Healing War Trauma

A Handbook of Creative Approaches

Raymond Monsour Scurfield, Katherine Theresa Platoni, Raymond Monsour Scurfield, Katherine Theresa Platoni

• Publisher: Routledge
• Year: 2013
• Print ISBN: 9780415637770
• eBook ISBN: 9781136576249
• Topic: Psychology
• Subtopic: Mental Health in Psychology
• Index: Psychology

Healing War Trauma details a broad range of exciting approaches for healing from the trauma of war. The techniques described in each chapter are designed to complement and supplement cognitive-behavioral treatment protocols—and, ultimately, to help clinicians transcend the limits of those protocols.

For those veterans who do not respond productively to—or who have simply little interest in—office-based, regimented, and symptom-focused treatments, the innovative approaches laid out in Healing War Trauma will inspire and inform both clinicians and veterans as they chart new paths to healing.

1 Innovative Healing Approaches to War Trauma

Raymond Monsour Scurfield (Vietnam)

Limitations and Concerns Regarding CBT Approaches

The purpose of this book is to introduce a wide range of innovative therapeutic approaches to healing from war trauma. We have intentionally minimized the presence of evidence-based manually-driven cognitive-behavioral treatment (CBT) protocols, even though they have brought a great degree of relief to a substantial number of military personnel and veterans and offer a significant degree of reliability and consistency to interventions across settings and practitioners.

The major strengths of most CBT approaches typically also are major limitations. There is a very narrow psychiatric symptom focus, oftentimes primarily—if not exclusively—on the “core” DSM-IV-TR criteria for PTSD. It is, therefore, often the case that vital factors intrinsic to military trauma are ignored or downplayed: factors essential to developing an expanded circle of healing. Typically, CBT protocols are applied in individual treatment sessions, involve a regimented intervention that requires strict adherence, and do not appeal to a number of veterans unwilling to be involved in intensive exposure-based approaches. Also, a significant number who do enter such treatment do not complete the full protocol.

Two such protocols, adapted from sexual assault treatment protocols and adopted by the U.S. Department of Veterans Affairs, are Cognitive Processing Therapy (CPT) (www.ptsd.va.gov/public/pages/cognitive_processing_therapy.asp) and Prolonged Exposure Therapy (PET) (http://www.ptsd.va.gov/public/pages/prolonged-exposure-therapy.asp). It has been reported that 70% of veterans who enter VA CBT treatment protocols complete the prescribed treatment regimens, and that 70% of those who complete the regimens indicate “treatment success” (Spira, 2011). This also means that about 50% of the veterans (e.g., 70% of those who start and complete the protocols and 70% of the 70% who actually complete the protocols with successful results) who choose to enter such CBT protocols in the VA do not have “successful” treatment results. Of course, such statistics do not indicate what percentage of the total VA patient population of veterans with PTSD and associated war-related mental health conditions do not, or choose not to, even enter such CBT protocols. This is a substantial group of veterans, with significant mental health conditions, who need treatment approaches that they find sufficiently appealing for them to seek these forms of treatment in the first place. Also, an even larger group of veterans do not utilize mental health treatment services provided by the VA, yet have war-related PTSD and/or other related mental health conditions.

Brock and Passey (2012) report that CBT protocols are frequently insufficient for many and too overwhelming for some, and that prolonged exposure has not been helpful for those service members and veterans with predominant feelings of shame or guilt, or for those with uncontrolled rage around their traumatic memories. Finally, those with significant dissociation or full blown flashbacks are poor candidates for PE until such symptoms are better controlled.

The Rationale for This Book

Veterans suffering from war and service-related PTSD and associated mental health conditions that do not, or are not able to, benefit sufficiently from involvement in most CBT protocols are the primary rationale for this book. One size does not fit all. This includes CBT protocols, no matter how impressive their evidence bases. Also, many service members and veterans with war-related PTSD/associated conditions frequently have great ambivalence, if not unwillingness, to seek treatment in the first place. The limitations and concerns regarding prolonged exposure approaches, and the ambivalence or resistance to seeking needed treatment, make it all the more compelling that there be the widest array of treatment approaches available; this makes it more likely that one or more treatment approaches will be found to be sufficiently appealing to the veteran for him or her to engage in treatment in the first place, and/or to engage in treatment to an extent adequate to garner the therapeutic benefits desired and needed.

