While this article addresses combat trauma specifically, the same symptoms occur for victims of sexual trauma, abuse and violent crime.
Meaning-making, PTSD, and Combat Experiences
By Priscilla Schulz, LCSW-C
Senior PTSD Treatment Trainer
Posttraumatic stress disorder (PTSD) is the most common psychiatric consequence of trauma exposure (Kessler et al., 2005). It is an array of psychological and physiological reactions, some of which first occur in the midst of the experience (e.g., feeling terrified, helpless, “cranked-up” and hyper-vigilant, or emotionally numb), and are expected, normal responses to life threat. Pathology in PTSD is understood as the persistence of some of the initial reactions along with the emergence of others shortly after the trauma. The reactions that may occur sometime later include intrusive recollections of the trauma, trauma-related nightmares, haunting thoughts about what the experience means, problems sleeping, and avoidance of anything that brings the trauma to mind. In PTSD this combination of reactions is intense and debilitating, and continues long after the traumatizing event has ended.
Throughout the US Dept of Defense “combat stress injury” is considered more appropriate, and a more accurate term for stress reactions to battlefield experiences. “Combat stress injury” acknowledges that exposure to combat may give rise to disturbing, and possibly uncontrollable and debilitating responses. It also sets an expectation that the disturbance is transitory, and it normalizes interventions, as with a physical injury, focused on healing (Nash, 2007). As a potentially traumatizing event, combat poses unique challenges in part because killing and death are inherent.
Making sense of experience is a uniquely human endeavor. Trauma survivors too must make sense of their extreme misfortunes, the horrors witnessed, or losses realized as part of their traumatic experiences. Questions such as “Why did it happen?” “Why did it happen to me/him/them/her?” Was it my fault?” “Should I have seen it coming?” “Can I ever trust [myself, others, the world…] again?” often haunt trauma survivors. These questions reveal an internal struggle to reconcile experience with worldview.
Answering such questions is fundamental to trauma recovery regardless of whether the event was human perpetrated or an “act of God” (Janoff-Bulman, 1989; McCann et al., 1988; Schok et al., 2011). How questions are answered affects recovery (Dunmore et al., 1999). Often, survivors’ initial answers contain inaccuracies. In PTSD these initial interpretations persist.
Much research has explored the memories and thoughts of trauma survivors. Animal models and research with human survivors both have detected memory impairment and problems in mental processing in the aftermath of acute stress, as well as in PTSD. Such research suggests that a likely cause of cognitive difficulties post-trauma and in PTSD is due to the impact of high emotionality (i.e., stress hormones) on cortical brain functioning (Brewin, 2005; Constans, 2005; Morgan III et al., 2000). For example, memory fragmentation has been detected in Military Survival School participants (Morgan III et al., 2006) immediately after extremely stressful survival “exercises.” Persistence of intense emotionality in PTSD is pernicious. Research finds significant differences in the content of trauma memories of persons with PTSD, compared to those without the diagnosis. Specifically, memories in PTSD tend to be disorganized, “snapshot” images of sensory-salient life-threatening moments that lack information about the larger context in which the events occurred (Ehlers et al., 2004; Halligan et al., 2003; Jones et al., 2007). Furthermore, studies find that PTSD sufferers tend to rely upon fragmented and highly distressing recollections of their traumas to explain causality with negative consequences for emotional well-being and quality of life (Ehlers & Clark, 1999).
A key feature of PTSD is avoidance of memories and reminders of the trauma. Avoidance behaviors are credited with chronicity of the disorder because it sets up a vicious cycle: distress undermines memories [leading to] →inaccurate interpretations → more distress → coping by avoiding the memories and all reminders → continued inaccurate explanations and high distress with memories.
Exposure to killing, and exposure to the consequences of killing (e.g., clearing human remains; exhuming mass graves), both strongly predict psychiatric morbidity (Fontana & Rosenheck, 1999; McCarroll, Ursano, & Fullerton, 1995; McNair, 2002; Maguen, 2010). Although killing is part of combat, military members engaged in modern warfare are increasingly at risk for killing compared to warfare in earlier eras. Hoge and colleagues (2004) found that 48 to 65% of Operation Iraqi Freedom soldiers and Marines knew they killed an enemy combatant; up to 28% were aware of killing a civilian or noncombatant.
Despite warfighters’ understanding that killing and death are part of war, witnessing and participating in killing raises moral concerns in sentient human beings (Litz et al., 2009). Emotionally, this is expressed as shame and guilt – feelings that are ubiquitous in PTSD, especially combat-related PTSD.
Trauma related guilt and shame arise from explanations about the deaths. Examples include, “I should have double-checked the coordinates before giving the order” and “If I’d fired my weapon sooner, they wouldn’t have been killed.” In many cases important aspects of the situation in which the deaths occurred (e.g., midst of a firefight; an ambush) are missing. But, because survivors with PTSD avoid purposeful reviewing of trauma experiences, opportunities to correct erroneous attributions of fault are lost. This phenomenon leaves survivors taking blame for heinous events; in the case of combat, survivors are blaming themselves for others’, sometimes many others’, deaths.
Cognitive approaches to PTSD target trauma interpretations. In this process, patients are guided through a delicate dialog where trauma memories are “mined” for facts and context. Then survivors are encouraged to compare “experience elements” (i.e., the physical and social environments in which the trauma occurred, their assigned role and training, “rules of engagement,” level of emotional distress, etc) to their interpretations, and to appraise meaning and causality with a full and fair consideration of all the facts.
Cataclysmic, life-threatening events are watershed experiences; they fundamentally and indelibly change survivors. “Recovery” means reconciling what happened with one’s beliefs and ongoing views of self and life. It is a process through which individuals re-discover forward momentum in their lives, despite knowledge of evil.
Recently, during a conversation about PTSD, a WWII Pacific theater Marine, and personal friend, became lost in thought. He had been in the Battle for Okinawa, among other campaigns during his tour of duty. After a while he asked, almost incredulous, “What kind of person kills another human being?!” He then sat there for a while again lost in thought. A few moments later he shrugged and said, “…but, what are you going to do? …If you don’t kill them, …they’re going to kill you!”
Memories of traumatic events are enduring. Meaning matters. Let’s help troops, who need help, grapple with their experiences by looking at the whole story, including the patriotism that brought them to a war zone, and the heroism they practice every day in the performance of their duties.
Reference List for Meaning-making, PTSD, and Combat Experiences