Combat Stress Injury

Theory, Research, and Management

Charles R. Figley, William Nash, Charles R. Figley, William P. Nash

• Publisher: Routledge
• Year: 2011
• ISBN:
  9781135919320
• Edition: 1
• Topic: Psychology
• Subtopic: Psychotherapy Counselling
• Index: Psychology

Combat Stress Injury represents a definitive collection of the most current theory, research, and practice in the area of combat and operational stress management, edited by two experts in the field.

In this book, Charles Figley and Bill Nash have assembled a wide-ranging group of authors (military / nonmilitary, American / international, combat veterans / trainers, and as diverse as psychiatrists / psychologists / social workers / nurses / clergy / physiologists / military scientists).

The chapters in this volume collectively demonstrate that combat stress can effectively be managed through prevention and training prior to combat, stress reduction methods during operations, and desensitization programs immediately following combat exposure.

1

Introduction: For Those who Bear the Battle

Charles R. Figley and William P. Nash

The nature of war is destruction, both of property and human life. It has always been known that combat takes the lives of warfighters on the battlefield and later, through wounds that are too serious to heal. It is also common knowledge that of those who survive the dangers of battle, some carry physical wounds forward through the rest of their lives. This book draws attention to another type of wound, a mental and emotional wound, that can also generate long-term disability, and can also lead to early death (Boscarino, this volume, chapter 5; Boscarino, 2004, 2006). Our purpose in describing injuries caused by stress rather than steel is to promote a greater scientific understanding of their causes and cures, and to promote more effective methods to prevent and manage stress injuries before, during, and after operational deployments. Like physical injuries, the natural course for most injuries caused by stress is to heal over time. But also like physical injuries, stress injuries heal more quickly and completely if they are promptly recognized and afforded the proper care, if only a brief period of rest.

The chapters in Combat Stress Injury report on the theories, research, and intervention programs that may save the lives and the mental health of the warfighters who serve their country in battle. Thirty professionals from medicine, psychiatry, psychology, nursing, social work, human development, engineering, physiology, clergy, and military science collaborated to produce a book that is highly readable and of immediate use to those who train, lead, and care for warfighters. Of special interest to the contributors were the military commanders who bear primary responsibility for the management of all hazards faced by warfighters, both physical and mental. Military leaders have always understood their unique responsibility to balance the sometimes competing priorities of mission accomplishment and conservation of personnel. An important focus of the chapters in this book has been to place tools into the hands of military leaders to help them preserve the fighting strength of their troops while also protecting their long-term health and that of their families.

Combat Stress Injury is also written for the men and women who attend to those in harm’s way: mental health professionals, the clergy, and medical professionals. These professionals want to be as prepared as possible to help the warrior recover from and even be inspired by their combat stress injuries. We hope that this book will serve as an important resource for the latest and most comprehensive information and guide to helping.

Although not written for policy and law makers, we hope that the knowledge available in Combat Stress Injury will lead to significant improvements in the way modern warfare is conceived and the warrior trained and managed. As a result these improvements will increase both warrior proficiency and resiliency in and after battle.

Finally, and most importantly, Combat Stress Injury is written for the warriors themselves and their families who wish to understand the stress-related psychosocial and medical consequences of battle. They will learn that there are positive as well as negative consequences to combat, and they have a role in managing these consequences. The various chapters, we hope, will help warriors and their families master the many challenges of deployment and homecoming. Deployment to a war zone is a transformative process for everyone connected with this enterprise; it is hoped that information contained in this volume will promote the enduringly positive life transformations that are possible while mitigating some of the negative changes that may be unavoidable. At the very least, we hope to prevent a repetition of the unfortunate experiences of previous cohorts of veterans, especially Vietnam veterans, who struggled with combat stress injuries in silence and misunderstanding (Figley & Leventman, 1980).

It is not known how many of the more than half million warfighters who have already served in Iraq or Afghanistan have experienced persistent stress injury symptoms, but veterans support organizations such as the U.S. Department of Veterans Affairs are gearing up to provide services to veterans of these conflicts. Families of veterans, also, have long been known to be greatly affected by the stress of war, both physically and emotionally (Figley, 1978). To be most effective, programs and services to serve this generation of warriors and their families must be built on a solid understanding of 21st century warfare, warrior culture, and stress injury science. We believe this book offers useful information to guide the development of such services, and to educate the current generation of service members, families, and support personnel.

