The Mental Conflict of a Modern Soldier: Understanding how Mindfulness and Core Concerns can Alleviate the Effects of Post-Traumatic Stress Disorder.

It is easy to be desensitized to the gruesome nature of war. For many of us, war is something that happens in other countries. We are geographically and emotionally detached from the horrors of war. However, our young man and woman who return from war are no longer the same person they were when they left. The fact is that war itself, regardless of how just or good, will leave many of these men and women with deep emotional scars. Because of the gruesome nature of war, the experience of warfare can have dramatic consequences for the mental health and well-being of military personnel. Witnessing death, destruction, and torture; experiencing unexpected and at times continuous threats to one’s life; or participating in hostilities and killing can potentially lead to mental health problems.

Until recently the solution included some medication and some form of talk therapy. However, this approach to treating PTSD left many veterans with no coping mechanism. This paper will explore how a soldier’s core concenrs; appreciation, affiliation, autonomy, status, and role can play a part in a soldier’s ability or inability to carry out a mission. This paper will also explore methods that can be used individually or as a group by soldiers to cope with the stress of war. These methods include mindfulness, yoga, and meditation. These programs could be implemented by the Department of Defense in order to help soldiers deal with the stress of war before deployment, during deployment, and after they return home and become productive members of society.

The number of soldiers suffering from PTSD is increasing. However, Post-traumatic stress disorder is not new. It was not, however, until 1980 that the American Psychiatric Association’s third edition of its Diagnostic and Statistical Manual named the condition “post-traumatic stress disorder” and brought it widespread recognition. Post-traumatic Stress Disorder (PTSD) is an anxiety disorder that can occur after you have been through a traumatic event.

The U.S. military and the VA strongly suggest the need for fundamental change. First, non-stigmatizing educational approaches grounded in self-care and mutual help would increase the number of participants. Like many in the civilian world, “Going to the shrink” is, for most military, personally embarrassing, socially stigmatizing, and potentially lethal to career advancement. In order to stop the stigma associated with going to a mental health doctor the military can make such visits mandatory. Similarly to going to basic training to become a soldier, the military can impose mandatory trips to the psychologist.

The military can implement exercises to help soldiers understand their core concerns. A better understanding of these core concerns can help a soldier better deal with stress, anxiety and their PTSD symptoms. The core concerns are distinct from each other, each concern has its own special contribution in stimulating emotions. Core concerns are human wants that are important to almost everyone. They are often unspoken but are no less real than are tangible interests. The difference between having a core concern ignored or met can make or break a soldier’s spirit and ability to productively deal with a stressful situation. Soldier’s like negotiators have to deal with internal emotions. The soldier’s ability to react positively to these negative emotions can improve his life as well as the life of those around him or her.

 

  1. The Problem with the Current Treatment of PTSD

The number of soldiers suffering from PTSD is increasing. However, Post-Traumatic Stress Disorder is not new. It was not, however, until 1980 that the American Psychiatric Association’s third edition of its Diagnostic and Statistical Manual named the condition “post-traumatic stress disorder” and brought it widespread recognition. [1] Post-Traumatic Stress Disorder (PTSD) is an anxiety disorder that can occur after you have been through a traumatic event. During this type of event, you think that your life or others’ lives are in danger. You may feel afraid or feel that you have no control over what is happening.[2] The solution to PTSD is no longer in not minding the pain but in finding a way to understand it. The Department of Defense is heavily invested in ways to treat PTSD. Experts at the Department of Defense and the Institute of Medicine believe that better screening for depression, suicide, and PTSD as well as better integration of clinical services, and more mental health professionals and preventive programs is a reasonable solution.[3]

Unfortunately, they are likely to make little difference in the numbers of men and women who die from suicide and are disabled by psychological distress, and equally important, to the numbers who actually use the services offered. In fact, the focus on diagnosis and treatment may continue to alienate those it is supposed to serve and perpetuate the problem rather than offer a viable solution. [4] The U.S. military and the VA strongly suggest the need for fundamental change.

