"Did You Shoot Anyone?" A Practioner'sGuide to Combat Veteran Workplace andClassroom ReintegrationChristina L. Lafferty, National Defense University

Kenneth L. Alford, Brigham Young University

Mark K. Davis, National Defense University

Richard O'Connor, The Pentagon

"What the Hell Happened to Terry?" ^Nothing seems out ofthe ordinary this day at theCalifornia-based health care firm. On the fourthfloor, the marketing staff goes about their busi-ness as warm autumn sunshine streams throughthe glass panels that form the building's exteriorwalls. A project team casually gaggles around aworktable spread with charts and documents.Suddenly, a voice calls out, "Hey! Look atthat!" A large, black military helicopter zoomslow across a nearby field, heading toward thebuilding. As employees gather at the glass wall,the chopper seems almost to fill the sky. thedroning of its blades rising to a roar. It soarsover rhe building, vanishing toward a nearbymilitary base, leaving a wave of excitement in itswake. As people drift back to work, one oftheproject team members looks around. "Where'sTerry?" Silently, a secretary point to a desk, itschair overturned. There, beneath the desk, handsclasped over his head, crouches Terry. As hesheepishly emerges, a voice from the back ofthegroup mutters, "Jeez, Terry, what the hell hap-pened?"

Since the onset of the Global War on Terror,more than 1.6 million men and women oftheUnited States Armed Forces have deployed toAfghanistan and Iraq. A large percentage ofthese are Guard (247,695) and Reserve(195,796). Many have experienced two and

' The service members' stories in this article areactual accounts and used with their permission.Their names have been changed or omitted forprivacy.

some even three or four tours of duty in combatzones. As these combat veterans leave the mili-tary and retum to civilian life, they bring withthem the physical and mental consequences ofwartime service. While advances in medical carehave saved numerous lives on the battlefield, weare still faced with a staggering number of menand women who have sustained serious psycho-logical injuries as a result of combat. One in foursoldiers discharged from Operation EnduringFreedom (Afghanistan) and Operation IraqiFreedom (Iraq) have filed disability claims withthe Veterans Administration, over 40,000 ofwhich have been for post-traumatic stress disor-der (PTSD) (Meagher, 2007).

America has come a long way from the timewhen returning Vietnam War veterans weregreeted with hostility and suspicion. "Supportthe Troops" has become everything from afashion statement to a national mantra. Yet whenwe move from the general to the specific, whenwe encounter the returning combat veteran in theworkplace or the classroom, when a helmet-cladevery soldier in a news magazine becomes a realperson sitting behind a desk, what does "sup-port" mean?

This paper proposes that there are practicalthings managers and educators can do to helpcombat veterans reintegrate into the workplaceand classroom. We'll begin laying the ground-work with what makes the War on Terror differ-ent from previous U.S. conflicts. Next, we'llconsider the psychological stress that canresult from combat operations, specificallyPTSD. Finally, we'll examine specific attitudes.

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behaviors, and strategies that can help ease thecombat veteran's transition to the civilian workand school environment, presenting some dosand don'ts for managers and educators seekingto support successful veteran réintégration.

A Different Kind of War"¡feel like Bill Murray in the movie GroundhogDay."

Indiana soldier preparing for a retumdeployment to Iraq (Bode, 2007)

It seems patently obvious to say that the war onterror is a different kind of war. Every war isdistinguishable in such ways as cause, place,technology, and political consequence. AuthorRonald Manderscheid (2007) points out threedistinctions affecting social réintégration follow-ing Iraq and Afghanistan service: duty tourlength and pattem; danger level; and disengage-ment from civilian culture. To that we add twomore: uncertainty of duration and the types ofcasualties the War on Terror brings.

Both Vietnam and Gulf War combatants sawrelatively short tours of duty. Most Vietnamtours lasted approximately 12 months, and formost individuals, one tour was all that theirservice demanded. Gulf War tours lasted nolonger than the brief duration of that conflict.Most recently, duty in Bosnia and Kosovo rarelylasted beyond a year. Deployment to Iraq andAfghanistan, in contrast, has extended as long astwo years (Manderscheid, 2007). More impor-tant, many combatants have served or are serv-ing their second or even third rotation in supportof Operation Iraqi Freedom (Iraq) or OperationEnduring Freedom (Afghanistan). While servicein the military itself is voluntary, deployment tothe combat zone is, in most cases, not a matterof choice. Too, the pattem is unpredictable:entire deployed units may be extended, or indi-viduals may be deployed and have their deploy-ment extended, in either case with short notice,adding significantly to stress.

