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					THE COMBAT TRAUMA
  CONTINUUM AND
     VETERANS
 Lessons from the Past, Wisdom from
  the Present, Healing in the Future.
     Robert J. Caffrey, LPC., J.D.
  THE COMBAT TRAUMA
CONTINUUM AND VETERANS
  • War and trauma take place on a continuum.
  • Physical Continuum – Combat Operational
    Stress Reaction (“COSR”) to Post-Combat
                Trauma (“PTSD”).
 • Narrative Continuum – Trauma is contextual,
  the warrior and his/her culture give the combat
              experience its’ meaning.
• Historical continuum – The wounds of war are
                      timeless.
                 Overview
• The “Paradox” of the Warriors’ World - The
  Need for Cultural Competence.
• The Physiology of Combat – The Re-wiring of
  the Warriors’ Nervous and Emotional System.
• Scars on a Warrior’s Heart – A History of the
  Impact of Warfare on Soldiers.
• Healers and Warriors – A Conversation about
  Healing Invisible Wounds.
   A Warrior’s Journey
The Bridge Between Worlds
• THE PARADOX
         The Warrior’s Paradox

• Soldiers are not as other men . . .They are those
    of a world apart, a very ancient world which
   exists in parallel with the everyday world but
  does not belong to it . . .The distance can never
    be closed, for the culture of the warrior can
         never be that of civilization itself.

        • A History of Warfare, John Keegan
       The Warrior’s Paradox

        Operating in a world of chaos

Old English “Wyrre” – “to bring into confusion.”
           The Warrior’s Paradox
                       • Combat Truths
• War is about combat, combat is about fighting, fighting is about
  killing, and killing is a traumatic personal experience.
• Frequency of combat and proximity of killing is directly
  proportional to the level of combat stress.
• A warrior must be able to psychologically and emotionally
  distance themselves from the environment, the killing, and the
  civilian world to win and to survive.
• There is, and always will be a deep and abiding contextual and
  cultural gap between a combat veteran and a civilian.

              • COL Timothy (“BT”) Hanifen, USMC
        The Warrior’s Paradox
• Warriors - those prepared to kill, or be killed or
  maimed, to protect another from actual or
  threatened violence.
• Victor Davis Hanson – The Western Way of
  War
• The culture of the Western warrior and the
  Western way of war.
• “The Knight in a straight up fight!”
        The Warrior’s Paradox

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

  Agreeing to enter a world organized for the
  specific purpose of annihilating you physically,
  emotionally, mentally.
            The Warrior’s Paradox
• Warrior’s Narrative – The story of “I” is an
  individually, culturally, and historically created
  construct.

• But the warrior identity can be rewritten by reality:
   –   “The enemy has a vote!”
   –   Cousteau’s “food chain”
   –   Nietzsche, “fighting monsters” and “gazing into the abyss”
   –   “John Rambo,” the other guys and “taking names.”
    The Warrior’s Paradox


I seek to take my enemy’s story from
  him, and he seeks to take mine!
       The Warrior’s Paradox
     The Narrative’s 10 Elements


1. The Transpersonal commitment v. Personal
   survival
2. Reality v. Mythology
   “Clean kills exist only in Hollywood”
        The Warrior’s Paradox
• 3. Killing and the Gods – The Temple of Mars,
  Yahweh, “Herem,” and anthropology's insight.
• 4. Skill v. Chance – Von Clausewitz and the
  “iron dice of fate.”
• 5. Ferocity v. the “Berserker.”
• 6. Brotherhood v. Tribalism – The creation of
  the “Other.”
         The Warrior’s Paradox
7. The “skill” of killing v. the “taking” of life.
8. Necessary violence v. needless destruction.
9. Obedience v. “toxic” leadership.
10. Loyalty v. Honor.
           The Warrior’s Paradox
            The Healer’s Role
• To help warriors live into rather than solve their
  paradox, we need to be mindful that:

• 1. A warrior’s effectiveness depends on being internally
  balanced.
• 2. In war, what you don’t know can and will hurt you.
• 3. In war, what you don’t teach often has dreadful
  consequences.
• 4. In the absence of internal and external leadership,
  there is only chaos!
 The Physiology of
     Combat
Re-wiring the Warrior’s Nervous and
         Emotional System
        The Physiology of Combat

                    • START ME UP!
• In response to threat, the limbic system releases
  hormones telling the amygdala to alert the
  hypothalamus to activate the sympathetic nervous
  system (SNS) to release neurotransmitters epinephrine
  (EPI) and norepinephrine (NE) to activate the body for
  fight/flight/freeze response.
• Respiration and heart rate increase (NE) moving blood
  to skin and muscles for rapid response.
        The Physiology of Combat

                  • SHUT ME DOWN!
• At the same time, the SNS releases corticotrophin-
  releasing hormone (CRH or CRF).
• CRH/CRF stimulate the pituitary gland to release
  adrenocortico-tropic hormone (ACTH) causing
  adrenals to release hydrocortisone (AKA cortisol).
• Threat is over, cortisol stops production of EPI and
  NE.
The Physiology of Combat



   • The Inevitability of
      “Startle/Flinch!”
    The Physiology of Combat
The Survival Stress Reaction (“SSR”)
• Fear activated heart rate increase = Erosion of
  combat skills!
• Combat – 70 BPM to 220 BPM in ½ second
• High and even moderate levels of stress
  interfere with fine muscular control & decision
  making.
• Most life and death confrontations – 145
  BPM in tenths of a second!
    The Physiology of Combat
The Survival Stress Reaction (“SSR”)
• 70 BPM – Normal.
• 115 BPM – Fine complex motor skills begin
  deterioration (Hand-eye co-ordination and some
  form of digital actions, multi-tasking).
• 115-145 BPM – Optimal survival & combat
  performance / complex motor skills high
  functioning ( “The Combat Rush”).
     The Physiology of Combat

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

• Brain center for hearing shuts down – “Didn’t
  hear/couldn’t make sense, understand”
       The Physiology of Combat
•    175 BPM – 185 BPM
1.   Cognitive processing deteriorates.
2.   “Tunneling” -visual system decreases peripheral info,
     combatant often retreats from the threat to widen the
     peripheral field. Pupils dilate to gather more information &
     depth perception is diminished
3.   Perceptual Narrowing occurs (“Coning”) narrowing of visual
     system slows processing of information, anxiety increases as
     combatant attempts to direct field of focus to threat.
4.   Critical Stress Amnesia – What happened? Who did what?

                                 ---
      The Physiology of Combat
• 185 - 220 BPM – Hyper-vigilance (“Freezing) &
  Irrational Behavior. “The Dead Zone!”
• BPM increases trigger SNS - cerebral cortex is by-
  passed to large extent as brain stem and amgydala
  prepare combatant for “flight, fight freeze.”
• Hyperventilation – associated with impairments in
  memory, concentration and diminished discrimination
  or perceptual abilities. Men in combat often “square on
  the target” due to loss of visual focus during stress.
     The Physiology of Combat
• Increased heart rates have a catastrophic affect
  on perceptual skills, cognitive processing skills,
  reaction time and motor skill performance.
• Absent proper training in performing needed
  survival skill, anxiety increases, stress increases,
  BPM increases, and combatant descends into
  trauma vortex.
• Breathing to control BPM is critical to managing
  stress and trauma.
The Physiology of Combat
 • The Terror of the “Boyd Cycle”
            • OODA
           • Observe
             • Orient
            • Decide
              • Act

 • Hick’s Law and Its' Consequences
             The Impact of Combat
• Sensory Overload (“Observe & Orient”) – How does the mind
  respond to the inability to identify danger in a foreign culture?

