(p. 166) Healing the Hidden Wounds of War: Treating the Combat Veteran with PTSD at Risk for Suicide
Although storytellers and writers going back to Homer described the profound psychological effects of war on those who fought, it was not until World War I that psychiatrists in Austria and Germany began to describe in detail the traumatic reactions to combat. They concluded that combat trauma involved a breaking through of the individual’s defense against stimuli (reitzschutz). “Traumatic neurosis” was the result of fright (schreck)—a condition occurring when one encountered a danger without being adequately prepared. The repetitive nightmares seen in the disorder were considered an attempt to be prepared after the fact, to dissipate by repetition the anxiety generated by the experience (Freud, Ferenczi, Abraham, Simmel, & Jones, 1921).
Abram Kardiner’s work with World War I veterans, and subsequent collaboration with John P. Spiegel, who worked with World War II veterans, clearly delineated the symptoms of posttraumatic stress disorder (PTSD; Kardiner & Spiegel, 1947). Although Kardiner acknowledged reitzschutz theory as a starting point for his own thinking, he incorporated traumatic stress into an adaptational frame of reference. Kardiner saw trauma as an alteration in the individual’s usual environment in which the adaptive maneuvers suitable to previous situations no longer sufficed. With the balance between the individual and his or her adaptive equipment broken, a new adaptation was not possible, and the individual accommodated his shrunken inner resources with the development of symptoms.
Kardiner described the features of what was then called traumatic war neurosis: fixation on the trauma, repetitive nightmares, irritability, exaggerated reactions to unexpected noise (startle reactions), proclivity to explosive aggressive behavior, and a contraction of the general level of functioning, including intellectual ability. He also saw loss of interest in activity as a result of the breakup of organized channels of action that were replaced by periodic outbursts of disorganized aggression. The internal conception of the self became altered, confidence was lost, the world was seen as a hostile place, and the patient lived in perpetual dread of being overwhelmed (Kardiner & Spiegel, 1947). The symptoms he described were subsequently categorized for use in a civilian population in the Diagnostic and Statistical Manual of Mental Disorders of the American Psychiatric Association that became the basis for the diagnosis of PTSD.
PTSD is a different disorder in a veteran population, and Department of Veterans Affairs (VA) researchers developed their own instrument to diagnose PTSD and to evaluate its severity. The most recent revision of the diagnostic criteria for PTSD (in the Diagnostic and Statistical Manual of Mental Disorders, fifth edition) places PTSD among the various “stress disorders,” which makes some sense but the DSM-5 diagnostic criteria do not fully describe the clinical phenonmenom of PTSD in combat veterans. VA researchers and clinicians, whether implicitly or explicitly, use their own conceptual model to assess and treat this disorder.
As early as the end of the nineteenth century, the effect of combat in contributing to suicide was recognized by the French sociologist Émile Durkheim, (p. 167) who reported that suicide rates among European military men were up to 10 times greater than those among male civilians of comparable age (Durkheim, 1951). Only after the war in Vietnam were systematic analyses undertaken in the United States that confirmed a higher rate of suicide among men who had served in the military than among other men of the same age (U.S. House of Representatives, Committee on Veteran Affairs, 1978; Centers for Disease Control and Prevention, 1987). Clinicians who worked closely with men who saw considerable combat in Vietnam noted that suicidal behavior was frequently a manifestation of what came to be known as PTSD (Jury, 1979; Kolb, 1986; Lipkin, Blank, Parson, & Smith, 1982; Stuen & Solberg, 1972). Vietnam veterans with PTSD have been shown to be four times more likely to die by suicide than veterans without PTSD (Bullman & Kang, 1996).
A seven-year research and treatment project begun in 1978 at a Veterans Administration medical center, consisting of combat veterans of the Vietnam War with PTSD who were at risk for suicide, laid the groundwork for the material in this chapter (Hendin & Haas 1984a, 1984b). Comparable research being done at the Michael DeBakey VA Medical Center in Houston, Texas, which focuses on veterans of the wars in Iraq and Afghanistan, is building on this work (Hendin, Al Jurdi, Houck, Hughes, Turner, 2010). This chapter is aimed at integrating this work to create a helpful guideline for the understanding and treatment of the combat veteran with PTSD at risk for suicide.
PTSD and the Risk for Suicide
The study of Vietnam combat veterans with PTSD provided insight into some of the factors associated with suicide among them. One-hundred combat veterans with PTSD completed a comprehensive questionnaire and five semistructured interviews, which we have described in detail elsewhere (Hendin & Haas, 1991). The interviews elicited additional information about the individual’s life before and after his service in Vietnam. None of the veterans had made a suicide attempt or been preoccupied with suicide prior to his combat experience.
