Tied Paper for Ind Study_final

8/8/2019 Tied Paper for Ind Study_final

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Running head: TRAUMA-INDUCED EXISTENTIAL DIS-INTEGRATION

52

The survivor may even come see the event as a powerful life lesson. Judith Lewis

Herman (1997) adds, The belief in a meaningful world is formed in relation to others

and begins early in lifetraumatized people suffer damage to the basic structures of the

self. Their sense of self has been shattered and can only be rebuilt as it was built initially,

through connections with others (p.61).

W hat br eaks? Shay asks, When a soldier is broken by combat, what breaks?

(1994, p. 165). Examining this issue from a mythological perspective, Shay describes

multiple areas of the human being that are prone to breaking including feelings of

emptiness, hopelessness, and suffocating despair. He states that the broken spiritwill often a display hostile, mistrustful attitude toward world, disconnection with others,

chronic on-edge feeling, and impending feeling of doom. Shay warns that these

symptoms can be mistaken as borderline or antisocial personality disorder. While he

believes that normal is not possible, recovery is possible as survivors of severe trauma

adopt their own lives including their limitations with passion and existential

authority (p. 185).

T he b rok en s p irit . According to Wilson, The broken spirit is a metaphor for the

fracturing of the soul, self, and identity (2004, p.110). While the concept has had many

names (soul, self, life energy), the spirit is the core, inner sanctum of the ego and the self

of a person (p. 110). Wilson contends that when this human domain becomes

fragmented, it results in the loss of coherency and continuity in the being. What is

broken is the sense of connection with the critical dimensions of [human] existence

(ibid.). These include ones connection with the self and others, nature and the sacred,

hopes for the future and sources of meaning in life. Disintegration of these virtues (to


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borrow a term from Erikson, below) occurs when the self is shattered by trauma or

extreme stress.

The structure of the self unravels, dismantles, and reverts to regressive forms of primitive ago functioning at a rudimentary survival level. What remains arefragmented pieces of the self that can be devoid of energy, hope, trust and viablesystem of meaning (p. 119).

Wilson viewed the dialectic between cohesion and fragmentation as a continuum

for the posttraumatic self (p. 114). Following trauma, the individual will fall somewhere

along this continuum from extreme fragmentation of the self to higher levels of cohesion.

Wilson outlined several possible manifestations of this continuum from the empty self

characterized by significant disintegration of the identity, to the cohesive self which is

characterized by ability to spring back from trauma demonstrating resiliency. In

between, there are several variations of the fragmented self which is characterized by

traits of identity diffusion, fragility, and strong feelings of discontinuity within

themselves and with others and are prone to dissociation. Finally, the integrated

transcendent self denotes the person who has been fragmented by their experience, but

has healed and transcended the trauma through engaging in self reflection and efforts

toward self actualizing (p. 123). Frankl (1994) described this as active transcendence

in which the old self is shed and replaced with a new, more vital and functional, self (p.

131) which, once reassembled can become a new form of strength and beauty (p.112).

D evelo pmen tal th eory . Earlier we discussed developmental theory with regard to

assumptions about the initial identity or ego development processes that have been

completed by the adult service member prior to experiencing deployment stress.


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Revisiting this issue from a different perspective (not with regard to initial identify

formation but of developmental disintegration) Erik Eriksons Stages of Identity

Development (1980) provides a significantly relevant framework for understanding the

formation and transformation of the identity across the lifespan as well as a contextual

model for examining the disintegration of the Core Self.

At the point of early adulthood when most military personnel join the service, most

have navigated through the first five or six developmental stages and have achieved some

degree of the underlying virtues of those tasks (table 4). However, many are still in the

process of working through the stages associated with establishing industry

(competence), identity (self) and intimacy (relationships). The military can provide

opportunities for the individual to find a sense of purpose, bond with others and achieve a

sense of belonging and sense of self. However, experiencing extreme stress can

undermine and unravel the developmental tasks previously attained, shattering the

existing schema and resulting in developmental regression. In returning military

personnel, we often see signs of a breakdown of the fundamental virtues of previous

developmental stages.

ST AGE T ASK V IR TU E IN C R ISIS

Stage 1 Trust vs. Mistrust Hope Develop mistrust, paranoidworld view, loss of hope infuture

Stage 2 Autonomy vs. Shame Will Shame and doubt debilitatethe individuals ability tomove forward

Stage 3 Initiative vs. Guilt Purpose The person is unable toconnect with individual

purpose or meaning


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Stage 4 Industry vs. Inferiority Competence Individual feels incompetent,inferior undeserving and

judges self harshly

Stage 5 Identity vs. Role Confusion Fidelity Feels betrayed by group

Stage 6 Intimacy vs. Isolation Love Unable to connect with othersor feel belongingness

Stage 7 Generativity vs. Stagnation Care Self-absorption stagnatesdevelopment and healing

Stage 8 Integrity vs. Despair Wisdom Unable to find meaning inexperiences

T abl e 4

For the warrior who has experienced extreme stress or trauma, the core of their being

where these virtues reside, becomes fragmented and development regresses to earlier

stages. Of veterans, psychologist Erik Erikson stated, What impressed me most was the

loss in these men of a sense of identity. They knew who they were; they had a personal

identity. But it was as if, subjectively, their lives no longer hung together and never

would again. There was a central disturbance ofego identity (Erikson, 1963, p. 42).

A ros e b y an y oth er n ame There have been many attempts to identify and

describe the elusive domain of human existence we identify as the spiritual domain and

differentiate this facet of being from the physical and mental domains. The review of

existing literature, both professional, and general, use the terms spirit, psyche,

personality, soul, schema, ego, and self, interchangeably. To further confuse matters, the

terms soul or spirit carry deep religious connotations which lead to a much different

discussion entirely. In the interest of clarifying this ambiguous terminology, for the

purpose of this treatise I will refer to this domain as the Core Self. The Core Self will


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refer to the vital, dynamic, interconnected component of the whole being that represents

the Noetic (spiritual) domain of the individual. While ever changing and evolving as new

experiences are integrated, this domain represents a manifestation of the individuals

accumulated experiences, past and present. Within this realm is held the individuals

unique compilation of values, beliefs, faith, trust, preferences, motivation, love, esteem,

goals, ambition, and world view.

T rauma -I nduc ed Exist ential Dis -I nt egration Mod el (TI ED )

C linical D evelopm ent of t he TI ED Mod el.