The character of this war also differs. Viet-nam and the Gulf War were largely conventionalconflicts. Enemy combatants were readily iden-tifiable (excepting guerilla combatants in Viet-nam), and. for the most part, clear distinctionsexisted between battle zones and safe zones(Manderscheid, 2007). In Afghanistan and Iraq,there are no safe zones, merely areas of greaterand lesser degrees of risk. Even the so-called"Green Zone" is under recurring mortar androcket attack. Soldiers and Marines on patrol are

under constant threat from improvised explosivedevices (IEDs), snipers, and the grinding tensionbetween terror and tedium. Moreover, many arebeing asked to undertake new missions tied tostability and reconstmction; in many cases,they're performing tasks for which they mayhave received little or no training, although thisis improving.

Next, this war is employing a mixed set ofvolunteers, including a large number of Guardand Reserve forces. While reserve componentmembers have a strong affiliation to theirunits, their contact is intermittant; they lack theuninterrupted association with the militarycommunity experienced by their active dutycounterparts. TTieir strongest affiliation lies withtheir civilian communities, and their réintégra-tion with this radically separate environmentwill differ greatly from that of combat veteransretuming to a military environment (Mander-scheid, 2007). Compounding this. Reservists canbe deployed as an entire unit, in small teams oras individuals. Their post-deployment support isoften split among their home unit, an affiliatedactive duty unit, and civilian health care provid-ers, making continuity of care and support aparticular challenge.

Another significant difference lies in theuncertainty of this war's duration. As recently asthe 2008 State ofthe Union Address, the Presi-dent noted that "They [al Qaeda] are not yetdefeated, and we can still expect tough fightingahead" (Bush, 2008). While he noted that U.S.participation is away from leading and towardpartnering and eventual overwatch, the subtext isan indefinite American presence. To the soldier,this translates to more of the same, i.e., the"groundhog day" effect. The Iraq War veteranfrom Indiana elaborates:

This time around I already know what isgoing to happen for the next 18 months.The bottom line: My battalion will deployagain, most of us will make it home, somewill no t . . . The one thing that motivatesme in my cunent grind is the knowledgethat if I survive my next deployment Tilhave the opportunity to start a normalexistence again. (Bode, 2007)

In that word, "normal," lies the most signifi-cant difference in the current conflict: injuriesthat complicate the struggle for normalcyupon retum from the combat area. Improve-ments in vehicle and personal armor, coupled

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with advancements in battlefield medicine, meanthat soldiers who in prior wars would have diedare now surviving, albeit often with debilitatingwounds. Moreover, because so many of theseinjuries involve concussive blasts from IEDs(single and multiple), we are seeing a highproportion of casualties with traumatic braininjury, ranging from mild to severe. Evidencesuggests that even mild traumatic brain injury isrelated to PTSD, indeed, many of the symptomsare indistinguishable (Hoge, McGurk, Thomas,Cox, Engel and Castro, 2008). Yet as we shallsee, it doesn't take concussive blast and trau-matic brain injury to produce PTSD.

Nature and Prevalence of Post-TraumaticStress Disorder

"The physical war is over. The mental war hasjust begun "

Iraq War veteran (Pitts, 2005,in Meagher, 2007)

