Combat Trauma Informed Practices
Histories of humankind and war run parallel, and descriptors of the psychological impact have evolved (e.g. post traumatic neurosis, nostalgia, irritable heart, da costa syndrome, effort syndrome, railroad spinal syndrome, soldier’s heart, neurasthenia, disorderly action of the heart, combat stress, shell shock, battle fatigue, combat exhaustion, acute structural maladjustment, gross stress reaction, etc.), and post-traumatic stress disorder (PTSD), as an operational diagnosis, was not added until the 1980 Diagnostic and Statistical Manual, Third Edition (DSM-III). Presently, the DSM-V recognizes the essential feature of posttraumatic stress disorder (PTSD) as developed symptoms following an event or “events in Criterion A include, but are not limited to, exposure to war as a combatant or civilian…” (American Psychiatric Association, 2013, p. 274). Furthermore, that “the presentation may vary. In some individuals, fear based reexperiencing, emotional, and behavioral symptoms may predominate, [and] in others, anhedonic mood states and negative cognitions may be most distressing, [and] some may exhibit combinations of these patterns” (APA, 2013, p. 274). “Rates of PTSD are higher in Veteran populations, averaging 8% for full PTSD, and 10-17% for threshold PTSD” (Moye, et al.,2023 p. 957).
I personally understand that war can change the trajectory of one’s life. This change could be a downward spiral of destruction (which I once was on), or one of post-traumatic “wisdom” realized “when you’ve lived through adversity, you can come to a point in your life where you can look back, reflect, learn, and grow from the experience” (Perry & Winfrey, 2021, p.285). It is the aim of this paper to recognize combat related stress in Veterans and outline trauma informed practices for realization of the latter.
Trauma informed care (TIC) assists the individual in the process of going back to what was lost or never received and re-writing the story. Why would one suppose that the rates of PTSD among Veterans are greater than the larger population? One conceptualization is that Veterans largely are from lower socioeconomic classes, which may have resulted in higher adverse childhood experiences (ACE). For example, in one study of 403 Veterans, “forty-four percent of participants reported experiencing six or more events” (Murphy & Turgoose, 2019, p. 807) on a childhood adversity scale. These Veterans reported that their families weren’t close, that they witnessed violence between parents, substance abuse, and that they spent time in foster care settings. Research has linked “low socioeconomic status (SES) to a higher rate of major depression in adults…It has been argued that those from low SES backgrounds are overrepresented in Army recruitment campaigns” (Murphy & Turgoose, p. 809).
Concerning the micro level of social work, theorists have “proposed that emotional support may aid Veterans in successfully navigating trauma re-engagement” (Moye, et. al., p. 962), and the writer believes that regardless of the intervention, “trauma-informed care must be grounded in a person-centered approach and recovery-oriented practices” (Kelly, et. al., 2014, p. 417). When this Veteran sought help after two Iraq combat tours, not once was what happened to me considered. Using the same questionnaire, I scored 9 out of 16 items on the cross-sectional design. Remembering clearly at age 10, my father bleeding due to being hit in the head with a beer bottle by my mother, my mother leaving myself and four younger siblings, alcohol and drug use by my parents, and the two younger siblings having to spend two years in Catholic Charity foster care. We all did poorly in school, dropped out, and essentially raised ourselves. Impoverished, my father urged me at 16 years of age to join the Army, so I did.
In the mezzo level of social work, any organization’s entire personnel should understand that “all service users value relationships with staff who demonstrate kindness, trustworthiness, reassurance, friendliness, helpfulness, calmness, and humor” (Sweeney, et. al., 2018, p. 329). Regardless of approach, paramount in the clinician’s mind should be to not re-traumatize the Veteran seeking help. Again, this was not my experience. My first tour of 12 months was painful, uneventful, very uncomfortable, and of course involved over a year of separation from family. However, the second 15-month tour involved heavy combat, the loss of 19 of my comrades (all of whom I saw up close during and /or after their deaths), and hundreds wounded in our battalion. As a battalion chaplain, my responsibility was to counsel the 800 Soldiers in my battalion around the clock, non-stop. Compassion fatigue was a real thing to me. Upon return, my marriage of 33 years ended, and my alcohol use progressed. Knowing that this had become a problematic means to self-regulate, and was resulting in poor decision making, I sought out help at FT. Benning Georgia’s Substance Abuse Program. I was skirted into an impersonal room and interrogated by the clinician, who later wrote in her notes that I was “combative.’ I was told I was an alcoholic and would have to immediately leave my position as a supervisory chaplain (responsible as a Major for five Captains and their enlisted personnel) and enter rehab. I was stricken with panic, as this would mean going back to my Brigade Commander (Colonel) and explaining to him that his seasoned staff officer was not fit for duty. I needed treatment but was unable to get it at the organizational level, and not until 9 years later at the Veterans Administration was I finally able to get substantial help.