  1. Finding a Solution for Treating PTSD.

First, non-stigmatizing educational approaches grounded in self-care and mutual help would increase the number of participants. Like many in the civilian world, “Going to the shrink” is, for most military, personally embarrassing, socially stigmatizing, and potentially lethal to career advancement. In order to stop the stigma associated with going to a mental health doctor the military can make such visits mandatory. Similarly to going to basic training to become a soldier, the military can impose mandatory trips to the psychologist. The departments of Veterans Affairs and Defense seem prepared to agree, and have backed a four-year study of moral injury in Marines. [5] In San Francisco, they are testing a program aimed at relieving the after-effects of ending a life. The focus of these programs is on education, compassion, and forgiveness. [6]The sessions ask veterans to write letters to the dead or have imaginary conversations with a superior officer, someone in a position to say the suffering may end. [7]

Additionally, Sherman, a professor at Georgetown, is the author of The Untold War: Inside the Hearts, Minds, and Souls of Our Soldiers. The piece is an in-depth analysis of soldiers’ stories through the “dual perspectives of moral philosophy and psychoanalysis.”[8] Rather than medication, Professor Sherman believes that philosophy provides an ideal solution for interpreting the testimony of combat veterans’ PTSD because it “sharpens the distinctions, maps the conceptual terrain, presses us to make more systematic or coherent what confuses or defies sense.”[9]

Professor Sherman proposes that “the military cannot afford to neglect the fact that emotions, just like skill and physical endurance, need cultivation and expression.”[10] The military understands that neglect will only put soldier’s life at risk. The Army, for example, began a suicide-prevention campaign, treating soldiers with post-traumatic stress disorder, and begun to field “master resiliency training” as part of its program of “comprehensive soldier fitness.” [11]

Because of the lack of mental health resources, many soldiers cannot deal with the pain and nightmares and commit suicide. Among the difference branches of the military the Army lost the most active-duty members last year to suicide: 182. During 2001, nine out of every 100,000 active-duty soldiers killed themselves, while, during 2011, the suicide rate was nearly 23 per 100,000, according to the American Foundation for Suicide Prevention. [12] In January 2012, the Army classified another 33 deaths as “potential suicides” among active-duty, National Guard and Army Reserve soldiers, according to the Department of Defense. [13]David Rudd, the co-founder and scientific director of the National Center for Veteran Studies based at the University of Utah believes that the armed forces needs to look at the “big picture” to understand what’s going on today. [14]

  1. Military Screening for PTSD

In December 1940, Harry Stack Sullivan, a psychoanalyst, joined the Selective Service System as a consultant to develop a screening program. Sullivan believed that the US armed forces should exclude not only individuals suffering from mental illness but also those with neurosis or maladjustment.[15] He reasoned that individuals who had been unable to adjust to the demands of American society would never adjust to the demands of army life. Military officials were particularly interested in detecting homosexuality, which they believed destroyed combat effectiveness and morale. [16] In addition, homosexuality was an offense for which one could be court-martialed.

Initially, military officials approved of screening programs because they promised that the armed forces would be made up of the most able men. Between 1941 and 1944, Sullivan’s screening methods excluded 12% (almost 2 million) of 15 million men examined, which was about 6 times the rejection rate of World War I.[17] In retrospect, it is not shocking that screening programs for psychiatric debility had poor prognostic power. Even today, the mental health consequences of war are poorly defined, with ever-shifting diagnostic categories, an uncertain theoretical foundation, and a lack of consensus on the relative contribution of predisposing and contextual factors. The failure of selection provided a serious challenge to the notion that predisposing factors were critical to the development of mental health problems during deployment. It challenged psychiatrists to explore other causes, such as the stresses of warfare.

Aware that screening for ill mental health would not prevent psychiatric problems in the US armed forces, military psychiatrists also devoted considerable attention to the management of psychological distress during deployment. During World War I, British psychiatrists saw a puzzling condition initially named shell shock.[18] Its symptoms comprised physical and psychological components, including stuttering, crying, trembling, paralysis, stupor, mutism, deafness, blindness, anxiety attacks, insomnia, confusion, amnesia, hallucinations, nightmares, heart problems, vomiting, and intestinal disorders. [19]

The military has established mental health teams. These teams have become an integral part of the fighting forces. The US armed forces have implemented extensive strategies to target combat stress, in line with the belief that all service personnel are potential stress casualties. [20] Staffed by specialist mental health professionals are responsible for prevention, triage, and short-term treatment with the purpose of retaining manpower and maintaining operational efficiency. These teams provide a range of services, including conducting surveys of the interpersonal climate within units, educating unit command, providing briefings on suicide prevention and reintegration advice for returning home, and providing informal support to soldiers.[21] Critical incident stress debriefing (specialist intervention as soon as possible after potentially traumatic events) has also been enthusiastically incorporated by modern stress control teams, which are deployed after natural disasters or terrorist action.

