THE COMBAT TRAUMA CONTINUUM AND VETERANS

1. THE COMBAT TRAUMA CONTINUUM AND VETERANS Lessons from the Past, Wisdom from the Present, Healing in the Future. Robert J. Caffrey, LPC., J.D.

2. 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.

3. 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.

4. A Warrior’s JourneyThe Bridge Between Worlds

5. THE PARADOX

6. 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

7. The Warrior’s Paradox Operating in a world of chaos Old English “Wyrre” – “to bring into confusion.”

8. 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

9. 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 ofWar • The culture of the Western warrior and the Western way of war. • “The Knight in a straight up fight!”

10. 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.

11. 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.”

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

13. The Warrior’s ParadoxThe Narrative’s 10 Elements • The Transpersonal commitment v. Personal survival • Reality v. Mythology “Clean kills exist only in Hollywood”

14. 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.”

15. The Warrior’s Paradox 7. The “skill” of killing v. the “taking” of life. • Necessary violence v. needless destruction. • Obedience v. “toxic” leadership. • Loyalty v. Honor.

16. The Warrior’s ParadoxThe 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!

17. The Physiology of Combat Re-wiring the Warrior’s Nervous and Emotional System

18. 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.

19. 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.

20. The Physiology of Combat • The Inevitability of “Startle/Flinch!”

21. The Physiology of CombatThe 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!

22. The Physiology of CombatThe 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”).

23. 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”

24. The Physiology of Combat • 175 BPM – 185 BPM • Cognitive processing deteriorates. • “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 • Perceptual Narrowing occurs (“Coning”) narrowing of visual system slows processing of information, anxiety increases as combatant attempts to direct field of focus to threat. • Critical Stress Amnesia – What happened? Who did what? ---

25. 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.

26. 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.

27. The Physiology of Combat • The Terror of the “Boyd Cycle” • OODA • Observe • Orient • Decide • Act • Hick’s Law and Its' Consequences

28. 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)

29. 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”)

30. 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.

31. The Physiology of PTSD • MEMORIES OF TERROR ARE OUR “GHOSTS IN THE MACHINE” • PTSD results in the decrease and impairment of hippocampalactivity( 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.

32. 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.

33. COMBAT TRAUMAA Historical Perspective

34. Scars on a Warrior’s Heart Psychic Trauma and Warfarethroughout History • Post-combat numbing, nightmares, dissociation, intrusive recollections. • Epic of Gilgamesh – (2750 – 2500 B.C.E.) Sumer. • Homer’s “Iliad” (850 B.C.E.).

35. Scars on a Warrior’s Heart Psychic Trauma and Warfarethroughout History • The Civil War

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

37. Scars on a Warrior’s Heart Psychic Trauma and Warfarethroughout 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.

38. Scars on a Warrior’s Heart Psychic Trauma and Warfarethroughout History World War I

39. Scars on a Warrior’s Heart Psychic Trauma and Warfarethroughout 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.

40. Scars on a Warrior’s Heart Psychic Trauma and Warfarethroughout 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.

41. Scars on a Warrior’s Heart Psychic Trauma and Warfarethroughout History • World War II

42. Scars on a Warrior’s Heart Psychic Trauma and Warfarethroughout 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.”

43. Scars on a Warrior’s Heart Psychic Trauma and Warfarethroughout 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.

44. Scars on a Warrior’s Heart Psychic Trauma and Warfarethroughout 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.

45. Scars on a Warrior’s Heart Psychic Trauma and Warfarethroughout 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.

46. Scars on a Warrior’s Heart Psychic Trauma and Warfarethroughout 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.

47. Scars on a Warrior’s Heart Psychic Trauma and Warfarethroughout History • Korea & Vietnam

48. Scars on a Warrior’s Heart Psychic Trauma and Warfarethroughout 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. ---

49. Scars on a Warrior’s Heart Psychic Trauma and Warfarethroughout 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.

50. Scars on a Warrior’s Heart Psychic Trauma and Warfarethroughout 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)