The editors of this book met by happenstance. A mutual acquaintance, David Wee, introduced them after hearing a paper presented by the second co-editor, Dr. Bill Nash. From their first e-mail exchanges the editors felt a connection through their love of the Marine Corps and a devotion to serving warfighters and their families. From those initial e-mail exchanges in May 2005, the editors conceived of a book that would draw upon the best minds and work available that answered five fundamental questions: (1) What are the positive and negative short- and long-term consequences of war fighting for the warfighter? (2) What are the pre-combat factors that affect these consequences? (3) What are the factors during and following combat that affect these consequences? (4) What are the psychosocial and medical programs, treatments, and interventions that mitigate the negative consequences of combat and enhance the positive consequences? (5) What can be done to utilize the answers to these questions in order to more effectively educate, train, lead, and care for our future military combatants?

To present the answers to these fundamental questions, the editors organized the 14 other chapters into three sections. Section I: Theoretical Orientation to Combat Stress Management contains three chapters that serve as the conceptual anchor for the volume. All three of these theoretical chapters were written by the second editor, William Nash, M.D., a senior U.S. Navy psychiatrist who served with the First Marine Expeditionary Force in the Al Anbar Province of Iraq during 2004 and 2005. In chapter 2, The Stressors of War, he describes the specific physical and mental challenges of the current war in Iraq as well as the attitudes of military personal toward the concept of “combat stress” that form an important cultural context in which they experience these stressors. It is vital for the reader first to have a clear understanding of the challenges of current warfare in order to appreciate the relevance of the rest of the book.

In chapter 3, Combat/Operational Stress Adaptations and Injuries, a model is presented for differentiating stress adaptations from stress injuries and illnesses. Stress adaptations include the spectrum of so-called normal and reversible reactions to the abnormal challenges of combat and military operations, while stress injuries and illnesses are a group of very specific syndromes with highly predictable symptoms and courses over time. The concepts of stress injury and stress illness in no way imply permanence or even chronicity, but to deny that combat and operational stresses can injury the brain and mind is to invalidate the suffering of those brave warriors who have been injured by combat and operational stress.

In chapter 4, Competing and Complementary Models of Combat Stress Injury, Dr. Nash and Dewleen Baker, M.D. (director of the PTSD and Stress Disorders Program at the San Diego, California, Veterans Administration Medical Center) review the major competing and complementary models of combat and operational stress and stress injury. After traversing the landscape of enduring military leadership theories, twenty-first-century neurobiological models, and the psychological theories that underpin all modern psychotherapies for posttraumatic stress disorder (PTSD), the authors leads us to two important conclusions: (1) no single conceptual model of overwhelming stress and its management answers all our questions regarding resiliency, prevention, and treatment; but (2) each of these models contributes uniquely to our understanding of these problems.

Section II: Research Contributions to Combat Stress Injuries and Adaptation includes the most important scientific findings relevant to answering the primary questions of this book. The section contains three chapters, starting with chapter 5, The Mortality Impact of Combat Stress 30 Years after Exposure: Implications for Prevention, Treatment, and Research, by Joseph A. Boscarino, Ph.D., M.P.H. (senior investigator at the Center for Health Research & Rural Advocacy, Geisinger Health System in Danville, Pennsylvania). Building on his 1997 reports and utilizing the same extraordinary data set of Vietnam veterans, Dr. Boscarino analyzed mortality rates of those diagnosed with PTSD. Among other findings in his chapter, Dr. Boscarino reported that Vietnam “theater” veterans (N = 7,924) with diagnosed PTSD (10.6%) were far more likely than other veterans to die. Controlling for all major demographic factors he found that adjusted post-war mortality hazards ratios [HR] were 1.7 (p = 0.034) for cardiovascularrelated death; 1.9 (p = 0.018) for cancer-related death; and 2.3 (p = 0.001) for all types of external-caused deaths (including motor vehicle accidents, accidental poisonings, suicides, homicides, and injuries of undetermined intent). For all causes of death, the HR was 2.2 (p < 0.001).