 

  1. A Holistic Approach to PTSD Treatment.

Unfortunately, research has not adequately supported approaches with a focus on frontline intervention.[22] Recent critical reviews have shown that critical incident stress debriefing does not decrease the development of symptoms and that, in some cases, it exacerbates them.[23] During the past few years, a number of studies have reported prevalence rates between 15.6% and 17.1% for PTSD among those who have returned from the Iraq War.[24] Surveys have indicated that military personnel are not taking full advantage of the medical and psychiatric resources at their disposal. Within the military, the view that displaying psychiatric symptoms indicates weakness of character or cowardice is still generally held.[25]

Soldiers most in need of mental health care do not seek it because of fear of embarrassment, difficulties with peers or officers, or interference with career opportunities within the military. It appears that the accumulated wisdom of psychiatry and increasingly efficient and sophisticated psychiatric treatment methods generally do not reach those who need them most. In the United States, $250 million has been spent on research, yet no specific set of symptoms indicating the existence of a war-related syndrome has been found and no clear cause has been identified. [26]

 

  1. Understanding a Soldier’s Core Concerns.

Soldiers want to be appreciated. This appreciation can come from family, friends or even other fellow soldiers. Soldiers do not join the military for the money. Being a soldier does not carry the same prestige as being a doctor or a lawyer. On the other hand, being a soldier does demand appreciation. Soldier’s put their lives at risk in order to defend the freedoms we enjoy. Being a soldier also keeps them away from their families. Their sacrifice is great, yet our appreciation is sometimes underwhelming. Some soldiers do enjoy the occasional recognition during a sporting event or at least once a year during veteran’s day. But many soldiers feel unappreciated because they no longer wear the uniform. Many soldiers who are honorably discharged from the military are having trouble finding the appreciation they feel they deserve. They are now just like any other civilian wearing plain clothe. Many struggle finding employment in the civilian world. The lack of employment leads them to feel unappreciated. The lack of verbal appreciation increases a soldier’s anxiety, stress and it lowers their self-esteem. If the military could implement a program that teaches a soldier to understand this specific core concern, he or she would be able to find appreciation from within. Appreciation can come from many sources. A soldier can find appreciation from understanding different sources of appreciation. For example, they can find appreciation from the knowledge that his family is safe here in the United States. Additionally, they can find appreciation in the fact that they were able to return from the war alive. In other words, appreciation can come from what you have now and not just from what you did in the past.

The second core concern is affiliation. Soldiers also want to be affiliated. While on duty, soldiers become part of a brotherhood. They train, eat, sleep together. Once they retired and returned home, soldiers have a difficult time adjusting to being apart from their unit. Being away from your unit, in conjunction with the trauma of war can have severe psychological effects. Affiliation is perhaps one of the most important aspects of being a soldier. A soldier’s affiliation comes from being part of a unit or military branch. When a soldier retires and returns to the civilian world they can feel alone. They might feel like they don’t belong. The military can improve a soldier’s affiliation concerns by implementing more group meetings as well as better military clubs. Additionally, the military can teach soldiers how to understand and expand the definition of affiliation. If a soldier could understand that his affiliation is not restricted to being a member of a specific unit or branch of the military but rather of a larger group he can find affiliation a little easier. A soldier can find affiliation with a group outside of the military. For example, being a member in a sport’s club, cooking class, gymnasium or any other group can help a soldier incorporate into society. Helping a soldier understand how he or she can be part of a group outside of the military can help them deal with their affiliation core concern.