What we today call PTSD has, in fact, been aconsequence of combat since earliest recordedhistory. In his groundbreaking works Achillesin Vietnam: Combat Trauma and the Undoingof Character (Shay, 1995), and Odysseus inAmerica: Combat Trauma and the Trials ofHomecoming (Shay, 2002), Department ofVeterans Affairs psychiatrist Jonathan Shayexplores the psychological trauma induced byprolonged exposure to wartime stress throughHomer's epic poems The Iliad and The Odyssey.Through these accounts of real, albeit ancient,historical events. Shay makes a compelling casethat PTSD has been around as long as war itself.During the American Civil War, the conditionwas termed "irritable heart" or more simply"nostalgia." World War I brought nomenclaturelike "shell shock," "hysteria" or the more clini-cal "neurasthenia." During the Second WorldWar, "battle fatigue" was the most frequentname, although "war neurosis" and "exhaustion"were also employed. Vietnam veterans werelabeled as suffering from "post-Vietnam syn-drome." It was not until 1980 that the thirdedition of the American Psychological Asso-ciation's Diagnosis and Statistical Manual ofMental Disorders (DSM-III) listed the condition"posttraumatic stress disorder" or PTSD (Cole-man, 2006). The current DSM-IV describesPTSD as "the development of characteristicsymptoms following exposure to an extremetraumatic stress or involving direct personal

experience of an event that involves actual orthreatened death or serious injury, or other threatto one's physical integrity." True PTSD re-sponse "must involve intense fear, helplessness,or horror (APA, 2000, 309.81).

Not every retuming Iraq or Afghan Warveteran suff'ers from PTSD. Yet the condition isprevalent enough that it has become the topic ofa recent study involving 2,525 soldiers. Resultsindicate that "more than 40% of soldiers withinjuries associated with loss of consciousnessmet the criteria for PTSD" (Hoge, McGurk,Thomas, Cox, Engel and Castro, 2008). Further,retired Army psychiatrist and consultant to theSecretary of the Army Brigadier GeneralStephen Xenakis stated that one Amiy studybased on data from questionnaires administeredupon retum from the combat zone and five or sixmonths later showed that at least 20-25% ofreturning soldiers experience "severe mentalproblems" (Xenakis, 2008). Other estimates(Greenwald, 2006) indicate that 30% of retum-ing soldiers will suffer from PTSD (symptomsor diagnosis), rising to 70% for those retumingfrom a second deployment.

Mental health experts in the field of PTSD(Hoag, Castro, Messer, McGurk, et al., 2004)admit that there are wide gaps in understandingthe full psychosocial ramifications of combat.Therefore, few longitudinal studies to inform thedialogue surrounding PTSD and the retumingcombat veteran (Litz, 2007). The MillenniumCohort Study (Ryan, Smith, Smith, Amoroso,Boyko, Gray, et al., 2007) was launched in 2000in response to health concems of military mem-bers surrounding deployment and other service-connected experiences, to include PTSD. Thestudy enrolled a first panel of 77,047 partici-pants from all branches and components of theU.S Armed Forces. Early findings indicate thatof the 40% of the cohort who were on activeduty between 2001 and 2006, there was a three-fold increase in PTSD symptoms or diagnosisamong those military personnel who reportedcombat exposure (Smith, 2007).

All this points to a significant proportionretuming combat veterans who will enter theworkplace or the classroom facing challengesbeyond mere culture change. As Dr. Brett T.Litz (2007), Associate Director of the NationalCenter for Post-traumatic Stress Disorder notes:

A new generation of veterans may be atrisk for life course disturbances implicatedby exposures to war-zone Stressors and

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adversities... There are initial signs thatveterans of the wars in Iraq and Afghani-stan are at risk for PTSD, which can be alifelong challenge for veterans. There ismuch we do not know about how servicemembers manage and adjust to the enor-mous and diverse demands and traumas inthese new war zones (Litz, 2007).

Faced with this challenge, and hampered bythe lack of empirical research, how are managersand educators to foster successful réintégrationof the returning veterans? Our approach is tolisten to the voices of the veterans themselves.

Recommendations to Managers andFaculty

"/ wasn't scared to go to Iraq. I wasn't reallyeven scared about what would happen when Itost my legs. You want to know what I was reallyscared of? I was absolutely terrified to gohome."

U.S. Army Corporal, Ohio, Wounded Warrior

Even veterans who do not suffer from PTSD ortraumatic brain injury still experience somedisorientation upon re-entering the civilianworkforce and classroom. Many are unsure bowthey will be received outside the military com-munity; the memories of the treatment of Viet-nam veterans linger still. Journalist KristinHenderson, author of While They're at War andspouse of a military chaplain who served in Iraqand Afghanistan, reminds us that

This problem of veterans who're returningand having trouble reintegrating — it's notjust a problem for them and their families.It's a community problem, particularly asthey detach from the military, or if they'reNational Guard or Reserve, they demobi-lize. They are leaving the military commu-nity, and they're out there' — they're yourneighbors . . . They're encountering teach-ers, they're encountering police officers,and these folks may not know where theveterans and tbeir families are coming fromwhen they first encounter tbem if they'restruggling (Henderson, 2008).

