Returning From the War Zone: A Guide for Military Personnel
By: the National Center for PTSD
ON BEHALF OF A GRATEFUL NATION WELCOME HOME!
This pamphlet is provided to assist military service membersand veterans, like you, with your return from the war zone. The days and weeks after your return from overseas duty will be a transition. During this time, service members often describe a range of emotions from excitement and relief, to stress, tension or concern. All of these emotions are a normal part of ahealthy transition from a war zone back home. You may also feel distant, uninterested, or be overly critical and impatient with others. These types of behaviors and feelings are normal combat stress reactions. This pamphlet, describes these normal reactions and how normal reactions can become problematic. You will learn about ways to cope with the return home, and if problems arise, ways to find assistance.
Healthy adjustment in the days and weeks following homecoming includes taking time to become reacquainted with family and friends.Talk and listen to family and friends in order to re-establish trust, intimacy and openness. This guide contains information that will allow you to better communicate with these important people.
This pamphlet was created to assist active duty and veteran military service members to positively cope with their adjustment during their transition back to civilian life. Because many service members will face redeployment back to overseas duty, it is especially important to address these transition difficulties during your time home. This guide also describes warzone experiences and reactions that may cause difficulties during your homecoming experience. Some service members have real difficulties and strugglewith their transitions back home. This pamphlet helps service members identify when combat stress reactions become a problem. Information is provided about ways to obtain assistance to positively cope with combat stress reactions.
EXPERIENCES IN THEWAR ZONE
During your deployment, you may have taken part in missions and operations that exposed you and your military unit or company to stressful or life threatening experiences. You may have been shot at, seen the death or injury of civilian and enemy combatants, or even witnessed the death or injury of other American personnel or people you knew. You or members of your unit orcompany may have been injured as a result of bombings, blasts, weapons or accidents. And, all of these experiences and others occurred in a hot, dry desert environment without any of the normal comforts of home.
WHAT IS A COMBAT STRESS REACTION?
Service members respond to traumatic situations in differentways. Some report feeling upset or “keyed up”. You may continue to think about events that occurred in combat, sometimes even acting as if you are back in a combat situation. These “combat stress reactions” (also called acute stress reactions) can last for days or weeks and are a normal reaction to combat experiences. Most service members who experience combat stress reactions will recover. Others, however, continue to struggle with the memories of their combat experiences and their reactions to it. You may begin to have problems in your relationships with family or friends, or troubles at work or with finances. Your sleep may be very disrupted. If you continue to experience these reactions and if it begins to cause you problems, you should seek help to learn how to cope. If you do not get treatment early your condition may turn into a prolonged combat stress reaction, also known as posttraumatic stress disorderor PTSD.
WHAT ARE THE SYMPTOMS OF PTSD?
You may have heard of PTSD, in relation to combat experiences or traumatic situations, but have questions about what it means exactly. Basically, PTSD is a set of reactions that can be normal immediately following a traumatic event such as combat, but when these reactions continue long after the combat or traumatic event has finished, it can become PTSD. PTSD varies widely in how severe it can be, from mild and short lasting to severe and chronic. These reactions can cause problems in getting along with family and friends, functioning on the job or at school, or adjusting to the transition back to civilian life.
There are three primary types of reactions or “symptoms” that make up PTSD. Remember, immediately following a traumatic experience, symptoms are commonly experienced by most people. If these symptoms persist months after the event, they may indicate more serious conditions.
1. RE-EXPERIENCING. After returning from combat, you may continue to think about things that happened in the war zone. You may have nightmares about events that you have witnessed or actual combat situations. At times, you may feel as though you are actually back in the war zone. Some report that upsetting images of the warzone can flash into their minds making it difficult to think or concentrate.Sometimes, these images are “triggered” by reminders, such as sights or soundsor smells that remind you of your combat experience.
2. AVOIDING REMINDERS AND NUMBING OF EMOTIONS. It seems normal to not want to think about distressing thoughts and to avoid upsetting reminders. However, individuals with combat stress reactions or PTSD often go to great lengths to prevent memories or discussions about their past experiences. You may avoid any reminders of the experience. You may withdraw emotionally or physically from family and friends. You may even become angry when asked to talk about your feelings or behavior.You may use alcohol, drugs, or prescription medications to avoid thinking or feeling.