Interventions
Until recently, there was “little adoption of evidenced-based treatments (EBTs) into routine practice” (Cook & Stirman, 2015, p.1) for trauma-informed care, and continuing education courses are still having little effect on this problem. However, with the emergence of implementation science, and attempt to fill the gap between research and clinical practice, standardized EBTs are moving forward. There exists over 100 types of interventions for TIC for trauma related disorders, and “oftentimes both general psychotherapeutic approaches are coupled with alternative modalities like yoga, meditation, neuro-feedback, massage, exercise, acupuncture, nutrition, and supplements (as needed), animal assisted therapy, art therapy, self-defense classes and more” (Courtois, 2014 ,p. 88). Professionals working at the macro level of social work must see that this gap is systemic, and work through advocacy, policy and research to create standardized EBTs. At the VA, I was able to receive CPT for PTSD, substance use counseling, yoga, nutrition, and follow on therapy, and to this day these have assisted me greatly.
Research has identified several efficacious and utilized trauma informed interventions as follows: Pharmacological. Experientially, the writer knows that medications can be ‘symptom band aids’, having been placed on a plethora of such. This approach does not cure disorders, and “lesson the symptoms and their negative impact, sometimes making it easier for clients to tolerate things like re-experiencing trauma in therapy sessions” (Courtois, p. 83). As research is integrated into practice (macro), the VA appears to be better understanding and implementing at the hospital and clinic levels (mezzo), and individual providers (micro) are becoming mindful of the fact that pharmacological treatments are best used simultaneously, if needed, alongside of psychotherapeutic approaches. EMDR (eye movement desensitization and reprocessing). EMDR is a mind-body approach, re-experiencing the trauma event while simultaneously engaging in eye movement for “adaptive emotional processing that helps the client to make distinctions between memories in order to resolve them” (Courtois, p. 86). In one metanalysis of 714 studies, where 14 studies were ultimately eligible,”11 studies (n = 547) showed that EMDR is better than CBT in reducing post-traumatic symptoms [SDM (95% CI) = -0.43 (-0.73- -0.12), p = 0.006]; however, metanalysis of four studies (n=186) at three month follow up revealed no statistically significant difference” (Khan et. al., 2018, p. 1). CBT (cognitive behavioral therapy). CBT teaches clients, through various strategies, how to change behaviors of thoughts, feelings and action. It “looks at what triggers and reinforces actions related to re-experiencing trauma and/or engaging one’s addiction and identifies ways to short-circuit the process” (Courtois, p. 84). In written form, it is called cognitive processing therapy (CPT), and involves writing out and processing with the therapist. In one study, comparing the efficacy between a support group and CPT therapy group participants, at the end of treatment, as well as 6 months post treatment, improvements were significantly greater in the therapy group” (Cook & Stirman, p. 3). In the metanalysis mentioned, the results “suggested that EMDR was better than CBT in reducing post traumatic symptoms and anxiety. However, there was no significant difference reported in reducing depression” (Khan et. al., p. 15). PE (prolonged exposure therapy). PE involves gradated, intentional, and incremental re-experiencing of past trauma, while in a safe environment, by engaging (not avoiding) the memory, also known as ‘flooding.’ “This technique, along with EMDR, has the most evidence of effectiveness in extinguishing symptoms of PTSD” (Courtois, p. 88). VA providers, while accepting the use of PE, have suggested several barriers (e.g. psychiatric comorbidities, cognitive limitations, a low-level of patient motivation) making patients less amenable to the treatment, but “those who work in PTSD specialty care settings, are less likely to endorse a belief that PE would increase patient distress” (Cook & Stirman, p. 2).
State-of-the Art Practice
In my opinion, acceptance and commitment therapy (ACT) is a state-of-the art approach, as it is based in the larger theoretical framework of relational frame theory (RFT), which is further grounded in functional contextualism. Dr. Niklas Torneke, physician and psychotherapist, notes that as he learned RFT, he realized that “acceptance and commitment therapy has more foundational theoretical and experimental bases than any other approach” (Torneke 2010, p. 2) One aspect of ACT that makes it innately trauma informed is that the clinician explores the client’s values, not her own, in the assessment and therapy processes. Another clear trauma informed practice of ACT is its non-judgmental nature. Clinicians understand the human being’s learned adaptations and use of eliminative agenda (e.g. substance and behavioral addictions, coping strategies, etc.) to regulate. They’re essentially just trying to get along in life the best way they know how, albeit maladaptively, and the clinician’s job is to help them to recognize this pattern and move toward who and what is important to them with action.