Persistent severe guilt over combat experiences was found to be the major factor differentiating veterans who had attempted suicide and those who were seriously preoccupied with suicide from those veterans who were neither. Nineteen of the 100 combat veterans with PTSD had attempted suicide at least once since returning from Vietnam. Guilt related to combat actions was significantly marked in all 19 of the suicide attempters but in only 32 of the 66 nonsuicidal veterans (χ2 = 14.24, df = 1, p < 0.001). Fifteen, who were not suicidal, had been seriously preoccupied with suicide since they left the service. Guilt was also marked in 12 of these 15 veterans compared to the 66 nonsuicidal veterans (χ2 = 3.71, df = 1, p = 0.05).
Although anxiety, survivor guilt, and depression marked those at risk for suicide, combat guilt outperformed the other three predictors when all three were entered into a logistic regression simultaneously.
Although logistic regression analysis did not identify survivor guilt as a significant predictor of suicide attempts, additional one-way analysis provided some evidence of the importance of the concurrent presence of the two types of guilt. Forty of the 100 veterans studied, for example, showed both marked guilt about combat actions and marked survivor guilt. Among the group, 14 (35%) had made a suicide attempt. By contrast, none of the 30 veterans who showed neither marked combat guilt nor survivor guilt had attempted suicide (χ2 = 13.3, df = 1, p < .001). The findings suggest that the combination of these two types of guilt play a significant role in determining suicidal risk among patients.
Moreover, among the 17 veterans who had killed civilians while feeling out of control and felt guilty about such actions but were not suicidal, only 2 had survivor guilt. By contrast 9 of the 12 suicide attempters who had killed civilians while feeling out of control experienced survivor guilt in addition to guilt over their combat actions (χ2 = 12.21, df = 1, p < .001).
The combat experiences of the suicidal veterans were examined for possible determinants of their guilt. The chaotic nature of guerilla warfare in Vietnam, the uncertainty about who the enemy was, the emphasis on body counts, and the Viet Cong’s use of women, children, and the elderly as combatants contributed to combat actions about which veterans felt severe guilt.
The Viet Cong, for example, would strip American soldiers they had killed and hang their naked bodies from a tree with their genitals stuffed into their mouths. Such tactics, designed to frighten soldiers, (p. 168) also tended to infuriate them and contributed to atrocities on both sides.
Meaning of Combat
How each veteran experienced the combat events (i.e., the meaning of the combat experience to the veteran) was integral in determining the nature of the guilt and the risk for suicidal behavior. The term “meaning of combat” refers to the subjective, often unconscious perception of the traumatic event and includes the affective state of the veteran before the event took place, when it took place, and the affects experienced subsequently.
Repetitive nightmares and re-experiencing symptoms are cardinal symptoms of PTSD. Both are valuable tools in determining the meaning of the experience to the veteran. The following case example is illustrative (Hendin & Haas 1984a).
Throughout his tour Greg L. thought he would be killed in action. The thought was comforting to him because it would enable him to avoid having his friends, family, and fiancée discover that he had lost control of his anger and killed without reason in Vietnam. During the last two weeks of his tour, when he learned that he was not going to be assigned to any more combat missions, he tried to kill himself with an overdose of drugs.
He had been an artillery spotter in Vietnam. He was preoccupied with a memory of a friendly village that he and his sergeant had helped to destroy in a contest designed to see who could call in the best coordinates. Through his binoculars, Greg had watched with excitement as the shells landed. As the village was being destroyed he saw an old woman with betel nut stains on her teeth running in his direction. She was shaking her arms trying to get him to stop the shelling. As she ran toward him, she was killed by an artillery round.
After he returned to the United States, Greg was tormented by a painful recurring nightmare that expressed his intense guilt over the destruction of the village. In the dream he is captured by South Vietnamese villagers, strung on a pole like a pig carcass, and paraded around the village so that everyone can curse him, spit on him, hit him, and throw stones at him. The old woman with the betel nut-stained teeth is taunting him. The villagers hold him responsible for all the death and destruction in their village. He knows they are going to kill him.
Greg made a second suicide attempt during a re-experiencing event in which he thought he saw the villagers covered in blood. He cut his wrists and described feeling a sense of relief as the blood spurted out. Both the nightmare and the reliving experience express his sense of guilt and need for punishment.
