1975).

• Post – Vietnam – VA estimate was Post – Vietnam – VA estimate was 15% of vets suffered from PTSD. 15% of vets suffered from PTSD. Figures of other groups range from Figures of other groups range from 18% - 54%. 18% - 54%.

• 2.8 million Vietnam vets – 420,00 and 2.8 million Vietnam vets – 420,00 and 1.5 million suffered from PTSD at 1.5 million suffered from PTSD at sometime after the conflict.sometime after the conflict.



• Iraq/Afghanistan – 2.3 million deployed Iraq/Afghanistan – 2.3 million deployed (2011)(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 2008 Rand Study – 14% met PTSD and

depression criteriadepression criteria• 1.3 million have left the service1.3 million have left the service• 711,986 used VA healthcare (2002 – 711,986 used VA healthcare (2002 –

2011)2011)



• THE IMPACT OF KILLING AND THE THE IMPACT OF KILLING AND THE RESISTANCE TO KILLINGRESISTANCE TO KILLING

• Thou shalt do no murder. Exodus 20:13

• Jesus said, “Thou shalt do no murder.” Matthew 19:18



• THE IMPACT OF KILLING AND THE RESISTANCE THE IMPACT OF KILLING AND THE RESISTANCE TO KILLINGTO 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 Present day US fire rates estimated at

95% - 98%.95% - 98%.• What is the psychic cost of being trained What is the psychic cost of being trained

to kill?to kill?• Of actually killing or seeing others killed?Of actually killing or seeing others killed?


WarfareWarfarethroughout Historythroughout History• S.L.A. Marshall – “S.L.A. Marshall – “Men Against FireMen Against Fire” ”

and the WW II 15% - 25% fire rate.and the WW II 15% - 25% fire rate.

• Changed training doctrine – Human Changed training doctrine – Human shaped targets, pop –up.shaped targets, pop –up.

• Fire ratios – Korea 50%, Vietnam Fire ratios – Korea 50%, Vietnam 95%, Iraq – Afghanistan – 95% - 98%.95%, Iraq – Afghanistan – 95% - 98%.


WarfareWarfarethroughout Historythroughout History• Studies suggest a correlation between Studies suggest a correlation between

post-traumatic stress and killing.post-traumatic stress and killing.

• 1988 – Research by Stellman and 1988 – Research by Stellman and Stellman found a correlation between Stellman found a correlation between intensity and frequency of combat intensity and frequency of combat experience and PTSD in Vietnam experience and PTSD in Vietnam veterans, yet “great majority” seeking veterans, yet “great majority” seeking mental health services were never mental health services were never asked about combat experience.asked about combat experience.



• The Impact of Killing StudyThe Impact of Killing Study – S. Maugen, – S. Maugen, et al.et al.

• Study of Vietnam vets 47% reported Study of Vietnam vets 47% reported killing or believing they killed a killing or believing they killed a combatant, 13% a non-combatant.combatant, 13% a non-combatant.

• ““After accounting for demographics and After accounting for demographics and general combat exposure, killing was general combat exposure, killing was associated with PTSD symptoms, associated with PTSD symptoms, dissociative experiences, functional dissociative experiences, functional impairment and violent behavior.”impairment and violent behavior.”


WarfareWarfarethroughout Historythroughout HistoryOIF 2004 NEJM study by C.W. Hoge, et al. OIF 2004 NEJM study by C.W. Hoge, et al.

– 48%-65 % reported being responsible – 48%-65 % reported being responsible for the death of an enemy combatant, 14-for the death of an enemy combatant, 14-28% for death of a noncombatant.28% for death of a noncombatant.

OIF – 90% reported having been shot at.OIF – 90% reported having been shot at.OIF – 71% to 86% reported engagement in OIF – 71% to 86% reported engagement in

firefight with 5 being the median number.firefight with 5 being the median number.OEF – 36% reported participating in a OEF – 36% reported participating in a

firefight with 2 being the median number firefight with 2 being the median number in Afghanistan.in Afghanistan.


WarfareWarfarethroughout Historythroughout History• Prevalence of PTSD increased with Prevalence of PTSD increased with

number of firefights.number of firefights.