Admittedly, there is minimal evidence-based scrutiny of the approaches described in this book—Alpha-Stim technology (Kirsch, Chapter 12) and Mindful-Practices (Mizuki, Chapter 10) are notable exceptions—yet these various approaches have been described, through considerable subjective indicators (the testimony and positive self-report of participating veterans, observations of participating clinicians, etc.), as very positive and impactful. Hopefully, one by-product of this book will be the stimulation of more empirically-based examination, to include qualitative research strategies, of the various healing approaches described.

The availability of innovative healing approaches continues to be significantly hindered by the clamor of many empiricists who insist upon (only) utilizing manual-based CBT protocols. There is the very real danger that the emergence of “new” therapeutic approaches that have yet to be empirically tested will continue to be stifled. Moreover, we have heard from VA colleagues that a number of VA and other clinicians do not prefer to have CBT protocols “prescribed” or mandated as “the” trauma-focused intervention, and that it can be very restrictive and exhausting to have such manually-based, narrow symptom-targeted protocols comprise the primary emphasis of their trauma-focused endeavors. Finally, there is concern that individualized treatment creativity, to address the idiosyncratic aspects of individual patients, is not fully sanctioned.

An Expanded Circle of Healing

Special Populations Impacted by War: The First Element of an Expanded Circle of Healing

Special populations impacted by war are one of two primary emphases of our first book, War Trauma and Its Wake: Expanding the Circle of Healing (Scurfield & Platoni, 2012) (described in the Preface). Trauma-focused interventions require specific knowledge and understanding of the distinctive dynamics and challenges that face several populations of warriors (Reserve forces, et al.), wounded warriors (physically wounded, et al.), and civilians (Iraqi and Afghan civilians, and surviving spouses of service members killed in action). And yet, most CBT treatment protocols do not address, either significantly or in a systematic way, the distinctive, if not unique, issues, dynamics, and challenges that characterize these various special populations. The implication seems to be that it is unimportant to understand, or to attend to, such overlooked characteristics.

We beg to differ.

Individualized assessment and interventions need to account for the distinctive and unique dynamics, characteristics, and healing challenges that typify various special populations. Service member one and two, or veteran one and two, are not identical. Each requires consideration of the veteran’s unique or distinctive characteristics, related to his or her special population status, to be built into treatment protocols and other interventions.

Supplemental and Alternative Healing Approaches

The second characteristic of an expanded circle of healing is to ensure that a full range of healing interventions is available (Scurfield, 2006a and b).¹ We have been impressed with the many paths to healing that are in addition to CBT office-based talk therapy. For example, several Army installations (e.g., Joint Base Lewis-McChord, Ft. Carson and Ft. Bliss) have the Warrior Adventure Quest (WAQ) program. WAQ combines high adventure, extreme sports, and outdoor recreational activities appropriate to the geographic locale; these include rock climbing, mountain biking, river rafting, paintball, scuba diving and ropes courses, followed by leader-led after action debriefings. Such “action-oriented” approaches have an intuitive appeal to many service members, and are geared to assist service members in transitioning their military operational experiences into a “new normal,” enhancing military readiness, reintegration, and adjustment to garrison or “home” life.

VA and community organizations both have implemented beyond-the-office interventions. For example, over 20 VA medical centers offer gardening programs, including a 12 acre parcel at the West Los Angeles VA where veterans propagate fruits, vegetables, and flowers in recognition of “working the earth” as good therapy (Adelman, 2009). The non-profit Farmer-Veteran Coalition helps returning veterans find jobs, training, and places to mend on America’s farms (http://www.farmvetco.org/). Healing War Trauma includes an expressive and creative arts approach embedded in the veteran peer group (Wise and Nash, Chapter 7), an experiential approach to treating traumatic war dreams (Daniels, Chapter 9) and writing as a healing medium for veterans (Capps, Chapter 8). Finally, there are wonderfully impactful canine assisted (Cortani, Chapter 13), equine assisted and scuba diving programs for veterans (Buckley and Raulerson, Chapter 14).