The nightmares of most veterans with PTSD correspond closely with the combat experiences and the terror over being killed that they engender. Veterans who have severe guilt over their combat are more likely to experience nightmares that reflect guilt, are punitive in nature, and indicate risk for suicide. Greg’s experience of feeling out of control while in Vietnam was usual among the suicide attempters. Sixteen of the 19 (suicide attempters 82%) had felt out of control as a result of excessive fear or rage during periods of their tours of duty, including the situations in which their anger led to deaths about which they felt guilty (Hendin & Haas, 1991). Veterans like Greg, who feel out of control while in combat, and remained so in civilian life, are the most difficult to involve in treatment, so it was not surprising that Greg turned down the offer of short-term psychotherapy that was available to participants in the research project. During the course of study, three of the veterans who also felt out of control, and did not accept the offer of treatment, did kill themselves.
Although killing the enemy or being in danger of being killed increases the likelihood of being severely distressed by combat, the work described here suggests the importance of looking closely at perceptual and adaptive factors, rather than simply at objective aspects of the combat experience, in seeking to understand veterans’ combat experiences. How combat events and situations are perceived, integrated, and acted on bears a primary relationship to the aftereffects of combat on the veteran.
Recognizing the Veteran at Risk for Suicide
Treating the veteran at risk for suicide requires identifying correctly those veterans who are at risk. In a (p. 169) previous study with patients who were not veterans, detailed data was obtained from therapists of patients who committed suicide while in treatment with them. Written responses to questionnaires and subsequent personal interviews with the therapist were used to determine what patients were feeling and experiencing in their lives immediately before their suicides (Hendin, Maltsberger, Lipschitz, Haas & Kyle, 2001). The data was contrasted with data from the same therapists on comparably depressed patients in treatment with them who were not suicidal. We found that the suicides were preceded by a time-limited state of suicide crisis that was marked by three factors that usually occurred in combinations of two or three in a single patient: a precipitating event, behavioral changes, and intense affective states.
Intense affective states that were intolerable and uncontrollable proved to be the factor most related to suicide (Hendin, Maltsberger, & Szanto, 2007). The uncontrollable nature of the affects engendered fear on the part of the patients that they were fragmenting (i.e., “falling apart”). Nine affects were examined: anxiety, rage, desperation, abandonment, loneliness, hopelessness, self-hatred, guilt, and humiliation. A striking contrast was observed in the patients who went on to suicide and the comparably depressed patients who were not suicidal. Just before death the suicides averaged more than three times the number of intense affects than comparably depressed nonsuicidal patients. These differences remained when controlled for severity of depression, psychiatric disorders, and borderline personality disorders.
That work made it possible to develop the Affective States Questionnaire, which was tested prospectively and successfully for its ability to predict short-term risk for suicidal behavior (three months) among a population of 240 outpatient and inpatient veterans, not selected for the presence of PTSD or the risk for suicide. Recognizing the intense, overwhelming emotional states that leave patients feeling out of control in a crisis period immediately preceding their suicidal behavior is critical in this process (Hendin, Al Jurdi, Houck, Hughes & Turner, 2010).
Treating the Veteran with PTSD at Risk for Suicide
Earlier concepts of the unconscious that are outdated have been rejected by modern psychodynamics that has recognized its underlying, enduring contributions to our understanding and ability to treat mental illness and, in particular, the role of the unconscious in influencing behavior, the value of dreams, and the nature of the relationship with the therapist conducting the treatment. Even slight differences in the dream and the actual experience can be helpful in understanding the nature of the experience and making treatment possible. Tom B. is an example.
Troubled by violent impulses toward his family as well as suicidal thoughts, Tom’s entire postcombat life had been pervaded by PTSD. For years he had suppressed the symptoms with drugs, which he began using when he returned from Vietnam. He stopped, because he felt they were destroying his body, but he then became aware of his preoccupation with Vietnam and the disturbing nature of his nightmares. Tom had one recurrent nightmare that he said “scares the hell out of me. It’s so real but I don’t know if it actually happened.” In the dream he is carrying the dead body of a young woman and trying to bury it so no one can find it. Upon waking from this dream he would sense that he had some involvement in the girl’s death but would be unable to recall what it was. When asked if he had ever raped any Vietnamese women, Tom replied that he had not. When asked if he had ever witnessed a rape, he said that he had.
His squad had been assigned to secure the entrance to a tunnel complex while four men from another squad went underground to explore the tunnels. His squad was in radio contact with the other squad and learned that they had found a Viet Cong hospital base. A short while later Tom heard shouting and the sounds of grenades exploding. The four men came out of the tunnel dragging a French nurse who was bleeding from arm wounds. Each of the four raped the nurse while Tom’s squad watched. When the last man was finished he pulled out his knife and killed the woman. When this happened Tom and his squad departed; he never knew how the men disposed of the nurse’s body. He did know that when the four soldiers reported the incident they made no mention of taking anyone alive. Tom claimed to have had no particular reaction to the event. He admitted that he had been sexually excited while watching what had (p. 170) happened, but he had never connected the episode with his nightmare.