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




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

•   “THE GARBAGE PILE AT CAMP WAR EAGLE.” (February, 2004)
         The Impact of Combat
• Combat skills and the “Combat Rush” – In
  combat, the midbrain has learned to bypass
  logical thought processes and established
  conditioned reflexes or SNS responses, instantly,
  without having to be told to do it.

• “The Drunk at Square Town.” ( October, 2003) (“OODA
  COMPLETED”)
           The Physiology of PTSD
                • Combat Frozen in Time – PTSD
                   • “The never ending trauma loop”
• PTSD sufferers hypersecrete CRF and have subnormal levels of cortisol.
• Result 1 – there is no “shut off valve.” With no ability to halt the body’s alarm
  reaction, flight/fight/freeze response continues unabated.
• Hyperarousal and exaggerated startle response may occur.
• Result 2 – The nervous system is “always on high alert.” PTSD sufferers and
  those exposed to trauma hyper secrete NE.
• SNS responds with tachycardia, hypertension, dizziness, increased
  perspiration.
• Elevated NE believed to play a role in flashback and panic attacks.
        The Physiology of PTSD
 • MEMORIES OF TERROR ARE OUR “GHOSTS IN THE
                            MACHINE”
• PTSD results in the decrease and impairment of hippocampal
  activity( explicit memory, facts, concepts, ideas, language
  dependent storage and retrieval of memories).
• Amygdala governs implicit memories( based on senses,
  emotions) and is functioning no matter how high the level of
  arousal.
• Hippocampal activity decreases and is impaired by trauma.
• During trauma, some events maybe stored in the implicit,
  but not the explicit memory.
        The Physiology of Combat
• MEMORIES OF TERROR ARE OUR “GHOSTS IN THE MACHINE” (
  continued)
• Lack of explicit memory leaves trauma memory devoid of placement in space
  and time.
• Inability to contextualize memories causes flashbacks and experience of
  reliving trauma.
• Serotonin levels decrease due to PTSD in the orbitofrontal cortex (OFC),
  which processes social and emotional information and plays a role in the
  emotional processing of affective memories.
• Decreased serotonin in OFC potentially contributes to
   misinterpretation on emotional stimuli, impulsivity aggression and
   inappropriate decision-making.
 COMBAT TRAUMA
A Historical Perspective
      Scars on a Warrior’s Heart
     Psychic Trauma and Warfare
         throughout History
• Post-combat numbing, nightmares, dissociation,
  intrusive recollections.
• Epic of Gilgamesh – (2750 – 2500 B.C.E.)
  Sumer.
• Homer’s “Iliad” (850 B.C.E.).
 Scars on a Warrior’s Heart
Psychic Trauma and Warfare
    throughout History


     • The Civil War
      Scars on a Warrior’s Heart
     Psychic Trauma and Warfare
         throughout History


• Civil War (1861 – 1865) “Nostalgia” and
  “Soldiers’ Heart.”
• Lethargy, fits of hysteria, withdrawal, numbing,
  extreme emotionality in soldiers from North and
  South.
       Scars on a Warrior’s Heart
      Psychic Trauma and Warfare
          throughout History

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

• Virtually all of the 291 veterans in the Indiana
  State Insane Asylum demonstrated classic
  symptoms of PTSD- hyper-vigilance, irrational
  fear of impending danger, resultant paranoia.
 Scars on a Warrior’s Heart
Psychic Trauma and Warfare
    throughout History



      World War I
       Scars on a Warrior’s Heart
      Psychic Trauma and Warfare
          throughout History
• “Shell shock.”
• Artillery bombardment and “intense fear,
  helplessness, or horror.”
• Exaggerated startle response, stupor, traumatic
  dreams, irritability, trembling.
• W.H. Rivers – utilized Freud’s “talking therapy”
  as well as oral and written trauma narratives.
      Scars on a Warrior’s Heart
     Psychic Trauma and Warfare
         throughout History

• 72,000 neuropsychiatric discharges by 1918
• 112,000 receiving benefits by 1922