In talking and working with veterans of thewar on terror on a daily basis for more than fiveyears, we have seen several themes emerge.From those, we have distilled a number of spe-

cific suggestions to facilitate the veterans transi-tions from war zone to work zone.

Curb your anxiety. Many managers and edu-cators, while eager to support those who haveserved their country, harbor anxieties about bowto deal with someone whose last professionalexperience involved carrying a weapon in ahostile environment. One professor explainedbis concerns during a recent public radio broad-cast:

This term I have two Iraq vets who are intheir 30s, both are hardworking, highlystressed, mentally fragile. Last year I hadan Iraq vet in class. He demonstrated anunbelievable level of stress. In an effort tohelp him, I gathered some backgroundinformation. Can you imagine bow I feltwhen I learned this very unstable individualearned a certificate of merit for his marks-manship skills? I felt as though I had atarget on my back tbe entire term. What ifhe were dissatisfied witb the grade heearned? I imagine that situations like thiswill increase in years to come. The univer-sity cannot do anything until the individualmakes a threat; by then it will be too late(Unidentified caller. 2007).

No empirical evidence suggests that returningcombat veterans are predisposed to dispatchprofessors or bosses with whom they disagree.Virtually every miiitary person who deploys(with certain exceptions: chaplains, for example)is proficient (certified) in one or more weapons.This does not make them any more likely torespond with violence than any other person inthe workplace or classroom. Indeed, the twomost recent high-profiie campus shootings wereby civilians.

Xenakis suggests that "the faculty member . . .can really help by not feeling alarmed . . . Andthere are ways of reaching out to them and there[are] ways of supporting them" (2008). Like theOhio veteran just quoted, many fear the reactionof family, friends, co-workers and classmates tosomeone who has seen and perhaps participatedin the violence that is warfare. Managers andteachers who behave toward the veteran muchas they behave toward other workers or stu-dents can do much to create an atmosphere ofnormalcy for the veteran.

It's ok to say thanks. It's not a good idea to let

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wartime service become the elephant in theliving room. While few veterans want coworkersand classmates to make a big deal out of theirwartime service, pretending it didn't happen isdetrimental to honest'communication. After all,they weren't vacationing in the Bahamas! Butdon't fuss. Soldiers are traditionally modestabout public praise. However, phrases like,"Thanks for what you did over there," "Wereally appreciate your service," and "It's great tohave you home" are ways to let the veteranknow that his or her efforts and personal sacri-fice are remembered and valued — regardless ofthe speaker's political viewpoint. Speaking ofpolitical viewpoints:

Curb your politics. Resist the temptation toask the returning veteran, "So, do you thinkwe ought to be in Iraq? What do you think ofBush?" Most military members keep their poli-tics to themselves and few appreciate being putin a position to debate the issue. Moreover, thereasons many people enlisted in the military andwent to war have little to do with political ideol-ogy. "I don't pay much attention to the politi-cians or what I see on TV," confided the Ohiocorporal. "I was there for my country, becauseof 9-11. And for my buddies." Remember thatmany have lost friends to the"war on terror, andin their minds, this is far more than an academicdiscussion.

Channel your curiosity. Ninety percent ofadult Americans have not served in the military(U.S. Census Bureau, 2006). So it's natural thatpeople may feel curious about what the wartimeexperience is like. Military members understandthis, and most are willing to discuss their serviceexperiences in general. However, for a recentlyreturned wartime veteran, some topics may bedifficult or painful. While this seems intuitive,it's surprising how many people ask things like,"Did any see anyone die?" "Were you scared?'or the ubiquitous "Did you shoot anyone?"Questions aren't prohibited; it just means thatsome sensitivity is in order. First,'Iet the indi-vidual set the tone; for instance,

"If s great to have you home'—welcome back.""Thanks — it's good to be home.""So how was it over there?"