3. AROUSAL. Besides re-experiencing and avoidance, you may have difficulty letting your“guard down.” You may have excessive concerns about your safety or the safety of a loved one. You may feel jumpy or easily startled. You might find yourself closely examining people or places to look for signs of danger or attack. Feeling keyed up can also make it harder to sleep and concentrate and you may become irritable.
Although most veterans do not develop PTSD, a sizeable minority will have PTSD for some period of their life. Preliminary findings suggest rates of PTSD will be at least 18% for Iraq veterans and 11% for Afghanistan veterans. PTSD is treatable. Acting early can prevent PTSD from becoming worse and causing problems in your career and relationships. Read on, to see what types of treatments are available.
HOW OFTEN IS PTSD DIAGNOSED IN VETERANS?
Among American Vietnam theater veterans 31% of the men and 27% of the women have had PTSD in their lifetime. Preliminary findings suggest that PTSD will be present in at least 18% of those serving in Iraq and 11% of those serving in Afghanistan. PTSD has been observed in all veteran populations that have been studied,i ncluding World War II, Korean conflict, Vietnam, Persian Gulf, Operation Enduring Freedom and Operation Iraqi Freedom veterans. It also has been found in United Nations peacekeeping forces deployed to other war zones around the world. PTSD is not only a problem for veterans, however. It occurs both in adults and children whohave been exposed to extremely stressful situations (such as assault, rape, disasters or serious accidents), men and women, Western and non-Westerncultural groups, and at all socioeconomic levels. A national study of American civilians conducted in 2005 estimated that 7% of people have had PTSD in their lifetime.
WHAT CAUSES COMBAT STRESS REACTIONS OR PTSD?
Mental health professionals do not know why some people have PTSD reactions to traumatic situations and other people don’t, but we do know that it does NOT say anything about the strength or character of the person suffering. Again, there is no relationship between how strong a person is and these symptoms; many people who are brave or strong end up with PTSD symptoms after experiencing trauma.
PTSD is not a result of something you want or choose. In fact, we know that most people would not choose to have PTSD. Life factors that are related to PTSD include: greater exposure to life threatening situations, experiencing traumatic events in the past, and not having supportive people in your life. Remember, combat stress reactions are simply reactions that you sometimes experience after life-threatening situations and are things you can often deal with given help.
OTHER COMMON REACTIONS
DEPRESSION. Depression involves feeling down or sad more days than not, and losing interest in hobbies or activities that used to be enjoyable or fun. You may feel low in energy and be overly tired. Depression also involves a feeling of hopelessness or despair, the feeling that things are never going to get better. Depression may be especially likely when you have had personal losses connected with deployment such as the death of close friends. Because of this, it is important for you to get help for depression if you, or others notice that you seem to be feeling down most of the time or less interested in things you used to enjoy.
SUICIDAL THOUGHTS. War experiences and combat stress reactions, especially personal loss, can lead a depressed person to think about hurting or killing themselves. Suicide is a permanent solution to a temporary problem. Thoughts about hurting or killing yourself indicate that you need assistance now. Contact the National Suicide Prevention Lifeline www.suicidepreventionlifeline.org for more information or dial 1-800-273-TALK (8255). In the case of an emergency, call 911.
ANGER OR AGGRESSIVE BEHAVIOR. Anger and irritability, symptoms of combat stress reactions and PTSD, are often related to loss of control or fear; if you are physically tense you tend to be angry as well. A typical example is over-reacting with anger to a slight provocation. Frustration over the inability to control PTSD symptoms(feeling that PTSD symptoms "run my life") and thinking about things that happened at the time of trauma (the unfairness of the situation) can also lead to anger. You may be especially over-protective of kids, or have angry reactions to normal child behaviors. These reactions may actually be your own fears about possible dangers the children could be exposed to. Anger can lead to a slew of problems, such as poor thinking and decision-making, ruined relationships, dismissal from jobs, legal and financial problems, incarceration, and health problems.
