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Returning from Combat:
Understanding the Mental
Health Effects of Deployment on
Education
Mark C. Brown, MD, MAJ, MC
Thanks to
Roger Duda, MD
MAJ, MC
4th Sustainment Brigade Psychiatrist
Agenda
– Deployment Stress
– Emotional Cycle of
Deployment
– Post Deployment Reactions
– Stressors and Combat
Experiences
– Recovery
– PTSD and Depression
– Coping with Post-Deployment
Stress
– Post-Deployment Growth
– Resources
Introduction
•
Military families have experienced the
emotional trauma of deployment on
an unprecedented scale since the
end of the Gulf War
•
Military downsizing increased
likelihood each soldier will eventually
participate on extended missions
•
Long separations are increasing
concern with two-thirds of soldiers
now married
•
Differing coping strategies are
needed through five stages of
deployment
•
Education of health care providers,
military leaders, soldiers and family
members to anticipate these stages
is crucial to ensure the soldier's safe
return and to minimize stress impacts
Deployment Stress
• Psychological responses
to deployment
• Often no immediate
symptoms
• Reasonable immediate
functioning upon return
home
Pre-Deployment
•Anticipation of loss vs
denial
•Train-up/long hours away
•Getting affairs in order
•Mental/physical distance
•Arguments
Post-Deployment
•Honeymoon period
•Loss of independence
•Need for “own” space
•Renegotiating routines
•Reintegration into family
Deployment
•Mixed emotions/relief
•Disoriented/overwhelmed
•Numb, sad, alone
•Sleep difficulties
•Security issues
Emotional Cycle of
Deployment
Re-Deployment
•Anticipation of homecoming
•Excitement
•Apprehension
•Burst of energy/”nesting”
•Difficulty making decisions
Sustainment
•New routines established
•New sources of support
•Feel more in control
•Independence
•Confidence “I can do this.”
Stage 1. Pre-deployment
• Stage begins with the warning
order for deployment
• Characteristics:
– Anticipation of loss vs. denial
• "You don't really have to go,
do you?"
– Train-up/long hours away
– Getting affairs in order
• Long "honey-do" lists
– Mental/physical distance
• Will my marriage survive?"
– Arguments
• "I wish you were gone
already."
• It is easier to be angry than
confront the pain and loss of
saying goodbye
Stage 2. Deployment
• Mixed emotions/relief
• Disoriented/overwhelmed
• Numb, sad, alone
• Sleep difficulty
• Security issues at home
• Positive side
– Ability to communicate home
is a great morale boost
Stage 3. Sustainment
• New routines established
•
• New sources of support
• Feel more in control
• Independence
• Confidence
• Discussing "hot topics"
• Unidirectional phone calls
Stage 4. Re-deployment
• Re-deployment
– Essentially defined as the
month before the soldier is
scheduled to return home.
– Anticipation of homecoming
• “Will he (she) agree with
the changes that I have
made?
• Will I have to give up my
independence?
• Will we get along?"
– Excitement
– Apprehension
– Burst of energy
– Difficulty making decisions
Stage 5. Post-deployment
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•
Honeymoon period
Intimacy issues
– Social, sexual, recreational,
spiritual, physical, affective,
intellectual
– Myth of Infidelity
•
Loss of independence
– Spouses may consider
themselves to be the true heroes
•
Need for "own" space
– "Who is this stranger in my bed?"
•
•
Renegotiating routines
Reintegrating into family
– Typical period where post
traumatic issues appear
– Three to six months after
deployment
•
Communicate with patience; focus
on feelings, “what not who”
Post Deployment Effects of
Deployment and Combat Experience
• Cognitive
(thoughts)
• Emotional
(feelings)
• Behavioral
(actions)
Top Deployment Stressors
Uncertain Re-Deployment Date
87
41
Long Deployment Length
52
Being Separated from Family
39
Boring or Repetitive Work
Difficulties Communicating Back Home
Not Having Right Equipment or Repair
Parts
Lack of time off for personal time
57
45
Lack of Privacy or Personal Space
55
55
36
50
17
21
71
OIF-I
42
OIF-II
38
0
20
40
60
80
100
Percent reporting high or very high concern
Combat Experiences
Combat Experiences
57
Receiving incoming artillery, rocket, mortar
Receiving small arms fire
49
Having a member of your own unit become
a casualty
43
44
Seeing dead or seriously injured Americans
44
Handling or uncovering human remains
IED/ booby trap exploded near you*
63
59
60
Knew someone seriously injured or killed
Being directly responsible for the death of an
enemy combatant
76
22
10
53
29
OIF-I
OIF-II
19
38
0
20
40
60
80
100
Percent at least once during this deployment
*IED question only asked during OIF-II
Protective Factors
• Well-functioning/supportive unit
• Perceived control over events
• Strong commitment to tasks
• See adverse events as challenges
• No prior trauma exposure
• Good mental health pre-exposure
• Strong social/family support
Risk Factors
• Severity of trauma
• History of previous trauma
• Preexisting psychiatric disorder
• Family history of psychiatric disorder
• Limited support systems
• Exposure to reactivating environmental events
Changes in Thinking
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Unwanted “reliving” of combat experiences
Distressing memories
Disturbing dreams or nightmares
Flashbacks
Upset when reminded of war zone events
Changes in Thinking (cont.)