The third core concern the military must teach a soldier how to understand is autonomy. The responsibilities associated with being a soldier are great. Soldiers want to feel like they are empowered to make their own choices and act freely based on those choices. On the other hand, the military life is one with a strong hierarchy. In some situations soldiers have very little autonomy. Transitioning to the civilian world can impact a soldier’s autonomy in different ways. First, a soldier might feel lost without the guidance of a superior officer. This can cause them to feel afraid of making decisions. Following orders is a big part of being a soldier. They have time designation for waking up, eating meals and going to bed. Not following these rules have consequences. In the civilian world, soldiers no longer have a superior officer yelling orders at you. Many soldiers are able to find employment and as a result they have a new superior officer giving them orders. However, those who are unable to find employment are left with too much autonomy and this can increase anxiety and stress. Additionally, many soldiers return from war with physical injuries. Many are missing limbs. Because of their current physical disability many are helpless and must rely on others to do simple tasks like eating and showering. This lack of autonomy is frustrating and leads many to a dark depression. The military must implement programs have help soldiers deal with autonomy issues. The programs must have individualize counseling depending on each soldier’s specific situation. However, the military can implement programs that teach soldiers as a group how to better understand autonomy.

The next core concern is status. This is perhaps one of the most important core concern for a soldier. Soldiers follow a strict code of ranks. These ranks come with a certain level of value and importance in a given situation. Those soldiers that enjoyed a certain level of status in the military are no longer afforded the same perks in the civilian world. A soldier who enjoyed the prestige of a higher rank might feel like important and depressed in the civilian life. We respect soldiers not because of their rank but because we understand that their job carries a realistic potential for self-sacrifice and unpleasant duties. When a soldier leaves service they no longer walk around with medals on their uniform or insignias showing their status. It is the military’s duty to help soldiers find a fulfilling status in the civilian world. The military can achieve this by finding gainful employment for soldiers. They can provide training that allows soldiers to get a successful career in the civilian world. The military can help soldiers better understand how to deal with feelings of inadequate status by teaching them about the core concerns.

Last but not least, the last core concern is role. Soldiers want to have a role. As soldiers, their role was to protect this country against all enemies. As a civilian, many struggle finding employment. Many of the skills acquired in the military are not compatible or applicable in the civilian world. Soldiers who struggle finding a rewarding role in society are prone to depression and substance abuse. Soldiers can play an integral role in the civilian world. They are disciplined, organized and hard workers. Soldier’s should be able to find a meaningful role in the civilian world. However, this is not the case for many veterans. Many suffer from PTSD and employers are unwilling to hire them. The military can implement better career placement as well as better medical treatment for soldiers so that they can minimize the symptoms of PTSD.

The power of core concerns is that they can be used for two purposes: first, as a lens to understand the emotional experience of each party, and secondly, as a lever to stimulate positive emotions in yourself and others. Awareness of core concerns can help soldiers see what might be motivating someone else’s behavior so that you can modify your actions to address that person’s concern. Further, awareness of your own core concerns can help to diffuse a situation in which you feel your emotions are escalating. For instance, if the other party says or does something that you perceive as an attack, instead of reacting, you can reflect a moment, ask yourself which of your core concerns feels threatened, and respond in a manner that restores balance to the interaction.

Mindfulness involves intentionally bringing one’s attention to the internal and external experiences occurring in the present moment, and is often taught through a variety of meditation exercises.

There is no quick fix solution for sealing with PTSD. The military should implement programs that incorporate both medicinal and psychological measures. There needs to be dedicated follow-up treatment and therapy for both the service member or veteran, and the family. This should be the norm, not the exception. For those in charge of military programs dealing with troops suffering from PTSD education needs to be more than a two-week course. Many of the “wounded warrior” programs on military installations are run by personnel who went through a two-week indoctrination course and often have never been in combat, according to soldiers in the Army Warrior Transition Units. Troops with unseen injuries repeatedly said their demeanor and actions are often misinterpreted or misunderstood as “being a difficult soldier.”