Although anger is a natural and healthy emotion, intense feelings of anger and aggressive behavior can cause marital, relationship, and family problems, job problems, and loss of friendships. Because angry feelings keep people away, they also stop you from having positive connections and getting help. During this transition, it may be important to learn how to cope with anger so that your anger doesn't lead to trouble. Anger that is expressed in helpful ways is healthy anger. The energy from anger can be channeled in healthy ways to help us reach goals, work harder, and solve problems in healthy ways.
If anger or aggressive behavior is related to threatened or actual violence, it is especially important to seek care from professional counselors (chaplains, behavioral health, primary care, nursing, family assistance program) to address the anger and combat stress reactions.
ALCOHOL AND/OR DRUG ABUSE. “Self-medicating” by drinking or abusing drugs is a common way many cope with upsetting traumatic stress reactions. This is often related to other readjustment concerns, as you try to deal with the difficult thoughts, feelings, and memories related to your war zone experiences. You may be using drugs or alcohol to numb yourself. When you want to avoid the memories or feelings associated with combat, alcohol or drugs may seem to offer a quick solution, but they actually lead to more problems. If you notice that you a rebeginning to lose control of drinking or drug use, it is important to get appropriate care.
SELF-BLAME, GUILT, AND SHAME. Sometimes service members, in trying to make sense of their war experiences, take too much responsibility for bad things that happened. As you try to make meaning of what happened, what you did or did not do, or for surviving when others didn’t (sometimes referred to as survivor guilt), experiencing guilt and self-blame is common. Military personnel, like you who have been faced with moral dilemmas or been through difficult combat situations, may even feel as if you have committed a moral or religious transgression, even if you were following orders. Cognitive restructuring is a technique that can help you evaluate the accuracy of your thinking and may help with symptoms of guilt and self-blame.
WAYS THESE REACTIONS MAY INTERFERE WITH YOUR LIFE
EFFECTS ON YOUR FAMILY LIFE
Getting into arguments and fights with family members and other people, often for minor reasons, can happen because of the angry or aggressive feelings that are common after a trauma. In addition to having more family conflict, those who return home from a war zone often feel disconnected or detached from others. Sometimes this has to do with your not feeling able to tell other family members about what happened, not wanting to intrude on them by speaking about the realities of the war zone, or just thinking that no one will be able to understand. Sometimes this is related to your having difficulty in feeling or expressing positive feelings. Sometimes feelings of wanting to be alone or needing to avoid family gatherings can make you become isolated from your family, with a loss of support, understanding, and intimacy.
Because the symptoms of PTSD change how you feel and act, traumatic experiences that happened to you can affect everyone else in the family. Family members react to the fact that their loved one has gone througha trauma. At the same time, trauma symptoms can make you difficult to get along with or cause you to withdraw from the rest of the family. It can be very hurtful and confusing for everyone in the family when these changes occur.
Effects of PTSD on the Family
- Vietnam veterans with PTSD are between three and six times more likely to divorce than Vietnam veterans without PTSD.
- Veterans diagnosed with PTSD, compared to those without PTSD, are more likely to be violent with partners and children, with rates as high as 63% for some type of physical violence in the past year.
- Partners of Vietnam veterans with PTSD reported markedly reduced satisfaction in their lives and greater demoralization compared to partners of Vietnam veterans not diagnosed with PTSD.
Many individuals who return home from a war zone will have difficulty reconnecting or maintaining close relationships, especially at first. PTSD symptoms can make things even worse. If you notice problems with your relationships, it can be helpful to find out ways to improve how you are all communicating. Problems with family relationships or relationships with other people should not be overlooked. Initial difficulties can turn into marital separation and divorce, family violence, and caregiver burden. Communication is essential to working through these problems. You may want to consider talking to a counselor for support and assistance.