Changes in Attitude and Outlook:
• Preoccupation with news about the war
• Worry about friends still deployed overseas
• Miss excitement of combat, urges to return
• Confused about direction and meaning in life
• Blaming self for actions in war zone
• Loss of “innocence” and belief in former values
Changes in Emotion
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Feeling unsafe, on guard
Irritability and outbursts of anger
Anxious, apprehensive, panicky, stressed out
Guilt, shame
Feeling alienated from others and society (“I don’t
fit in any more!”)
• Loss of interest and enjoyment in life
• Down, depressed, hopeless
• Shutting down and emotional numbness
Changes in Behavior
• Trouble falling asleep and/or staying asleep
• Easily startled, jumpy
• Physical symptoms and health problems
• Problems with concentration and attention
• Avoiding people, places, or things that are
reminiscent of military duty
• Increased use of alcohol or drugs
• Isolated, withdrawn, sullen, uncommunicative
• Overly controlling and worried about safety
Recovery
• Understanding and the support of others
helps stress reactions pass more quickly
• Structure your time with normal activities –
keep busy with a normal schedule
• Don’t label – this is a normal reaction to an
abnormal event
• Talk to people – it is the most healing
medicine
Recovery
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Get plenty of rest
Eat healthy – even if you don’t feel like it
Daily exercise
Spend time with others
Share your feelings
Do things that feel good
Don’t make any big life changes
Mental Health Awareness:
Returning Soldiers are at Risk for:
•
•
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Domestic Violence
Substance Abuse
Depression
Anxiety disorders
Post-Traumatic Stress Disorder (PTSD)
Current Statistics
• Depression
– 8-10% in post-deployment
• PTSD
– OIF 15-20% of returning soldiers
– OEF 10-15% of returning soldiers
• Substance Misuse
– Up to 30% of returning soldiers
Effects of Witnessing Traumatic Events
• It is quite normal for people to experience
emotional or physical reactions after a
traumatic event
• They can occur immediately after the
event, or may take hours, days, weeks or
months to appear
• They are normal and for most will resolve
or not have significant impact on life
Risk Factors for PTSD
• Nature of the trauma: prolonged, severe
• History of prior trauma
• Family history of anxiety disorders
• Personal history of mood disorder, anxiety
disorder
Suggested Coping Skills for Dealing
with Post-Deployment Stress
• Unwanted distressing memories, images or thoughts
– Remind yourself that they are just that—memories
– Talk to someone you trust about them
• Sudden feelings of anxiety or panic.
– Slowing down your breathing may help.
– Learn to “ride the wave”
• Depression
– Talk about losses, changes and gaps between what you dream
and what you have
– Monitor and disrupt negative self-talk
– See the doctor if it last longer than a month
Suggested Coping Skills for Dealing
with Post-Deployment Stress (cont.)
• Feeling like the trauma is happening again
(“Flashbacks”)
– Keep your eyes open. Look around you and notice where you
are. Tell yourself, “I am at ___”
– Call someone you trust and tell them what’s been happening.
• Trauma-related dreams and nightmares
– If you awaken from a nightmare in a “panic,” remind yourself that
you are reacting to a dream
– Talk to someone or your doctor about your nightmares; certain
medications can be helpful.
Suggested Coping Skills for Dealing
with Post-Deployment Stress (cont.)
• Difficulty concentrating
– Write things down. Making “to do” lists may be helpful
– Break task down into small do-able “chunks”
• Having difficulty feeling or expressing
positive emotions
– Ensure regular participation in activities you enjoy or
used to enjoy.
– Take steps to communicate caring to loved-ones in
little ways: “pleasers,” write a card, leave a small gift,
phone and say hello
Suggested Coping Skills for Dealing
with Post-Deployment Stress (cont.)
• Difficulty falling or staying asleep
– Avoid using your sleeping area for anything other
than sleeping or sexual intimacies.
– Do not lie in bed thinking or worrying. Get up and
enjoy something soothing or pleasant;
• Irritability, anger, and rage
– Take a “time out” to cool off or to think things over
– Talk to someone about the triggers to the anger and
irritability
Helping A Person
Affected By Combat Experiences
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Listen carefully
Spend time with them
Reassure them they are safe
Help with everyday tasks
Allow some private time
Don’t take their anger or other feelings
personally
• Ask how you can assist them
Post-Deployment Growth
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Improved sense of own
vulnerability
•
Sense of increased competence
and self-reliance
•
Increased gratitude for
relationships with significant others
•
More compassion and empathy for
others
•
Greater efforts directed at
improving relationships
•
Greater appreciation for life
•
Positive changes in one's priorities
•
Stronger religious/spiritual beliefs
Resources
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WBAMC OPS 569-2801
El Paso Child Guidance Center Grant
TRICARE
Military One Source
Army Behavioral Health web site:
– www.behavioralhealth.army.mil