The spiritual domain . Many theorists not only acknowledge that the spiritual

domain exists and have made attempts to describe it, they also suggest that this domain

can be injured or wounded, resulting in an array of emotional, social, and behavioral

outcomes. In my own quest to understand the phenomenological effects of war on the

soldiers and veterans with whom I work, I arrived at similar conclusions. I have

witnessed the way that the war experiences can injure individuals at the very core of their

being through my clients who have shared their struggles to understand the profound

changes that they feel in themselves. The prolonged experience of engaging in war can

lead to a wounding of the core self. While many refer to these wounds as PTSD, I have

come to believe that this wound is separate and distinguishable from the diagnosis of

PTSD and I propose that this phenomenon is a separate, but highly co-morbid, condition

that arises in response to the same etiological conditions. While PTSD is an anxiety-

based condition that manifests as a result of experiencing extreme trauma, I believe that


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what we have been missing is separate, spiritually-based condition that manifests as a

result of other aspects of the war experience. With several years of validated research to

support the criteria of PTSD, it is clear that many of our warriors today suffer from

reliving their traumatic experiences, hyper-vigilance, avoidance, and numbing related

specifically to traumatic events of combat. They suffer from nightmares, endure

flashbacks, and report that they are unable to shake the feeling of intense anxiety as if

they are on guard nearly all of the time. However, the diagnosis of PTSD by itself does

not accurately or effectively encompass all of the symptoms reported by returning service

members. Even though being deployed to a war zone (with the awareness of the potentialof trauma/mortality and focus on the mission) could certainly be regarded as a prolonged

stressor, meeting the criteria for consideration of the diagnosis of Complex-PTSD, many

warriors reports that they did not have a traumatic event during the deployment, yet

over 50% of patients seeking treatment have exhibited the DESNOS symptoms upon

their return (Ford, 1999). To address the leftover symptoms we must turn our attention to

humanistic and existential theory to delve further into examining the effects of trauma

and extreme stress on the core self and to provide a framework for understanding our

clients when they talk about feeling as if their very soul has become fragmented. Much

like the age-old Nature vs. Nurture argument, the field has been divided for generations

between regarding this constellation of symptoms as an anxiety-based or dissociative

disorder. When backed into a corner without many options, one tends to feel the need to

choose sides. Yet, as we step back to observe the whole picture (i.e. the whole person),

we begin to see that this is a complex three-dimensional issue, affecting every domain of

the individual body, mind and soul. It is impractical to continue trying to merge all the


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symptoms together under one diagnosis? What if we looked at it through two lenses

instead of one? When I started exploring this as two distinct, yet highly co-morbid

conditions, the components of the proposed model, Trauma-Induced Existential Dis-

Integration, began to fall into place.

Franklian P syc h ology . The underlying framework for this model is based

heavily on the tenets of Franklian Psychology (also known as Logotherapy). Developed

throughout the 20 th century by Viktor Frankl, Logotherapy (Logos referring to

meaning) is often referred to as the Third Viennese School of Psychotherapy. In

contrast to Freuds Psychoanalytic theories which postulate that human beings are

motivated by their quest for pleasure, or Adlers theories which emphasize a quest for

power, Frankl states that our greatest motivator is our quest for personal purpose or

meaning. Franklian Psychology rests on three basic pillars: life has meaning under all

circumstances; human beings are motivated by the search for their own unique meaning

in their lives; and, human beings have the freedom (and responsibility) to discover

meaning in all that they do or experience even in the face of great suffering (Frankl,

1988, p. 16). One of the assumptions present in Frankls theory is the observation that

suffering is inevitable; it is one characteristic of being human that we all share no matter

what our socioeconomic status, or culture. Statistically, 50 % of us can expect to survive

at least one traumatic event over the course of our lives (Meagher, 2007, p. 21). All

human beings will, at some time in their lives, experience what he called the tragic

triad of pain, guilt, and death (Fig 2). There is no human being who may say that he

has not failed, that he does not suffer, and that he will not die. (Frankl 1988, p 73).


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Figur e 2

S u ffe ri n g is i nev ita bl e: an o pp ortu n ity f or me an i n g . The assumption that all humans

suffer is an ironically comforting quality that allows a therapist who may not have

experienced war to emotionally identify with the clients experience of trauma, and can

connect with regard to the clients suffering since that is something we all share. It levels

the playing field, so to speak, and connects us with all others. It also normalizes

suffering as a uniquely human experience and validates the feelings associated with our

suffering. Another assumption made in Franklian Psychology is the belief that humans

are able to reflect on their suffering and strive to discover personal meaning in the

experience. Whether the traumatic event is sudden and unexpected, or prolonged,

Logotherapy recognizes that a person who has endured a profoundly stressful experience

may be injured in body, mind, and/or the spirit (noos). The third assumption inherent in

Logotherapy is the belief that human beings (in general) have within them, the ability to

rise above, overcome, and even grow from their adversity. We have built in ability to

adapt to our changing environment and to the stresses and circumstances of like out

adaptability acts as protection. (Meagher, 2007, p. 22). Franklian psychology

emphasizes the quest for meaning and enrichment of the strengths of the individual to

overcome tragedy, specifically addressing the injuries and healing of the spirit (noos).

Pain

DeathGuilt

TRAGIC TRIADcan lead to

Existential Vacuum& Despair


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Frankl differentiates between the emotional discomfort of searching for meaning which

he views as being a desired human trait, and the pathological emptiness or void he calls

the existential vacuum.(1988).

Struggling for a meaning of life, or wrestling with the question of whether thereis a meaning to life, is not in itself a pathological phenomenon. There is no needto feel ashamed of existential despair because of the assumption that it is anemotional disease, for it is not a neurotic symptom but a human achievement andaccomplishment (ibid., p.91).

I found this theory is especially relevant and applicable to understanding and addressing

the needs of our returning warriors, for whom a strong sense of personal meaning is so

prevalent in their lives. According to Frankl, emotional illness and depression is a result

of the individuals inability to find or create their own sense of meaning in life, leading to

an internal emptiness and disconnection with ones sense of personal meaning. The loss

of this personal connection with personal meaning or purpose causes a chain reaction of

existential crises, which leads to a shattering of the Core Self. What was once a cohesive

structure becomes fragmented or dis-integrated. This dis-integration affects the

individuals sense of who they are as a person (or who they once were); their individual

sense of purpose, and ultimately their ability connect with others or find meaning in their

new lives. According to Franklian theory, it is this ability to remain connected within

ones self in the face of adversity that leads the individual toward resiliency, recovery and

growth. He postulates that not only do all human beings share the experience of pain and

suffering, but that we all have the capacity of overcome the suffering through an

individual sense of meaning and purpose. Through his work with suicidal and

despondent patients who had lost all hope or desire to continue living, Frankl developed a

strong belief in the resiliency of human beings to overcome tragedy and adversity


