What’s a library of books, if no one ever reads ‘em? At the VTSC, we have heaps of books on military culture, transition, and relevant therapeutic approaches. This is the first installment of a new series where yours truly will read a book from the VTSC Library, and provide you with the takeaways.
Once a Warrior Always a Warrior is a fantastic read which is applicable to veterans (or those who are still serving), their families, or service providers who want to expand their perspective and gain a greater understanding of how to connect with their veteran(s). The entire book is worth a read; I shared some concepts in this book with my husband [a 2x combat veteran] to which he exclaimed, “Every service member should have to read this book as part of TAPS class!” I agree. Throughout the book I found three recurring themes: transition is not pathological, PTSD is a real thing, and people can use components of evidence based therapies themselves (i.e. self-help) for both transition and PTSD. Let’s delve into each.
- Transition is not pathological
- And, on the other hand, PTSD is real
- Self-Help use of components of evidence based treatments
Anyone shocked by this? I am, having transitioned off active duty and still serving in the Reserves, transitioning from military to civilian culture feels pathological. Dr. Hoge illustrates this concept in a variety of ways, the most powerful:
“Society hasn’t yet grasped that transitioning home from combat does not mean giving up being a warrior, but rather learning to dial up or down the warrior responses depending on the situation” (p. x). Speaking for my social group & myself, the message society sends us that our military self cannot be interwoven with our civilian self. Learning to blend both identities would alleviate a lot of distress!
Hoge also explains a few ways in which this blending can be tricky. First, he states that: "The dilemma is that the reactions that are necessary for survival and success in combat are not easy to dial down and adapt after coming home. Society believes that a warrior should be able to transition home and lead a “normal” life, but reality is that most of society has no clue what it means to be a warrior. Those who have worked in a war zone understand that their warrior responses, including responses doctors may label “PTSD” could be needed in the future." (p. xii). This point is key for the mental health providers; what is “normal” for the general population is not necessarily normative for military culture.
Dr. Hoge later explains the roles of the limbic system (ensures that you can react immediately to threat) & prefrontal cortex (in charge of impulse control, judgement, & decision making). The problem here is that the prefrontal cortex can’t work effectively when there is sleep deprivation, high-intensity combat, or other very stressful experiences. This results in less control of the limbic system, which means higher likelihood of overreacting (generally with anger) or activation of other fight/flight responses to situations that aren’t particularly dangerous (p. 56). Given that the prefrontal cortex does not stop developing until about the age of 25, I would also be interested in hearing the author’s thoughts on brain development in a military/combat context.
The military does not exactly offer an incentive to seek mental health care, or to even accept that PTSD/any mental health diagnosis is a possibility. That, coupled with the message that “transition is not pathological,” can be confusing. PTSD is real though. Thanks to the inception of the DSM-III, which included PTSD for the first time, veterans & mental health professionals can communicate about the collection of symptoms associated with life threatening traumatic events. Fun fact: the DSM-III came into effect in 1980; meaning Vietnam War Era Veterans were unable to receive treatment or compensation for the very serious post-war reactions they suffered (p. 8).
Dr. Hoge addresses my concern about the confusing dialectic of PTSD being real and transition being non-pathological. Hoge states: "The answer has to do with the perspective in our society that problems attributed to mental health are “disorders” or “illnesses” and you can only ask for help when something is “wrong” with you. This perspective doesn’t match reality and we need to get used to the idea that some normal emotional or physical responses can be devastating and life-changing and that we always need a way to work through these events. We need to start viewing mental health problems as part of the normal human experience." (p. 171). For mental health providers & family members this means changing your questions (or biases) from “what’s wrong with you?” to “what’s bothering you?”
As a mental health provider myself, I was stoked to see the innovative self-help use of components of multiple evidence based treatments! Dialectical Behavior Therapy (DBT), Narrative Therapy, Progressive Muscle Relaxation, & Prolonged Exposure all made cameos in this book. With that being said, it would be overwhelming to attempt to practice all the skills in this book; I recommend that the reader read one skill a week and make a plan to consciously practice the skill throughout the week. Just like going to the gym, it’s unlikely I’ll see results if I go just once.
DBT (Linehan, 2015)- This text offers a very simplified version of the DBT Emotion Regulation Skill, Check the Facts. On page 98, Hoge walks the reader through an exercise where they identify the emotion & labeling the threat. It looks a little something like this: Am I feeling afraid/scared/fearful? Yes No If yes, what am I afraid of?
Later in the text, Hoge presents a dilemma where the reader is to imagine that they were bumped into, and that this elicited an irritable response within the reader. Hoge then walks the reader through multiple causes for why they were bumped into. One being that the other person was drunk and didn’t realize they bumped into the reader. This is an example of the observe and describe mindfulness skill in DBT; you can’t describe what you don’t know! The reader automatically assumed the bump was a slight against them, when likely it had nothing to do with them at all. On the other hand, what if it was intentional? The effective (another DBT mindfulness skill!) thing to do would be to avoid picking a fight, even it were satisfying at the time. Also worth quoting, Dr. Hoge states, “One of the key warrior skills is to know when it’s necessary to fight and when a fight can be avoided. This is the path of the Samurai. This is wisdom.” (p. 101).
The last set of DBT skills I’ll mention are radical acceptance & the mindfulness skills effective, observe, & describe. These skills were present in the author’s explanation of the illusion of choice. When life is uncontrollable, humans tend to imagine other options that would have turned out better (i.e. “If I had…”). Pondering these options gives us the feeling of control, the illusion of choice, but not true control. In a backwards way, this adds to the distress. As Hoge eloquently put it, “The problem is that most of this depends on accurately predicting the future, which is impossible.” (p. 149).
Narrative Therapy- My grandfathers served in Vietnam, and as a child my parents (my dad is also a combat veteran) would prompt me: “Remember, don’t ask Grandpa about Vietnam.” Society hasn’t changed much since then. Sebastian Junger wrote a book and did a TEDtalk on it; and a colleague of mine (Jeb Wyman) took it a step further by personally hearing [literally and figuratively] service-members’ stories and compiling them into a book (What They Signed Up For: True Stories By Ordinary Soldiers). Back to Dr. Hoge’s book, it was relieving to me to see him acknowledge that narration is hard, but also validating its necessity by encouraging narration with supportive exercises (p. 116).
Prolonged Exposure- Hoge magnificently (or controversially?) developed a way to use principles of prolonged exposure on ourselves, while simultaneously providing encouragement to the reader to see a mental health professional if the self-help version is not working. Hoge used the term “resiliency inoculation exercise,” instead of prolonged exposure (p. 135); for the population reading this book, I found it to be charming & appropriate.
Progressive Muscle Relaxation- Progressive Muscle Relaxation is heavily used in a variety of therapeutic modalities; and being a provider who teaches this to their clients I was surprised to see that I should practice what I preach. Hoge explains that warriors often hold a combat-ready posture, even “when strolling through the park or mall.” Hoge exemplified the physical problems this can trigger (chronic pain, high blood pressure, poor sleep), and provided a solution: progressive muscle relaxation (p. 65).
Hoge, C. W. (2010). Once a warrior always a warrior. Guilford, CT: Globe Pequot Press.
Linehan, M. M. (2015). DBT skills training. New York, NY: The Guilford Press.
Kimberly Hardy, MA