Tom was seen for several months of short-term psychotherapy during which time he was helped to explore and feel the emotions connected with his nightmare. Just as in the dream where he was carrying and trying to find a place to bury a woman’s dead body, he had tried for years to bury the entire experience. Although he had succeeded on a conscious level, the burden of guilt he was nonetheless carrying is evident in his dream. In therapy he was able to connect it with the rape and killing of the nurse he had witnessed, to recognize that he was a “participant” in her rape, and to experience the emotions connected with it. He stopped having the nightmares, became less angry with his family, no longer had thoughts of suicide, and remained so on follow-up a year later.
Tom had been treated with behavioral therapy and medication without any improvement before he was referred to the research and treatment program. His nightmare, however, had been treated only as a symptom to be suppressed with sleeping medication rather than an opening to unconscious feelings that were troubling him.
Tom is not likely to have had a successful therapy if he had not first stopped his substance abuse. Substance abuse and/or difficulty functioning—at work and in family and social relations—increase the risk for suicide (Hendin et al., 2010). For substance-abusing veterans with PTSD at risk for suicide, enrollment in a treatment program needs to be a requirement for participation in a psychodynamic treatment.
What Protects Some
Given the nature of combat in Vietnam, it is not difficult to understand the high incidence of PTSD among men who fought in that war. It is more difficult to attempt to explain what protected some who saw intense combat from developing the disorder. Since combat adaptation is one of the factors significantly correlated with PTSD and the form it takes, it was desirable to examine the experience and adaptation of veterans who experienced severe combat but who did not develop the disorder (Hendin & Pollinger Haas 1984a).
Although a large-scale survey (U.S. House of Representative, Committee on Veterans Affairs, 1978) had established that there are Vietnam combat veterans who did not appear to be suffering from posttraumatic stress, no detailed examination of their combat adaptation had been made. We undertook a pilot study of a representative group of 10 veterans, selecting them because, in spite of having had intense combat that included killing enemy soldiers and the possibility or likelihood of being killed, being wounded, or seeing comrades wounded or killed, these veterans did not develop PTSD. They appeared to be dealing with postwar civilian life without evidence of a stress disorder. Each participated in the study on a volunteer basis and completed the same five-session clinical evaluation that we gave to Vietnam veterans with PTSD but did not need the additional seven sessions that the other veterans did.
From comparison of the results of this analysis with data on the 100 veterans with PTSD whose study was completed, several key differences between the combat adaptations of the two groups were evident. Veterans in the group that did not develop PTSD regarded the ability to stay calm under pressure as a good soldier’s most important attribute. All seemed to see impulsiveness as a threat to individual and group survival. Consistent with the emphasis these men put on self-control for proper decision-making was their ability to tolerate better than most veterans the unstructured nature of the war. Among combat soldiers there was a widespread sense that the conflict was utterly meaningless and that they had no control over any of it, a sense that seems to have been expressed in the “don’t mean nothing” phrase frequently used by combat soldiers in Vietnam to describe whatever was going on. The combat veterans who did not develop PTSD were better able than most veterans to see the war in terms of the limited objectives of each day’s mission. The following case is illustrative.
Paul B., a 34-year-old. tall, thin veteran, had been married for 11 years and owned a garage in a small town in New York State. He had a calm, relaxed manner and related the events of his arduous combat tour in Vietnam as though these experiences were part of an unpleasant but distant past.
Paul had grown up with three siblings in a working-class family in the same town in which he currently (p. 171) lived. From his father, who was an auto mechanic, he learned how to repair cars, and after graduation from high school he obtained full-time employment in this field. He was involved in a steady relationship with a young woman when he was drafted.
During his first months in Vietnam, his company had a commanding officer whose poor judgment, Paul felt, resulted in several unnecessary deaths. Paul’s sense that he too would not survive was heightened when the company was overrun by enemy soldiers, and in a fierce battle two-thirds of the 100-man company was killed.
Shortly after the episode, while on a search-and-destroy mission, Paul’s squad set up an ambush and 12 enemy soldiers walked into it. After the unit’s machine gun jammed, Paul grabbed grenades from the other men and circled the area in which the enemy was trapped, throwing grenades. He described this as the only time during his tour in which he felt angry, something he was unable to explain. Although he later received a Bronze Star for that action, he felt the way he had exposed himself to danger had been reckless. Two days later, in a similar ambush, he fired at the enemy but was careful not to expose himself in the same way.
