Soldiers returning from the Iraq and Afghanistan wars share the same grievances of all warriors throughout history, such as grief, bodily injury, combat stress, fatigue, and emotional anguish. Added to these assaults, many are ambushed by the aftereffects of combat experience, characterized by multiple and extended deployments, conditions such as PTSD and traumatic brain injury (TBI), as well as injuries.
It should also be emphasized that the trauma of war is colored by a variety of emotional experiences, not just horror, terror, and fear. Candidate emotions are sadness about losses or frustration about bearing witness to suffering, guilt about personal actions or inactions, and anger or rage about many facets of the war (e.g., command decisions, the behavior of the enemy).
Described below are the types of stressful war zone experiences that veterans of the first Persian Gulf War reported as well as the psychological issues and problems that may arise as a result. We assume that many of these categories or themes will apply to returnees from the wars in Iraq, Afghanistan and now potentially more.
Some veterans may report anger about perceiving that they were not sufficiently prepared or trained for what they experienced in the war. They may believe that they did not have the equipment and supplies they needed or that they were insufficiently trained to perform necessary procedures and tasks. Some soldiers may feel that they were ill prepared for what to expect in terms of their role in the deployment and what it would be like in the region (e.g., the desert).
Some veterans may have felt that they did not sufficiently know what to do in case of a nuclear, biological, or chemical attack. From a mental health professional’s perspective, veterans who report feeling angry about these issues may have felt relatively more helplessness and unpredictability in the war zone, factors that have been shown to increase risk for PTSD.
It appears that the new wars entail more stereotypical exposure to warfare experiences such as firing a weapon, being fired on (by enemy or potential friendly fire), witnessing injury and death, and going on special missions and patrols that involve such experiences, than the ground war offensive of the Persian Gulf War, which lasted three days. Clinicians who have extensive experience treating veterans of other wars, particularly Vietnam, Korea, and WW II should be aware of the bias this may bring to bear when evaluating the significance or impact of experiences in modern warfare.
Namely, clinicians need to be careful not to minimize reports of light or minimal exposure to combat. They should bear in mind that in civilian life, for example, a person could suffer from chronic PTSD as a result of a single, isolated life-threat experience, such as a physical assault or motor vehicle accident.
Aftermath of battle
Veterans of the new wars will no doubt report exposure to the consequences of combat, including observing or handling the remains of civilians, enemy soldiers, U.S. and allied personnel, or animals; dealing with prisoners of war; and observing other consequences of combat such as devastated communities and homeless refugees. Veterans may have been involved in removing dead bodies after battle. They may have seen homes or villages destroyed or they may have been exposed to the sight, sound, or smell of dying men and women. These experiences may be intensely demoralizing for some. It also is likely that memories of the aftermath of war (e.g., civilians dead or suffering) are particularly disturbing and salient.
Veterans may report acute terror and panic and sustained anticipatory anxiety about potential exposure to circumstances of combat, including nuclear (e.g., via the use of depleted uranium in certain bombs); biological; or chemical agents; missiles (e.g., SCUD attacks); and friendly fire incidents. Research has shown that perceptions of life-threat are powerful predictors of post-war mental health outcomes.
Difficult living and working environment
These low-magnitude stressors are events or circumstances representing repeated or day-to-day irritations and pressures related to life in the war zone. These personal discomforts or deprivations may include the lack of desirable food, lack of privacy, poor living arrangements, uncomfortable climate, cultural difficulties, boredom, inadequate equipment, and long workdays. These conditions are obviously non-traumatizing but they tax available coping resources, which may contribute to post-traumatic outcomes.
Concerns about life and family disruptions
Soldiers may worry or ruminate about how their deployment might negatively affect other important life-domains. For National Guard and Reserve troops, this might include career-related concerns (e.g., losing a job or missing out on a promotion). For all soldiers, there may be family-related concerns (e.g., damaging relationships with spouse or children or missing significant events such as birthdays, weddings, and deaths). The replacement of the draft with an all-volunteer military force and the broadening inclusion of women in a wide variety of positions (increasing their potential exposure to combat) significantly change the face of this new generation of veterans.
Single parent and dual-career couples are increasingly common in the military, which highlights the importance of developing a strong working relationship between the clinician, the veteran and his or her family. As is the case with difficult living and working conditions, concerns about life and family disruptions can tax coping resources and affect performance in the war zone.
Sexual or gender harassment
Some soldiers may experience unwanted sexual touching or verbal conduct of a sexual nature from other unit members, commanding officers, or civilians in the war zone that creates a hostile working environment. Alternatively, exposure to harassment that is non-sexual may occur on the basis of gender, minority, or another social status. This kind of harassment may be used to enforce traditional roles or in response to the violation of these roles.
Categories of harassment include indirect resistance to authority, deliberate sabotage, indirect threats, constant scrutiny, and gossip and rumors directed toward individuals. In peacetime, these types of experiences are devastating for victims and create helplessness, powerlessness, rage, and great stress. In the war zone, they are of no less impact.
Minority soldiers may in some cases be subject to various stressors related to their ethnicity (e.g., racist remarks). Some service members who may appear to be of Arab background may experience added racial prejudice/stigmatization, such as threatening comments or accusations directed to their similarity in appearance to the enemy. Also, Arab-Americans may experience conflict between American identity and identity related to their heritage. Such individuals may have encountered pejorative statements about Arabs and Islam as well as the devaluation of the significance of loss of life among the enemy.
Perceived radiological biological and chemical weapons exposure
Some veterans of the war will report personal exposures to an array of radiological, nuclear, biological, and chemical agents that the veteran believes he/she encountered while serving in the war zone. Given the extensive general knowledge of Persian Gulf War illnesses among soldiers (and the public), there is no doubt that veterans of the new wars will experience concerns about the potential unknown low-level exposure that may chronically affect their health. For some, these perceptions may produce a hyper-vigilant internal focus of attention on subtle bodily reactions and sensations, which may lead to a variety of somatic complaints.
Although this list is not all-encompassing, every mental health practitioner can start with gaining an appreciation of the veteran’s war zone experiences. We must enter into the assessment process informed about the possible stressors and difficulties that may be associated with service in war zones and open to suspending any preconceived notions about how any given individual might react to their personal experience during war.
The psychological assessment and treatment of veterans returning from war is likely to be complicated and clinically challenging, but without question one of the most rewarding specialties a mental health practitioner can work in. Veterans are more than their prior service. Assisting with healing and integrating our brave men and women back into health and happiness is our great privilege.