Chapter 6, Combat Stress Management: The Interplay Between Combat, Physical Injury, and Psychological Loss, is written by Danny Koren, Ph.D. (professor in the Psychology Department, University of Haifa, Israel), Yair Hilel (former member of the Israeli Army and current Ph.D. candidate in the Psychology Department of the University of Haifa), Noa Idar (also a Ph.D. candidate in the Psychology Department of the University of Haifa), Deborah Hemel, B.A. (2005-2006 Fulbright Fellow in the Department of Overseas Studies, University of Haifa), and Ehud Klein, M.D. (professor in the Department of Psychiatry, Faculty of Medicine, Technion–Israel Institute of Technology, Haifa, Israel). Among other things, they present the findings of their study that isolated the unique contribution of physical injury to the subsequent development of PTSD. They compared 60 injured soldiers to 40 noninjured soldiers, controlling for rank, military occupational status, length of service, and combat situation using various standard mental health measures including the Structured Clinical Interview for DSM-IV (SCID). Among their findings was that the injured had PTSD by a 10 (injured):1 (noninjured) ratio, and had significantly higher scores on all clinical measures, compared to controls. Consistent with earlier findings (Figley, 1978), the presence of PTSD was not related to severity of injury. However, the lack of a relationship between PTSD and severity of the trauma was surprising. They discuss the implications of this and other findings about the impact of combat-related injury as a major risk factor—not a protective factor—for PTSD, that bodily injury contributes to the appraisal of the traumatic event as more dangerous, and that this heightened level of perceived threat is far more complicated than once thought. The authors suggest improvements in the treatment protocols to offset these predictable reactions and enable the injured to be far more resilient through effective combat and combat injury stress management.

Chapter 7, Secondary Traumatization Among Wives of War Veterans with PTSD, is written by Rachel Dekel (associate professor at the School of Social Work, Bar-Illan University, Ramat-Gan, Israel) and Zahava Solomon (professor at the School of Social Work, Tel Aviv University, Israel, and former Major, Israeli Defense Force). In their chapter they review the extensive research that demonstrates the secondary effects of combat stress in combatants on combatant wives. Among other things, they and others have found that a husband’s impairment and a wife’s sense of burden predicted both of the latter’s emotional distress and the overall marital adjustment, compared with the general population in Israel. Since perceived caregiver burden was more closely associated with distress than the level of the combatant’s impairment the authors discuss ways of lowering emotional distress by changing the perception of burden by the wives.

Section III: Combat Stress Management Programs is appropriately the largest and final section with eight chapters. Collectively these chapters demonstrate that combat stress can be managed both through prevention and training programs prior to combat, effective stress reduction methods during operations, and especially the desensitization program immediately following to long after combat exposure.

Chapter 8, Historical and Contemporary Perspectives of Combat Stress and the Army Combat Stress Control Team, was written by Bret A. Moore, Psy.D. (U.S. Army Captain, Clinical & Aeromedical Psychologist, 85th Combat Stress Control, Fort Hood, Texas) and Greg Reger, Ph.D. (U.S. Army Captain, Clinical & Aeromedical Psychologist, 98th Combat Stress Control, Fort Lewis, Washington). After differentiating between physical and psychological war casualties and the history and terms relevant to combat stress, Captains Moore and Reger discuss the history and mission of the Combat Stress Control Teams, of which they are members, and the vital roles played by the various behavioral health professionals in managing combat operational stress reactions (COSR). The latter section of the chapter presents three case studies to illustrate the way these teams provide treatment for, prevent, and consult with command/leadership about COSR. Moore and Reger were both deployed to Iraq in support of Operation Iraqi Freedom III during the construction of this chapter.

