B0038M1ADS EBOK (3 page)

Society hasn't yet grasped that "transitioning" home from combat does
not mean giving up being a warrior, but rather learning to dial up or down
the warrior responses depending on the situation. This book will also benefit mental health care professionals who want to expand their perspective
and gain greater understanding of how to connect with and treat the many
great men and women who have risked their lives in a war zone in the service of their country.

There are numerous self-help books on PTSD and other problems
related to combat deployment, but this one takes a different approach.
It's true that like many of the other books, this one was written by a mental health professional (I'm a medical doctor with a specialty in psychiatry). However, my intention in writing this book is to cut to the chase,
eliminate as much of our jargon as possible, and provide something that
will bridge the vast divide that exists between combat veterans, society,
and mental health professionals in understanding what we call PTSD
and other war reactions.

After a twenty-year active-duty military career, I have a growing understanding of the limitations of the current health-care system in addressing
the concerns of warriors back from war. My knowledge is drawn from treat ing service members returning from Iraq and Afghanistan at Walter Reed
Army Medical Center, directing a widely recognized research program on
the mental health effects of the Iraq and Afghanistan wars, investigating
suicides and homicides involving soldiers after they returned home from
deployment, and assisting leaders at the highest levels of the Department
of Defense (DoD) and the Department of Veterans Affairs (VA) in developing mental health programs for service members, veterans, and their
loved ones.

I've been involved in developing interventions for Pentagon employees after 9/11, and guiding research to validate training materials that
enhance resilience before, during, and after combat. The articles my
colleagues and I wrote on PTSD and traumatic brain injury, published
in the world's leading medical journals (e.g., the New England Journal of
Medicine, the Journal of the American Medical Association), have resulted in
large increases in health-care funding to help service members and veterans. I've testified on several occasions to Congress and have appeared on
national TV and radio news shows.

I also deployed to Iraq during the second year of the war, where I
traveled throughout the country, assessing the quality and availability of
combat stress control services. Although never in a situation where I had
to discharge my weapon, I have an appreciation for what it feels like to
live with danger, convoy in dangerous sectors, be shot at, have soldiers
killed by indirect fire adjacent to where I was sleeping, travel "outside the
wire," and cope with separation from my family.

These experiences have given me a unique appreciation for the different perspectives service members, veterans, clinicians, policy-makers,
family members, and the public have on transitioning home from war.

This book is about transitioning home from a combat deployment. It
includes information on PTSD-not only on the disorder that medical professionals diagnose and treat, but the more common ways in which this label
is used to describe the myriad normal, confusing, and paradoxical transition
experiences encountered after returning home from a war zone.

This book is not intended to provide standard mental health educational material with lists of symptoms and descriptions of the many ways in which you or your loved one may have been psychologically "injured" by
war, deployment, or military service. You probably don't want to read long
stories of fellow warriors or spouses struggling with transition problems, or
receive laundry lists of "coping strategies" without adequate explanation of
their limitations. What I believe to be important is an understanding of what
to expect from postwar reactions, including PTSD, but on your terms, rather
than the terms defined for you by the medical establishment or society.

The Contradictions of PTSD

PTSD is full of contradictions. Virtually every reaction that mental health
professionals label a "symptom," and which indeed can cause havoc in
your life after returning home from combat, is an essential survival skill
in the war zone. The dilemma is that the reactions that are necessary for
survival and success in combat are not easy to dial down and adapt after
coming home. Society believes that a warrior should be able to transition
home and lead a "normal" life, but the reality is that most of society has no
clue what it means to be a warrior. Those who have worked in a war zone
understand that their warrior responses-including responses doctors
may label "PTSD"-could be needed again in the future-for instance, if
they mobilize for another deployment, someone tries to break into their
home, or they take a job in a dangerous profession (e.g., law enforcement,
security, emergency services). Once a warrior-always a warrior.

PTSD means different things to different people. To mental health professionals, it's one of nearly 300 diagnoses detailed in the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM).
To others it's a catchall phrase for the various ways that service members
and veterans react to things after coming back from war, synonymous with
terms from past wars, such as battle fatigue and shell shock. PTSD as a result of
combat is almost always associated with various physical reactions, emotions,
and perceptions that do not conform to a neat diagnosis.

For this generation of warriors from the Iraq and Afghanistan battlefields, PTSD has even become confused with concussion, now being called
"mild traumatic brain injury," or "mTBI." This means that getting a concussion on the battlefield has special significance it didn't have in earlier wars. A concussion is a brief period of being knocked out or disoriented
from a blow or jolt to the head ("getting your bell rung," "seeing stars").
Concussions are very common from military training, such as combatives,
as well as contact sports and motor vehicle accidents; concussions also
occur during combat from blasts, falls, accidents, or other injuries. Most
service members who experience a concussion can expect a full recovery, generally in a matter of a few hours or days, but the wars in Iraq and
Afghanistan have created the fear that concussions/mTBIs (particularly
blast-related) may lead to lasting health effects in a large percentage of
service members. Many warriors and veterans have been told that their
postwar problems, such as anger, sleep disturbance, fatigue, concentration problems, memory problems, or PTSD symptoms, are likely due to
untreated concussions from exposure to blasts. The reality is that these
problems occur for many reasons. Concussion/mTBI has been overdiag-
nosed, underdiagnosed, and misdiagnosed in Iraq and Afghanistan veterans, leading to unwarranted-and, in some cases-harmful treatments.

There is controversy over when normal reactions to combat or stress
become PTSD. Everyone has a "breaking point," and warriors sometimes
reach this in reaction to severe combat events or complete physical or
mental exhaustion. These "combat stress reactions" (also called "acute
stress reactions," or "operational stress reactions") are expected to occur
on the battlefield, and good leaders prepare their units for this inevitability. Combat stress reactions are treated with rest and reassurance, and
rarely turn into PTSD. They are not a mental disorder.