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through this ability to create or find our own personal sense of meaning from these

challenging experiences in life. It is through embracing this sense of personal meaning or

purpose that provides the strength and determination to endure suffering and the

opportunity to grow as a person (Graber, 2004). Frankls theories were put to the test

when he, himself, was imprisoned in German concentration camps for three years during

the Holocaust. His determination to see his parents and wife again and to publish his

manuscript to bring his theories to the public fueled his determination to survive, even as

those around him were giving up. As the great philosopher, Nietzsche, declares He who

has a why to live can bear almost any how (2010).T ragic o p ti m ism. Frankl believed that the path to healing this disintegration of

the Noos was through reintegrating the parts of the self through meaning-making. He

postulated that there were three primary ways that human being create or find meaning in

their lives. First, the path to meaning making was through looking outside of, and

beyond the self. In fact, self-absorption was considered to be detrimental to finding

meaning and leads to pathology and despondency. It is through reaching outside of the

self through work, love, and/or experiencing nature/beauty, that we find our sense of self.

He referred to these components as the Triad of Optimism (fig, 3) (Frankl, 2006, p.111).

The Triad of Tragic Optimism:

Figur e 3

Love

BeautyWork

Meaning-Making

Growth & Resilience

Re-Integration


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The Triad of Tragic Optimism provides the means to discover or create personal

meaning. From this perspective, human beings actualize their potential meaning in life

by focusing on a cause to serve or another person to love rather than by focusing on the

self. Logotherapy encourages de-reflection (looking outside oneself) rather than hyper-

reflection (looking within the self) and believes that self actualization is not a goal - it

is a by-product derived from the activity of creating meaning. Frankl refers to this as the

transcendence of human existence (2006, pp. 110-111).

W ork . Personal meaning can be created or discovered through work or

generatively. Whether it is a job, a volunteer position, or creating something that is

meaningful, finding meaning through work or creation allows the individual to give

something of themselves to the world. The creation of this work gives their life purpose

and meaning and helps sustain in the difficult moments. For Frankl, he experienced this

first hand as he fought to retain his manuscript during his containment in the

concentration camps of Auschwitz. He was motivated to bring his theories to the world

to help others and this purpose often helped him endure the pain and suffering of the

concentration camp (2006).

Love. Another path to life meaning is through love and our relationships with

others. Our lives have meaning because we know that we are connected to another

person. We matter to someone else. Often we can endure suffering in order to see our

loved ones again or to be strong for them. Frankl also stated that his desire to see his

wife and parents again gave meaning to his struggle to survive each day in the

concentration camps. Our own personal life meaning is discovered through our

relationships and that knowledge that other people need us. I have spoken to many


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suicidal clients whose only reason for not attempting suicide is that it would hurt a loved

one (Frankl, 2006, p. 110).

B eauty . The third path to meaning in the Triad of Optimism is what Frankl

referred to as Aesthetics, also referred to as beauty or nature. This realm is personal and

unique. It represents the moments in life when we feel connected with nature and all

things. It may be through an increased awareness of the divine, or of our interconnected

relationship with nature seen through a beautiful sunset. Meaning turns suffering into

human achievement and accomplishment, motivating and empowering one to take

responsible action and leads to the concept of posttraumatic growth and resiliency (2006,

p.111).

T rauma -I nduc ed Exist ential Dis -I nt egration .

While the literature review presented thus far represents only a fraction of the

available material related to trauma, I feel that it is sufficient to establish the foundation

from which to discuss the need and development of a new conceptual framework. As we

have seen, attempts to define the post-trauma phenomena have had a long and varied

history, and have been riddled with controversy and confusion. Throughout generations,

service members returning from war and/or combat have reported similar symptom

clusters regardless what professional paradigms were prevailing at the time. Even today,

with decades of research validating the existence of PTSD, our warriors continue to

suffer with the same of debilitating symptoms as in previous generations and are still not

adequately defined, addressed or treated under our current guidance. We are a country at

war, and the numbers of service members who have already returned from war, and the

number who will be returning, are staggering. We have learned much over the years and


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generations of previous wars, but it is time to take our knowledge to the next level. I

believe we must take a serious and intentional look at the symptoms that do not fit our

current classification system, and attempt to understand how and why these symptoms

continuously hang together. Paradigms are changing and emphasizing a move toward

holistic treatment. Can we address the needs of our returning service members from a

holistic perspective and fill the gaps we are seeing in the field and translate to more

effective treatment?

The proposed model, Trauma-Induced Existential Dis-Integration provides the

framework needed to address the indentified gaps in our existing nomenclature andelevate our understanding of the existential effects of extreme stress and trauma on the

individuals who experience it. Integrating practice wisdom, clinical observation, and

multiple evidence-based theories, the proposed model provides a platform from which to

examine the elusive symptoms of extreme stress that are beyond the scope of PTSD,

while integrating these symptoms into an etiologically-based therapeutic model. Finally,

the model seeks to provide within its framework, the implication for treatment that

embodies an expectation of transformation, growth, and recovery taking treatment into

the realm of holistic care. Within the name, lies the framework for etiology, diagnosis,

and treatment and provides the nomenclature that will facilitate discussion and further

inquiry.

T rauma -I nduc ed (Etiology ): In accordance with the etiological assumptions for

Disorders of Extreme Stress Not Otherwise Specified (DESNOS), TIED is often seen in

people who have endured extreme, prolonged or severe trauma or stress-laden

experiences. However, it can be noted that people can experience TIED without a


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specific trauma event and that enduring extreme stress can bring about the phenomenon

of TIED. While this essay specifically focuses on the application of this theory to the

military population, war is not the only environment that may produce this phenomenon,

but is certainly conducive to the development of this condition. It is noted that this

phenomemon can be found in a variety of populations and people across the lifespan. A

hallmark feature for TIED is that an external experience triggers an internal existential

crisis during which the person begins to question their very existence, life meaning, and

future. This experience can involve an increased awareness of ones own mortality,

facing death, danger, or significant life change.

