Wednesday, January 17, 2007

Viewing Combat Stress Injuries as Opportunities
for Preventing PTSD:
Invitation to the
on February 16, 2007
Charles R. Figley, Ph.D

This is a call to arms! That was our attitude last year when we held the first National Symposium on Combat Stress Injuries. We organizers sensed that there was insufficient attention to those who “bore the battle.”[1] In particular most of the attention was on combat-related PTSD and what to do about it once these men and women returned from war. Far more needed to be done when they were IN the war. This article is part of a special publication of that will focus on the upcoming Symposium I will co-chair on February 16, 2007. I talk more about the Symposium later.

Combat Stress Injuries

I have been investigating the immediate and long-term psychosocial consequences of combat for the combatants since 1971. As one of the Symposium organizers I want to emphasize the distinction between the stress of combat, something every combatant experiences if they are alive, and combat stress injuries that most often lead to Post-traumatic Stress Disorder (PTSD).

No matter what you think of today’s wars being fought by the US military, these warfighters represent less that 1% of the US population.[2] They deserve our respect and our help. One way of helping is for the other 99% of the US to be more aware of what these men and women are going through and how best to help them during and following deployment. The 2nd National Symposium will increase awareness.

The concept of combat stress injuries[3] is an important distinction. Mental health diagnostic labels can harm both warfighters and the military units they serve within. Navy Captain Bill Nash, MD who is co-chair of the Symposium and co-editor of Combat Stress Injuries, makes the point in Chapter 3; that there are major problems associated with medicalizing and pathologizing operational stress problems. Stress injuries have been kept separate from the physical injuries or wounds. He points out that if given any label at all, they have been classified as having something benign like “battle fatigue,” “exhaustion,” or “combat stress reaction.” The avoidance of labeling and a focus on normalization have also long been central to civilian crisis management efforts. The Israeli Defense Force has always used Combat Stress Reaction (CSR), for example, which is discussed by Zahava Solomon in her new book by the same name.[4] But there are limitations for normalizing what might be acute dysfunction with long-term negative consequences unless the right action is taken, rather than simply returning the injured warfighters to battle or discharging them to fend for themselves as a civilian.

As with any injury, complications may set in. In the case of combat stress injuries, the complications may be a stress disorder, depression, substance abuse, family violence, homicide, and suicide. Further, Dr. Nash suggests that combat stress injuries can be divided into three categories depending upon the source of the stress: (1) stress fatigue, caused by the wear-and-tear of accumulated stress; (2) grief stress, caused by the loss of someone or something that is highly valued, and; (3) traumatic stress, caused by the impact of terror, horror, or helplessness. Each requires acute care as soon as possible. Navy Captain Nash will discuss the implications of these injuries at the upcoming National Symposium.

It may be surprising to some but the actual rate of combat stress injuries have actually declined over the years. Unpublished stress casualty rates for United States troops deployed to Iraq vary but have never exceeded 2% of all war theater soldiers and Marines deployed to Iraq and Afghanistan. However, this makes the assumption that there were no false negatives. In other words: Our current ability to accurately tell who is and who is not injured is very poor. These current wars, some would argue, are far more stressful than previous wars because of the sectarian violence, the complicated political context, numerous individual explosive devices; multiple tours with insufficient between deployment down time, and; the high percentage of troops from the National Guard and reserve forces.

Fortunately, most authorities agree that the Military is getting better at being able to anticipate and prevent combat stress injuries. This is due to better training, great reliance on chaplaincy and mental health services. They in turn are better trained thanks to the cumulative knowledge about the causes of such injuries and how best to respond to minimize damage.

Normal Stress versus Stress Injury

At the same time, because stress reactions are viewed by some as a “normal reaction” to being down range (the combat environment), differentiating what is normal and what is not, is a major challenge. Everyone experiences combat stress. Deciding who experiences a stress injury is tricky. But even if we are able to determine which is or is not a stress injury, there is considerable resistance to admitting injury among warfighters – physical or mental. A buddy or small unit leader may be the only ones who have witnessed the indicators of a combat injury and are in the best position to get help. Many are not trained to administer the appropriate interventions and those to whom they are referred have minimal training and resources.

