Unique Considerations in Unique Considerations in the Treatment of the Treatment of

Operation Enduring Operation Enduring Freedom/Operation Iraqi Freedom/Operation Iraqi Freedom/Operation New Freedom/Operation New Dawn (OEF/OIF/OND) Dawn (OEF/OIF/OND)

Service MembersService Members

The Nature of Current CombatThe Nature of Current Combat

Traditional elements of war:◦Firefights◦Observing injury and death◦Feelings of horror and helplessness

Traditional elements of war (con’t):Traditional elements of war (con’t):

• Boredom

“In combat, there’s two things…bored out of your mind or scared out of your mind…and some of us like scared to death because it makes the time go faster”

Traditional elements of war (con’t):Traditional elements of war (con’t):

Long work hours ◦Not uncommon for soldiers to work

13-hour shifts for 2 to 3 weeks at a time ◦During sustained operations,

combat soldiers often get less than 4 hours of sleep per night

Issues specific to the current conflicts:Issues specific to the current conflicts:• Sandstorms – Iraq averages 4 to 6” of rain/year, wind gusts can

reach 50 mph– Sand covers homes, clogs equipment, causes breathing

ailments

Issues specific to the current conflicts:Issues specific to the current conflicts:

Heat◦Average

summer temperature is 120 degrees F

◦Temperatures up to 152 degrees F have been recorded

Issues specific to the current conflicts:Issues specific to the current conflicts:

Insurgency warfare◦Unlike traditional warfare, insurgents

mix into the populace, making it unclear who is friend and who is foe.

““You don’t You don’t know who know who to shoot to shoot until they until they start start shooting at shooting at you”you”

Issues specific to the current Issues specific to the current conflicts:conflicts:Ambiguity

surrounding the rules of engagement◦Female suicide

bombers◦Checkpoints in

which shoot/no shoot decisions must be made in seconds

Issues specific to the current conflicts:Issues specific to the current conflicts:Insurgency warfare◦Research has found that ambiguity and the

need to restrain force can result in feelings of fear, frustration, anger, and resentment2

There is no front line -Attacks can happen anywhere

Mosul mess hall: Dec. 21, 2004, after a large explosion that left 22 dead Associated Press, Aug. 19, 2005

Issues specific to the current conflicts:Issues specific to the current conflicts:

Improvised Explosive Devices (IEDs)

“I have come to hate garbage in

a whole new way…”

Issues specific to the current conflicts:Issues specific to the current conflicts:

Urban warfare◦Complex battle

space◦Buildings conceal enemies and channel soldiers’ movement◦Decentralized

Troops

Ready access to e-mail and phone contact Ready access to e-mail and phone contact with partners and family memberswith partners and family members

◦Allows for immediate access to issues at home (finances, parenting, etc.)

◦A study by the Army War College indicates that this heightened

contact with family lessens soldiers’ focus on combat3

Homemade warzone videos

are common online

(“the first YouTube war”)4

Who is serving in OEF/OIF?Who is serving in OEF/OIF?National Guard and Reserves

represent about 40% of those serving◦Train 1 weekend per month and 2 weeks

per year◦Need to put civilian careers on hold

DOD reports that 41% of Reservists earn less while deployed than in their civilian jobs

Older recruitment age ◦Limit raised from 34 to 39 years old

No Women in Combat??No Women in Combat??Increasing numbers of women serving ◦Women are officially prohibited from

serving in direct combat, but reports show that large numbers of women are participating in combat

operations◦Women have received Army Commendation Medals, Purple Hearts, and Bronze Stars

86% Know someone who was 86% Know someone who was seriously injured or killed.seriously injured or killed.

77% Have shot at or directed 77% Have shot at or directed fire at the enemyfire at the enemy

68% Have seen dead or seriously injured

Americans.

Reintegrating Into Civilian LifeReintegrating Into Civilian Life

Coming home to….Coming home to….Strained economy making it hard to find

jobsFamily/marital issues – families cannot

relateFinancial issues leading to stressHomelessness for manyLack of knowledge about their benefitsNational Guard have little support

compared to Active Duty working daily in military jobs

Legal ProblemsLegal Problems

Driving while impaired, aggressive driving, Motor Vehicular Accidents

Domestic violence & Child AbuseEmotional crisis Drug & alcohol related incidentsPrecipice of committing suicide or

worst case scenario = completion

Common Issues for Post-Common Issues for Post-Deployment Combat Veterans (CV)Deployment Combat Veterans (CV)

Traumatic Brain InjuryPost Traumatic Stress Symptoms Alcohol and Drug AbuseMilitary Sexual TraumaDepression Suicidal and Homicidal Ideation Physical Exposures

Causes of TBICauses of TBI Head sustains blunt trauma or is violently shaken, (ex. MVA,

blast or explosion), a concussion or closed head injury can result.