 

  1. Mindfulness and the Core Concerns.

Today, emotional strength may be lacking in today’s warriors when compared to past generations. The reason is that perhaps past soldiers were better steeled for battle by the epic financial hardships they faced at home. Dealing with stress is all about coping skills. What creates our coping skills? You take a young, patriotic guy. He goes over to Afghanistan or Iraq and sees things he can’t even comprehend. And so what does it do? He tends to feel the effects of that stress more fully because he has not developed the coping skills. The military lifestyle is full of uncertainty. Because of the war in the east, soldiers face multiple deployments to Iraq and Afghanistan. These deployments have a heavy psychological impact on soldiers. These young soldiers some of them 20-somethings do not really understand what it means to be at wartime. Asking them to switch hats and deploy abroad within weeks is something that is difficult to do. Many young soldiers have a social life, girlfriends, some are married and have kids. The multiple deployments leaves these soldiers with very little time to heal. Eventually, this constant stress leaves soldiers with strong psychological issues. The military, in general is not too receptive of implementing psychological treatment of their soldiers.

During the 20th century, psychiatrists offered their assistance to the military to mitigate the effects of these and other traumatic experiences inherent in warfare. Military officials everywhere have displayed a strong ambivalence toward the involvement of psychiatrists in military affairs. For example, they have often labeled soldiers suffering from psychiatric symptoms as cowards lacking moral fiber. [27] Military officials have also been concerned that the presence of psychiatrists encouraged the display of psychiatric symptoms. However, military officials have been interested in psychiatric issues whenever they were perceived to affect the primary mission of the armed forces. The involvement of psychiatrists in military conflicts not only resulted in the development of extensive expertise in the management of war-related psychiatric syndromes but also profoundly affected the development of the entire discipline of psychiatry, which incorporated new theoretical perspectives, diagnostic categories, and treatment strategies first proposed and developed by military psychiatrists.

 

  1. Using Mindfulness and other Alternatives to Treat PTSD.

People who have been psychologically traumatized are agitated in both mind and body; those who are depressed are physically as well as mentally depleted. Movement can help break up these fixed physical and emotional patterns and activate those immobilized by despair. Aerobic exercise, for example, has repeatedly been shown to be as effective for depression as anti-depressant drugs or psychotherapy.[28] The Department of Defense and VA are beginning to recognize the importance of therapies that address the body — studies on yoga and martial arts are underway — but including movement in all approaches should be the rule, not the exception.[29]

This is partly a matter of economy. No matter how many mental health professionals are hired there will never be individual therapy for all. But there are also advantages to groups. For many, individual sessions with a mental health professional are unpleasant and demeaning. Therefore groups therapies- especially ones where sharing is central and where interruption, analysis, and interpretation are forbidden — take the embarrassing spotlight off individual speech and behavior. Members are all in it together and so is the leader, who often does the self-care exercises along with them and shares his or her experience and feelings. Small groups which can be led by trained peers as well as professionals are also familiar and supportive. They are the way troops are organized in the military. Groups should be routine, individual approaches the exception.

And groups can yield results that are at least as good as individual therapies. Research on the Center for Mind and Body Medicine group model, published in peer-reviewed journals, shows an 80 to 90 percent improvement in PTSD symptoms in war-traumatized populations, along with significant elevations in mood and a lifting of the sense of hopelessness.[30] The results were largely maintained, in spite of ongoing armed conflict and severe economic stress, at seven months follow-up. Even more important, this approach — and similar ones which emphasize self-care and mutual help — appeals to large numbers of people, including military, who have been dissatisfied with or refused to seek out conventional mental health care or who do not have access to it.[31]

Yoga excercises can also improve body control and breathing techniques. Yoga postures improve flexibility and restore confidence. Slow deep breathing lowers heart rate, relaxes tense muscles, and, for many, quickly leads to better sleep. Simple biofeedback devices show troops that they can use their mind to warm hands chilled by stress. Guided imagery and drawings mobilize their imagination to provide answers to previously insoluble problems. Interventions based on training in mindfulness skills are becoming increasingly popular. Mindfulness involves intentionally bringing one’s attention to the internal and external experiences occurring in the present moment, and is often taught through a variety of meditation exercises. [32]

The University of Massachusetts Medical Center established the Mindfulness-based stress reduction (MBSR) in 1979. [33] The Center defines Mindfuless as an awareness that is nonjudging, friendly, and does not seek to add or subtract anything from the experience before it. [34] Studies of these techniques have shown some positive effects, but are limited by small sample sizes, enrollment of exclusively male Veterans, and lack of follow-up.[35] Without a control for nonspecific aspects of the group meetings, however, it is difficult to definitively attribute these gains to use of the approach. In 2012, Kearney and colleagues conducted an uncontrolled study of mindfulness-based stress reduction (MBSR) as an adjunct to usual care in Veterans with PTSD. MBSR is a group intervention that incorporates mindfulness practices, including meditation and yoga. The authors reported a medium effect size in change in PTSD, depression, and functioning in those who took part in the group. Although mechanisms of change could not be determined by this uncontrolled study design, it is notable that changes were mediated by changes in mindfulness.