Paul received a second Bronze Star in another close encounter with the enemy, in which he was fired on from only a few feet away after he had thrown a grenade into a North Vietnamese bunker. Although his hand was nicked by a bullet, he got away by crawling on his knees; he “had the shakes” for several days after the incident. In time, however, he said his fear in combat became less as he became more experienced.
One of his recollections of Vietnam was an action in which women and children were unnecessarily killed. His company had been told that anyone they saw in a particular area would be unfriendly. When they came on a group of people walking through a field, the lead platoon fired and only later realized that they had killed women and children. Paul’s platoon was in the rear that day and he considered it fortunate that he was not directly involved in the killing.
Paul shared the commonly held view that the war was pointless, saying he even felt bad about having to kill enemy soldiers, since “You killed people in one place and then had to do it again in the same place or someplace nearby. It wasn’t that you took territory and then moved on to the next area.” He considered, however, that much of what happened to anyone in Vietnam was a function of leadership. He had become a squad leader, and part of being a good leader, he felt, was explaining to the men what their particular mission was for each day. He thought it was demoralizing to be “slogging away feeling it don’t mean nothing.” He was proud that none of the men in the squad he led were killed during his tour.
When Paul returned from Vietnam he went back to work as a mechanic and resumed the relationship with his girlfriend, whom he married one year later. He described his wife as a thoughtful, caring person, and from the beginning he was happy in his marriage. After several years he bought his own garage, which he ran with the assistance of one of his brothers. His father also helped out a few hours a day. His parents were in good health and lived in the same town as he did, and he had remained close to them as well as to his siblings.
Although Paul never developed PTSD, he had had some residua of his combat experience. There had been times, soon after he returned from Vietnam, when he would drive around alone late at night thinking of the things he had experienced during the war. In the early years he had occasional dreams about his company being overrun and being fired at from close range by North Vietnamese soldiers, but these had completely stopped. Rather than feeling emotionally numb or socially withdrawn since coming home from Vietnam, he said he had generally felt more self-confident and more talkative, adding that his wife had also noticed this difference.
Paul had occasional startle reactions but did not suffer from insomnia, had experienced no difficulties with his concentration, and had no combat-related guilt. Neither did he report any significant episodes of anxiety, explosiveness, or depression. Indeed, there was no evidence that his combat experiences had had a lasting negative effect on his life.
In looking for the explanation of how Paul and others emerged basically intact from the war, one is struck by the number of fortuitous occurrences that seemed to have protected them both physically and psychologically. Paul could easily have been severely wounded or killed by the enemy soldier who had fired at him from close range. Despite his skill as a squad leader, chance determined that no one in the squad was killed, particularly in the operation in which his company was decimated. Paul could also have been in the platoon that mistakenly killed women and children. In either case he would have had to deal with (p. 172) the increased potential for resulting distress. Although luck often played a role in the combat histories of these veterans, each of them brought to combat a way of thinking, feeling, and acting that appeared to constitute a more systematic form of protection.
Sometimes the exercise of judgment required these men to take responsibility for countermanding orders from their superior officers. One veteran described an incident in which his squad was out on ambush and about 60 Viet Cong came by. Realizing that the Claymore mines they had set would have killed only about half of the enemy, which would have left his squad at the mercy of another 30 soldiers, he went against standing orders and directed his men not to activate the mines. After the Viet Cong passed by, he called in to request artillery fire in the direction they were heading. Another veteran told of a comparable incident in which his squad had been instructed to make a body count at night in an unsafe area. Considering it foolish to go out before daybreak, he lied and told his officer that the count had been completed. In no case did such disobedience appear to express defiance or a need simply to challenge authority. Rather, these men trusted their own values and judgment and made choices that were consistent with both effectiveness and survival.
Acceptance of fear in themselves and others was also characteristic of this group. Paul had “the shakes” for a few days after he was fired at from point-blank range. He accepted his fear as an appropriate reaction to what had happened, expected that it would subside, and was not ashamed of what he felt. He shared with other veterans in the group the feeling that experience increased the ability to distinguish dangerous versus safe situations so he was not in constant state of anxiety. As a group, they also accepted signs of fear in their comrades.