If the response is something like, "Prettytough" or "Worse than here," followed by si-lence, chances are that's all the person wants to

say. "People are pretty inquisitive," explained awounded Iraq veteran from Colorado who, nowrecovering, is newly employed. "General ques-tions are OK, like asking what the guy did in theArmy. People are proud of their accomplish-ments. But," he cautions, "specific questions,like 'Did you hurt anyone?' — those couldtarget certain memories." Sometimes the ques-tion elicits tentative conversation or even a burstof war stories. The father of one Iraq War vet-eran suffering from both traumatic brain injuryand PTSD suggests looking for signals thatquestions may be welcome. "My son had all hismedals framed and hung them in his cubicle atwork. When his boss asked me, 'What should Isay to him?' I replied, 'Ask him about bis med-als." Another veteran shares this advice:

By all means, ask. It helps if you showgenuine interest in the person's experienceand really listen. Questions should be open,general. A gentle approach is always agood idea, and focus on hearing versustelling. And don't take it personally if theperson doesn't want to talk about it (Per-sonal interview, 2008, name withheld).

It's nor about you. Some people becomeoffended or feel rejected when the returningveteran doesn't want to talk about his or herexperiences. It's important to know that thisreluctance to share is rarely personally directedat the questioner. Minnesota Army NationalGuard chaplain Major John Morris explains:

Co-workers should brace for strong indif-ference from veterans . . . an attitude alongthe lines of "I've been at the center ofworld events, and everything I've beendoing is more important than what you'vebeen doing." On their side, co-workers canstop asking the kind of troubling questionsveterans now get. You do not want to ask,'Did you kill anybody?' Morris said. "Orsometimes people ask, 'Do you think weshould be there? Do you think we're win-ning?' Then they use that to go into theirown politics, which is not appreciated.Instead. Morris suggests showing interestwith open-ended questions, so veterans cango only as far as they're comfortable,questions such as: "What was your experi-ence like?" "How was it coming home?""What would you like to share about yourtime in Iraq?" (Cummins, 2006)

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Closely tied to the ambivalence related to thenature of the wartime experience is the combatveteran's sense that only other veterans can trulyunderstand their experience. Some veterans arereluctant to speak with anyone who wasn't "inthe AOR (Area of Responsibility)," while otherswill open up to those who wear or have worn theuniform. A study examining the effect of combatexperience on personality development sums upas follows:

This sense of security, safety, and comrade-ship does not fit well with life in the realworld. This is due to civil life being lessrigid and well defined, and there being littleimpetus to develop üfe-or-death comrade-ships. And the vast majority, without com-bat experience, cannot empathize withthese emotions. IThe "Warrior Ethic"] hasno place and few analogies in civil life . . ."(Rutólo, 1993)

Respect their privacy. Managers and teachersmay find themselves wondering, "Does this guyor gal have PTSD? How will I know?" Frankly,you may not, any more than you would knowwhether someone in your workplace or class-room suffers from diabetes or depression. How-ever, you may observe signs of stress andtension that lead you to suspect that some formof combat-related stress is still present. Theseinclude:

Trouble concentrating for long periodsDiscomfort with silenceUnease in large gatheringsIncreased absenteeismDecreased ability to function at workDisturbances in relationships with co-workersand classmates

Remember, too, PTSD often becomes moresevere in months following departure from thecombat zone (Litz, 2007). One veteran whoreturned to college described it this way:

You'd freak out. Two hundred peoplearound you when you're used to just — ifyou're just fresh out of war or something,or even been out for just'six, seven months,you're still going to have the paranoia ofhaving so many people around you . . . It'slike, wow, you know, my heart starts going,I start looking around, and that's when Istarted walking around and just looking

around and seeing if everything's okay.And it's just — people just, they look atyou and It's like, wow, what's wrong withthat guy? (Turner, M., 2008)

Compounding stress reactions is the impactof military culture on veterans suffering fromPTSD. In War and Gender, author Joshua Gold-stein explains, "In World War I, and other cases,shell shock was treated as tantamount to a fail-ure of manliness," because" "shame is the gluethat holds the man-making process together"(Goldstein, 2001). So it's no surprise that a 2006study of 1,767 Army and Marine war on terrorveterans found that less than 50% of those whoscreened positive for a mental health problemsought help. Reasons cited included fear ofbeing treated differently; being seen as weak;losing the confidence of unit members; and fearof harming their career (U.S. Army. 2006).