Because MBSR is a well-established intervention with some demonstrated effectiveness for treatment of anxiety more generally, additional empirical evaluation of MBSR is indicated. A struggle for those who undertake such studies will be selection of appropriate controls. For example, it may be appropriate to compare mindfulness to relaxation, to establish that observed changes are attributable to something more than a quiet pause in one’s day. Alternately, it may be important to compare a mindfulness-based approach to other commonly used coping skills, such as cognitive-behavioral anxiety management techniques.

Based on the vast literature in this area, there could potentially be different mechanisms underlying different types of meditative practice. The literature on cognitive changes related to mindfulness suggests that through practice of shifting attention and assuming a nonjudgmental stance, patients may learn to be less reactive to intrusive or ruminative thoughts. Meditation has more commonly been linked to decreasing physiological arousal. For patients with PTSD, this may be a good coping strategy for times when memories are intentionally (as in exposure-based therapy) or unintentionally triggered. Compassion meditation, which involves directing feelings of warmth and compassion towards others, has been linked to increases in positive emotion and social connectedness. Given the deficits in positive emotion and feelings of connection with others that are characteristic of PTSD, compassion meditation is a promising strategy, but is without empirical application to PTSD. It is also possible that there are nonspecific factors common to all of these types of meditation. Future research should evaluate these approaches and attempt to understand the mechanisms by which they create change.

There needs to be classes on helping soldiers re-integrate back into their units after suffering from post-traumatic stress. Many military personnel say the emphasis is on suicide prevention, instead of educating soldiers about PTSD.[36] Troops suffering from unseen injuries tell often find themselves ostracized or criticized for short-term memory loss, lack of or over-concentration, panic attacks, and anger management, said Roxanne Merritt, a civilian employee of the U.S. Army John F. Kennedy Special Warfare Center and School.[37] Military leaders need to step in while the troops are still deployed in war zones, experts say. Many soldiers suffering from PTSD said in Afghanistan and Iraq, they would just chalk up their “headaches” as part of “the daily slog in the suck.” The overuse of stimulants such as caffeine and chewing tobacco may mask some traumatic brain injury symptoms. And most troops say they want to stay with their units “in the fight,” so they may not report symptoms of their exposure to blasts. “At some point, a senior guy or leader must directly intervene and save the operators out there from themselves,” said Maj. Gen. Michael Repass, head of Special Operations Command Europe, and former commander of U.S. Army Special Forces. “People with experience know when someone isn’t up to full speed. Direct intervention is too often the only way to head off problems.” [38]

Back home, the families of these war veterans suffering from unseen injuries need to be placed in therapy programs to learn to recognize triggers and understand that memory lapses are the norm, not the exception.

 

Conclusion

There is no quick fix solution for dealing with PTSD. The military should implement programs that incorporate both medicinal and psychological measures. There needs to be dedicated follow-up treatment and therapy for both the service member or veteran, and the family. This should be the norm, not the exception. For those in charge of military programs dealing with troops suffering from PTSD education needs to be more than a two-week course.

PTSD is mostly treated with drugs. For many, this method does not work. Teaching soldiers how to understand their core concerns can help them understand their emotions. Additionally, using other methods such as mindfulness, meditation and yoga can help the soldiers deal with stress, anxiety and other symptoms of PTSD. Mindfulness meditation can help soldiers focus on a single thing happening at the moment. This extensive focus can help soldiers to deal with anxiety and other stress-related negative emotions. Meditation and yoga can also help the soldiers control their blood pressure, heart rate and breathing and eventually reducing stress.

