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|Rules of Engagement - Page 2|
By nature and training, most combat veterans are action-oriented, and since action helps reduce their anxiety by increasing their sense of empowerment, capitalize on it. During your first contact, whether or not they make an appointment, give them something to do--a couple of websites to look at or books to check out. Tell them about www.afterdeployment.org, www.iava.org, www.helmetstohardhats.org, and http:// sgtbrandi.com. The Department of the Army's mental-resiliency programs (http://www.army.mil/csf and www.battlemind.org) are other good resources, as is the Defense Centers of Excellence's website (http://www.realwarriors.net). Make a point of familiarizing yourself with these and other websites before recommending them.
Once combat veterans are actually in your office, plan for the following points during your time with them:
Expect angry reactions. Intense anger is a predictable side effect of having been "down range." It's often the reason combat veterans seek care. There are two key reasons for this. First, of the three self-preserving responses hardwired into the human brain (fight, flight, freeze), combat training is all about habituating "fight" as the automatic response to any threat, and eliminating the "flight" and "freeze" responses. Once that's ingrained, every perceived threat, regardless of context, is likely to be met with the anger that encourages the fight response—which can create a host of problems in civilian life. Second, combat veterans whose job in theater had anything to do with being in a convoy or on a patrol have almost certainly experienced the destructiveness of roadside bombs (improvised explosive devices, IEDs), detonated by an unseen enemy who has no uniform, no distinguishing demographics, and no rules, and, therefore, offers no focus for a natural drive for revenge. In a cauldron of war-induced stress, feelings of injustice, helplessness, and a profound desire to retaliate come to a rapid boil.
In assessing these clients, help them identify the ways in which their anger is compromising them in civilian life or detracting from their quality of life (frightening their children, hurting their spouse, alienating friends, decreasing commanders' trust, affecting their job security), not protecting them as it did in combat.
This is an opportunity to help them regain emotional control. After explaining how breathing can help slow down both the bodily reactions that come with rage and the impulsive thinking that can escalate emotions, teach them a breathing technique known as "tactical breathing": breathe in slowly for 4 counts, hold for 2, out for 4, hold for 2, repeat. To mitigate their belief that this might make them look silly or dumb (a threat to their warrior image), you might explain that this breathing technique is what snipers use to calm their nerves and steady their hands. This kind of military-oriented information will assure them that you're invested in what's most important to them—maintaining their identity as warriors. Encourage them to use self-regulating techniques like tactical breathing, counting to three, and walking away anytime, including during therapy.
Since their physiological arousal state remains highly activated long after deployment (if they've been deployed multiple times, they'll consciously keep it intact until discharged out of the military), you can expect anger to be a staple of therapy. They're likely to list people, experiences, and issues that are angering them. Interspersing meaningful psychoeducation will help them focus on changing the things they can control and not merely venting about the things they can't control.
Focus on emotional pain. Assess how much emotional pain your military clients are experiencing at the beginning of the session, perhaps by using a 0-10 scale. It helps them acknowledge how much pain they're really in—something they avoid doing. At the end of the session, ask that they again attach a numerical value to their emotional pain level. This helps them acknowledge that they can feel better, instilling hope, and that the things you did together in the session worked—which has the additional bonus of increasing their trust in you and in the therapeutic process.
Conduct a sleep assessment. Because sleep is critical to coping, be sure to assess their sleep quality and quantity, and then focus on getting that in line. If it's way off, find out how much caffeine and alcohol they're consuming. According to the DSM IV-TR, caffeine intoxication (one of four psychiatric conditions related specifically to caffeine) occurs when 250 mg of caffeine is ingested in a short time. Consuming a couple of energy drinks can easily surpass that amount. Many young people have no idea they're consuming high quantities of caffeine, or that it could be the source of their anxiety, nightmares, sleeplessness, irritability, and shakiness. Teach them about the effects of caffeine, and then suggest a slow decrease to wean them from it, to see whether their symptoms lessen.
Ask what losses they suffered. Unrecognized, and hence unresolved, grief is a huge component of soldiers' pain. Emphasize the importance of "honoring the fallen and their sacrifices"—that every fallen soldier deserves to be wept over and missed by his brothers and sisters in arms. Explain that their grief may be part of what's making them feel so bad so much of the time.
Never ask a combat veteran, "Did you kill anyone?" This is an incredibly intimate question, the answer to which a civilian will never truly understand, because the context of war is unique. Every single combat veteran to whom I've spoken has been asked this question at some point, and they've all told me it either angered or upset them. If they offer the information, recognize the sacredness of the trust they're sharing, but don't press them for details.
Depathologize their feelings, experiences, and thoughts. This can be one of the most powerful interventions in your arsenal. I've seen incredible improvements in soldiers who were tormenting themselves over their belief that they were weak. The phrase "You're having a normal reaction to an abnormal experience" may sound canned, but these men and women still appreciate hearing it. They want to be reassured that they aren't "crazy." We just need to make sure, as Navy psychiatrist Bill Nash likes to point out, that in normalizing their reactions, we don't unintentionally communicate that they don't need treatment and care. A serious burn on your hand might be a "normal reaction to an abnormal experience," but that doesn't mean it isn't an injury needing competent intervention and attention.