B0038M1ADS EBOK (8 page)

Fundamentally, everyone's experiences are important, and we can't
define what a traumatic event is for one warrior compared with another.
Anyone deployed to a war zone, whether in line or support roles, has likely
experienced some level of trauma exposure. Each person's experience is
unique and relative, and only relevant to themselves.

While the nature of trauma is distinctly personal, there are some experiences known to increase the risk of developing PTSD or other reactions
after coming home. The list of events that can occur in the war zone is
sobering. Table 1, taken from one of our studies, details some combat
experiences reported by warriors involved in the initial ground invasion
of Iraq.

Although the level of combat has fluctuated over the course of the
wars in Iraq and Afghanistan, the frequency and intensity have remained
high for numerous units (both line and support) throughout the many
years of war in both countries. Mental health professionals would refer to
these experiences as "Potentially Traumatic Events," or "PTE" for short,
implying that only a traumatic event that produces PTSD is relevant from
their perspective. However, these experiences are anything but "potential." They are immediate and inescapable, not just statistics in a table.
Each warrior has a unique story regarding their own experiences, and
there are millions of stories just like this:

The vehicle in front of us was destroyed by IED [improvised explosive device]. We established security and called a medevac. As
security was established a secondary IED detonated approx 20
meters from my location and directly under where I was just standing. Then a third IED detonated. Helpless feeling because I could
not see them and did not know where the trigger man was.

-JUNIOR OFFICER IN IRAQ

(From Hoge, et. al. New England Journal ofMedicine 2004; 351:13-22)

The worst was picking up body parts, "bagging," standing by helplessly as the Bradley burned after we had tried to get our buddies
out but were overcome by the heat. The smell sticks.

-ENLISTED SOLDIER IN IRAQ

I didn't think the old man approaching was a threat because he
was holding the hand of a boy. I must have turned away just when
he detonated his belt. It knocked me out and cracked my back SAPI
plate [Kevlar protective plate]. Two of my soldiers were killed,
along with the boy.

-SENIOR NONCOMMISSIONED OFFICER IN AFGHANISTAN

I wasn't prepared to see so many injured women and children. It
was frustrating not being able to help them.

-NAVY CORPSMAN WITH MARINES, POST-IRAQ

Trauma in the war zone encompasses much more than taking direct
or indirect fire, including experiencing a near miss on one's life; knowing
someone who was seriously injured or killed; handling body parts; witnessing or being involved in accidents involving vehicles or aircraft; witnessing
noncombatants suffering; or seeing poverty, pain, destruction, or ethnic
violence. Some events are so catastrophic that there isn't anything that
compares, especially losing a close buddy, but there are also cumulative
effects from multiple less severe incidents.

Distinct from most traumas in civilian settings, we are not talking about
single events. Warriors may encounter "potentially" traumatic events on a
daily basis, and there are effects from working every day under constant
threat of attack or ambush, even if nothing happens; long periods of boredom and waiting can be punctuated by bursts of insanity. Environmental
stressors (heat, cold, carrying heavy loads), exhaustion, and sleep deprivation magnify the impact that these experiences have.

What distinguishes traumatic events for warriors is their preparation
and the fact that they might experience multiple events in the course of
their professional duties, whereas civilians exposed to trauma are usually victims of a single situation for which they were unprepared. Warriors may
still be surprised or devastated when combat events occur, but they have
an understanding that these things will likely happen, and have prepared
for them to the best of their ability. The PTSD definition and treatment is
generally conceptualized around a single traumatic event, although warriors routinely experience multiple events.

The Impact of Killing

One important event that is not addressed as directly as it should be is killing. The impact of killing is misunderstood. Killing the enemy is what a
warrior is trained to do, and success in this, like any occupational success,
can be gratifying. One NCO (noncommissioned officer) in Iraq said:

Two days ago I killed an Iraqi for the first time. He was a triggerman and had an IED 500 meters down the road. I shot his ass
with 60 rounds of coax 7.62 [machine gun] and then 15 rounds of
the 25MM. I have not been this happy since I've been in Iraq. This
fuck was going to kill us and I killed him.

Although killing the enemy is not something that's usually associated with remorse, warriors sometimes go back to the experience of
killing and second-guess themselves. They go over events like these in
their minds, wondering if some of those rounds may have gone astray
and killed an innocent person. They also may ignore evidence suggesting that the person they killed wasn't really a "triggerman." There can
be a nagging unspoken awareness at times that innocent people may
have been killed or injured. As noted in table 1, approximately half of
soldiers and marines who participated in the initial ground invasion in
Iraq reported being directly responsible for killing an enemy in Iraq or
Afghanistan, and 14 to 28 percent reported being directly responsible
for killing a noncombatant. In Mental Health Advisory Team surveys
my team conducted in Iraq, approximately 10 percent of soldiers and
marines reported that they had damaged Iraqi property when it wasn't
necessary, and 5 percent reported that they had kicked or hit a non combatant when it wasn't necessary. These incidents aren't always easy to
live with after coming home. If a warrior is going over and over in their
mind experiences such as these after coming home, the transition can
be rocky.

Military Sexual Trauma

It's important to acknowledge another serious type of trauma that also
occurs in the war zone: sexual assault by fellow service members, or
"military sexual trauma," as experts in the field refer to it. Sexual assault
is also one of the most common causes of PTSD in civilians. Usually it
involves men assaulting women, but men can also be victims. In one
2005 study conducted by the Research Triangle Institute, 7 percent of
women and 1 percent of men in the military reported unwanted sexual
contact.