 

Soldiers who can master the art of mindfulness can use it during their long flights to the east. While on flight the soldiers can close their eyes and mediate. By the time they reach Iraq, they can be in a more positive state of mind. They are also able to stop their brains from going into overdrive and hinder their mission.

Additionally, the use of Mindfulness and the Core Concerns is very cost effective. These techniques can be implemented in a classroom setting with a trained professional. The cost associated with these methods inconsequential when compared with the cost of medication. Furthermore, these techniques can be done as a group or individually at home. Another positive aspect of these techniques is that they can be taught to family members of these veterans. If the family is better equipped to deal with the stress they can provide better support for the soldier. It is time for the military to implement preventive measures. It is no longer adequate to send soldiers to war and expect to treat them with pills once they return.

 

 

[1] James Gordon, A Practical Approach to Military PTSD, The Atlantic (Dec. 11, 2012, 06:05 AM). http://www.theatlantic.com/health/archive/2012/12/a-practical-approach-to-military-ptsd/266088/

[2] James Gordon, A Practical Approach to Military PTSD, The Atlantic (Dec. 11, 2012, 06:05 AM). http://www.theatlantic.com/health/archive/2012/12/a-practical-approach-to-military-ptsd/266088/

[3] James Gordon, A Practical Approach to Military PTSD, The Atlantic (Dec. 11, 2012, 06:05 AM). http://www.theatlantic.com/health/archive/2012/12/a-practical-approach-to-military-ptsd/266088/

[4] James Gordon, A Practical Approach to Military PTSD, The Atlantic (Dec. 11, 2012, 06:05 AM). http://www.theatlantic.com/health/archive/2012/12/a-practical-approach-to-military-ptsd/266088/

[5] A New Theory of PTSD and Veterans: Moral Injury by Tony Dokoupil, Dec. 3, 2012 12:00 AM EST. http://www.thedailybeast.com/newsweek/2012/12/02/a-new-theory-of-ptsd-and-veterans-moral-injury.html

[6] Id.

[7] Id.

[8]  Nancy Sherman, The Untold War: Inside The Hearts, Minds, and Souls of Our Soldiers (W.W. Norton & Company 2001).

[9] Nancy Sherman, The Untold War: Inside The Hearts, Minds, and Souls of Our Soldiers (W.W. Norton & Company 2001).

[10] Nancy Sherman, The Untold War: Inside The Hearts, Minds, and Souls of Our Soldiers (W.W. Norton & Company 2001).

[11] Nancy Sherman, The Untold War: Inside The Hearts, Minds, and Souls of Our Soldiers (W.W. Norton & Company 2001).#

[12]  Bill Briggs, Why Modern Soldiers are more Susceptible to Suicide, NBC NEWS (March 2, 2013, 04:45 AM) http://usnews.nbcnews.com/_news/2013/03/02/17148761-why-modern-soldiers-are-more-susceptible-to-suicide?lite

[13] Bill Briggs, Why Modern Soldiers are more Susceptible to Suicide, NBC NEWS (March 2, 2013, 04:45 AM) http://usnews.nbcnews.com/_news/2013/03/02/17148761-why-modern-soldiers-are-more-susceptible-to-suicide?lite

[14] Bill Briggs, Why Modern Soldiers are more Susceptible to Suicide, NBC NEWS (March 2, 2013, 04:45 AM) http://usnews.nbcnews.com/_news/2013/03/02/17148761-why-modern-soldiers-are-more-susceptible-to-suicide?lite

[15] Sullivan Harry Stack, Mental Hygiene and National Defense: A Year of Selective-Service Psychiatry, Mental Hygiene 26, no. 1 (1942): 7–14; Harry Stack Sullivan, “Psychiatry and the National Defense,” Psychiatry 4 (1941): at 201–17.

[16] Berube Allan, Coming Out Under Fire: The History of Gay Men and Women in World War Two (New York: Free Press, 1990).

[17] Glass Albert J., Francis J. Ryan, Ardie Lubin, C. V. Ramana, and Anthony C. Tucker, “Psychiatric Prediction and Military Effectiveness, Part I & II,” US Armed Forces Medical Journal 7, no. 10 (1956): 1427–43, 1575–88; see also Eli Ginzberg, James K. Anderson, Sol W. Ginsburg, and John L. Herma, The Lost Divisions (New York: 1955).