Exist ential (Symptmatology ): Based on the structure of the whole being as

postulated by Aristotle, Frankl, and others, TIED recognizes the existence and

importance of the Noos, or spiritual domain as a viable human entity referred to as the

Core Self. TIED recognizes that this domain can be wounded by experiences of

extreme stress which leads to an existential crisis or vacuum shattering the previous

sense of self at the core of ones being (values, feelings, beliefs, choices, purpose) and is

related to the persons sense of who they are, why they exist, why they made certain

choices, whether or not they matter, or make a difference. Existentialism is the branch of

philosophy conceptualizing the individuality of each persons quest to understand life and

his or her place in it through deriving meaning from life events. Based on my own

clinical observation, psycho-social assessments and attempts to diagnose returning

service members, along with the work of others such as Herman and van der Kolk, the

diagnostic criteria for TIED is similar to the symptoms outlined in the DESNOS criteria


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which has been validated by multiple studies. While DESNOS covers a wide variety of

symptoms, TIED specifically focuses on the following symptom clusters;

1. alteration in regulation of affect and impulses (Irritability, risk-taking,impulsive purchases, attempts to replace the lost meaning),

2. alteration in attention or concentration - (Hyper-reflection on self, obsessivefocus on changes to self, depersonalization),

3. alterations in self perception (Feeling permanently changed or damaged,Feeling that no one can understand, changes in Core Self virtues),

4. alterations in relations with others (Dis-connection or discomfortemotionally connecting with others, mistrust, paranoia, and

5. alterations in systems of meaning (Strained or lost sense of meaning or purpose, despair, hopelessness, loss of previously sustained beliefs).

Ample research is available to suggest the existence and prevalence of these symptoms

clusters among returning veterans in conjunction with the centuries of anecdotal reports

from previous eras of soldiers throughout time. TIED recognizes these symptoms as

central to the individuals discomfort and not associated features of another diagnosis.

In addition, while it is important for this constellation of symptoms to have a specific and

unique identity, it should be noted that experiencing these symptoms does not,

necessarily suggest the presence of pathology. The presence of a degree of tension

created in the moments in life that offer the greatest opportunity for meaning-making and

growth is considered by Frankl to be a healthy and natural sign of growth and resiliency.

All too often, the normal emotional reaction to the abnormal events of war,

separation, deployment, is considered to be pathological. However, while the discomfort

of this life crisis or existential vacuum may be normal, the person often needs guidance


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and reassurance to navigate through this process of re-integration. In addition, if the

person becomes stuck or stagnate in this existential vacuum, it can lead to serious

pathological problems such as depression, identity diffusion, and suicide. For the

individual, this is a process that spans a continuum between normal/functional to

pathological/dysfunctional. Pathology is based on the intensity and severity of the

individuals feelings of being disconnected from their core self and sense of purpose.

Dis -int egration ( N ormal, P at h ological & R ecov ery ): The concept that what

was once whole or connected is now fragmented and lacks cohesion or integration. This

dis-integration happens on many levels from the core of the being, to a connection with

the self, others, society, or higher sense of purpose or divinity. According to Dr. Charles

Figley, this injury is permanent in the sense that that the pieces will not go back together

exactly the way they were before (2007). Healing comes from the re-integration of the

fragmented components of the self to help the person become whole again. TIED

recognizes that the new self will be permanently changed by the experiences. This

change can be positive and can result in the individual becoming stronger and more

resilient than before. The goal of therapy is to support the client as he or she re-integrates

these fragments while deriving meaning from the experiences.

Fac e Validity - Addr esses C linical Obs ervation . Trauma-Induced Existential

Dis-Integration attempts to provide a diagnostic and treatment structure to address the

clients primary question, who am I now? A hallmark characteristic of this syndrome,

it is an indicator that the individual is trying to convey his or her awareness of the

profound changes and/or feelings of disconnection with ones core self and need for re-

integration. TIED recognizes that this is not the realm of the cognitive, or the physical, it


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is the realm of the spiritual self and can only be reached through exploration of existential

theory, particularly with Franklian Psychology, this model addresses this transformation

and sees it as a continuum from pathology to recovery.

The or etical assumptions . Embedded within the Trauma-Induced Existential

Dis-Integration model are the following assumptions adopted from other theories or

models presented. It assumes the existence of the Spiritual Domain as a very real, vital

and integral component of the whole. This domain is referred to at the Core Self. The

Core Self is the unique part of the human being that can be likened to the personality,

persona, ego or identity. Simply stated, it is who they are and who they know themselves

to be. The Core Self can be shattered or wounded by severe stress, trauma or extreme life

event. We assume that, prior to the experience of extreme stress; the Core Self was

integrated and functional (at least in the environment in which they were accustomed).

When the Core Self is wounded, it becomes dis-integrated, (as in, no longer

integrated). All of the Core traits that once formed a cohesive structure that was known

and comfortable to the individual are no longer integrated or cohesive. Fragments remain

of the Original self, along with fragments of new elements created from the new

experiences. The glue that holds the self together, or allows for resiliency during periods

of great stress or trauma is the individuals ability to create or discover meaning in these

experiences. An overwhelming of this process leads to an existential vacuum, which can

lead to despair and manifest into symptoms of extreme stress as outlined above.

Another assumption on which this model is based is that all humans will

experience periods of suffering in their lives and that we all have the potential capacity to

endure, survive, and even thrive in the face of great danger or adversity. This, of course,


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has been proven time and time again by everyday people. From war, the Holocaust,

crime, and natural disasters, people have a strength and determination to survive. TIED

assumes that the goal of treatment is to help the individual navigate their way through

this journey and reintegrate the fragments of the self with the new experiences leading to

transformation and growth.

Application : W h at do es t h is m ean for our military? Among returning

warriors, there exists a duality between those whose sense of Core Self remains

integrated as opposed to those who return dis-integrated. While both groups often

report having similar experiences during deployment, and both groups may report having

combat-related symptoms and readjustment challenges, the individual whose Core Self

remains integrated has an intact sense of self, ability to remain connected with others,

and has retained, or developed, a personal sense of purpose or life-meaning. Far from

being rigid, these are individuals who have integrated their life questions and war

experiences into a new sense of self. They appear to be much more resilient and able to

successfully reintegrate back into civilian life in spite of predicable anxiety and

readjustment issues. Whereas, the individual who returns with a fragmented, shattered or

disintegrated Core Self has much more difficulty deriving personal meaning from their

traumatic experience, becomes withdrawn and has disconnected from others, and has

difficulty re-integrating back into civilian life. These individuals display a high co-

morbidity with PTSD, Major Depressive Disorder, and other emotional/behavioral

conditions. They can be difficult to engage, have atypical responses to medication

management and traditional therapies, and express a myriad of bio-psycho-social

complaints. I have witnessed individuals in this group drift in and out of multiple


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treatment facilities and attempt numerous treatment modalities including a vast array of

medications, with little or no reported relief. As Dr. Tick astutely observes, You cannot

medicate the soul (2005, p. 116). This group often displays an increased risk for

dysfunction within multiple areas of life including interpersonal, emotional, vocational,

substance abuse, homelessness, and suicide. There are several aspects of military

services which lend our warriors to being more susceptible to this existential vacuum.