Chapter 9, Virtual Reality Applications for the Treatment of Combat-Related PTSD, is written by Skip Rizzo, Ph.D. (research scientist and research assistant professor at the University of Southern California Institute for Creative Technologies, Marina del Rey, California), Barbara Rothbaum, Ph.D. (professor of psychiatry and director of the Trauma and Anxiety Recovery Program, Emory University School of Medicine, Atlanta), and Ken Graap (president and CEO of Virtually Better, Inc., Decatur, Georgia). Their chapter focuses on the use and advantages of virtual reality (VR) methods for managing combat stress injuries and the more serious combat-related PTSD. After briefly reviewing the definitions and theoretical basis for using VR in a cognitive behavioral PTSD treatment, they review the empirical evidence in treating Vietnam warfighters using the “Virtual Vietnam” scenario. In the final section of the chapter the authors present a detailed overview of current work developing a “Virtual Iraq” scenario for the assessment and treatment of Iraq War PTSD. This approach is believed to offer certain advantages over imaginal and in vivo exposure methods for the treatment of anxiety disorders and early findings from the PTSD VR literature have been encouraging.

Chapter 10, Experiential Methods in the Treatment of Combat PTSD, was written by James L. Spira, Ph.D., M.P.H, ABPP (associate clinical professor in the Department of Psychiatry, University of California, and the Mental Health Services, Naval Medical Center, San Diego), Jeffrey M. Pyne (Center for Mental Health and Outcomes Research, Central Arkansas Veterans Healthcare System, Little Rock), and Brenda Wiederhold (Interactive Media Institute, San Diego). This chapter is a step-by-step guide to using virtual reality in the treatment of PTSD following a discussion of other more traditional treatment approaches and a description of the benefits of VR-assisted treatments. The primary focus of this chapter will be the role of experiential psychotherapy treatments that teach cognitive, affective, and behavioral control to better cope with combat-related PTSD. In particular, the authors focus on self-help skills during exposure therapy, particularly those utilizing virtual reality systems, to assist returning troops gain control over PTSD symptoms.

Chapter 11, Medication Management of Combat and Operational Stress Injuries in Active Duty Service Members, is written by Nancy M. Clayton, M.D. (U.S. Navy Lieutenant Commander, Medical Corps) and William P. Nash, M.D. This chapter concisely and clearly surveys the major classes of medication proven to be useful in the treatment and prevention of combat and operational stress injuries, and gives practical guidance for the use of such medications by active duty service members. Current clinical practice guidelines are cited for all major classes of medications. This chapter demonstrates that while pharmacotherapy cannot be considered a “cure” for operational stress injuries, the benefits of medications are often substantial, and they should always be considered in a management program.

Chapter 12, The Royal Marines’ Approach to Psychological Trauma, is written by Major (rtd) Cameron March (Acting Major, Royal Marines) and Dr. Neil Greenberg (Surgeon Commander, Royal Navy). The trauma risk management (TRiM) program was developed in 1997 by the Royal Marines. It is a postincident protocol for use by hierarchical organizations, such as the Royal Marines, to systematically manage the psychological consequences of potentially traumatic events. It assumes that service personnel are, in the main, resilient individuals and the best immediate management strategies for such personnel are to effectively bolster peer support and to enable/assist those who need professional help to find it at an early stage. TRiM practitioners are nonmedically trained personnel drawn from all ranks. They receive specific training which does not intend to turn them into counselors, but instead aims to build on their innate human management skills gained by life experience and military service. Suitably trained TRiM practitioners are able to manage all psychological aspects of adverse incidents. They use established protocols and a structured risk assessment procedure to identify those at risk of developing problems and ensure such personnel are correctly managed. This is mainly done by making use of established management systems which are an inherent part of military culture. They are supported and supervised by medical and mental health services from within the Royal Navy, but are an accepted source of first-line support and are an integral part of all Royal Marines units. This chapter explains the history behind the TRiM system, how it works, and where its future lies.

Chapter 13, The Operational Stress Injury Social Support Program, is written by Lieutenant Colonel Stephane Grenier (project manager of the Operational Stress Injury Social Support [OSISS] program and the DCSA, National Defense Headquarters, Ottawa), Kathy Darte, ...

Table of contents

• Cover Page
• Half Title Page
• Routledge Psychosocial Stress Series
• Title Page
• Copyright Page
• Dedication
• Contents
• About the Editors
• Contributors
• Series Editor’s Foreword
• Foreword by Jonathan Shay, M.D., Ph.D.
• Acknowledgments
• Dedication
• 1 Introduction: For Those who Bear the Battle
• Section I Theoretical Orientation to Combat Stress Management
• Section II Research Contributions to Combat Stress Injuries and Adaptation
• Section III Combat Stress Management Programs
• Index