Sound waves that travel from explosions can damage can effect soft tissue (brain, eyes) even up to 500 feet away.

Multiple deployments can lead to multiple concussions which may have more serious problems- 3X Greater after 1st TBI

Improvised Explosive Devices IEDs, and Rocket Propelled Grenades RPGs, often result in devastating injuries such as amputations, sensory loss and brain damage.

There is currently no cap/limit on re-deployments, so the likelihood of further trauma is increased with multiple deployments.

TBI SymptomsTBI SymptomsMemory Issues – Short-term/AmnesiaImpulsivityPoor Judgment - Irrational thinkingDifficulty UnderstandingDepression and Mood SwingsHeadaches Hearing Loss and TinnitusLack of physical coordination

Trauma SymptomsTrauma Symptoms

Difficulty sleeping, recurring nightmares Intrusive ThoughtsHyper-vigilance, feeling on guard, and

scoping the environmentStartle reactionAnger, aggressionWithdrawal, isolationTrying to avoid thoughts or reminders of

the traumatic event

What Are the TriggersWhat Are the TriggersSudden Loud Noises – Fireworks!!Crowds (depends on individual deployments)Traffic, man holes, culverts, roadblocksTrash on side of the Road“Stupid people,” especially at workIneffective ProcessesMid/Eastern dress, language, buildings, Not being PREPARED- creates tension in

family

Identifying TriggersIdentifying TriggersAsk the Question, “What’s different now?”

or what seems to set you off?This will be individual for each person,

based on their particular , with commonalities

Give them HOPE and sense of CONTROL. Push them as soldiers to “take on the mission of recovery.”

SM are task oriented and trained to complete missions (tasks). Use treatment plan as an “operational order.”

Trauma Effects the BrainTrauma Effects the BrainSurvival Instinct of Fight/Flight/Freeze.

Adrenaline can be addicting-risky behaviorsLimbic center (emotional-no sense of time)

control reactions, NOT the frontal lobe (rational/logical).

Cannot separate the past dangers from present due to learned responses

Hyper arousal causes anxiety, insomnia, Family, friends do not have war experience

(and SM does not want them to know) so they will not react/prepare the same ways

How to Treat TriggersHow to Treat TriggersProvide insight into the Life/Death reactions

that no longer apply in country, i.e. trafficHonor the “Learned Response” – This

helped the SM survive WAR and served them well

Provide education to SM and family on Fight/Flight, Adrenaline Reactions, and PTSD symptoms in a recovery format

Use Cognitive Restructuring to identify that these triggers no longer represent danger

Dealing with AvoidanceDealing with Avoidance

Avoidance is most common way of dealing with triggers that cause anxiety

Continued avoidance sustains the triggerOverexposure to triggers may exacerbate

the symptoms, nightmares, intrusive thoughts

Teach SUDS scale 1-10 to SM and encourage them to approach anxiety to a 5-6 level

Encourage them to retreat when at over 6

Issues to Address In Treatment Issues to Address In Treatment

1. Defining Reintegration issues and PTSD symptoms

2. Recovery model3. Anger Management 4. Cognitive Restructuring – A-B-Cs5. Guilt and Forgiveness6. Family Issues – Impact of symptoms

Recovery ConceptsRecovery Concepts

IndependenceEmpowermentSatisfying RelationshipsQuality of lifeMeaningful Activity

Take home points…Take home points…The soldiers we are currently treating

are different than those we’ve treated in the past for several reasons

These differences have implications for treatment

We have a professional and ethical duty to familiarize ourselves with the cultures of those whom we treat

OEF/OIF/OND CONTACTSOEF/OIF/OND CONTACTSChristopher.Wilkes@va.govShreveport – 318 990-4978Laura.Campbell3@va.gov Shreveport – 318 990-5012

ReferencesReferences1. La Bash, H. A. J., Vogt, D. S., King, L.A., & King, D. W. (2009). Deployment

stressors of the Iraq War: Insights from the mainstream media. Journal of Interpersonal Violence, 24, 231-258.

2. Litz, B.T. (1996). The psychological demands of peacekeeping for military personnel. NCP Clinical Quarterly, 6, 1-8.

3. Lubold, G. (2006). Family contact cuts combat focus, study finds. Air Force Times, 66, 36.

4. Anden-Papadopoulos, K. (2009). US soldiers imaging the Iraq War on YouTube. Popular Communications, 7, 17-18.

5. Seal, K. H., Metzler, T. J., Gima, K. S., Bertenthal, D., Maguen, S., & Marmar, C. R. (2009). Trends and risk factors for mental health diagnoses among Iraq and Afghanistan veterans using Department of Veterans Affairs health care, 2002-2008. American Journal of Public Health, 99, 1651-1658.

6. www.va.gov – Search any Veteran’s topic

7. www.ptsd.va.gov

8. Militaryonesource.com

9. http://www.samhsa.gov/ for publications on trauma