This is a volunteer fighting force. The warriors have chosen to serve and oftentimes, to

deploy. For some, this is a point of comfort and sense of personal choice and power, for

others this can increase the sense of guilt, remorse, and self doubt. Our soldiers arehighly trained, professional, intelligent warriors who have a deep sense of individual and

collective purpose and meaning to all that they do. These choices, strengths and

adaptability allow the Core Self to change and transform in order to survive. This

transformational process, with emphasis on the changes to the Core Self is outlined below

and summarized in table 5 on page 77.

O rigi nal C or e S el f . Prior to the experience of extreme stress or trauma (i.e. prior

to deployment), the individual is functioning with his or her Original Core Self intact.

Within this Core Self lies the sum total of the persons existence to this point. Past

experiences, previous learning, accomplishment of developmental tasks, previous abuse

or trauma, instilled values, belief system, hopes, dreams, preferences, motivations,

esteem, doubts, sense of self in the world and sense of meaning - all reside in a relatively

cohesive entity. While this entity is far from perfect, we will assume for the warrior

population, that it is generally stable and functioning, even with any possible deficits

such as previous trauma, abuse, or psychosocial issues. This persona often becomes the


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baseline to which later variations of the self will be compared. When they state, I am

not the person I used to be, they are holding the memory of this self in their mind, as

are their family members who cling to unrealistic expectations that the warrior will return

to the person they once had been. When preparing to go into battle, the Original Core

Self must transform from their civilian persona to the warrior persona in order to survive

and fulfill the mission. This transformation is adaptive and functional for survival yet,

ironically it is this powerful transformation, under the pressure of life and death

circumstances that creates such difficulties when a service member returns and tries to re-

integrate into their civilian life.

W arrior S el f. During the preparation for deployment the transformation from

civilian to warrior begins. First, there is the process of anticipatory separation from their

loved ones. They begin to plan and talk about their departure, and must face the

possibility that they may not return. They start emotionally separating long before the

geographic separation occurs. As they enter pre-deployment training cycles, they

begin to connect and bond with their battle buddies as the group motivation toward

fulfilling the mission is instilled. The bonds and connections that define the Original

Core Self, are loosened in order to assimilate and accommodate new demands. They

must transform to become an integral member of the group, troop, or battalion the

American Uniformed Services. This is an immensely powerful transformation since,

with this warrior identity, comes intense pride, patriotism, and purpose. The values of

life, death, freedom and safety lie in their hands. The individual must allow the

connection with their previous values, beliefs, and tendencies of the Core Self, to be

loosened in order to take on the values of the group and develop cohesion and the


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collective identity. The warriors life, the lives of their troop members and innocent

civilians depend on successfully making this transformation. When this happens, they

become more than just a member of a group, they become a part of something greater

than themselves. Something mythical, timeless they become warriors. This great sense

of purpose is something outside of themselves that they are willing to suffer, sacrifice and

die for. Their affiliation as a member of this group is seen and reinforced through the

powerful symbolic images of their uniform, the American flag, insignia, and their shared

credo (see appendix C). Throughout the deployment, they have the mission of holding

the countrys security, pride, and future, and the very life and death of countless battle buddies and civilians, in their hands. The values and beliefs of the Core Self and

previous connections with others are challenged, strained and even broken for the

individual to survive this abnormal life experience. This transformation challenges even

the most basic values forcing the individual to overcome ingrained human resistance to

kill by instilling a mission first, kill or be killed belief system (Grossman, 1996, p. 29).

This transformation is based on survival. There is an increased awareness that there is a

real element of perpetual danger and the warrior must be ready to put mission first and be

willing to die for the cause. Meaning and purpose of the group is greater than the

individual. Inside the individual, however there is a conflict between the values and

beliefs of the Original Self, and those adopted by the Warrior Self. Tim OBrien, a

combat veteran, describes this duality of within,

War has the feel the spiritual texture - of a great ghostly fog, thick and permanent. There is no clarity, everything swirls. The old rules no longer binding, the old truths no longer true. Right spills over into wrong. Order blendsinto chaos, love into hate, ugliness into beauty, law into anarchy, civility intosavagery. The vapors suck you in. You cant tell where you are, or why youre


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there and the only certainty is overwhelming ambiguity. In war you lose your sense of the definite, hence your sense of truth itself, and therefore its safe to saythat in a true war story, nothing is every absolutely true (OBrien, 1980 as quotedin Herman, 1997, p.53).

This quote provides a glimpse into the internal conflict and profound opportunity for

deep existential and philosophical questioning as everything they once knew to be true

begins to come apart. There is no external certainty, and therefore, no internal certainty

or cohesion. The existential experience can be similar for those who engaged in combat

and in those who were there in support and did not experience battle or traumatic

experiences. The mere fact that they were separated from their previous life and

relationships, and serving the same mission, still aware of their own mortality, and having

the time to ruminate on their life, purpose, goals and existence. I believe this helps to

explain why we often see a similar constellation of symptoms in those who did not

experience combat or trauma and therefore, would not meet the diagnosis of PTSD. They

may not exhibit symptoms of anxiety, but may return with many of the DESNOS

symptoms discussed earlier.

D is-I n t e grat ed S el f. Upon return from the deployment experience, the individual

carries with them fragments of the Original Core Self as well as fragments of the Warrior

Self but, neither of these adequately fit their new environment. The grip held on the

values, beliefs, and motivations of the Warrior Self must now loosen in order to

transform to meet new demands and to be able to reintegrate into civilian life. Previous

relationships must be renewed and the person must often (especially in the case of

National Guard and Reservists) return to previous neighborhoods and jobs. The person

struggles to re-integrate these pieces of the selves into a cohesive structure that meets


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the demands of the new reality. Their experiences and new knowledge must be

integrated into this new self as well. Horowitz explains this as a failure to re-schematize

inner cognitive maps of self and the world to accord with a new realityenduring

preexisting attitudes are in sharp discord with the experiences produced by traumatic

events (Horowitz, 1997) leading to what he calls Stress alarm (Horowitz 1999, p. 10).

Traumatic events impact on identity and may lead to a variety of self concept

disturbances such as identity diffusion (a chaotic sense of self fragmentation) or

depersonalization. Feeling disconnected and confused, individuals begin to judge

themselves, their actions and experience harshly leading to guilt and remorse. Theymay lose their connection with the powerful feelings of purpose and meaning that they

felt while in country. Upon return, they may have felt let down or even betrayed by the

group, unit, military or country and began to question what purpose their sacrifice served.

They may express that they think they may be going crazy and are sometimes afraid to

tell people for fear that these thoughts will be confirmed. They wrestle with values that

are so powerful and overwhelming that they feel no one could possibly understand.