• History’s Lesson -Combat stress casualties
  appear to worsen or become symptomatic with
  the passage of time.
 Scars on a Warrior’s Heart
Psychic Trauma and Warfare
    throughout History



      • World War II
      Scars on a Warrior’s Heart
     Psychic Trauma and Warfare
         throughout History
• Post - WW I – Theory advanced that certain
  individuals predisposed to psychic trauma.
• WW II – 1.6 million men rejected for
  “psychiatric reasons.”
• U.S. lost 504,000 men (50 divisions) due to
  psychiatric collapse.
• Army recognizes that any individual will
  succumb to trauma at personal “breaking point.”
       Scars on a Warrior’s Heart
      Psychic Trauma and Warfare
          throughout History
• History’s Lesson – Longer the exposure to
  combat, greater the likelihood of psychic
  injury.
• WW II after 60 days of continuous combat
  98% of surviving soldiers will be some kind of
  psychiatric casualty.
• History’s Lesson – Critical factors are time
  in combat and intensity of combat.
       Scars on a Warrior’s Heart
      Psychic Trauma and Warfare
          throughout History
• History’s Lesson – Support troops not
  involved in direct combat are also
  susceptible to becoming psychiatric
  casualties.
• Pre-existing trauma history, attachment issues
  play a greater role for these individuals.
• Stressors include separation from home and
  friends, social and physical deprivations,
  boredom, lower unit cohesion.
      Scars on a Warrior’s Heart
     Psychic Trauma and Warfare
         throughout History

• History’s Lesson – Front line treatment v.
  removal from theater, proved more effective.
• “P.I.E.” – Proximity, immediacy and
  expectancy.
• WW II – 60% returned to duty with their
  division; 90% returned to some duty in theater.
       Scars on a Warrior’s Heart
      Psychic Trauma and Warfare
          throughout History
• Despite frontline treatment, after 4 years of war
  of the 800,000 U.S. soldiers that saw ground
  combat 37.5% became such serious psychiatric
  casualties that they were permanently lost from
  the war effort.
 Scars on a Warrior’s Heart
Psychic Trauma and Warfare
    throughout History



   • Korea & Vietnam
      Scars on a Warrior’s Heart
     Psychic Trauma and Warfare
         throughout History
• Korea 24% of U.S. soldiers became serious
  psychiatric casualties during tour.
• Korea – Of these 88% returned to duty with
  division; 97% some duty in theater.
• Korea – 1 year rotation policy initiated.

                      ---
      Scars on a Warrior’s Heart
     Psychic Trauma and Warfare
         throughout History
• Vietnam – Psychiatric casualty rates reported
  between 2% - 5% during combat phase (1965-
  1975).
• Post – Vietnam – VA estimate was 15% of vets
  suffered from PTSD. Figures of other groups
  range from 18% - 54%.
• 2.8 million Vietnam vets – 420,00 and 1.5
  million suffered from PTSD at sometime after
  the conflict.
      Scars on a Warrior’s Heart
     Psychic Trauma and Warfare
         throughout History
• Iraq/Afghanistan – 2.3 million deployed (2011)
• 977,542 deployed more than once
• 107,000 deployed 3 or more times
• 2008 Rand Study – 14% met PTSD and
  depression criteria
• 1.3 million have left the service
• 711,986 used VA healthcare (2002 – 2011)
      Scars on a Warrior’s Heart
     Psychic Trauma and Warfare
         throughout History
• THE IMPACT OF KILLING AND THE RESISTANCE TO
                    KILLING


     • Thou shalt do no murder. Exodus 20:13

• Jesus said, “Thou shalt do no murder.” Matthew
                        19:18
       Scars on a Warrior’s Heart
      Psychic Trauma and Warfare
          throughout History
• THE IMPACT OF KILLING AND THE RESISTANCE
                 TO KILLING
• US murder rate = 6 per 100,000.
• US aggravated assault = 4 per 1,000.
• Present day US fire rates estimated at 95% -
  98%.
• What is the psychic cost of being trained to kill?
• Of actually killing or seeing others killed?
      Scars on a Warrior’s Heart
     Psychic Trauma and Warfare
         throughout History
• S.L.A. Marshall – “Men Against Fire” and the
  WW II 15% - 25% fire rate.

