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Survivors of Trauma: Combat-Related Stress

Combat-related experiences are among the most horrifying and threatening of all traumatic events. Unfortunately, family, friends, and even professional helpers often are unable to fully understand the impact these experiences have on a person’s ability to function in the civilian world. Evidence shows that military traumas often cause severe and, sometimes, long-lasting psychological problems in many survivors.

What Is Combat-Related Trauma?

Traumas in the military can occur in a variety of circumstances, at home and abroad. Severe injury, and sometimes loss of life, can occur during training as well as combat. As might be expected, the longest lasting effects seem to emerge from wartime experiences. Veterans of every war have seen death and destruction during combat. Often they are required to be on alert, ready at a moment’s notice, waiting for days or weeks at a time, for a confrontation to happen. Their lives are directly threatened. Sometimes soldiers witness the killing of civilians and the death of fellow soldiers, even friends. Soldiers are ordered to kill the enemy. Even individuals in supporting roles, such as medics, nurses, persons serving grave duty, transport pilots, and MPs, among others, are at risk to develop problems. Civilians, too, can be caught in the crossfire, captured, or become refugees who must flee their homes, thereby becoming survivors of war stress.

Research shows that a certain proportion of individuals will suffer psychologically after a war experience. The more loss of life, horror, or physical injury seen or experienced, the more likely the person is to have problems. As time goes on, many of these individuals will find that their distress becomes less severe. For some, however, the disturbance remains strong and continues to interfere with their functioning and enjoyment of life.

What Are the Problems?

Although a range of problems can result from war experience, the most common problems survivors exhibit are intrusive memories, nightmares, sleep difficulties, heightened anxiety and vigilance, excessive startle (for example, jumping at the sound of a car backfiring), feelings of depression, and avoidance of things that remind the survivor of the war. Survivors also report irritability, anger, and feelings of being numb inside. When these problems are severe, mental health professionals call them posttraumatic stress disorder (PTSD).

Related problems can be as disturbing as the PTSD itself. Guilty feelings about having survived when others did not is a common experience of war survivors. Feelings of unhappiness and isolation can become so severe that suicide is seriously contemplated or attempted. Frequently, combat survivors use alcohol or other drugs in an attempt to get temporary relief from their distress. Together these problems can have severely damaging effects upon the survivor, the survivor’s family and friends, and job functioning. At the very least, the emotional distance and difficulty communicating can isolate the combat survivor from essential social contact. At its worst, the anger and impulsivity can lead to divorce, violence, verbal abuse, difficulties at work, and legal problems.

As many as 15% of Vietnam War veterans suffer from PTSD 30 or more years after their combat experience. According to some reports, an even greater percentage of World War II and Korean War veterans suffer from PTSD. Repatriated prisoners of war from the Korean conflict appear to have PTSD well in excess of 50%. Refugees from countries around the world, especially torture survivors and political prisoners, have shown high rates of PTSD-related difficulties. Veterans of the Gulf War suffer from PTSD, and the estimated risk for PTSD from service in the Iraq war is 18%.

Can Therapy Help?

Yes. Professional psychotherapy has been shown to be a significant help in the healing process for a wide range of symptoms that combat survivors can have. Although treatments differ for PTSD and combat-related stress, most clinicians and researchers agree that three steps to recovery are critical:

1. Developing a trusting relationship with a professional;

2. Telling one’s experience of trauma in the context of therapy; and

3. Developing or reviving one’s connection to family, friends, and community.

Most therapists agree that telling one’s story is central to feeling more in control. Also, the earlier the survivor obtains help, the more likely serious problems can be averted or prevented. Survivors are caught in a vicious cycle in which the memories and thoughts surrounding the memories keep coming back. Because the survivor reacts to these with anxiety and, sometimes, horror, he or she pulls away from the thoughts and memories, thereby reinforcing the anxiety and pain by immediately removing the thoughts and memories. The survivor never really comes to understand or process the memory, because it is always cut off before the person can make sense of it. In cognitive behavior therapy, the individual is assisted in processing the memory in ways that make it tolerable. The memory will never be a happy one, but it will no longer cause intense physiological distress.

Cognitive behavior therapists try to make the symptoms understandable to the survivor. In the context of a caring and trusted relationship with the survivor, the therapist helps the survivor reduce the symptoms by using techniques like relaxation. Therapists also try to take away the power of the memories or flashbacks by having the survivor relive and re-experience them. Sometimes the therapist will explore the survivor’s thoughts about the traumatic incident and, where appropriate, help the survivor understand when his or her beliefs about the incident are contrary to reality. Cognitive behavior therapists often teach additional skills, depending upon client needs, such as how to grieve, how to manage anger and rage, and how to socialize again. The ultimate goal is to reintegrate the survivor into his or her social structure.

In addition, cognitive behavior therapy includes specific skills training in areas selected to match the client’s needs. Anger management, problem solving, communication, assertiveness, and learning how to grieve are especially relevant to the combat survivor. These interventions help provide the foundation for reclaiming a loving connection to one’s community.

At times, medication is appropriate and helpful to combat survivors, especially those who suffer from severe depression. Antidepressants have been shown to be useful adjuncts to psychotherapy for combat-related PTSD. Anti-anxiety drugs are sometimes used but may carry the potential for addiction or dependence. Brief hospitalization may be considered in cases where the client is in danger of hurting himself or others.

Regardless of the particular treatment method, behavior therapists are attentive to the unique and varied needs of each combat survivor. In practice, the therapist must be willing to hear the traumatic story unfold as well as help the client manage the overwhelming emotions that accompany remembering past trauma. Finally, it is likely that the practitioner who adopts a multimethod approach will be best able to respond to the numerous needs of these survivors.

What is Cognitive Behavior Therapy?

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