EFFECTS ON WORK FUNCTIONING
Adjusting back to life at work after experiencing a trauma or being in a war zone can be a very difficult experience. For example, going back to work is made harder by changes that have happened on the job during your deployment. Following the exhilaration of deployment, you may find you lack interest in your job. You might have had to quit your job before deployment. You might be returning to get your first civilian job and have difficulty finding a job or a career to get started in. Some of the symptoms of PTSD, such as feeling irritable or “on edge” or having a hard time sleeping or relating to people, make going back to work seem very difficult or even an impossible undertaking. This may be made worse by your worries that an employeror future employer might not want to work with somebody who is dealing with symptoms of PTSD or other combat stress reactions.
EFFECTS ON OTHER FUNCTIONING
There are many other aspects of your life that may be influenced by your experience in the war. There may be financial issues that may be adding to stress at work or home, or to the need to find a job. Sleep is often disrupted. Getting a full night of sleep is important to maintaining a healthy and happy life. All of these reactions and difficulties are common for people who experience PTSD or combat related stress reactions. It is important to be able to recognize these difficulties, and get treatment in order to prevent them from becoming larger problems in your life.
WHAT YOU CAN DO TO HELP YOURSELF
Most combat stress reactions go away over time. Only a minority of military personnel will have reactions that continue and develop into PTSD. Taking action and getting early treatment for your concerns can help prevent your reactions from growing into problems.
Educate yourself on the normal reactions to traumatic events and the facts about PTSD.
Find ways of improving your relationships and how you communicate, find and practice ways of properly coping or make connections with others who experience similar problems. There are many services available to help you, even before problems occur.
DON’T ALLOW STIGMA TO GET IN YOUR WAY
A study of soldiers returning from Iraq found that only 40% of service members experiencing war related stress reactions said they were interested in receiving help. In many cases this was due to concerns about what others would think, and how it would influence their military career.
Seeking assistance for these ‘invisible injuries of war’ is a sign of strength. 19,000 Afghan/Iraqi War Veterans have already sought help from the VA Readjustment Counseling Services (Al Batres, BBC News). Veterans who have had counseling report that getting help early was key in feeling good again. Getting help allowed things to get back to normal in their careers and on the home front.
We understand your concerns about seeking help, but encourage you to find the strength to do so. Do not allow career concerns or fear of stigma to prevent you from taking action to help you and those who care about you. There are VA Medical Clinics, Vet Centers,and many other avenues to assist you with recovering and finding solutions to problems.
TREATMENT FOR PTSD
The good news is that there are effective treatments for PTSD and the other problems mentioned above. Treatment for PTSD is really very practical and involves common sense steps. You have regular conversations witha trained counselor, in order to think about your situation and how you want to change it. You learn more about what PTSD is and how it’s affecting you. You work with counselors and other veterans to get support while you make gradual changes that are important to you. Sometimes, medications may also be beneficial.
Many veterans receive treatment for PTSD in Veterans Affairs (VA) PTSD treatment programs and Readjustment Counseling Service Vet Centers. Others get help in general mental health clinics within VA. In the usual typeof outpatient treatment you would come into a clinic for individual appointments and perhaps group sessions. For the most severe cases of PTSD, residential treatment, where the veteran lives in the treatment program for several weeks, is often recommended.
Wherever you seek help, treatment usually focuses on the following activities:
- Being assessed. Treatment typically begins with a detailed assessment of problems you’re facing, symptoms you have, and other difficulties in your life.
- Setting goals. You and your counselor decide what you want to accomplish to improve your life and what changes will help you achieve those things.
- Learning about PTSD. Through discussions with your counselor and classes with other veterans, you’ll learn what PTSD is and how it affects you and your loved ones.
- Learning coping skills or “tools.” There are a lot of skills that can help you in recovery, including skills for lowering physical tension, skills for communicating more effectively with family and friends, and skills for handling anger and conflict with others.
- Connecting with other veterans. VA PTSD treatment often involves having more contact with other vets like yourself. As part of treatment, you talk with other service members and veterans, learn from their experiences, and give support to them - Veterans helping veterans.
- Participating in support groups. Veterans in PTSD treatment often meet regularly with other vets, to discuss how they’re doing, get feedback and support, develop friendships, and help each other.
- Looking at yourself. Treatment often involves learning to notice what you are thinking and feeling, how you act with other people, and what situations or thoughts trigger your distressing emotions.
