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by Morgan T. Sammons, Ph.D.

I’m frequently asked by colleagues back in the states about how one provides psychological services in a combat/operational environment. Although we aboard Camp Fallujah are within the confines of a relatively large, well protected forward operating base, the front lines, such as they are in this conflict of insurgency and urban warfare, are never far away. Psychotherapy is conducted to the frequent accompaniment of outgoing artillery fire (incoming artillery fire is fortunately far rarer). In vivo exposure to potentially traumatizing events is a reality in this situation, where combat stress services are provided a few steps away from our surgical trauma bays in a ramshackle building requisitioned from Saddam’s army in 2003. Psychological services, like all medical services here, are provided by US Navy personnel, who as a part of the Navy-Marine Corps team provide all medical support to Marine Corps Warfighters. At any one time, approximately five Navy psychologists and five Navy psychiatrists are deployed in support of Marine and Navy personnel in Iraq and Kuwait, in addition to a number of psychiatric technicians. Our sister services also deploy significant numbers of mental health professionals in support of Army and Air Force troops.

I hope in this short letter to provide a brief description of how a psychologist- and his patients- fare in this environment. First, it’s important to note that the vast majority of the individuals stationed here will never seek out services for combat stress. All warfighters are changed by the experience of combat. Few are truly psychologically wounded by it, and fewer still to the point that they seek or require professional services. Most of the patients I see do not have diagnoses of Post-Traumatic Stress Disorder (PTSD) or related conditions; the modal diagnosis I encounter is likely to be an adjustment disorder or partner relational problem. Acute stress disorder is also not uncommon, as are insomnia and mild depression. However, a small but significant portion of my caseload is made up of Marines, Sailors, and soldiers who experience diagnosable symptoms of PTSD. I’ll share my thoughts about these patients in particular.

One thing I have realized in treating acute and post-traumatic stress disorder in combatants here in Fallujah is how much mythology has sprung up around PTSD. PTSD has developed a reputation like AIDS - dreaded, lifelong, with a universally poor outcome, and a disorder that only highly trained specialists can treat (often in some abstruse technique, like EMDR). This, however, is the point of view of the provider, not of the patient. I believe that we as professionals have gotten into this predicament because our conceptualizations of PTSD have led us down a path that results in over-pathologizing responses to traumatic stress and grief.

Sometimes our misunderstandings of PTSD reach the point of absurdity. Not too long ago, one recently-minted psychologist advised me that he had been taught that he couldn’t treat PTSD in theatre because his patients “were at risk of being re-traumatized.” This was a well-meaning and intelligent psychologist, but one who had been fundamentally miseducated about how to approach and manage PTSD. These misconceptions, I believe, are far more likely to result in permanent disability than early and direct interventions. Treated early and well, PTSD and related disorders are completely recoverable problems. But in order to treat PTSD in combatants, it is vital to understand not only the context in which the trauma occurs, but the culture and training of warfighters.

I treat a great deal of acute and chronic stress in theatre, using a basic cognitive framework that relies heavily on reducing affective response to distressing recollections and re-interpreting emotional and physical reactions to traumatic recollections. I combine this with a phenomenological/existential approach. I find that this approach is easily accepted by patients and assists them in integrating traumatic experiences into their lives.

If intrusive recollections, re-experiencing, and nightmares are the initial target symptoms, the first step I take is to get the patient to understand that he/she is trying to strike a bargain that can’t be struck - trying to redo (or more commonly, undo) the past. Understandably, the patient wants anything other than to live with the memory of horrific events. But live with them they must. Forgetting is not only an impossibility, but the attempt to forget or suppress is exactly what causes memories and overwhelming emotions to intrude unpredictably. Understanding this is the first step. Once the patient stops attempting to forget or remake the past, the intrusive recollections get better.

The second step is to lessen the emotional effect of these events. This is somewhat more difficult but in my experience can nearly always be accomplished. Cognitive reframing and correction of cognitive errors or distorted thinking is essential. My patients, almost all Marines, often express a complex survivor guilt via a belief that they could have taken some step to avoid the tragic outcome - that they, somehow, were responsible for the loss. In part, this is a reflection of the culture of honor with which these Marines are imbued, a culture that emphasizes integrity, self-responsibility, and placing the well-being of others over one’s own.

Combatants are trained to respond reflexively in the face of chaotic, evolving situations. They are trained to take total responsibility for any situation. Their first responsibility is to their mission and to their fellow combatants. An unfortunately common corollary to this training is that when something goes awry, the combatant will take responsibility for that as well. The loss of a colleague then becomes misattributed as an abdication of responsibility. This misattribution of responsibility is a frequent, almost universal, belief among combatants. This belief is almost always a distortion of reality. Almost exclusively, these Marines or soldiers were performing their job expertly and simply were involved in situations that were out of their control. This is extraordinarily difficult to accept for a well-trained combatant in whom a sense of expertise, control, and responsibility for others is deeply ingrained.

Grief therapy is a vital component of treating PTSD. Marines and other combatants form extraordinarily deep and complex bonds with team members. They have, therefore, always lost someone to whom they feel profoundly connected. They may have trouble articulating the intensity of the emotional connections that they have formed, but such bonds are generally present and are generally the driver of unresolved grief. Psychologists who do not have experience with the military or the culture of warfighters may have difficulty in understanding the centrality of these bonds to the type of PTSD responses these Marines express.

Loss begets anger, and it’s important to focus on this as well. Ray Novaco1 has done some seminal work in understanding the role of anger in the perpetuation of symptoms of PTSD. His insights are an important component of my therapy. There is often much anger at the loss of others or at the loss of personal integrity. Most importantly, there is often anger directed towards the demands of learning to deal with a new life - a life the patient neither asked for nor anticipated, and for the most part, doesn’t think is fair for someone in their early twenties to have to handle.
But with time and understanding comes acceptance. Those Marines who overcome these problems realize they have changed in unanticipated ways. Their experiences have reshaped their essential world-view. They may need assistance in understanding that this separates them from their civilian peers and may affect their re-integration into the college environment or the civilian workforce. Those who succeed mature rapidly - often far beyond their years. They accept that their lives will never again be as carefree. At the same time they also understand that their lives are not tragically ruined, but fundamentally reshaped - different, a little darker, but in equal parts richer than before.

1 Some good references for Dr. Novaco’s work in this area are:
Forbes, D., Hawthorne, G., Elliott, P., McHugh, T., Biddle, D., Creamer, M., & Novaco, R. W. (2004). A concise measure of anger in combat-related posttraumatic stress disorder. Journal of Traumatic Stress, 17, 249-256.
Novaco, R. W., & Chemtob, C. M. (2002). Anger and combat-related posttraumatic stress disorder. Journal of Traumatic Stress, 15,123-132.
Chemtob, C. M., Novaco, R. W., Hamada, R. S., & Gross, D.M. (1997). Cognitive-behavioral treatment for severe anger in posttraumatic stress disorder. Journal of Consulting and Clinical Psychology, 65, 184-189.

Morgan T. Sammons, Ph.D. was deployed to Iraq in September 2006 and returned to the US in March 2007. He is a Captain in the US Navy and Specialty Leader to the Navy’s Surgeon General for the US Navy’s approximately 120 uniformed clinical psychologists. He serves as Director for Clinical Support at the US Navy Bureau of Medicine and Surgery, and is one of the first prescribing psychologists in the Navy. Dr. Sammons is currently President/Chair of the National Register of Health Service Providers in Psychology.