Ways to strengthen this emerging state-of-the-art intervention is to provide meaningful community. I have tried for several years to be involved with combat Veterans in a group setting, but Vet Center’s volume is too great, and instead have actively involved myself in Veterans of Foreign Wars (VFW) to be with my ‘clan.’ In desperation, in September of 2023, I and a patriotic community member, founded a Combat Veterans group in Tyrone, Georgia that meets once per month. Here we can share meaningful, in-depth thoughts and feelings amongst people who experientially know and understand. Dr. Perry notes that “for thousands of years humans lived in small intergenerational groups. There were no mental health clinics but plenty of trauma. I assume that many or our ancestors experienced post-traumatic problems: anxiety, depression, sleep disruption. But I also assume they experienced healing? (Perry & Winfrey, 2021, p. 200).
At my combat Veteran group, a friend of mine astutely noted that the reason that American Vietnam Veterans have a much higher rate for PTSD as compared to their Vietnamese counterparts, is that our Veterans returned to a fragmented society, divided communities, and geographically dispersed, and disintegrated families, which exacerbated their trauma. No place to tell their story, be listened to, or hear the stories of their elders about hope and healing. For the first time in the history of American warfare, a soldier could literally be in combat experiencing the horrors of war one minute, and within hours be walking in their neighborhood. Prior to this, Soldiers would spend days and even weeks on ships processing their experiences of trauma with one another. Conversely, the Vietnamese went home to close knit loving and nurturing families and communities, telling their stories, and listening to stories of healing from others.
In the writer’s era, we received re-integration briefs in county (in fact, my job was to perform these), the support of family readiness groups (FRGs) which stayed in constant contact with the Soldiers of their respective units, mental health processing stations upon return, and ongoing encouragement from the Army to seek out help from mental health and chaplain services. It wasn’t perfect, but better. Research at the macro level drove practice (micro level) knowing that “given the association between psychological problems and trauma among OEF/OIF, OND Veterans, we recommend evidence-based approaches using trauma informed care” (Kelly et. al., p. 417). TIC practices mimic the nurturing community needed for healing. In one approach, “the LATR model, trauma re-engagement may lead to resilience if successfully navigated, or to increased stress if not, such as in the form of PTSD or depressive symptoms” (Moye et. al., p. 957).
In the case of Jesse, a severely traumatized pre-teen mentioned in Perry’s and Winfrey’s book (What Happened to you?), the healing power of the nurturing community was the primary reason for his vast improvement. Introduced early in the book, Jesse was an example of what happens when trauma is severe and prolonged, unpredictable, uncontrollable, and extreme. He experienced neglect and multiple types of abuse (since the age of five, he was sex trafficked and prostituted), and was left hospitalized in a coma after a fight with his stepfather before being placed in multiple foster care homes. The epilogue of the book shows him as a young, adjusted man, working as a lifeguard, and living in a dorm situation at an assisted care facility with older adults. Perry observed him being showered with hugs and kisses by the residents, and while Jesse still remembered the specifics of his trauma, he was living a normal, healthy, and healed life in that community.
Connectedness is of utmost importance. Dr. Perry referred to a religious tribe’s moniker: “whanaungatanga” (Perry & Winfrey, p. 250), and elaborated that as healers, we cannot separate treatment into parts (e.g. eye, heart, bone, brain doctors), as we do in western medicine, but we need an integrated (connected) approach in TIC, utilizing the healing power of community. The healing process would be greatly strengthened should more emphasis on this salient point be implemented. I experienced no such community (as mentioned there has been no openings in a group), and personally have been shifted to over 10 providers, having to repeatedly retell my trauma story.
Considering ACE in screening is another way to strengthen TIC. One study showed doubled prevalence of PTSD (22% compared to 44%) of Veterans seeking help for mental health problems presenting with “complex profiles” with ACE” (Murphy& Turgoose, p. 805). We know that there exists a higher prevalence of ACE with military Veterans, and a definite link between ACE and poor mental health; and therefore, this is “very relevant to clinical teams working with those Veterans…understanding of what factors might lead to some individuals being more vulnerable to developing mental health difficulties” (Murphy & Turgoose, p. 806).
Finally, while research, practice, and policy (macro level of social work) focusing on Veteran’s difficulties is not new, topics include MST, TBI substance abuse, women issues, etc., very little attention has been given for Veterans who have been convicted of crimes, and “data from before 9/11 conflicts showed that Veterans accounted for nine of every hundred individuals in US jails and prisons” (Christy et. al.,2012, pp. 461-462). One tenth of the prison population! Attempts to help Veterans who are involved in the justice system have been made. An April 2009 Information Letter from the VA’s Under Secretary for Health provided background on the needs of Veterans in the criminal justice system and Veteran’s Health Administration (VHA) authority “provided services to the Veterans while outlining pertinent VHA outreach and making recommendations regarding services to this group of Veterans” (Christy et. al., pp. 462-463). Macro level social workers should continue to assist in policy making and legislative processes for services to this marginalized group of Veterans.