• OIF – 0 = 4.5%; 1-2 = 9.3%; 3 -5 = OIF – 0 = 4.5%; 1-2 = 9.3%; 3 -5 = 12.7%; 5+ =19.3%.12.7%; 5+ =19.3%.

• OEF – 0 = 4.5%; 1-2 = 8.2%; 3-5 = OEF – 0 = 4.5%; 1-2 = 8.2%; 3-5 = 8.3%; 5+ = 18.9%.8.3%; 5+ = 18.9%.



• Combat frequency – As of 2008 30% Combat frequency – As of 2008 30% of OIF OEF soldiers were on their of OIF OEF soldiers were on their THIRD TOUR!THIRD TOUR!

• 15% to 20% of all soldiers fighting in 15% to 20% of all soldiers fighting in Iraq and Afghanistan at that time, Iraq and Afghanistan at that time, were then showing signs of were then showing signs of depression or PTSD.depression or PTSD.

• This rate jumps to 30% for soldiers This rate jumps to 30% for soldiers that have been on 3 or more tours.that have been on 3 or more tours.


WarfareWarfarethroughout Historythroughout History• ConclusionsConclusions

• Stress of combat operations ultimately effects Stress of combat operations ultimately effects all warriors, some more than others.all warriors, some more than others.

• Duration of tour and intensity of combat appears Duration of tour and intensity of combat appears to be causally connected to post-combat trauma.to be causally connected to post-combat trauma.

• Killing in and of itself may be a causal Killing in and of itself may be a causal ingredient in the development of combat related ingredient in the development of combat related PTSD beyond general combat experiences.PTSD beyond general combat experiences.

• OIF/OEF veterans are engaged in an OIF/OEF veterans are engaged in an unprecedented operational tempo and combat unprecedented operational tempo and combat cycle.cycle.

Healers and WarriorsHealers and Warriors

•INTERVENTIONSINTERVENTIONS

Healers and WarriorsHealers and Warriors – – Preparing forPreparing for a a

Conversation about Healing Conversation about Healing Invisible WoundsInvisible Wounds• 1. Become a student of war – To normalize one needs 1. Become a student of war – To normalize one needs

fact based understanding. 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 3. Let each veteran understand that each warrior’s

journey is unique and each story fits in the narrative of journey is unique and each story fits in the narrative of their life.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 4. “The mind leads the body and the body leads the

mind.” – The need for “Awareness” based intervention.mind.” – The need for “Awareness” based intervention.• 5. Combat history, frequency, and severity is of critical 5. Combat history, frequency, and severity is of critical

importance.importance.• 6. Unit integrity, morale and leadership quality play a 6. Unit integrity, morale and leadership quality play a

critical role in resilience needed to ward off combat critical role in resilience needed to ward off combat stress and PTSD.stress and PTSD.

Healers and WarriorsHealers and Warriors – – A A Conversation about Healing Conversation about Healing

Invisible WoundsInvisible Wounds

CULTURAL RESISTANCECULTURAL 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


• Ultimately, combat trauma is a normal reaction Ultimately, combat trauma is a normal reaction to an external threat rather than an illness.to an external threat rather than an illness.

• Try to hear past the words to the statement of Try to hear past the words to the statement of emotional need underneath it.emotional need underneath it.

• AffirmationAffirmation – The war and the warrior are – The war and the warrior are separate and distinct. Whether we oppose the separate and distinct. Whether we oppose the war or not, we trained them, we sent them, war or not, we trained them, we sent them, they went for us, they deserve our respect and they went for us, they deserve our respect and need our reassurance.need our reassurance.

• Support Support – Identify and involve the soldier’s – Identify and involve the soldier’s support network. Family, community, place of support network. Family, community, place of worship.worship.

Healers and WarriorsHealers and Warriors• Normalizing the combat experienceNormalizing the combat experience

• ““An abnormal response, to an abnormal An abnormal response, to an abnormal situation, is normal behavior.”situation, is normal behavior.” Victor FranklVictor Frankl

• Combat reflexes will normally decay with time to a Combat reflexes will normally decay with time to a greater or lesser degree.greater or lesser degree.