In light of this, managers' and professors' bestcourse of action is to refrain from questioningthe veteran about specific health conditions.Instead, a private inquiry, "I noticed you seem abit tense. Is everything all right?" or "Is thereanything I can do for you?" is the best way toexpress your concern and open the door fordialogue. But essentially, we recommend fol-lowing the advice of retired FBI supervisoryagent and workplace violence expert GeneRúgala, who says, "I wouldn't treat veterans anydifferently, other than knowing what they'vegone through and being more sensitive to someof those issues that develop" (Collett, 2008).

Know your resources. Local Employee Assis-tance Programs are often a useful place to start.As the number of returning veterans grow, sotoo does program awareness and experience.Depending on location, transition support forreintegrating veterans may be available throughthe Veterans Administration. Support may bereadily available through the company healthcare plan or school health care center. Theremay be local community resources that supportstress management. In addition, these Web sitesare useful for those wanting to learn more aboutveteran issues and support:

• Post-deployment health care: http://www.pdhealth.mil/

• The National Center for Post-traumatic StressDisorder: http://www.ncptsd.va.gov/ncmain/index.jsp

• Military Benefits: http://www.military.com/

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benefits/resources/ptsd-overview• Military Veterans PTSD Reference Manual:

http://www.ptsdmanual.com/

Finding the New Normal"War stories end when the battle is over orwhen the soldier comes home. In real life, thereare no moments amid smoldering hilltops fortranquil introspection. When the war is over,you pick up your gear, walk down the hill andback into the world."

Iraq War Veteran (Crawford, 2005)

Since the earliest record of warfare, the return-ing warrior has struggled to rejoin the societyleft behind. It has never been an easy transition,but the war on terror brings new and unantici-pated complications for the combat veteran.New technology means survival for those whowould have died in prior wars, yet that verysurvival is fraught with challenges we are onlynow learning to address. Understanding whatdistinguishes this war as it pertains to the return-ing combat veteran; comprehending the ramifi-cations of traumatic brain injury and PTSD; andseeking to identify the attitudes and behaviorsthat ease the disorientation of return is oneservice that managers and educators can offer tothose who have served their country under theharshest conditions.

Dr Lafferty. Colonel. U.S. Air Force (Ret.), inher fifth year with the Department of StrategicLeadership of the National Defense University,is a social scientist and former member of thefaculties of The George Washington University.Arizona State University, and Ohio University.She is also a civilian advanced practice oncol-ogy nurse. Dr Alford is a retired colonel whoserved 29 years in the U.S. Army, includingmany teaching assignments. He has publishedand presented on numerous subjects at confer-ences. Colonel Davis, a licensed clinical psy-chologist with the U.S. Army, is currently aprofessor of Behavioral Science in the Depart-ment of Strategic Leadership in Washington. D.C. He recently returned from deployment in Iraq.Colonel O'Connor, who holds two masters ofscience degrees, served 13 months in Iraq withthe 3rd Cavalry Regiment as commander of theSupport Squadron.

Note: The views expressed in this article arethose of the authors and do not reflect the offi-cial policy or position of the National Defense

University, the Department of Defense, or theU.S. Government.

REFERENCESAPA (2000). Diagnostic and statistical manual of mental

disorders (4th ed.). Arlington VA: American Psychologi-cal Association.

Bode, K. (2007). Soldier's gritty Iraq picture. In CollegeNews: Editorials undCommentaries.RetúevedÍTomhltp://www.coil egenews.org/x68 86.x ml

Bush. G.W. (2008). State of the union address. Retrieved fromhltp://w ww.whitehouse.gov/news/releases/20U8/01/20080I28-13.html

Coleman, P. (2006). Flashback: Posttraumatic stress disor-der, suicide, and the lessons of war. Boston: Beacon Press.

Collett, S. (2006, December I ) Gettitig vets back to work. InCSO Perspectives. Retrieved from http://www.csoonline.com/read/I 20106/fea_veterans_pt.html

Crawford. J. (2005). The last true stoiy I'll ever tell: An

accidental soldier's account of the war in Iraq. New York;Riverhead Books.

