Kelly Phipps, Ph.D.: "They don't need to hear 'Get over it.' We
should be saying, 'Get through it.'"
Credit: Aaron Levin
Soldiers returning from war in Iraq and Afghanistan often bear the psychic
scars of battle, but a closer understanding of their experience can help
reintegrate them into civilian life and avoid overpathologizing their
conditions, said two clinicians who have studied and treated posttraumatic
stress disorder (PTSD).
"We need to move from an obsession with PTSD to focus on combat
stress, injury prevention, and management," said Charles Figley, Ph.D.,
a professor at Florida State University's College of Social Work and director
of the university's Traumatology Institute and Psychosocial Stress Research
Figley spoke at a conference on mental health needs of returning soldiers
and their families in Columbia, Mo., sponsored by the International Medical
and Educational Trust at the University of Missouri.
Calling wartime trauma "combat stress injury" would place it in
the same light as other war wounds: preventable and manageable, if sometimes
irreversible, said Figley.
However, prevention and management must begin early, he said. Troops should
acknowledge the likelihood and fact of injury beginning in boot camp. Before
they are wounded, troops believe they are invulnerable and even after physical
injury, often deny they are hurt. To a soldier, injury, whether physical or
psychological, is a source of embarrassment. They have to move from denial to
needing to talk about their injuries, said Figley.
The actual experience of combat turns on its head the conventional idea of
stress, which would suggest that stress was highest during actual combat, said
Figley, a Marine veteran of the Vietnam War.
However, he said, stress is higher before battle, but drops during the
fighting—when combatants are "in the groove"—and rises
again afterward, as soldiers come to grips with their experience. Combat
stress injury is some combination of postcombat trauma, fatigue, and grief,
compounded by feelings of guilt. Guilt can arise from having survived when
others may not and when soldiers ask themselves why they behaved as they did
in the midst of battle.
"This war is harder than Vietnam because they are all volunteers and
have high expectations for themselves," said Figley. "It is much
harder to forgive themselves for 'failing' in any way."
Often core beliefs—say, that the world is benevolent and meaningful
or that war objectives are noble—are damaged. Recovery means first
getting soldiers to talk, to hear themselves, and to reconstruct a new set of
beliefs about themselves, beliefs that allow for human weaknesses. They need
help to overcome their shame, self-ridicule, and self-blame, he said. That
requires a quality and continuity of care that are not always available, but
inevitably involve civilian mental health practitioners. Professional
organizations need to educate mental health personnel to mobilize gaps in
"The current paradigm is deficiency- and
psychopathology-oriented," he said.
This paradigm leads to either a wide-spread denial of symptoms by soldiers
or the overuse of medications. Finally, a flawed disability system only"
insults the soldier and discourages resiliency," he said.
Caring for these veterans means encouraging resiliency, said Kelly Phipps,
Ph.D., of the Harry S. Truman Memorial Veterans Hospital in Columbia, Mo., in
a separate talk at the conference. "Emphasize what we can do, not what
we can't do."
Experiencing combat may lead to a number of psychiatric diagnoses, although
the majority of veterans are not diagnosed with a mental disorder.
DSM-IV lists six PTSD criteria: a stressor, a time delay (at least
one month), functional impairment or distress, and three symptoms:
reexperiencing, avoidance, and psychological arousal. Even the most mundane
experiences at home can recreate a sense of danger that recalls the war
Phipps related stories about the "Wal-Mart effect." When
soldiers just back from patrolling the streets of Baghdad go into a big store,
the large, open space and crowds of people can make them feel unprotected and
Of course, hypervigilance isn't pathological in Iraq or Afghanistan, but it
becomes so upon returning home. Soldiers may be trained to face the emotional
stress of the battlefield, but not to readjust to life back in the United
States, she said.
(The U.S. Army's Battlemind program does address the stresses of
functioning in war zones and ways to re-adapt when soldiers return home after
deployment. Other elements of Battlemind, which was developed by the Walter
Reed Army Institute of Research, make it clear that life-saving behavior on
the battlefield can be dysfunctional at home or among family and educate
spouses about the psychological effects they may see in their loved ones
during deployment or after they return.)
The three symptomatic clusters of DSM-IV
criteria—reexperiencing, arousal, avoidance—don't reveal the full
effect of trauma, said Phipps.
Intrusions—nightmares and flashbacks—are sensory experiences,
but the PTSD model doesn't include cognitions—the assumptions,
appraisals, thoughts, and beliefs that help people make sense of what they
experience, she said. Also, while psychological arousal typically involves
fear and anger, emotions like sadness, disgust—and most
importantly—guilt, play important roles, too.
But many of today's troops don't have time for a natural readjustment
process. Upon their return, they immediately try to assume old roles as
spouses or parents go back to civilian jobs. (Studies have shown that National
Guard and Reserve soldiers return to work within two weeks, on average, for
instance.) But such quick reimmersion into civilian life too often means
thrusting aside any real readjustment as veterans "don't have time to
deal with it."
That sets them up for avoidance, said Phipps. Avoidance to her means a
whole range of dysfunctional behaviors: aggression, self-harm, substance
abuse, social withdrawal, and others. Those lead to diagnosable Axis I or II
disorders, she said.
"Therefore, the number-one thing we can do to help vets is to prevent
avoidance," said Phipps, who admitted that she's not offering a magic
bullet. "They don't need to hear 'Get over it,'" she said."
We should be saying, 'Get through it.'"
There are a lot of different treatments that work, and it's not worth
arguing about what works best, she said. These include prolonged exposure to
stressors, cognitive therapy, psychopharmacology, and cognitive processing
therapy (CPT). The choice should be what works best for the individual. At
present, she is exploring CPT at her hospital. CPT has been tested in clinical
trials with victims of rape or childhood sexual abuse and with Vietnam
veterans, and she has found that it offers rapid gains to the patient. The VA
is about to roll out a CPT program nationally, she said.
Both speakers emphasized approaches reducing the stigma attached to the
mental effects of war on its participants.
"We need a paradigm shift from psychopathology to resilience and
recovery," concluded Figley. Or, as Phipps put it, "I would like
to take the 'D' out of PTSD."