Often, they have unrealistic expectations that they are supposed to return to the Original

Self, and when this does not happen, they feel a great deal of self doubt and fear about

who they are, or who they are supposed to be. Much of this transformation process is a

normal and natural part of being human. We are constantly learning, growing and

changing gradually meeting the tasks of development. But, for these individuals, too

much has happened too fast, under extreme conditions. This loss of self and purpose

leads to what Frankl called the existential vacuum. This is characterized by hopelessness

and despair. When the individual sees their goal as returning to the Original Self


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baseline, they will become fixated on the unrealistic attainment of this goal. This is often

reinforced by family members who were expecting the person to go back to being the

Original Self as well. A person fixated on themselves becomes hyper-reflective (focused

on their internal pain and suffering) which is in direct opposition to the path to healing

described by Frankl (1994, p.123). According to Logotherapy, the goal of treatment is to

find or create meaning by de-reflection (making connections outside of the self through

the Triad of Tragic Optimism). To begin to re-integrate the fragmented pieces of the self,

the person must become reconnected through reaching beyond themselves through their

work, experiences or relationships. Herman emphasizes that A secure sense of connection with caring people is the foundation of personality development. When this

connection is shattered, the traumatized person loses her basic sense of self (p. 52).

According to Lt. General Eric Schoomaker, Army leaders say that broken personal

relationships seem to be the most common thread linking suicides. "The one

transcendent factor that we seem to have, if there's any one that's associated with

[suicide], is fractured relationships of some sort" (Thompson, 2010). Clearly, the dis-

integration occurs first within the individual and then with the relationships, community,

work and finally, the self is dis-integrated with the world.

Re -I n t e grat ed C or e S el f. Many individuals have described experiencing a

profound, life-changing process during deployment or in the months of adjustment

following their return. Some turn to family, friends, clergy, or re-adjustment counseling

centers for support and assistance during this process. In addition to this existential pain,

many may also be suffering from PTSD and other emotional challenges and physical

injuries and pain. War wounds all part of the being and all must be addressed in a


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holistic model of care. These domains of body, mind and spirit (or Core Self) are

inseparable and intertwined. It is imperative that all three be considered in the holistic

treatment model.

Focusing on the Core Self (spiritual) domain, re-integration involves accepting

and embracing the fragments of both the Original Self and Warrior Self while realizing

that the end result of re-integration is a New Core Self. As Figley points out, the pieces

will not go back exactly the way they were, but can be whole again (Figley, 2007). It is

important for the individual to let go of the unrealistic goal of returning to the Original

Core Self in order to be able to move forward. New values, thoughts, feelings and beliefs

are re-integrated into a new cohesive structure and the person develops a connection with

new sense of life meaning or purpose. According to Frankl, the goal of treatment is

aimed at helping the individual discover or create meaning from their experiences and not

to fear the changes, but to embrace the New Self. Once the internal fragments are re-

integrated, the person is then able to genuinely connect with others. Conflict between

original self, warrior self, and new self has been resolved. The individual can become

stronger and more resilient than they had ever been before and may have better insight

and coping skills to deal with future stressors. There is a long tradition of this belief that

human beings have the potential to become stronger by overcoming adversity. Ernest

Hemmingway wrote, The world breaks every one and afterward many are strong at the

broken places (2010). Once re-integration is complete, the Core Self returns to a state of

homeostasis in which he or she is more at peace with their new identity and has

successfully assimilated the new knowledge and experiences into a new Core Self.


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T ransformation Mod el:

T abl e 3

Original S elf : Individual core-self is in homeostasis (below stress threshold)

Individual sense of core-self intact (I know who I am, what I feel,value & believe)

Individual sense of purpose intact (I know what I do and why)

Relationships (connections with others) are in homeostasis

Warrior S elf : Individual identity is replaced with group identity (unit identity)

The group identity and purpose becomes greater than oneself

Individual values and beliefs begin to be questioned if they conflictwith group

Faces the "Tragic Triad" daily (Guilt, Pain, Death) = ExistentialVacuum

Dis -I nt egrat ed S elf : Core assets of the self are questioned (values, beliefs, feelings, purpose)

Conflict between new thoughts, feelings, beliefs with originalself/warrior self

Fragmented sense of meaning and purpose

Discomfort engaging with others

R e-I nt egrat ed S elf : Conflict between original self, group self, and new self has beenresolved

Experiences have been reframed through meaning-making

The new values, thoughts, feelings and beliefs have been reintegrated

Person has developed connection with new sense of life meaning or

purpose

Person is able to connect with others

The individual is stronger and more resilient and has better copingskills to deal with future stressors

Identity (Self) returns to homeostasis


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Implications for T r eatm ent and R ecov ery

By reintegrating the spiritual domain back into the realm of the whole being and

truly offering a holistic model of care, we open many new doors to therapeutic

interventions that were once just out of our reach. I have experienced in my own practice

how powerful addressing this realm can be in a traditional therapeutic relationship. The

following points are ones I have discovered and lead my pracctices.

y Letting the patient know that we understand and share their pain, questions and

confusion is a wonderful step to leveling the playing field. We all suffer. We all

face adversity.

y Normalize this experience, let them know they are not alone (and that they are not

going crazy)

y Encourage exploration of these existential questions

y Focus on the strengths, and the future (time really does heal)

y Let them know that they are on a transformational journey and this is not the end,

it is just a temporary oasis

y Most of all, help them find meaning in their suffering, and a new purpose in life

Addressing these questions, giving it a language of its own and the permission to talk

about the changes to the Core Self), allowing them the opportunity to get to know

themselves again and possibly not fear this transformation or cling to unrealistic

expectations. This can lead to the concept of Post-Traumatic Growth (PT-G).


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P ost -T raumatic Gro w th & TI ED . Throughout time, human beings have proven

themselves to be resilient fighters and survivors of war, the Holocaust, natural and man-

made disasters, accidents, loss, and personal adversity. Throughout history, we have

risen to the demands of life with immense strength and determination. Where does this

strength come from? Do we strive for pleasure as Freud suggested, or for power as Adler

postulated? Ask a survivor of trauma or adversity what it was that helped them face the

suffering and they will tell you, in some variation, that they had some connection deep

inside the core of their being that allowed them to endure. Many will tell you that they

thought of loved ones or had to be strong for others. Through these connections, theyfound meaning in their difficult experiences. More than just enduring the experience,

many people report that, while they would not have chosen to have the trauma, they feel

that they are in some ways better for having had the experience. Research on this human

resiliency and concept of Post-Traumatic Growth is starting to emerge. According to

research conducted by Calhoun and Tedeschi (1999), posttraumatic growth refers to

positive psychological and personal changes that are produced as the result of an

individuals struggle with a difficult life circumstances that challenges their

understanding of the world and their place in it. These are not merely intellectual or even

emotional effects, and that is what makes them so powerful for many trauma survivors.