Cummins. H. J. (2007. July 21 ). Combai veterans, employersmust recognize need for adjustment. The Star Tribune.Minneapolis MN. p. ID.

Greenwald. J. (2006. September 18). Reservists face chal-lenges returning to work. Business Insurance, p. 1.

Goldstein, J. S. (2001). War and gender : How gender shapesthe war .tystem and vice ver.sa. Cambridge, United King-dom: Cambridge University Press.

Henderson, K. (2008. January 29). Veterans mental healthcare. The Diane Rehm Show [Radio broadca.stl. Washing-ton D.C.: American University Radio WAMU 88.5 FM.

Hoag, C.W.. McGurk, D.. Thomas, J. L.. Cox. A. L.. Elgel, C.C. and Castro. C. A. (2008). Mild traumatic brain injury inU.S. soldiers returning from Iraq. The New England Jour-nal of Medicine. 358(5), 453^63.

Litz, B.T. (2007). Research on the impact of military trauma:CurTent status and future directions. Military Psychology./9(3), 217-238.

Manderscheid. R. W. (2007). Helping veterans return: Com-munity, family, and Job. In Archives of Psychiatric Nurs-ing.2l(2). 122-124.

Meagher. I. (2(X)7). Moving a nation to care: Pas!-traumaticstress disorders and America's returning troops. NewYork: lG Publishing.

Ryan, M. A. K., Smith, T. C , Smith, B.. Amoroso. P.. Boyko,E. J.. Gray, G. C, et al. (2007). Millennium cohort:Enrollment begins a 21-year contribution to understand-ing the impact of military service. Journal of ClinicalEpidemiology. 60,181-191.

Rutólo, L. J. (1993). The effect of combat on the developingpersonality. Unpublished paper. U.S. Army War College,Carlisle Barracks, PA.

Shay, J. (1995). Achilles in Vietnam: Combat trauma and theundoing of character. New York: Simon and Schuster.

Shay, J. (2002). Odysseus in America: Combat trauma and thetrials of homecoming. New York: Scribner.

(References continued on page 18)

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Appendix

Criteria for Posttraumatic Stress Disorder from DSM-IV**

(Source: Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision.Copyright 2000 American Psychiatric Association)

Diagnostic criteria for 309.81 Posttraumatic Stress Disorder

A. The person has been exposed to a traumatic event in which both ofthe following were present:

1) the person experienced, witnessed, or was confronted with an event or events that involved actual orthreatened death or serious injury, or a threat to the physical integrity of self or others

2) the person's response involved intense fear, helplessness, or horror. Note: In children, this may be expressedinstead by disorganized or agitated behavior

B. The traumatic event is persistently reexperienced in one (or more) ofthe following ways:

1) recurrent and intrusive distressing recollections ofthe event, including images, thoughts, or perceptions.Note: In young children, repetitive play may occur in which themes or aspects ofthe trauma are expressed.

2) recurrent distressing dreams ofthe event. Note: In children, there may be frightening dreams withoutrecognizable content.

3) acting or feeling as if the traumatic event were recurring (includes a sense of reliving the experience, illusions,hallucinations, and dissociative flashback episodes, including those that occur on awakening or whenintoxicated). Note: In young children, trauma-specific reenactment may occur.

4) intense psychological distress at exposure to internal or external cues that symbolize or resemble an aspect ofthe traumatic event

5) physiological reactivity on exposure to internal or external cues that symbolize or resemble an aspect ofthetraumatic event

C. Persistent avoidance of stimuli associated with the trauma and numbing of general responsiveness (not presentbefore the trauma), as indicated by three (or more) ofthe following:

1) efforts to avoid thoughts, feelings, or conversations associated with the trauma2) efforts to avoid activities, places, or people that arouse recollections ofthe trauma3) inability to recall an important aspect ofthe trauma4) markedly diminished interest or participation in significant activities5) feeling of detachment or estrangement from others6) restricted range of affect (e.g., unable to have loving feelings)7) sense of a foreshortened future (e.g., does not expect to have a career, marriage, children, or a normal life

span)

D. Persistent svmptoms of increased arousal (not present before the trauma), as indicated by two (or more) ofthefollowing:

1) difficulty falling or staying asleep2) irritability or outbursts of anger3) difficulty concentrating4) hypervigilance5) exaggerated startle response

E. Duration ofthe disturbance (symptoms in Criteria B, C, and D) is more than 1 month.

F. The disturbance causes clinically significant distress or impairment in social, occupational, or other importantareas of functioning.