In addition to these very common parts of treatment, you and your counselor may decide to include some other activities:
- Taking medications. Treatment also usually involves consulting with a doctor about possible medication. Sometimes, medications can reduce the anxiety, depression, irritability, or insomnia often associated with PTSD. They can also make it easier for you to participate in other counseling activities.
- Telling your story. Talking about what happened to you and how you feel about it can be painful. But talking about your traumatic experiences can be very helpful to recovery if you are able to talk to someone you learn to trust and take a fresh look at your experiences and your opinions about them.
Often, this kind of therapeutic talking takes place over many discussions, and gradually, you may find that your memories become more controllable, and maybe a bit less painful or frightening. Treatment may last a few weeks or months or for several years. Usually, contact with a counselor is more frequent at first, and gradually becomes less regular as you learn different strategies of how to deal with your thoughts, feelings, memories, and relationships. You can re-contact your treatment program and go in more regularly if you havea setback or if your problems begin to get to be too much again.
COMMON THERAPIES USED TO TREAT PTSD
COGNITIVE-BEHAVIORAL THERAPY (CBT) has been shown to be the most effective treatment for PTSD. CBT involves working with your cognitions, or thoughts, to change your emotions, thoughts, and behaviors.
There are several types of CBT:
- Exposure therapy uses careful, repeated, detailed imagining of your trauma (exposure) in a safe, controlled environment, to helpyou face and gain control of the fear and distress that was overwhelming in the trauma.
- Cognitive Restructuring is an approach in which you identify and examine upsetting thoughts about your trauma, challenge those thoughts, and replace them with more balance and accurate ones.
- Stress Inoculation Training reduces symptoms through anxiety reduction techniques, teaching you coping skills, and correcting your inaccurate thoughts related to the trauma.
If your help is necessary or helpful in any counseling activity, willing family members need to offer to participate
MEDICATION can reduce PTSD symptoms as well as the anxiety, depression, and insomnia you often experience with PTSD. Several kinds of medication have been tested and shown to cause improvement in symptoms, and some others have shown promise. Medication can help relieve distressing symptoms and make it possible for you to participate in other types of talk therapy that have been shown to be effective.
TALKING TO YOUR DOCTOR ABOUT PTSD
You may find it helpful to talk with your primary care physician about any symptoms you have --- even if he or she does not ask you about them. PTSD is related to physical health problems. You can help your doctor understand you better and plan your treatment by sharing this crucial information about yourself. Keep in mind that your primary care doctor will not be an expert on the emotional or psychological after-effects of war trauma, but still may be helpful in other ways.
At first, it may seem hard to discuss your experience(s), although it will become much easier with time and practice. Because it may be difficult for you to discuss what happened to you, and the symptoms that you suffer, here is a quick checklist that you can complete and show to yourdoctor. It may help you to begin to talk about the symptoms you areexperiencing.
Quick Checklist of Trauma Symptoms
Check those symptoms below that you experience (that may or may not be related to a traumatic event) and make some notes as needed:
I experienced or witnessed a traumatic event during which I felt extreme fear, helplessness, or horror.
The event happened in (day/month/year)__________________________.
1) I have the following symptoms of “re-experiencing” or "reliving" the traumatic event:
- Having upsetting and intrusive thoughts about the event
- Having bad dreams or nightmares about the event or something similar
- Behaving or feeling as if the event were actually happening all over again ("flashbacks")
- Having a lot of emotional feelings when I am reminded of the event
- Having a lot of physical sensations when I am reminded of the event (e.g. heart races, pounds, or"misses a beat"; sweating, hard to breathe, feel faint, feel like I’m"going to lose control")
2) I have the following symptoms of avoiding reminders of the traumatic event:
- Avoiding thoughts,c onversations, or feelings that remind me about the event
- Avoiding people, places, or activities that remind me of the event
- Having difficulty remembering some important part(s) of the event
3) I have noticed that since the event happened
- I have lost interest in, or just don’t do things that used to be important to me
- I feel "detached" from people or I find it hard to trust people
- I feel emotionally "numb" or I find it hard to have loving feelings even toward those who are emotionally close to me
- I have a hard time falling or staying asleep
- I am irritable and have problems with my anger
- I have a hard time concentrating
- I think I may not live very long - so why plan for the future?