Many combat soldiers report excitement and a sense of triumph during engagements in which they killed the enemy. Some were stimulated by rage or hatred of the enemy to develop a lust for killing and for more engagement. None of the veterans who did not develop PTSD reported triumphal killing; they tended to regard killing enemy soldiers as a disturbing but unfortunate necessity. Although rage occasionally led some to perform heroic acts, sustained rage was more likely to lead to behavior that was self-destructive both to the individual and his comrades. As a group, the veterans who did not develop PTSD believed that rage clouded judgment and led to dangerous mistakes. One veteran in this group told of a man in his squad who spent hours sharpening his long hunting knife and talking about how he was planning to sneak up on unsuspecting Viet Cong and slit their throats. Feeling this man was a danger to the unit, the veteran had arranged with his squad leader to have him transferred out.
Consistent with their maintaining a high degree of emotional and intellectual control during combat and not being stimulated by violence was the absence of actions over which they felt or needed to deny guilt. None of these veterans had engaged in nonmilitary killings of civilians, prisoners, or other Americans; in sexual abuse; or in mutilation of enemy dead. Since such actions—and consequent guilt—were seen in a significant proportion of the veterans who developed PTSD, their absence among the non-PTSD group was striking.
The veterans in this group did not dehumanize the enemy in their attitudes, speech, or behavior even when others in their units were doing so. Several in this group related incidents that suggested not only the absence of rage and dehumanization but also a strong sense of humanity and compassion. One man, for example, had been with another soldier when they saw at some distance people who appeared to be part of a Viet Cong hospital unit carrying litters. Although they felt they would have been able to kill at least some of the group from their concealed position behind the tree line, they decided not to fire.
The cluster of traits seen among veterans who did not develop PTSD—calmness under pressure, intellectual control, ability to create structure, acceptance of their own and others’ emotions and limitations, and lack of excessively violent or guilt-arousing behavior—constituted an adaptation that was uniquely suitable for the preservation of emotional stability in situations that were often unstructured and unstable. These veterans experienced combat in Vietnam as a dangerous challenge to be met effectively while attempting to stay alive. They did not perceive combat as a test of their own worth as men, as an opportunity to express anger or vengeance, or as a situation in which they were powerless victims.
Certainly, the combat adaptations of these men reflected their prewar character structure and emotional stability. At the same time, the fact that under the intense pressure of combat other men whose prewar personalities seemed stable and intact evidenced destructive behavior argues against viewing combat functioning simply as an expression of pre-existing strengths or vulnerabilities. In addition, (p. 173) although most of the men in this group came from supportive families who gave them a sound beginning in life and played a significant role in their postwar readjustment, three were virtually forced to raise themselves. Interestingly, all three were functioning well at the time they were drafted. It appeared throughout our work that how well a veteran was functioning immediately prior to going to the service, although not infallible, was a good measure of how he would function in combat.
Large-scale controlled studies of what protects soldiers exposed to combat from subsequently developing PTSD are indicated. The anonymous surveys that have been done focus more generally on the degree of combat exposure (Sareen et al., 2012) and multiple deployments (Kuehn, 2010) as contributing to “mental disorders.” An exception is a study that looked at the interaction between combat exposure and unit cohesion in predicting suicidal ideation among postdeployment soldiers. The results indicated that soldiers who had greater combat exposure but also had high levels of unit cohesion had lower levels of suicide-related ideation. Those who had higher levels of combat exposure and lower unit cohesion were most at risk for suicide-related ideation (Mitchell, Gallaway, Millikan, & Bell, 2012). This finding is consistent with what was reported by the veterans who did not develop PTSD as well as established experience that social support protects against suicidal behavior.
Although killing the enemy or being in danger of being killed increases the likelihood of being severely distressed by combat, the work described here suggests the importance of looking closely at perceptual and adaptive factors rather than simply at objective aspects of the combat experience in seeking to understand veterans’ combat experiences. How combat events and situations are perceived, integrated, and acted on bears a primary relationship to the aftereffects of combat on the veteran.
Treating Combat Veterans of the Wars in Iraq and Afghanistan with PTSD and at Risk for Suicide
There is a significant difference in the population that served in Vietnam War and the wars in Iraq and Afghanistan. The veterans of the wars in Vietnam were drafted, their average age was 20, and they rarely had histories of depression or suicidal behavior prior to the war. Veterans of the wars in Iraq and Afghanistan were volunteers, their average age was 28, and they frequently had histories of precombat mental illness including suicidal behavior (LeardMann et al., 2013). In cases we have seen, their enlistment was often a way of trying to provide structure to their lives, which left them vulnerable when it did not work.