Reaching a "breaking point" in combat does not mean that a warrior
is broken. It just means that the warrior needs to regroup and recharge in
order to be able to go back into the fight. Most warriors, even after going
through extreme stress and trauma, do not develop PTSD. But they are
also not the same person after deployment as they were before, and this is
part of what it means to be a warrior. They react differently after deployment. There is a strength of character that is sharp and direct, but one
that may at times make others feel uncomfortable. There is maturity, but
combat also takes its toll and can make one feel older. It's not uncommon
for service members to feel as if they've aged one or two decades during a single deployment. Warriors are more independent, but this may make it
difficult to tolerate authority at work.

Many warriors have a hard time reconnecting with loved ones, despite
their demonstrated ability to form lifelong bonds with unit peers. This
is not only because of how they've changed, but also because their loved
ones and society don't necessarily understand these changes, or view these
changes as "bad" or as an "illness." Unfortunately, PTSD has become confused with various normal reactions that warriors experience.

PTSD is in many ways indistinguishable physically from prolonged
severe stress. Under prolonged stress, the stress "thermostat" is reset to
a different level. Prolonged stress causes numerous changes in the nervous system and endocrine (hormone) system that affect the entire body.
These can include increased heart rate and blood pressure, changes in
hormone levels, elevation in adrenaline, changes in concentration and
memory, and reduced immunity to fight infection. Studies suggest that
cells in the body that are under prolonged stress may undergo accelerated aging, validating the perceptions of combat veterans that they have
aged more rapidly than their peers back home. Deployment to a war
zone, which is a form of prolonged and severe stress, can change the
way in which the body adjusts to or responds to normal everyday levels
of stress. These physical (physiological) changes in the body are doubleedged. Warriors develop remarkable observational skills and reflexes.
However, post-deployment, they sometimes overreact to things in a way
that leads to strained relationships and problems at home or work.

Coming Home

Coming back from a combat deployment is like returning to the threedimensional world after experiencing a fourth dimension. It's hard to sort
out who is really crazy-you, or the rest of the world. The rest of the world
can't comprehend the concept of a fourth dimension; they can't relate to
it, and may not even be interested. Service members and veterans often
feel they're wasting their time dealing with people who can't relate to their
perspective, and many actually feel more at home in the war zone. One
infantry soldier, several months after returning from Iraq, said: "Through all the hell and anguish I've experienced fighting a war, I'd still rather be
fighting at war than wake up everyday to the bullshit I have to deal with
and overcome here at home in what I call my job and life."

A marine who had been in Iraq said, "Truth is, many marines are lost
when they get home; there is a gap between us and civilians, which is having
an effect on each other understanding one another."

In this book we'll examine why the soldier quoted above feels like
he'd rather be back in combat, and why the marine feels a split between
his peers and civilians. We'll explore the contradictions and paradoxes
of PTSD, and untangle what PTSD is from what it's not. Most important,
you'll be provided with concrete guidance toward a goal of living life with
greater joy and meaning, embracing your warrior spirit and using skills
you already have to successfully "transition" or "readjust" after combat,
whether that's within a few months of coming home or decades later. It's
never too late. The "transition" and "readjustment" process doesn't mean
you give up being a warrior, but rather learn to dial up or down your warrior responses depending on what's happening around you, always adapting to the environment you find yourself in.

"Transition" and "Readjustment"

The "transition/readjustment" time frame that is the focus of this book is
ill-defined and full of hazards. Depending on who you talk to, it seems to
span the time from getting off the plane (or boat); completing the reintegration process (including the post-deployment health assessment for veterans of the Iraq/Afghanistan wars); the "honeymoon" period (for all of
you who had a spouse or partner waiting for you through the long deployment); block leave; the first three months home; deactivation (if in the
National Guard or Reserves); post-deployment health re-assessment (for
veterans of Iraq/Afghanistan); the next nine months or so of the first year
home; and then perhaps for a long time thereafter (years), depending on
your wartime experiences, whether or not there was another intervening
deployment(s), whether your previous job was waiting for you upon your
return, whether or not your marriage or relationship broke up, how much
pain you were in due to physical injuries, whether you got embroiled in a custody battle for your kids, and various other factors. In short, there's no
clear definition of what the normal "transition/readjustment" period is,
and the extent to which this book is going to be helpful has nothing to do
with how long or short a time it's been since you came home.

How warriors and family members describe the transition experience
often reflects a gap in perspectives. Married service members just home
from a tour of duty in the sandbox or jungle can't possibly understand
what could be worse than being shot at every day or living constantly under
that threat, while their spouse feels that it was they who had it worse-waiting, worrying, single-parenting, running the household alone, juggling
life back here, and so on. The two experiences seem incongruous, and
the reality is that each person has matured individually during the deployment period and is not the same person he or she was when they parted.
There is a similar split with friends and family.

Each generation of warriors considers their war to be unique, and
indeed, in many ways, every war is. World War II and Korean War veterans
faced high-intensity combat over extended fronts. They were welcomed
home as heroes, but there was minimal or no public discussion of the
potential impact of their experiences. Vietnam veterans faced yearlong
tours involving high-intensity conventional and guerrilla warfare. They
faced a hostile public upon their return that had little understanding or
compassion for the impact of their combat experiences. PTSD was not yet
recognized, and many Vietnam veterans were told that their war-related
reactions were the result of alcoholism or drug abuse, implying that their
problems were their "fault." Gulf War I veterans faced enormous uncertainties during a yearlong buildup to combat operations, including a high
threat of chemical and biological attacks, followed by a brief high-intensity
conventional ground operation.