• Combat establishes neural networks that can be Combat establishes neural networks that can be reactivated.reactivated.• ““It’s a normal reaction. Here’s what to do when it It’s a normal reaction. Here’s what to do when it

happens.”happens.”• Combat stress and trauma is simply how the veteran is Combat stress and trauma is simply how the veteran is

manifesting their experience of the war.manifesting their experience of the war.• Previous training, or the lack thereof, often explains Previous training, or the lack thereof, often explains

how feelings of fear, helplessness, or horror were how feelings of fear, helplessness, or horror were minimized, or not.minimized, or not.


• Normalizing the combat experienceNormalizing the combat experience (continued)(continued)

• ““intense fear, helplessness, or horror.”intense fear, helplessness, or horror.” DSM- DSM-IVIV

• ““HelplessnessHelplessness”” – Did you know what to do? – Did you know what to do?• ““HorrorHorror”” – Did things happen that you felt – Did things happen that you felt

unprepared for?unprepared for?• ““FearFear”” – What training did you have to manage – What training did you have to manage

your fear? Tactical breathing?your fear? Tactical breathing?• ““Re-experiencingRe-experiencing”” – Was the soldier ever – Was the soldier ever

debriefed about the incident/incidents?debriefed about the incident/incidents?


• Exposure therapy and Cognitive Exposure therapy and Cognitive Processing therapy.Processing therapy.

• Body centered modalities – EMDR, Body centered modalities – EMDR, Somatic Experiencing, autogenic Somatic Experiencing, autogenic breathing, open awareness exercises.breathing, open awareness exercises.

• Reconstruction of the narrative – Post-Reconstruction of the narrative – Post-traumatic growth and the distinction traumatic growth and the distinction between “brooding” and “reflective between “brooding” and “reflective pondering.”pondering.”


• Open focus exerciseOpen focus exercise – Both PTSD and – Both PTSD and combat can create experience of combat can create experience of “coning.” Stress of not being able to “coning.” Stress of not being able to fully visualize environment can fully visualize environment can accelerate stress response.accelerate stress response.

• To break out of tunnel vision having To break out of tunnel vision having combatants scan and breathecombatants scan and breathe - After - After taking a shot, by physically turning the taking a shot, by physically turning the head and scanning the battlefield after head and scanning the battlefield after engagement seems to cause tunnel engagement seems to cause tunnel vision to diminish.vision to diminish.


• PRE-EXISTING WOUNDSPRE-EXISTING WOUNDS


• Pre-existing trauma history can play Pre-existing trauma history can play a huge role in predisposing a huge role in predisposing individuals to PTSD.individuals to PTSD.

• In 2007 study, 69.1% of women In 2007 study, 69.1% of women veterans suffering from PTSD veterans suffering from PTSD reported pre-enlistment sexual reported pre-enlistment sexual assault. 73% reported sexual assault. 73% reported sexual trauma such as sexual assault or trauma such as sexual assault or rape while serving in the military.rape while serving in the military.


• Studies suggest securely attached Studies suggest securely attached individuals, with a history of high individuals, with a history of high quality caregiver relationships were quality caregiver relationships were less likely to develop PTSD than their less likely to develop PTSD than their less securely attached counterparts.less securely attached counterparts.

• Low cognitive function prior to Low cognitive function prior to exposure strongly influenced measured exposure strongly influenced measured vulnerability to developing PTSD.vulnerability to developing PTSD.


• In helping a veteran, remember the In helping a veteran, remember the words of SMG William Von Zehle:words of SMG William Von Zehle:

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


VETERANSVETERANS• ResourcesResources

• www.realwarriorswww.realwarriors• 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 Jonathan Shay, Ph.D. – “Achilles in Vietnam” ; “Odysseus in

America”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, M.S. Micale & P. Lerner (Eds.) – “Traumatic Pasts: History,

Psychiatry and Trauma in the Modern Ager, 1870 – 1930”Psychiatry and Trauma in the Modern Ager, 1870 – 1930”• National Center for PTSD – Veterans AdministrationNational Center for PTSD – Veterans Administration


VETERANSVETERANS• Bob CaffreyBob Caffrey

• www.caffreycounseling.comwww.caffreycounseling.com• [email protected]@gmail.com

• (860) 331-0641(860) 331-0641

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THE COMBAT TRAUMA CONTINUUM AND VETERANS