- I am "jumpy" and get startled easily
If medication treatment is being discussed, you might like to ask some of these questions:
- How is this medication supposed to help me?
- How will it affect my symptoms?
- How long will I have to take it?
- Can I stop it if I don’t like it?
- How will we know if it is working or not?
- What will happen if it doesn’t work?
- What are the side effects of the medication?
- How will it affect my other medications that I’m taking?
- Why do I need to go for counseling if I’m receiving medication treatment?
- How will medication treatment fit in with my PTSD counseling?
- How will medication affect my substance abuse recovery?
WHERE TO GO FOR HELP
Once you have departed from your military service, you are eligible to receive cost-free health care and readjustment services through the Department of Veterans Affairs for any conditions related to your combat service for two years following active duty. After two years, services are still available for a co-pay based on income. If you serve in the National Guard or Reserves and were deployed to a war zone, you are eligible for the same benefits. It can be important to access these services early if you think you may have PTSD. You must enroll to be eligible for these services so do it today. Fill out an application online at: https://www.va.gov/healthbenefits/
VA HEALTH CENTERS. VA health care centers are located across the country, and range from small, local clinics (CBOCs) to large hospitals. At these facilities, you can receive help for any health problem, both physical and mental health. Many VA facilitieshave experts in PTSD and related problems who you can talk with.
VET CENTERS. Vet Centers are another great resource for getting help after returning home. Vet Centers are located throughout the country and are primarily focused on helping veterans readjust to life after deployment. They offer readjustment and mental health counseling, and provide veterans and their families with resources for the experiences associated with post-deployment.
To access care at a VA or Vet Center,you will need to establish your status as a combat veteran by showing the Enrollment Coordinator at your local facility one of the following pieces of evidence when you apply for care, or any time.
- Your DD 214 indicating service in a designated combat theater of operations; or
- Proof of receipt of the Afghanistan Campaign Medal; Iraq Campaign Medal; Armed Forces Expeditionary Medal; Kosovo Campaign Medal;Global War on Terrorism Expeditionary Medal (does not include Global War on Terrorism Service Medal); or Southwest Asia Campaign Medal; or
- Proof of receipt of Hostile Fire or Imminent Danger Pay (commonly referred to as “combat pay”) after November 11, 1998; or
- Proof of exemption of Federal tax status for Hostile Fire or Imminent Danger Pay after November 11, 1998.
For more information about veterans benefits, or to locate the VA nearest you, call 1- 877-VETS or go to www.vba.va.gov/EFIF. For Vet Center information, call 1-800-827-1000 or go to www.va.gov/rcs.
VETERAN SERVICE ORGANIZATIONS (VSOS)
Another great resource for individuals returning from a war zone are Veteran Service Organizations (VSO). These organizations specialize in providing resources and assistance to military servicemen and women following deployment, and help bring individuals with similar experiences together. These groups are large organizations, such as the American Legion and Veterans of Foreign Wars, and smaller VSOs that may be organized by branch of service, religion, ethnicity, war zone theater, purpose, or many other categories. To find out more information or become involved with one of these organizations, check out www.va.gov/vso.
We hope you have found this pamphlet informative. Learning what to expect upon returning from a war zone, and about combat stress reactions and PTSD is an important first step to being able to recognize when to get extra help. We want to emphasize that most combat related reactions are not permanent. In many cases, they will go away over time on their own. When they do continue, effective treatments are available. In most cases cognitive behavioral therapy (with or without medication) can either eliminate or at least improve stress reactions, alleviate functional problems, and help stop family disruption.
Many returnees hesitate to receive mental health treatment for fear that it will hurt their image or even ruin their military careers. But remember, combat stress reactions are like any other physical injury from war. There is a range of how severe these invisible injuries are, just like there is a range of how severe physical injuries are. With early proper treatment, you may avoid problems that impact your relationships and career. If problems do persist, treatment may help you continue with or return to your military career or job and lead a happy, well-adjusted life.
For more information about stress-related disorders see our Web site www.ptsd.va.gov/