* * The criteria provided here are for informational purposes only. The diagnosis of PTSD should be made only inconsultation with a clinician who by special training is competent to diagnose this condition.

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Dr. Elkins. vice president for Extended Pro-grams and Regional Development at TennesseeTechnological University, has served as anexaminer for the Baldrige-based TennesseeQuality Award. She has co-authored papers inthe area of continuing higher education, quality,and student retention and presented at numerousconferences. Dr Bell, president of TennesseeTechnological Univ., has published ÍH'O books,numerous articles, cases and scholarly papers inthe fields of management, organizational design,computer science, and quality and productivitymanagement. He is currently on the board of theTennessee Center for Performance Excellence.Dr Reimann, a chemist by training, holds theM ay berry Chair of Excellence at TennesseeTechnological Univ. and is senior scientistemeritus at the National Institute of Standardsand Technology. He is a past director of theMalcolm Baldrige National Quality Award.

REFERENCESBaldrige National Quality Program. (2007). Criteria for per-

formance excellence IBrochure], Gaithersburg, MD. Re-trieved from http://www.quality.nist.gov/Criteria.html

Center for the Study of Rural America (2003). Annual Report.Federal Reserve Bank of Kansas City. KS.

Collins, J. (2001). Good to great. New York: HarperCollinsPublishers. Inc.

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county-by-county analysis. Results of the EducationalNeeds Index Project for the SREB States. Retrieved fromTennessee Higher Education Commission at http://www .state. tn. us/thec/

Eatherly, J., and Rawls, K. (2007). P-!6 council profile:TNCPE level I que.stionnaireTennesseeBoa.Tdof Regents.Tennessee Board of Regents. (Available from Jill Eatherly,1415 Murfreesboro Rd., Suite 324, Nashville, TN 37217-2833).

Keifer, M., and Rawls, K. (2007). Community profile: TNCPElevel I questionnaire for three-star communities. Tennes-see Department of Economic and Community Develop-ment.

Koch. S. E. ( 1999). Community development: A guídebookforrural leaders. Washington, D.C.: Foundation for RuralEducation and Development.

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Tennessee Center for Performance Excellence. (2(K)7). Crite-ria for performance excellence. Nashville. TN. Retrievedfrom http://www.tncpe.org

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Weiler, S. (2004, March). The main street economist com-mentary on the rural economy. Federal Re.serve Bank ofKansas City. Center for the Study of Rural America.Racing toward new frontiers: helping regions compete inthe global marketplace.

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Smith. T. C. (2007). PTSD: Prevalence, new onset, persis-tence, and resiliency in a large population-based militarycohort. Unpublished doctoral dissertation. University ofCalifornia, San Diego.

Turner. M. (2008, January 30). Making vets more comfortableon campus. National Public Radio's Morning Edition[Radio broadcast]. Washington D.C.: American Univer-sity Radio WAMU 88.5 FM.

Unidentified caller. (2008, January 29). Veterans mentalhealth care. The Diane Rehm Show [Radio broadcast].Washington D.C.: American University Radio WAMU88.5 FM.

U.S. Army (2006. November 17). Mental health advisoryteam (MHAT) IV Operation Iraqi Freedom 05-07 ßnal

report. Washington D.C.: Office of the Surgeon, Multina-tional Force-Iraq, and Office of the Surgeon General,United State.s Army Medica! Command.

U.S. Census Bureau (2006). R210I. Percent of the civilianpopulation 18 years and over who are veterans: 2006. http://factfinder.census.gov/servlet/GRTTable?_bm=:y&-geo_ id=01000US&-_box_head_nbr=R2101&ds_name=ACS_2006_EST_G00_&-redoLog=false&-for-mat =US-3O&-mt_name=ACS_2OO4_EST_ G00_R2101_US30&-CONTEXT=gn

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