The combat experiences of Vietnam veterans also differed significantly from the experiences of veterans of the wars in Iraq and Afghanistan, where improvised explosive devices were a principal cause of traumatic brain injury (TBI). Veterans with TBI are also more likely to die by suicide than those without TBI (Brenner, Ignacio, & Blow, 2011). Guilt over the killing of noncombatants is less likely to play a role in their suicide than it is with Vietnam veterans who experienced the chaotic combat firefights and sustained guerilla warfare of the war in Vietnam. Iraq veterans with experiences roughly comparable to those of Vietnam veterans usually fought in battles, like those in Fallujah, Ramadi, and Nasiriya, in which sustained firefights (over months and years) in cities and within buildings led to actions in which women and children were killed and situations where soldiers felt guilt afterward. Multiple deployments, however, that characterized the wars in Iraq and Afghanistan have been shown to contribute to veterans’ physical and mental health problems (Kline et al., 2010) and may also contribute to suicide independent of combat exposure.
Many therapists who are treating combat veterans of the wars in Iraq with PTSD are fearful about treating suicidal patients. The primary goal of the psychodynamic therapy is to treat veterans with PTSD who are at risk for suicide and are disturbed (guilty) over their behavior in combat. This involves understanding the experience and relieving the guilt associated with it. Yet anxiety often causes therapists to avoid raising or discussing the veteran’s combat experience. They fear what the veteran’s reaction will be, including the possibility of being blamed if the veteran becomes suicidal. These therapists need to be helped to overcome this anxiety to a degree that they cannot only ask the right questions but are also comfortable in doing so. Otherwise the inquiry is apt to result in the reaction they fear. At first they may need to assume a calm they do not yet feel.
Another problem for therapists stems from the fact that the nightmares of veterans who are guilty over their behavior in combat need to be elicited and understood to fully understand their guilt, and (p. 174) most therapists are not used to utilizing dreams in psychotherapy. Here the problem is eased by the fact that the combat nightmares of veterans are not that disguised—are less symbolic—and not difficult to understand by therapists with no prior experience in dealing with dreams.
Therapy often flounders when the veteran has shared at least some of the disturbing specifics of his combat tour. The therapist may inadvertently respond with revulsion, anger, or fear. More frequently, the therapist’s discomfort is communicated in the need to convey understanding before he or she is in a position to do so. When this happens, it is the therapist’s discomfort rather than what is specifically said that the veteran responds to, only increasing his distress.
It is better for the therapist to accept and respect the veteran’s guilt, to acknowledge the pain of the experience, to indicate that he has already punished himself enough, and to work to help him not let the event continue to define his life. Telling a veteran who feels appropriately guilty about his behavior in combat “These things happen in war” is counterproductive.
Another principle of psychodynamic therapy applicable in treating nonveterans as well as veterans, and of use in eliciting the combat experiences of veterans, is not to accept all statements made by patients at face value.
One patient seen in Boston in his initial session after saying hello to his therapist said, “I want you to know I am not a Boston Red Sox fan.” Most people probably know that Boston’s passion and devotion to the Red Sox in good times and bad are unmatched in baseball. That he was letting his therapist know that he was a contrarian became more evident in his therapy.
Another patient dreamed of saving his child from drowning. He interprets the dream as saving his child from danger, saying he worries that something bad will happen to her. In his sessions he had been expressing his anger with his child for the strain he felt at the child’s impact on his relationship with his wife. He is the author of the dream, and he has put the child in a life-threatening situation. In his dream he is expressing his anger and denying it at the same time. Nor does the dream mean he actually wants the child to die. The discussion of the dream made it possible to work with him to resolve the difficulties he was having in being a father.
Knowledge of this principle will help therapists deal with one of the most common problems in eliciting combat experiences of veterans. Veterans will often relate a somewhat troublesome experience to avoid discussing a far more troublesome experience. That is either a plea bargain and/or a test of what the therapist’s response will be. A common one used by veterans of the war in Iraq is of shooting and killing drivers who do not stop at check points—learning later from others in the car that the driver could not see or read the check point sign.
An example is Jack B, a veteran of the war in Iraq. He related an incident in which he shot and killed an old man who did not stop at a check point sign. From other passengers in the car he learned that the man had not seen the sign. The veteran described this as his most disturbing experience. It was pointed out to him that while he had killed someone he had not needed to kill, he had done so inadvertently while following military procedures. He was asked if he was more disturbed by killing that he had done when he was not following military procedures. He revealed that he had killed a captured prisoner of war whom he was guarding.
Therapists learn more when they ask about the veteran’s nightmares. A veteran of the Iraq war had killed a captured prisoner but said it did not bother him because “everybody did it.” He had a recurrent nightmare, however, in which he is captured and killed by Iraqi soldiers. When this contradiction was pointed out, it enabled the therapist to help him deal with his guilt.