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

• Fire ratios – Korea 50%, Vietnam 95%, Iraq –
  Afghanistan – 95% - 98%.
       Scars on a Warrior’s Heart
      Psychic Trauma and Warfare
          throughout History
• Studies suggest a correlation between post-
  traumatic stress and killing.

• 1988 – Research by Stellman and Stellman
  found a correlation between intensity and
  frequency of combat experience and PTSD in
  Vietnam veterans, yet “great majority” seeking
  mental health services were never asked about
  combat experience.
      Scars on a Warrior’s Heart
     Psychic Trauma and Warfare
         throughout History
• The Impact of Killing Study – S. Maugen, et al.
• Study of Vietnam vets 47% reported killing or
  believing they killed a combatant, 13% a non-
  combatant.
• “After accounting for demographics and general
  combat exposure, killing was associated with
  PTSD symptoms, dissociative experiences,
  functional impairment and violent behavior.”
      Scars on a Warrior’s Heart
     Psychic Trauma and Warfare
         throughout History
OIF 2004 NEJM study by C.W. Hoge, et al. –
 48%-65 % reported being responsible for the
 death of an enemy combatant, 14-28% for death
 of a noncombatant.
OIF – 90% reported having been shot at.
OIF – 71% to 86% reported engagement in
 firefight with 5 being the median number.
OEF – 36% reported participating in a firefight
 with 2 being the median number in Afghanistan.
      Scars on a Warrior’s Heart
     Psychic Trauma and Warfare
         throughout History
• Prevalence of PTSD increased with number of
  firefights.

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

• OEF – 0 = 4.5%; 1-2 = 8.2%; 3-5 = 8.3%; 5+ =
  18.9%.
       Scars on a Warrior’s Heart
      Psychic Trauma and Warfare
          throughout History
• Combat frequency – As of 2008 30% of OIF
  OEF soldiers were on their THIRD TOUR!
• 15% to 20% of all soldiers fighting in Iraq and
  Afghanistan at that time, were then showing
  signs of depression or PTSD.
• This rate jumps to 30% for soldiers that have
  been on 3 or more tours.
         Scars on a Warrior’s Heart
        Psychic Trauma and Warfare
            throughout History
                        • Conclusions
•   Stress of combat operations ultimately effects all
    warriors, some more than others.
•   Duration of tour and intensity of combat appears to be
    causally connected to post-combat trauma.
•   Killing in and of itself may be a causal ingredient in the
    development of combat related PTSD beyond general
    combat experiences.
•   OIF/OEF veterans are engaged in an unprecedented
    operational tempo and combat cycle.
 Healers and Warriors