The Salience of Military Peer Relationships to Surviving War and Post-War Healing

The vital peer connections among military personnel reflect the profound interpersonal aspects of healing that are distinctive and crucial to war veterans. Combat or war zone trauma is never an individual experience that occurs in isolation. Rather, it is inextricably embedded within the context of the small, operational, military unit in which profound bonds of comradeship occur among peers and with their small unit command. Once in harm’s way, it is well understood, by those who have been there, that by far the most compelling factor that overrides everything else is the welfare and safety of one’s fellow and sister comrades in the small operational military unit. This often takes precedence even over one’s own safety and, indeed, over the commitment to fighting for one’s country (Scurfield, 2006a).

After returning home, there is the deeply held bond and identity of being a veteran that has been bonded through war and military service, and there is the accompanying belief that non-veterans cannot possibly understand or fully appreciate the military and veteran experience. These fuel the very strong initial tendency that, if a veteran is going to talk with anyone about his or her war experience, it almost universally will be with others who have fought in that same war or served in that same era. For many veterans, this is where the expansion of the healing circle stops. And the same is true for military families—the bonds and belief that understanding can only come from other military families who have “walked in their boots” (ibid.).

This peer bonding and identity is the first and, for many, the most powerful element in an expanding circle of healing relationships. Hence, it is essential to consider how we can make peer groups available as part of what we can offer to help heal from war trauma. Unfortunately, many CBT protocols for war-related PTSD do not pay any meaningful attention to the healing milieu of the military and veteran peer group.

Veterans of Other Generations, Eras and Theaters

Beyond veterans-to-veterans of the same era and war, an additional powerful level is veterans-to-veterans of different eras. For example, this can occur in a therapy group, with veterans of different eras participating, in which veterans of earlier wars readily become mentors with those “new” Iraq and Afghanistan veterans who are facing many of the very same kinds of post-war challenges and issues (Scurfield, 2006a). Chapters in this volume by Zacchea (Chapter 3), Valdes (Chapter 5), Csandl (Chapter 6), and Wise and Nash (Chapter 7) are examples of healing approaches that meaningfully involve veteran peers.

Beyond the Veteran-to-Veteran Circle

Beyond the veteran-to-veteran circle, an expanded circle of healing recognizes that, for a substantial number of service members and veterans, there are additional sets of fractured, alienated and/or voided relationships that, inevitably, have been affected. The indelible impact of combat is a legacy embedded within that can contain, to varying degrees, alienation, loss, grief, anguish, and, for some, bitterness, resentment, and/or hatred. And so, who else, if anyone, does the veteran most need to allow entrance into his or her circle of healing in order to further enhance a more complete post-war recovery?

Today there is a new feeling of strength and self-direction among the People.

It would be good if the Circle of Powers were made whole again.

It would be good to see again Men and Women, Elders, priests, deacons and Sisters

All equal in sharing in the circle of gifts for helping the people.

It would be good to sit down together, to listen to the Elders, to listen to each other’s hearts, to consider, to choose, to pray, for a way of traveling together.

Best for the whole people.

(“The Circle Restored,” in Twohy, 1987, p. 245)

Scurfield describes elsewhere an expanded set of relationships (2006a). Three sets of relationships are briefly summarized here, in order to facilitate consideration of the incorporation of such a paradigm into an expanding circle of healing.

Relationships with Non-Veterans

The next step beyond veteran-to-veteran is for veterans to include those who are significant others in t...

Table of contents

• Cover Page
• Half Title Page
• Series Page
• Title Page
• Copyright Page
• Contents
• List of Contributors
• Series Editor’s Foreword
• Preface
• Acknowledgments
• 1 Innovative Healing Approaches to War Trauma
• Part I Surviving Both War and the Battles Back Home
• Part II Culture-Specific and Community-Based Approaches
• Part III Expressive-Experiential Approaches
• Part IV Mind–Body Approaches
• Part V Animal Assisted and Outdoor Approaches
• Part VI Technological and Web-Based Approaches
• Part 7 Other Creative Approaches
• Index