Posttraumatic growth is not simply a return to baseline from a period of suffering; instead

it is an experience of improvement that for some persons is deeply profound. According

to Calhoun, the clinician's role is to assist in the facilitation of meaning-making, and

reconstruction of schemas. Calhoun and Tedeschi (1999) have created a 21-item

assessment tool to help identify the qualities that are associated with Post Traumatic


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Growth. These qualities include; relating to others, personal strength, spiritual change,

and appreciation of life.

R esili ency . Another concept that is emerging in discussion, policies and

programs is the concept of resiliency. Research is also emerging with regard to using

resiliency programs as a preventative or protective measure within the military. Warrior

Resiliency and Family Resiliency programs are being implemented for deployed soldiers

and their family members with components being implemented before, during and after

deployment. This is being met with positive enthusiasm.

Logot he rapy . Franklian psychology provides a uncomplicated framework of theory and

therapy that specifically addresses the importance of meaning and purpose as a central

motivation in life. According to Frankl, having meaning and purpose in ones life gives

us a reason to live and endure hardships. Therapists are able to implement Logotherapy

within their existing therapeutic programming by offering their patients opportunities to

discover meaning through multiple therapeutic techniques and strive to reconnect with

others. These activities help the person focus on the future and re-integrate the

fragmented parts of the self.

C onclusion

The subject of post-deployment mental health has been a difficult and elusive

topic for generations. In my practice, and research, I have found myself traversing the

same paths as theorist, researchers and philosophers before me. In my review of the

literature I was shocked to find that others have been trying to resolve the issues related

to the diverse and debilitating symptoms that can destroy a person at the core of his or her


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Core Self. Struggling to find a framework in which to synthesize the symptoms that do

not fit the PTSD or other mental health diagnoses, and to try to understand what holds

these common symptoms together, the proposed model began to evolve.

The concept of Trauma-Induced Existential Dis-Integration (TIED) not only

provides a framework for the identification of individuals who may be at higher risk for

dysfunction (by examining the pervasive symptoms of existential crises). It also provides

an effective nomenclature by which we can discuss, research, and study the phenomenon.

In addition, embedded within the framework is the key to treatment and opportunity for

recovery by focusing on meaning-loss, meaning-making. This model goes beyond

anxiety, beyond behavioral conditioning, and beyond the physiological neuro-chemical

reactions to reach into the inner core where the shattered, dis-integrated self resides. If

we are to successfully provide holistic treatment, the injuries to this part of the

individual must be recognized, brought to light, and proactively treated. Once an

individual is able to heal the fragmented and dis-integrated parts of the self and able to

derive meaning from his or her experiences, the person is also better able to grow

stronger and more resilient from this experience leading to the concept of Post-Traumatic

Growth. Once the pieces of the inner self are re-integrated, the person can more wholly

connect with others and find meaning in life experiences.

Implications for Futur e

R esearc h . While this model is an example of evidence-based theory meets

practice wisdom, empirical research needs to be completed to further validate the criteria

and establish the validity of the theory that these symptoms are a manifestation of a


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wound to the soul. We are doing a great injustice to these individuals to misdiagnosis

them as having PTSD (in the current understanding of this anxiety based disorder)

Standardiz e nom enclatur e. When the diagnostic criteria for PTSD was finally

accepted and included in the DSM-III, it provided the language and criteria to standardize

the concept PTSD giving the field a common set of criteria with which to study the

phenomenon. The primary criteria has been validated time and again and has been used

to further the development of screening and assessment tools, and treatment modalities

with research on symptoms reduction. It is crucial to have an accepted name for this

condition that accurately describes the etiology, symptomology, progression and potential

treatment modalities and guide further research.

Develop scr eening tool . Many of the symptoms of DESNOS/TIED are very

disturbing and debilitating to the individual and can lead to severe despair, hopelessness

and suicidal ideation. Having a validated, effective screening tool would be helpful to

identify individuals who may be at risk and to help to determine the efficacy of programs

or treatment modalities.

T r eatm ent guid elin es. Once the existence of TIED are effectively validated,

screening and assessment tools are in place, research to determined effective treatment or

interventions can be developed to provide treatment guidelines that allow for holistic

care.

P r evention efforts . Understanding this transformational process as a journey can

link with other treatment and intervention programs to prepare individuals for the

experience of change to the Core Self. Resiliency training is starting to provide this care.


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Sp ecific to social work . Social work is accustomed to considering the person-in-

environment and are familiar with the need to treat the whole person. Social workers can

operate in the holistic realm; we focus on strengths, self-determination and personal sense

of meaning. Social workers have the unique opportunity and responsibility to help

define, identify and change the system to embrace a holistic approach. We must advocate

for the needs of our clients to be met through listening to their needs and developing and

implementing models of care that meet their needs. We need to help change the

expectations in the field from a paradigm of pathology to a paradigm of recovery.

Limitations

Work in progr ess . This is a work in progress. A thorough historical overview

has been completed that reveals a long history of wrestling with the diverse of elusive

needs of returning veterans. This is just a beginning and will hopefully continue to

evolve into a solid, validated theoretical and therapeutic model.

The ory -bas ed but not empirically support ed . While the basis of the model is

based on validated, empirically based models and classic theory, the model itself has not

been subject to empirical validation and study.

M eant to g en erat e discussion . At this point, this postulated theoretical model

has been presented and circulated through many avenues (professional conference, group

therapy sessions, and individual and family sessions, as well as being reviewed by

professionals in the field. This is meant to generate discussion and obtain feedback from

professionals and clients alike. Anecdotal feedback supports a high level of face-validity


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and support for the model. It is well received by clinicians, administrators, and clients. It

is easily understood and clients appear to be appreciative of the efforts to tell their story.

N ot an eithe r or, but a y es-and . It should be understood that I am not proposing to

change or eliminate the diagnosis of PTSD. I believe that we have a great deal of

validated research to support the PTSD (trauma-related anxiety disorder) criteria. I am

suggesting that we take a closer look at the symptoms that really do not fit in that

category and recognize the limitations of this diagnostic criteria to be an all

encompassing diagnosis for trauma experiences . As recognized by Judith Herman, what

we are seeing are, Two co-morbid manifestations of the same etiology effecting

different part of the self All are, in the end, inseparably connected (Herman p.32).