• INTERVENTIONS
Healers and Warriors – Preparing for
  a Conversation about Healing
         Invisible Wounds
• 1. Become a student of war – To normalize one needs fact based
  understanding.
• 2. Assume you are entering a different culture.
• 3. Let each veteran understand that each warrior’s journey is
  unique and each story fits in the narrative of their life.
• 3. Expect it to be worse than you anticipate.
• 4. “The mind leads the body and the body leads the mind.” –
  The need for “Awareness” based intervention.
• 5. Combat history, frequency, and severity is of critical
  importance.
• 6. Unit integrity, morale and leadership quality play a critical role
  in resilience needed to ward off combat stress and PTSD.
 Healers and Warriors – A
Conversation about Healing
    Invisible Wounds
    CULTURAL RESISTANCE
             • Stoicism
   • Refusal to admit vulnerability
      • Loss of cultural status
         • Shame and guilt
          • Protectiveness
     • Loss of warrior identity
        • Language deficit
          Healers and Warriors
• Ultimately, combat trauma is a normal reaction to an
  external threat rather than an illness.
• Try to hear past the words to the statement of
  emotional need underneath it.
• Affirmation – The war and the warrior are separate and
  distinct. Whether we oppose the war or not, we trained
  them, we sent them, they went for us, they deserve our
  respect and need our reassurance.
• Support – Identify and involve the soldier’s support
  network. Family, community, place of worship.
              Healers and Warriors
               • Normalizing the combat experience
      • “An abnormal response, to an abnormal situation, is
                     normal behavior.” Victor Frankl
•   Combat reflexes will normally decay with time to a greater or
    lesser degree.
•   Combat establishes neural networks that can be reactivated.
        • “It’s a normal reaction. Here’s what to do when it happens.”
•   Combat stress and trauma is simply how the veteran is
    manifesting their experience of the war.
•   Previous training, or the lack thereof, often explains how feelings
    of fear, helplessness, or horror were minimized, or not.
            Healers and Warriors
    • Normalizing the combat experience (continued)
•   “intense fear, helplessness, or horror.” DSM-IV
•   “Helplessness” – Did you know what to do?
•   “Horror” – Did things happen that you felt
    unprepared for?
•   “Fear” – What training did you have to manage your
    fear? Tactical breathing?
•   “Re-experiencing” – Was the soldier ever debriefed
    about the incident/incidents?
         Healers and Warriors
• Exposure therapy and Cognitive Processing
  therapy.
• Body centered modalities – EMDR, Somatic
  Experiencing, autogenic breathing, open
  awareness exercises.
• Reconstruction of the narrative – Post-traumatic
  growth and the distinction between “brooding”
  and “reflective pondering.”
         Healers and Warriors
• Open focus exercise – Both PTSD and combat
  can create experience of “coning.” Stress of not
  being able to fully visualize environment can
  accelerate stress response.
• To break out of tunnel vision having
  combatants scan and breathe - After taking a
  shot, by physically turning the head and
  scanning the battlefield after engagement seems
  to cause tunnel vision to diminish.
Healers and Warriors

• PRE-EXISTING WOUNDS
         Healers and Warriors
• Pre-existing trauma history can play a huge role
  in predisposing individuals to PTSD.
• In 2007 study, 69.1% of women veterans
  suffering from PTSD reported pre-enlistment
  sexual assault. 73% reported sexual trauma such
  as sexual assault or rape while serving in the
  military.
         Healers and Warriors
• Studies suggest securely attached individuals,
  with a history of high quality caregiver
  relationships were less likely to develop PTSD
  than their less securely attached counterparts.
• Low cognitive function prior to exposure
  strongly influenced measured vulnerability to
  developing PTSD.
         Healers and Warriors

• In helping a veteran, remember the words of
  SMG William Von Zehle:
• “Sir, when engaging a target, slow is smooth,
  and smooth is fast.”
      THE COMBAT TRAUMA
    CONTINUUM AND VETERANS
                                • Resources
• www.realwarriors
• LTC Dave Grossman – “On Killing”; “On Combat”
• Babette Rothschild – “The Body Remembers”
• Richard Holmes – “Acts of War”
• Bruce K. Siddle – “Sharpening the Warrior’s Edge”
• Daniel Goleman – “Emotional Intelligence”
• Jonathan Shay, Ph.D. – “Achilles in Vietnam” ; “Odysseus in America”
• Ben Shepard – “A War of Nerves”
• Joanna Bourke – “An Intimate History of Killing”
• John Keegan – “The Face of Battle”; “A History of Warfare”
• M.S. Micale & P. Lerner (Eds.) – “Traumatic Pasts: History, Psychiatry and
  Trauma in the Modern Ager, 1870 – 1930”
• National Center for PTSD – Veterans Administration
  THE COMBAT TRAUMA
CONTINUUM AND VETERANS
            • Bob Caffrey
    • www.caffreycounseling.com
       • rjcaffrey@gmail.com
          • (860) 331-0641



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