For many, the phrase “deployment trauma” brings to mind images of combat: improvised explosive devices, taking small arms fire, or traumatic amputations and brain injuries. Over the last 10 years, direct exposure to combat during deployments has decreased. Nonetheless, treating trauma in the deployed environment remains an ever present challenge for military mental health practitioners. This blog will discuss why even objectively safe deployments trigger trauma and some questions to ask when considering whether to process trauma in the deployed environment.
Deployments, including non-combat or low-combat deployments, provide an ideal milieu for unresolved trauma to bubble to the surface of a person’s subjective experience. The deployed environment includes a variety of physical combat trauma triggers. For example, a soldier who was in a mass casualty event when a mortar round hit a DFAC (dining facility) five years ago may fear walking into a similar DFAC, an action required three times a day in the present. Similarly, a transporter currently working a desk job in Kuwait on corps staff may find that the physical environment (tan buildings and tents, the desert, motor pools with military vehicles) triggers the physiological stress response that they repeatedly experienced years ago while convoying on dangerous roads daily. Cognitively, both people may know that their current environment is objectively safe, yet their daily felt-sense (internal bodily awareness) is that they are in danger.
Psychologically containing trauma, a common strategy for managing disruptive trauma symptoms, becomes more difficult for many while deployed. Life can be simpler, which can translate into fewer ways to distract from painful internal experiences. People who avoid uncomfortable thoughts and emotions by staying busy may struggle without the daily demands of childcare, regular access to hobbies, or a part-time job. People who escape their emotions through less healthy means may have difficulty without regular access to the numbing effects of alcohol or online dating sites. Life can also be more frustrating on deployment. There is less control over the day to day environment which can increase irritability and reactivity.
Consider a primary care doctor with a prior deployment that involved repeatedly treating gunshot wounds and blast injuries. The doctor may have successfully kept memories at bay while stateside with a demanding clinic schedule and family responsibilities. A subsequent deployment may be much calmer with a low daily sick call census and ample free time. Instead of enjoying the experience, this person experiences intrusive trauma-related thoughts for the first time in years, corresponding sympathetic nervous system activation, and self-judgment since the current situation should be "easy."
People with a history of attachment trauma, especially in childhood, appear to have greater difficulty with the interpersonal deployed environment. They may struggle with the limited access to their social support networks at home. Often, people with attachment trauma take years to build trusting relationships and their default with new people is to keep a distance to maintain their physical and psychological safety. This can make the loss of one’s established support network more devastating and the task of finding support in the current environment more challenging. They may also feel more threatened by their unit or chain of command. This can be especially difficult when there is no opportunity for time away from the unit. In garrison, many service members go home at the end of the day, providing access to an environment that they have more control over and thus may feel safer in. But on a deployment, they often go back to group sleeping quarters where senior leaders set the bay rules and may sleep feet away. There is no escape if the chain of command feels threatening. In many cases, service members with a history of attachment trauma may be aware of their physical and emotional stress and interpersonal conflicts, but they may not have awareness of or language for the underlying fear or feeling of threat to their safety.
So we know that on deployments, unresolved trauma will bubble up. The next question is what to do with it. Do we attempt to process the trauma in theater or to try to help the person contain their symptoms until they are home? While there is no set answer to that question, I offer some points of consideration that may be useful in collaborating with service members around the decision. Ultimately, we offer counsel, but clients make the call.
Is there a stable frame for treatment? This question involves both therapist and client availability. A therapist responsible for multiple locations who is constantly travelling may not be able to provide regular, predictable treatment. A client’s mission demands could similarly interfere if they involve regular travel, 14-16 hour days seven days a week, or constantly changing shift work that results in chronic sleep deprivation.
Are multiple sessions a week an option? There is good evidence of the efficacy of multiple sessions of trauma treatment in a week. Prolonged exposure and cognitive processing therapy can both be delivered using multiple sessions in a week with similar or better effects than more spaced therapies. Consolidated treatment, if the situation allows, can provide faster relief for the service member and a faster return to full-functioning for the command.
Is this the right time? I’ve processed trauma in theater with outcomes ranging from successful resolution to hospitalization and evacuation. It can be hard to predict how a person will respond to the initial entrance into traumatic material. Discussing the likelihood that symptoms will get worse before they get better with clients is important. For some people, deployments are ideal opportunities to process trauma. Maybe they are a National Guard or reserve service member without regular access to health care in the rear. Or maybe they have more free time, emotional space, and energy with so many demands of daily living removed. Other people may prefer to stay focused on the mission and wait until they return home to process their trauma in a more supportive environment.
A discussion of whether to process the trauma should include informing the client of the risk of symptom worsening, discussing the range of possible outcomes, and discussing strategies to mitigate the risk. Strategies could include helping the client manage symptoms through relaxation training or positive activity scheduling or, if the client is willing, informing the chain of command of the treatment and the potential short term impact on performance. I try to balance being an honest broker with clients (“Yes. This is going to be painful.”) with unwavering belief in their ability to tolerate their own experience (“I know you can do this. And I’ll be right here with you.”)
Ruscio is an Army clinical psychologist and a clinical psychology subject matter expert at the Psychological Health Center of Excellence. She deployed to Camp Arifjan, Kuwait, with the 98th Combat Operational Stress Control detachment August 2016 – May 2017.
The views expressed in Clinician's Corner blogs are solely those of the author and do not necessarily reflect the opinion of the Psychological Health Center of Excellence or Department of Defense.