[18] Peter Leese, Shell Shock: Traumatic Neurosis and the The Anatomy of Madness, ed. William F. Bynum, Roy Porter, and Michael Shepherd. The Anatomy of Madness: Essays in the History of Psychiatry (London: Tavistock, 1985).

[19] Peter Leese, Shell Shock: Traumatic Neurosis and the The Anatomy of Madness, ed. William F. Bynum, Roy Porter, and Michael Shepherd. The Anatomy of Madness: Essays in the History of Psychiatry (London: Tavistock, 1985).

[20] US Department of the Army, Combat Stress Control in a Theater of Operations: Tactics, Techniques, Procedures: Field Manual 8-51 (Washington, DC: Department of Defense, 1994); US Department of the Army, Leaders’ Manual for Combat Stress: Field Manual 22-51 (Washington, DC: Department of Defense, 1994).

[21] US Department of the Army, Combat Stress Control in a Theater of Operations: Tactics, Techniques, Procedures: Field Manual 8-51 (Washington, DC: Department of Defense, 1994); US Department of the Army, Leaders’ Manual for Combat Stress: Field Manual 22-51 (Washington, DC: Department of Defense, 1994).

[22] Solomon Z, Benbenishty R, The role of proximity, immediacy, and expectancy in frontline treatment of combat stress reaction among Israelis in the Lebanon War. Am J Psychiatry. 1986 May; 143(5):613-7.

[23] Raphael B, Wooding S, Review Debriefing: its evolution and current status. Psychiatr Clin North Am. 2004 Sep; 27(3):407-23.

[24] Hoge CW, Castro CA, Messer SC, McGurk D, Cotting DI, Koffman RL, Combat duty in Iraq and Afghanistan, mental health problems, and barriers to care. N Engl J Med. 2004 Jul 1; 351(1):13-22.

[25] Friedman MJ, Acknowledging the Psychiatric Cost of War. N Engl J Med. 2004 Jul 1; 351(1):75-7.

[26] Engel Charles C., Kenneth C. Hyams, and Ken Scott, “Managing Future Gulf War Syndromes: International Lessons and New Models of Care,” Philosophical Transactions of the Royal Society, Biological Sciences 361 (2006): 708.))

[27] Edgar Jones, LMF: The Use of Psychiatric Stigma in the Royal Air Force During the Second World War,” Journal of Military History 70 (2006): at 439–58.

[28]  James Gordon, A Practical Approach to Military PTSD, The Atlantic (Dec. 11, 2012, 06:05 AM). http://www.theatlantic.com/health/archive/2012/12/a-practical-approach-to-military-ptsd/266088/

[29] Id.

[30]  James Gordon, A Practical Approach to Military PTSD, The Atlantic (Dec. 11, 2012, 06:05 AM). http://www.theatlantic.com/health/archive/2012/12/a-practical-approach-to-military-ptsd/266088/

[31] James Gordon, A Practical Approach to Military PTSD, The Atlantic (Dec. 11, 2012, 06:05 AM). http://www.theatlantic.com/health/archive/2012/12/a-practical-approach-to-military-ptsd/266088/

[32] Clinical Psychology: Science and Practice, 10, 125-143. doi: 10.1093/clipsy.bpg015.

[33] Mindfulness-based stress reduction by Jeffrey Brantley

[34] Id.

[35] Bormann, Thorp, Wetherell, & Golshan, 2008; Brooks & Scarano, 1985.

[36]  Alex Quade, Dealing with the unseen scars of war, CNN Health (Nov. 11, 2010, 08:53 AM), http://www.cnn.com/2010/HEALTH/11/08/ptsd.military.treatment/index.html

[37] Alex Quade, Dealing with the unseen scars of war, CNN Health (Nov. 11, 2010, 08:53 AM), http://www.cnn.com/2010/HEALTH/11/08/ptsd.military.treatment/index.html

[38] Alex Quade, Dealing with the unseen scars of war, CNN Health (Nov. 11, 2010, 08:53 AM), http://www.cnn.com/2010/HEALTH/11/08/ptsd.military.treatment/index.html