Once a Warrior, Always a Warrior
Charles Hoge, M.D.
As we honor our fallen brothers and sisters on Memorial Day, I’d also like to honor everyone who has ever risked their lives in a war zone in the service of this wonderful country. Let’s acknowledge the stark reality that we are now in the ninth year of war in Afghanistan and Iraq, and that we (the big societal “we”) still can’t grasp what war really means. Let’s begin a new kind of dialogue that bridges the gaps in perspective between Warriors and everyone else (family members, politicians, reporters, medical professionals, “the American people”, etc.). Let’s change the discussion about war-related “silent wounds” (or “signature injuries”) of post-traumatic stress disorder (PTSD) and mild traumatic brain injury (mTBI), and take time to understand what these really mean. Let’s honor Warriors who have died by suicide, and appreciate that their sacrifice means just as much as the ultimate sacrifice on the battlefield.
Here’s how the gaps in perspective play out: Sergeant J, a stellar Warrior home from two combat tours (one in Afghanistan and one in Iraq) jumps every time he hears loud noises, avoids crowded locations, can’t sleep more than three hours a night, drives in the middle of the road, is emotionally distant from loved ones, and flies into a rage frequently. He also experiences headaches, trouble concentrating, and intense guilt about certain events that happened down range, including the death of a close buddy. Sergeant J is despondent as Memorial Day approaches. He feels personally responsible, and believes that he should have been able to do something that would have resulted in a better outcome. He feels that something must be wrong with him, that he is “weak,” because he can’t control his reactions. Thoughts of suicide cross his mind.
Is Sergeant J “crazy” or “weak”? When Sergeant J reacts to things, people around him act like he is; they ask, “What’s wrong with you?”, “What’s the matter with you?”, “Do you need to see a shrink?” However, Sergeant J served his country honorably, performed brilliantly in combat, and has the medals to prove it. He’s someone you want on your team. So he’s obviously not “crazy” or “weak.”
Does Sergeant J have PTSD? Yes, probably, according to the medical definition. However, the “symptoms” that he’s experiencing are also adaptive and beneficial reactions in the war zone environment, reactions that became sharply honed reflexes through rigorous training and experience. In the war zone, Sergeant J learned to function on little sleep, react instantly when threatened, shut down emotions to focus on mission-essential tasks, take care of team members, and use anger to control fear and engage the enemy. These are hallmarks of combat physiological reactions; the way the body reacts to extreme physical stress and threat to one’s life – fight or flight. The paradox of PTSD is that what medical professionals label “symptoms” are also beneficial physiological reactions in the war zone environment. PTSD is not a psychological or emotional disorder; but rather a physiological condition that affects cognitions, emotions, and physical health.
If Sergeant J goes to see a mental health professional, he might find relief. However, if this professional doesn’t understand the paradox of combat-related PTSD, and doesn’t help Sergeant J to understand that these reactions are expected after combat, then the reactions (symptoms) might be inadvertently reinforced, along with Sergeant J’s personal feeling of being “weak.” (Studies have shown that even the best treatments for PTSD are only about 50% effective, due in large part to people dropping out after starting therapy; mental health professionals don’t always understand how they contribute by communicating in a manner that “medicalizes” expected reactions to extreme life events.)
Are Sergeant J’s headaches and concentration problems caused by lingering effects of mTBI? Possibly, but it’s very difficult to know exactly because these are also common symptoms after combat (combat causes hormonal and autonomic nervous system changes that can affect health), and because there isn’t any definitive medical test for mTBI months after injuries have occurred. Sergeant J might find relief from these symptoms if he sees a medical professional who explains to him that mTBI is the same thing as concussion, that recovery is expected, and that there are effective medicines to alleviate the headaches and address the concentration problems (for example, by helping him get some much needed rest). However, if Sergeant J is instead told that he is “brain injured” and referred for further evaluation with various “specialists” (each of whom present him with a different opinion), these symptoms might inadvertently be reinforced, leaving Sergeant J with no other recourse than the local bar (just joking about the bar… the truth about alcohol is that it can seem to help with sleep initially, but actually damages the body’s ability to sleep restfully, and makes all of the combat physiological responses worse).
So what can we do? First, is to honor Sergeant J’s service (and everyone who has ever deployed). Second, is to not view the things that Sergeant J does after coming home as necessarily being “crazy.” If he hits the ground because of a load noise, say something like “Can I get you a soda?” (Spouses can try, “When you feel like getting back up off the floor, can you take the garbage out, like I asked you?”). Accept that these types of reactions are adaptive reflexes. Instead of, “What’s wrong with you?” ask, “What’s happening?”, “How are you feeling?”, “Can I do anything for you?” Medical and mental health professionals can better educate their Warriors about combat physiology, and not make everything so clinical. Instead of “trauma,” “injury,” “symptom,” or “disorder”, they can try using words like “experience,” “event,” “reaction,” or “physiological responses.” That doesn’t minimize the importance of medical terminology, especially in guiding effective treatment, but it also acknowledges the Warriors’ need for validation of their own experiences.
What can Sergeant J do for himself? Most importantly is to find someone he trusts and talk about what happened down range (or find another way of telling his story, such as through writing). Talk about what he appreciated most about his fallen buddy, and how much he loved him. Talk about the guilt until it eases, and he can forgive himself for surviving. Express all of the emotions of grief. None of this is easy, but one of the mysteries of grief is that it has to be allowed to run its course. Part of this involves coming to terms with the uniquely human illusion of choice – the ability to look backwards in time and see various apparent options that were not actually available in that previous moment. Another important thing is to know when to seek professional help (for example if there are suicidal thoughts), and accept that this is a sign of strength, not weakness.
Let us honor all of our heroes on Memorial Day, and understand that Warriors’ experiences in combat and their resiliency in living on with the memories of those who have fallen, are part of their strength and what it means to be a Warrior.
Charles W. Hoge, M.D., Colonel (Ret), Veteran of OIF, Author of “Once a Warrior-Always a Warrior: Navigating the Transition from Combat to Home, including combat stress, PTSD, and mTBI.” www.onceawarrior.com; email: firstname.lastname@example.org
Charles Hoge, M.D. Bio
Charles W. Hoge, MD, Colonel, U.S. Army (Retired) is a national expert on war-related mental health issues and traumatic brain injury.Learn More