In the military, where women are outnumbered 10:1, women may often
find themselves in situations where there is male-oriented sexual banter,
sexually explicit humor, or exposure to pornography, even though this
is prohibited in the war zone. Women have different levels of tolerance,
and different levels of comfort for when to take offense; but clearly this is
an environment where unwanted advances, touching, or rape sometimes
occur. Since supervisors are very often men (and may themselves be the
ones exhibiting inappropriate behavior), women can find themselves in
awkward situations and feel discomfort bringing accusations forward. The
same thing can go on in other male-dominated professions, like law enforcement or firefighting. Strong leadership that creates integrity and cohesion
in the unit is important to address this.

An element that is pertinent to the discussion of "military sexual
trauma," but not addressed by military leaders (except as "zero tolerance")
is the desire for escape, even briefly, through sexual intimacy in the war
zone. This adds another dimension to the situation women find themselves in during deployment in the male-dominated war environment. The
bottom line is that the war zone presents some unique elements in terms
of interactions between men and women that are not evident in other
types of work environments. Sexual trauma is very different than combat trauma, and may be even more debilitating because of the feeling of being
violated and betrayed.

In conclusion, criterion A-1, the traumatic event, is very much an individual experience. What distinguishes trauma for warriors is that there
may be multiple traumatic events that are expected as part of professional
duties. In one 2006 study we conducted (published in the Journal of the
American Medical Association), out of 223,000 soldiers and marines returning from deployment to Iraq, 112,000 (50 percent) reported feeling in
great danger of being killed. There are vast differences in each person's
experience of trauma. The important thing is not what specific trauma
occurred, but whether or not there was a feeling of danger or threat, and
whether or not the experience sticks in one's memory in a way that makes
it difficult to cope with life after coming home.

Criterion A-2. Response to the Trauma

Part 2 of criterion A of the PTSD definition, which concerns the "abnormal" response to trauma, is more confusing. It states that the person's
response to their traumatic experiences must have involved "fear, helplessness, or horror." The problem with this for combat veterans is that
they don't often express "helplessness," and "fear" is something that they
learn to live with on a daily basis as part of their job. While fear, helplessness, or horror are very common terms used by civilian victims of trauma,
they are much less likely to be used by warriors to describe how they
respond to combat situations, even if these situations lead to significant
reactions.

In one study, we asked soldiers from line infantry units (in the U.S.
Army, these are called "Brigade Combat Teams"; for marines, "Regimental
Combat Teams") about their combat experiences while serving in Iraq. No
more than a quarter of the warriors who reported life-threatening direct
combat or who had serious symptoms of PTSD said they experienced "fear,
helplessness, or horror" at the time of the events.

In other words, the criteria for how one responds to trauma in order
to receive the distinction of having PTSD does not hold true for warriors.
Warriors don't speak of their wartime experiences in the same way that civilians who are victims of assault, hurricanes, motor vehicle accidents, or
other traumas speak of their experiences. During combat, warriors report
"locking down" their emotions, falling back on their training, or feeling
anger. The important difference has to do with not feeling like a victim.
Warriors are professionals trained to deal with trauma; most civilians are
not, and often feel like victims when they experience trauma.

Warriors who face life-threatening events as part of their job learn
how to control fear, how to respond using their training (not helplessly),
and how to control feelings of horror. Otherwise, they wouldn't be able
to function under fire. Controlling fear does not mean that a warrior
doesn't feel fear, but that they learn how to operate in the presence of it,
and how to use fear as an alert signal that helps them and their buddies
stay alive. The same thing holds true for firefighters, emergency medical
personnel, law enforcement professionals, and others working in dangerous professions.

Although the A2 criterion used by mental health professionals lacks
utility for warriors, there are a couple of important caveats. We did find
that the 20 to 25 percent of soldiers who reported "fear, helplessness, or
horror" fared worse than those who reported other responses. This suggests that if a warrior experiences an event where they feel overcome by
fear or helplessness, they will find it harder to recover. It turns out that fear
and helplessness are processed by the parts of the brain shown in human
and animal studies to be most affected by severe stress, and most vulnerable in terms of the likelihood of developing PTSD. In civilian populations,
rape and assault are some of the most common traumas that lead to PTSD
because they are strongly associated with fear and helplessness.

There are some unique situations in which warriors will acknowledge
feeling helpless, and it appears that these can contribute to them developing serious PTSD symptoms on return from combat. These are situations in which warriors are unable to respond militarily, either because
the enemy is elusive or because they're constrained by the rules of engagement (ROE). Rules of engagement are policies established by leaders in
the war zone to protect civilian noncombatants, but warriors often feel
hampered by them. Here are some examples:

Watching JEDs go off, locking and loading but not firing due to the
ROE, left me feeling helpless.

-JUNIOR ENLISTED SOLDIER, IRAQ

All we do is roll on missions and hope we don't get blown up, and
then when we get hit there is nothing we can do but watch my dead
friends get pulled out in pieces.

-SENIOR NCO, IRAQ

The most stressful part of my job is going out every day and waiting to get blown up. When / if someone gets hit, ROE prohibits
us from doing what should be done. Everyone here is "innocent. "
Yeah, right. If someone dug up the road in front of YOUR house
and buried a bomb there, YOU would know about it.