Another factor increasing the need for punishment and complicating treatment occurs when veterans who have lost emotional control in combat remain out of control in civilian life (Hendin & Pollinger Haas, 1991). This condition can be the result of neurochemical or physical changes in the brain or epigenetic changes caused by the stress of combat. To what degree psychological treatments can result in beneficial epigenetic changes has yet to be determined. For now, mood-stabilizing medication may be needed to make psychological treatment possible.
The relationship between the veteran and the therapist plays a key role in the healing process of veterans who have PTSD, and this is particularly true for those who have severe combat guilt and are at risk of suicide. The veteran needs to forgive himself for the behavior that triggered his guilt and the (p. 175) self-punitive way it is expressed. When the veteran feels relief at having shared the experience with a trusted therapist, the therapist is in a position to give him “permission” to forgive himself, to resolve problems that have developed in the course of the illness, and to go on with his life. Guilt is an emotion that can be harmful when it is self-punitive, but it can be a powerful force for changing the direction of one’s life.
Both the VA and the Defense Department have expressed concerns that treatments currently in use are not slowing the rate of suicide among the active military and combat veterans with PTSD (Frances, 2013; Shinseki, 2010). Cognitive Behavioral Therapy (CBT), and Dialectical Behavioral Therapy (DBT) are the treatments of choice of the VA for veterans with PTSD. Although they have shown the ability to reduce some PTSD symptoms, they have not yet shown the ability to prevent suicidal behavior among this population. Prolonged Exposure Therapy is being used to treat civilian and military personnel with PTSD, but has not been tested for its ability to prevent suicidal behavior among military personnel or veterans.
Several factors are likely to explain why the current treatments used by the military and the VA are so far not proving effective in preventing suicide among those with PTSD who are at risk. Not determining the often unconscious, subjective, emotional meaning of the traumatic combat experiences of the veterans is only part of the problem. Of equal importance is not adequately recognizing the ways in which the relationship between the veteran and the therapist can be used to enable the veteran to give up self-destructive behavior. The belief that human behavior can be understood without reference to unconscious processes runs counter to advances in neuroscience that see the mind as operating largely by unconscious processes taking place in the brain (Kandel, 2013).
A less constrictive approach has been incorporated in short-term psychodynamic therapy that also utilizes techniques of interpersonal therapy, dialectical behavioral therapy, and cognitive behavioral therapy. There is reason to believe that these therapies would be more successful in treating veterans with PTSD at risk for suicide if they incorporated some simple psychodynamic principles.
No psychological approach is the whole answer to treating veterans with PTSD who are at risk for suicide. Many who are severely depressed need medication in order to be amenable to any psychotherapy. A large number of those most at risk, who were emotionally out of control during the combat experience over which they feel guilty, are continuing to suffer from that same loss of control in civilian life. Mood stabilizers may need to be employed to make psychotherapy with them possible.
A unique short-term (12 sessions) treatment approach has been presented that targets the guilt from combat-related experiences that underlies suicidal behavior in combat veterans with PTSD who are most at risk. The risk is intensified if they also have survivor guilt. It has shown promise of being able to prevent suicidal behavior with veterans of the wars in Vietnam and Iraq and Afghanistan who have experienced chaotic firefights resulting in out-of-control behavior that aroused guilt. The section describing the adaptation of veterans who were exposed to severely traumatic combat experiences but did not develop PTSD provides a perspective on what appears to help some to avoid developing the disorder.
The treatment’s essential components define the meaning of combat to the veteran with the aid of the veteran’s nightmares and address relief of guilt. The next step is to test the treatment with a control group large enough to determine its effectiveness. We are hopeful that practitioners of other therapies will incorporate psychodynamics into their practice and research. Their doing so might increase the possibility that more veterans will receive the treatment they need.
The quality of care provided by the VA has improved dramatically in the past 30 years, but the VA is underfunded and understaffed in relation to the increased need for its services. The VA and the Department of Defense have been criticized for failing to implement properly and evaluate treatments employed with combat veterans at risk for suicide; they are now working together to change that. (p. 176) Reducing suicide among military personnel and veterans is a challenge that needs to be met. Although the large majority of patients are not suicidal, those who are suffering from guilt over combat experiences are an important subgroup responsible for a disproportionate number of suicides.
Mental health professionals in the VA are ready to learn, develop, and test treatment approaches to PTSD that will work. The public and Congress are currently in a mood to support their treatment. That support tends to weaken as the years after veterans return go by. There will need to be an ongoing effort to sustain public awareness of the problem so that Congress provides adequate funding. The need for help does not fade, nor does the danger of suicide abate, in a disorder that is rightly described as “posttraumatic.”
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