Summary . In my research, practice, and interviews, I found a common thread

among the individuals who were describing this pervasive sense of emptiness and dis-

integration at the core of their being. These individuals reported having lost (or were

questioning) a sense of purpose and meaning in their lives. Nothing had meaning they

had no purpose. Their sense of purpose and meaning in all things had broken down. In

some cases, they looked OK on the outside because they knew how to go through the

motions, but on the inside they were coming apart. They had no cohesion in the core of

their self (values, beliefs, thoughts, schema) were dis-integrated. Their sense of

relationships and connections were dis-integrated. Their very connection to the world

around them and their sense belonging to it was dis-integrated. In my practice, I have

found that the Trauma-Induced Existential Dis-Integration Model provides a framework

for building a bridge between the trauma dis-integrated state and recovery through the

activities of meaning-making and reintegration of the core self.


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While change is slow, it is it inevitable. Lessons learned from Vietnam include an

awareness of how deeply the wounds of the soldiers can spread to wound their families

and our society for generations. We are still feeling the generational effects of our poor

response to the reintegration and trauma needs of the Vietnam veterans and their families.

We have learned that early intervention and support is a key factor in successful

reintegration. Pretending there isnt an issue wont make it go away, and we either deal

with it now or deal with it later. Also changing is the realization that we have come a

long way, but we clearly have gaps in our understanding. It is hoped that this model will

serve to generate a forum and foundation for future study and research, and discussionand provide a glimpse into what the future could hold for true holistic treatment and

recovery from trauma.

Life does not owe you happiness it offers you meaning ~ Viktor Frankl


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OBrien, T. (1980). How to tell a war story, in The things they carried . Boston. HoughtonMifflin.

Post Deployment Health Reassessment Program. Deployment Health Clinical Center.Retrieved from http://www.pdhealth.mil/dcs/pdhra.asp.

RAND Center for Military Health Policy Research. (2008). The invisible wounds of war:Psychological and cognitive injuries, their consequences, and services to assistrecovery. Tenielian, T. & Jaycox, L. Eds. Retrieved from www.RAND.org.

Seal, K., et. al. (2010). VA mental health services utilization in Iraq and Afghanistanveterans in the first year of receiving new mental health diagnoses (p 5-16) . Published Online: Feb 9 2010. Retrieved 6/15/10. DOI: 10.1002/jts.2049

Shay, J. (2002). O dysseus in America: Combat trauma and the trials of homecoming . New York. Scribner.


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Shay, J. (1994). Achilles in Vietnam: Combat trauma and the Undoing of character. NewYork, Scribner.

Shephard, B. (2001). A w ar of ner ves . Cambridge Mass, Harvard University Press.

Thompson, M. (2010). Is the U.S. Army Losing Its War on Suicide? Time magazine.Washington. April 13, 2010. Retrieved on 6/10/10 fromhttp://www.time.com/time/nation/article/0,8599,1981284,00.html#ixzz0r92D6jD

Tick, E. (2005). War and the soul. Wheaton, Illinois, Quest Books.

Van Doren, C. (1942). The literary w orks of Abraham Lincoln . New York. The Press of the Readers Club.

Wilson, J.P. (2004). The broken spirit: Posttraumatic damage to the self. Broken spirits:

The treatment of traumatized asylum seeker, refugees, war and torture victims. New York. Brunner-Routledge.


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App endix A

C ompil ed List of C ommon Symptoms

DES N OS Diagnostic C rit eria


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C ompil ed List of C ommon Symptoms R eport ed by R eturning Warriors

C lassic P T SD Associat ed w ith P T SD and ot he r disord ers * = DES N OS

Disconnection with oneself *

Disconnection with others *

Guilt *

Remorse *

Shame *

Grief *

Rage *

Cognitive distortions and changes *

Feelings of worthlessness *

Increased risk of substance abuse *

Withdrawn from others, society *

Loss of time *

A/V hallucinations

Derealization *

Hopelessness (general) *

Suicidal Ideation or attempts *

Surreal Feelings *

Sleep Problems

Nightmares

Flashbacks

Hypervigilance

Avoidance of Stimuli

Driving/Road Anxiety/Rage *

Anxiety in Crowds

Trust Issues *

General Anxiety/Worry

Racing thoughts

Impatience

Low Tolerance Level *

Irritable *

Mood Swings *

Recklessness *

Crave/Seek Stimuli *

Adrenaline Rush

Euphoria

Risk Taking *

Anger & Rage *

Physical pain & ailments *

Denial *

Appetite Changes *

Fear of self

Poor Memory/forgetful *

Easily Frustrated *

Panic Attacks

Obsessive checking

Sexual difficulties


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Disord ers of Extr em e Str ess N ot ot he r w ise Sp ecifi ed (DES N OS ) C R IT ER IA:

I. Alteration in regulation of affect and impulse control: (A and one of B-F required)a. Affect regulation

b. Modulation of Anger

c. Self-Destructived. Suicidal preoccupatione. Difficulty Modulating sexual involvementf. Excessive risk-taking

II. Alterations in attention or concentrationa. Amnesia or

b. Transient dissociative episodes and depersonalizationIII. Alterations in self perception (two required)

a. Ineffectiveness b. Permanent damagec. Guilt and responsibilityd. Shamee. Nobody can understandf. Minimizing

IV. Alterations in relations with others (one required)a. Inability to trust

b. Revictimizationc. Victimizing others

V. Somatization

a. Digestive system b. Chronic painc. Cardiopulmonaryd. Conversion symptomse. Sexual symptoms

VI. Alterations in systems of meaninga. Despair and hopelessness

b. Loss of previously sustaining beliefs


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App endix B

Diff er ential Diagnosis Matrix


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Diff er ential Diagnosis Matrix


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App endix C

Soldi ers C r eed


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T he S ol d i ers C r eed

I am an American Soldier

I am a Warrior and a member of a team. I serve the people of the United States and live

the Army Values.

I will al w ays place the mission first.

I will never accept defeat.

I will never quit.

I will never leave a fallen comrade.

I am disciplined, physically and mentally tough, trained

and proficient in warrior tasks and drills. I always maintain my arms, equipment andmyself.

I am an expert and I am a professional.

I stand ready to deploy, engage, and destroy the enemies of the United States of Americain close combat.

I am a guardian of freedom and the American way of life.

I am an American Soldier.ARMY VAL UES

Loyalty Bear true faith and allegiance to the U.S. constitution, the Army, and other soldiers.Be loyal to the nation and its heritage.

DutyFulfill your obligations.Accept responsibility for your own actions and those entrusted t o your care.Find opportunities to improve oneself for the good of the group.

R esp ect R l th g ld l

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