Personal Framework
Not until my own ACE and combat trauma was considered in VA CPT, was I able to piece together and find meaning and healing in trauma. This makes since in that “exploration of childhood adversity forms an important part of therapeutic intervention” (Murphey, p. 810). At the mezzo level of social work TIC, nothing may be done about past trauma experienced by Veterans, “but opportunities should be taken to implement standardized ways of improving access to methods of preventative and proactive factors, such as social support, mastery, and promoting the ability to manage stressors” (Murphy & Turgoose, p. 810). Providers should practice the Five Rs (1. Recognition of past experiences. 2. Realization of the effect of trauma, then providing support. 3.Responding with care. 4. Respect by creating a safe environment. 5. Resiliency for focusing on their strengths and resources) as a foundation for TIC practices.
Combat Veterans are reticent to talk about their experiences with people who can’t possibly understand. Working alongside the VA and VFW, as mentioned already, the writer has started a PTSD group providing a safe place of connectivity, care, and compassion amongst its members. This essentially is a surrogate family and community, as Veterans who have done well in their recovery have cited “the role of partners, children, grandchildren, as well as confidence in their medical providers and treatments” (Moye et. al., p. 961).
Ironically, some of the writer’s weaknesses have become strengths. “Recent research has found a dose response relationship between the breadth of exposure abuse or household dysfunction during childhood… [makes one] more vulnerable to stressful events” (Murphy & Turgoose, p. 806). So. the weaknesses of my own childhood experiences of neglect and substance use in the home, while a “predictor of mental health problems among military personnel” (Murphey & Turgoose, p. 806), led to my diagnosis of PTSD. Fortuitously, these weaknesses have essentially become strengths and resources for this clinician through the process of his own healing. I am now able to more effectively, empathically, and compassionately work with other trauma survivors.
The writer’s beliefs can be summed up in the four fundamental truths from Dr. Van Der Kolk’s seminal work, The Body Keeps the Score:
(1) Our capacity to destroy one another is matched by our capacity to heal one another. Restoring relationships and community is central to restoring well-being; (2) language gives us power to change ourselves and others by communicating our experiences, helping us to define what we know, and finding common sense of meaning; (3) we have the ability to regulate our own physiology, including some of the so-called involuntary functions of the body and brain; (4) we can change social conditions to create environments in which children and adults can feel safe and where they can thrive (Van Der Kolk, 2014, p. 38).
My trauma history struck at the very core of my belief system. Trust, self-respect, goodness, love, safety, truth, theology, spirituality, etc. were all impacted and held in suspicion. Meeting with a trusted psychologist in CPT sessions, ongoing therapy sessions, group sessions, support group, family, and VFW are all restorative means to deconstruct and transcend beliefs and find a new normal sense for meaning. Van Der Kolk further notes that “children who develop in the context of ongoing danger, maltreatment, and disrupted caregiving systems are being ill-served by the current diagnostic systems that lead to an emphasis on behavioral control with no recognition of personal trauma” (Van Der Kolk, p. 159). As explained earlier, being labeled as AUD, PTSD, etc., re-traumatized me, but once in recovery for alcohol, I am daily being able to deal with life on life’s terms, and freedom from believing that there was something intrinsically wrong with me. I have essentially turned towards who and what is important to me (values), understanding that “all behavior is influenced by the context in which it occurs. It is influenced by the things that follow upon behavior (consequences) and by the things that precede it (antecedents). By altering these two aspects of the context (language), the therapist can influence the client” (Torneke, p. 191). My ‘talk’ about myself concerning what happened to me (silent or verbal) has been changed, changing the outcomes (consequences).
Most significantly, my new understanding of neuroscientific research has caused me to give myself and others ‘a break’, normalize, and realize that allostatic changes in physiology and psychology have occurred due to trauma experiences. These recent findings have “demonstrated the impact of trauma on the brain, including changes to the sensory systems, gray matter volume, neural architecture, and neural circuits. There is also strong evidence that trauma leaves an imprint not only on the brain, but on the mind and the body too” (Sweeney et. al., 2018., p. 320). As an ACT therapist, I can guide myself and others toward our own values and away from behaviors (eliminative agenda) which move us away from what and who is important to us, resulting in cognitive dissonance (not following our own values). Furthermore, my belief that we all can use maladaptive means to cope, due to our language about ourselves and others, and this enables me to not be judgmental and potentially re-traumatizing.
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