Do you see why we need far more attention to this critical issue? We can’t help if we don’t know who needs it. All of the experts on combat stress and recovery agree that the earlier the detection and intervention the better. Why? Because low rates of combat stress injuries do not necessarily predict low rates of eventually diagnosed combat-related stress problems. The mental health problems experienced by Vietnam veterans after their war ended attest to the gap between identified battlefield stress casualties and the true extent of combat stress reactions actually generated in that conflict. A Walter Reed Army Hospital research team has found that 17% of heavily engaged Army and Marine “trigger pullers” admitted significant stress symptoms 3 to 6 months after returning from Afghanistan or Iraq. The team also reported, unfortunately, these those most affected were least likely to seek help. Why? They saw that the costs were too high. They were concerned about stigma and treatment effectiveness. Numerous government and journal reports confirm that there is a looming public health problem among these brave 1% who volunteered to serve in the military who “bore the battle.”

Personal Invitation to the 2nd National Symposium

This is where the National Symposium on Combat Stress Injuries comes in. The co-organizers have created a Symposium which offers serious and significant resources for understanding and helping combat veterans without a hint of politics or partisan rah-rah. The organizers are not pro-war but pro-warrior. We hope that the Symposium will be seen as one of the most inclusive and interdisciplinary gatherings of its kind. Innovation and thoughtful debates are welcome as we maintain a central focus on the welfare of the
warrior and warrior families.

Finally, I would like to personally invite everyone who reads this article to join us at the 2nd National Symposium, February 16th at Florida State University in Tallahassee, Florida. The purpose of the symposia series is to note and discuss new and important knowledge about how to understand, measure, prevent, and management combat stress injuries in order to avoid the long-lasting, negative consequences for the warfighters and their families. One major development since the first Symposium (held at the same venue, February 10, 2006) is the publication of the Combat Stress Injuries book. Through a special arrangement with the publisher (Routledge), the first 100 registrants for the Symposium will receive a copy of the book as part of their registration materials.

One of the co-sponsors of the Symposium is the Vietnam Veterans of North Florida, Inc. The VVNF is incorporated in the State of Florida and is a federally incorporated veteran’s non-profit organization (a 501.c19). The VVNF Color Guard raised the first flag over the Vietnam Veterans Memorial in Tallahassee, after touring with it all over the northern half of Florida to every county seat to display that first Flag prior to it being dedicated with the Monument. That operation was known as the Great Vietnam Veterans of Florida, State Coalition, Flag Drag. Other co-sponsors include the Collegiate Veterans Association and the National Veterans Foundation. We welcome co-sponsorships as a way of emphasizing importance of both the history of veterans’ causes and the importance of inclusiveness in unity of cause. If you are either unable to attend or to co-sponsor the Symposium, feel free to join the join the Combat Stress Forum to collaborate on research.

[1] `` let us strive on to finish the work we are in, to bind up the Nation's wounds, to care for him who shall have borne the battle and for his widow and his orphan ,'' Abraham Lincoln, Second Inaugural Address
[2] As of January 2005, there are some 250,000 military service personnel out of nearly 300,000,000 estimated population of the US.
[3] There is increasing reason to believe that overwhelming stress of combat can inflict literal, physical injuries to the neurobiology of warfighters and civilians. The term “injury” has significant advantages when communicating with warfighters about the nature of their reactions to severe stress and how best to care for them. Warriors understand that stress injuries, like sports injuries, may be unavoidable, at times—they are just part of the cost of doing what they do. And like sports injuries, most stress injuries heal up quickly, even without professional attention. But also like sports injuries, stress injuries are most likely to heal quickly and completely if warfighters monitor themselves for symptoms of injury, and take proper care of those injuries that are sustained.
[4] Dr. Solomon is a keynote speaker at the National Symposium.