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Authors: Charles W. Hoge M.D.

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"How are you doing Michael? Glad to see you home. " This was
the big question from seemingly everyone I knew when I came
home from war. My response was always, "I'm okay, " which is the
answer most people wanted me to say. What most people do not
want to hear is, "I feel like shit; my mind is gone. I've just returned
from war and two years of killing the enemy and extreme hardships that you can't even imagine. I'm also angry, hate society,
and wish that I could return to my unit and war right now. " The
"real" answer to the big question of how you are now that you're
back would have most people believing that you are a cold-blooded
killer, crazy, or both.

FIRST SERGEANT MIKE SCHINDLER

This chapter continues the LANDNAV training for the home front,
expanding on the skills in earlier chapters to help you learn to build
resilience. Earlier chapters have covered learning skills related to paying
attention to your physical reactions and feelings, putting space between
your reactions and actions, physical conditioning, improving sleep, noticing your breath, meditation and attention skills, and narrating your story.
This chapter will help you learn additional skills to refine and add depth
to your ability to respond to stressful situations and encounters involving
people.

These skills focus on learning to deal with the strong reactions that you
may have to stressful "triggers" in the home environment. There are many
types of situations that can cause warriors to immediately shift into high
alert-a crowd, a line of people, trash on the side of the road, overpasses, a
hot day, someone asking "How are you?", sand, diesel fuel, traffic, a person
of Middle Eastern or Vietnamese ethnicity, a loud noise, smoke, a movie
image, a calendar date, a conversation about the war, a helicopter overhead, someone not following through with something they were supposed
to do, being boxed in somewhere, busy intersections, certain smells, etc.
Numerous things can trigger reactions of anxiety, fear, and anger, or result
in the warrior suddenly being flooded with images and feelings, bringing
the war zone home or the warrior back to the war zone.

What happens over time for many warriors is that they stop going out,
and avoid anything and anybody that trigger reactions. They retreat as far
back behind the front as they possibly can, and find the most secure bunker available. This can include not going to the mall or grocery store, not
going to the movies, avoiding certain roads, avoiding social occasions with
friends or family members, not showing up for work, or not getting help
(because they know they'll have to talk about what's going on). This tendency to avoid things can result in numerous problems because it conflicts
with the expectations and desires of loved ones, friends, or coworkers for
the warrior to do "normal" things that people do.

Four skills are presented in this chapter. The first is a resiliency "inoculation" exercise designed to help you train your body to deal with particularly stressful situations that often lead to avoidance or withdrawal. The
second skill involves building your resilience in dealing with the range
of idiotic and stupid stuff you may encounter daily with people. The
third skill addresses more serious situations involving people. The fourth
skill assists in developing better understanding of anger, the distinction
between anger and rage, and how to "manage" your anger.

Developing these skills doesn't imply conformity to the expectations
of others. As a warrior, you're probably quite independent and satisfied
with the way you are, even if others perceive your behavior as inconsistent
with their expectations, or the norms of society. The reality is that most
people have little or no understanding of what it means to be a warrior,
and might have unreasonable or unrealistic expectations. Nevertheless,
it's useful to have these skills available when you need them. These skills
are not going to change your likes or dislikes, but they'll provide some
useful knowledge to help cope with unpleasant and difficult situations you
encounter in everyday life.

SKILL 1: RESILIENCY INOCULATION TRAINING
(FACING YOUR FEARS)

This skill demonstrates how you can train your body to not react so strongly
to situations that trigger high stress or anxiety. For example, if you feel
your heart pound and your anxiety level jumps through the roof when you
walk into a crowded mall, or you start to get a panic attack waiting in a line,
or you avoid driving at certain times because you can't stand being boxed
in on the road, then this training is designed to help.

The skill is to learn to "inoculate" yourself to triggers that cause you
high distress or lead you to modify your life in some important way to
avoid the triggers. The goal is to improve your ability to do things that you
need or want to do, but avoid because they result in high distress.

Two terms that mental health professionals use to describe this
"inoculation" process are habituation and desensitization. Habituation
and desensitization in this context mean growing accustomed to things
that normally distress you or that you react strongly to. For example,
people who live in houses right next to a railroad track grow accustomed to the loud sounds and vibration of the trains. Their bodies
habituate to the trains, and after a while they don't notice them. If you
go to visit their house for a few days, you'll probably lose lots of sleep
and feel very annoyed by the noise, but after a while you too would
gradually habituate.

Your body can get used to things that initially cause you a fair amount
of distress. This happens naturally, and doesn't require you to do anything,
other than remain in contact with the distressing or annoying stimulus
long enough for your body to habituate to it. Another term that mental health professionals use to describe this inoculation process is reconditioning. For warriors, this means breaking the connection between the
wartime experiences and the automatic, "conditioned" reactions to things
that remind you of the war environment.

This exercise is similar to what an allergy doctor does to help someone
overcome severe allergies. For example, some people are so allergic to the
sting of a bee that they can die from shock within minutes. A person who
has such an allergy can go to an allergy doctor and be cured by receiving
tiny doses of the very same bee venom that can kill them. The treatment
for a severe bee allergy is to receive the bee venom that the person is
deathly allergic to. Over many treatments, starting at extremely low doses
and gradually increasing the amount of venom that is injected, the person's immune system gets accustomed to the venom without reacting to it.
After these treatments a person can be stung by a live bee, or be injected
with the same amount of venom as they would receive being stung, and
have no reaction. This type of treatment saves many lives.

The resiliency inoculation skill is adapted from therapy techniques
called in-vivo exposure and systematic desensitization. This means putting
yourself in everyday life situations that trigger your distress or avoidance
reactions and gradually increasing the "dose" until these situations don't
cause the same degree of reaction. One note of caution regarding this
training is that it has not been tested as a "self-help" technique, and therefore, if you have problems doing this or find that it's not helping to reduce
anxiety (or anxiety is increasing after doing this), don't beat yourself up
with "shoulds" (like "I should be able to do this"), and go see a professional.
If you go to a mental health professional, this chapter can give you some
valuable insights.

The first thing to do is own up to the things that cause you the most
distress on a day-to-day basis, or that you regularly avoid because they trigger distress or strong reactions. In other words, identify the things that you're particularly "allergic" to. For example, if going to a crowded mall
triggers high levels of anxiety, write this down on the following list under
the heading "List of Triggers." Think about all the things that trigger high
distress or that you avoid doing because they're associated with high distress. This could include things like "sitting in a movie theater," "going
to the mall," "driving," "bridges and overpasses," "spiders," "flying in a
plane," "waiting in a line of people," "elevators," etc.

After writing down several prominent triggers, circle the level of distress that this activity usually causes you. For this scale, consider a "1" to be
relaxed with no distress and a "10" to be the most distress or anxiety you
can imagine. After you've listed out the things that cause you high distress,
pick one or two for your "inoculation" training.

List of Triggers

Example of Going to a Crowded Mall

For example, let's say you indicated that going to a crowded mall generally causes you to experience an "8" or a "9" level of distress or anxiety.
Let's also assume that this is frustrating to you because you'd like to be
able to go to the mall with your friends or family members (even if only
for their sake). If this example doesn't apply to you, pick another one
from your experience.

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