CHAPTER SEVEN

COMING HOME: VETERANS WITH PTSD ADAPTING TO LIFE AT HOME

Patricia Hentz

    Only the dead have seen the end of war. I have seen the end of war, but the question is, Can I live again?

—From the film Brothers (2009)

This case study focuses on the experiences of veterans returning from war. It draws from a variety of sources including this author’s clinical practice with veterans who were diagnosed with posttraumatic stress disorder (PTSD), historical accounts from literature, films, and research and theories in the areas of trauma and trauma treatment approaches. The focus of the study has been to examine, in depth, the challenges veterans face living with symptoms of PTSD and their process of reclaiming a “normal” life when returning home. The clinical sample for this study included veterans diagnosed with PTSD. However, the broader aim has been to explore and understand veterans’ experiences beyond the diagnosis of PTSD and its list of symptoms.

Using two cross-case exemplars, the author hopes to provide the readers with an inside view of veterans’ psychological challenges returning home from war. Several major themes emerged as relevant to the veterans’ experiences that are presented within this chapter—these themes are reflected in two exemplar case examples. The major themes that were identified in this study included a heightened fear process, compensatory survival behaviors, social disengagement and attachment difficulties, and a shift in attachment bonds.

This case study aims at sensitizing the reader to the experience of veterans with PTSD and their challenges in recreating their lives after experiencing trauma during their military service in combat areas. Of specific interest was how trauma and military experiences impacted veterans’ ability to recreate a sense of “normal” in their everyday lives. Utilizing a case study method framework, this study has sought to shift the focus from the abstract and conceptual list of symptomatology toward the personal and humanistic aspects connected to life experiences.

Case study research places emphasis on identifying the object of study within its social context and the importance of the bond between the object of study and the social context. To illustrate the object of study within its social context, this study has explored the experiences of veterans who have returned home and are experiencing combat-related PTSD. The object of study involved exploring their processes of adapting back to “life at home” and the attempts at coping with symptoms of PTSD. Foundational philosophical underpinnings for the case study research approach were adapted from ethnography and grounded theory research methods and the interviewing, data collection, and analysis involved an ongoing comparison of data and ongoing data analysis and the identification of major themes.

THE LITERATURE

The study of psychological trauma “means bearing witness to horrible events” (Herman, 1997, p. 7). For veterans, the process of healing is indeed a social process requiring a supportive social and political environment. As history has informed us, many veterans have not received the support needed to enable them to recover from their psychological trauma. As one Vietnam veteran shared with this researcher, “I have never told anyone outside of the military of my experiences in the Vietnam War … you are the first person who was not in the military that I have told.” I felt both privileged, and a sense of responsibility toward this veteran.

“To hold traumatic reality in consciousness requires a social context that affirms and protects …. For the larger society, the social context is created by political movements that give voice to the disempowered” (Herman, 1997, p. 9). In essence, the responsibility of this study has been to give voice to the experiences of veterans. The aforementioned veteran had been living with symptoms of PTSD for 40 years: fearful of crowds, trusted few except fellow veterans and family, and exhibited hypervigilance and exaggerated self-protection behaviors.

It was not until 1980 that the diagnosis of PTSD first made an appearance in the Diagnostic and Statistical Manual of Mental Disorders (3rd ed.; DSM-III; American Psychiatric Association [APA], 1980). The PTSD diagnosis was in direct response to the experiences of veterans who served in the Vietnam War. Before Vietnam War, terms such as “soldier’s heart,” “shell shock,” and “war neurosis” were reflective of the psychological difficulties combat soldiers experienced. It is unfortunate that soldiers in these earlier times were often viewed as “moral invalids” and many believed that these men should be court-martialed or dishonorably discharged. They were not offered medical treatment (Herman, 1997). These war experiences were not unique to U.S. military. What we now describe as PTSD symptoms were similar to the nevrose de guerre and kriegsneurose of the French and German scientific literature (Crocq & Crocq, 2000). During World War II, there was increased interest in combat neurosis, which was identified as a psychological problem. It was not seen as a moral deficit but rather was recognized that any man under fire could experience this break down. Appel and Beebe, two American psychiatrists who studied war experiences, came to the conclusion that 200 to 240 days of combat seemed to be the limit of combat experience one could endure and beyond that the strain of combat was very likely. It was believed that the potential for breakdown was related to both the intensity and duration of the exposure to combat. Simply stated, “There is no such thing as getting used to combat” (Herman, 1997, p. 25). Cumulative research has supported the position that higher exposures to extreme stress are associated with greater symptomatology, what might be viewed as a dose–response relationship (King, King, Kean, Foy, & Fairbank, 1999, p. 164). These early ideas have been critical in the understanding of PTSD; both in understanding the risk factors as well as patterns of coping and resilience. What was identified as a protective factor against the development of PTSD symptoms was the strong emotional attachment created among soldiers. These attachments appeared to be grounded in an emotional dependence among peers and leaders and were directly related to both physical survival as well as soldiers’ ability to cope. Veterans today speak about fellow “brothers and sisters” and how they trust them with their lives.

The reality of PTSD and its long-term effects has been very apparent among Vietnam veterans. An estimated 700,000 Vietnam veterans, almost a quarter of soldiers sent to Vietnam from 1964 to 1973, required some form of psychological help (Crocq & Crocq, 2000). PTSD presents as a chronic syndrome that causes significant psychological distress impacting on social, occupational, and relational aspects of the individual’s life. Symptoms include “(i) recurrent and distressing re-experiencing of the event in the form of nightmares, intrusive thoughts or flashbacks; (ii) emotional numbing and avoidance of stimuli reminiscent of the trauma; (iii) and a persistent state of arousal or hypervigilance” (Crocq & Crocq, 2000, p. 53).

Our understanding and treatment of PTSD are still evolving. This researcher’s work with Vietnam veterans, Iraq veterans, and veterans who served in Afghanistan has provided evidence that PTSD is chronic and persistent, impacting on the veterans social functioning and emotional well-being. As one veteran commented: “I have been in therapy 10 years and I was always told to try not to think about the trauma but that never worked.” Many veterans from the Vietnam War have been living with PTSD symptoms for more than 40 years. Many described how they felt like they had become a different person after returning from war. Some spoke about how drugs or alcohol were a means of coping. Others described feeling isolated and out of place in society and a sense of guilt for having survived when so many had lost their lives.

CASE STUDY METHOD

As an advanced practice psychiatric nurse specializing in trauma and therapy approaches, it became evident that the many veterans were not adapting well after returning home from war. The veterans’ symptoms met PTSD criteria and their means of adapting were often extreme and maladaptive. Their efforts to adapt in a nonmilitary environment seemed to defy logic and will. What became evident was that veterans had thoroughly honed their survival skills while in the military, and many of these overlearned skills had been incorporated into their daily lives. As one veteran who served in Iraq commented: “I learned from the Vietnam veterans, ‘DNTA’.” He explained that DNTA means, “do not trust anyone.” Veterans with PTSD remain on high alert and are hypervigilant even in benign/safe situations.

Relevant to the study was how the social contexts, both in war and returning home, were critical to understanding the experiences of veterans. Two exemplar case examples included in this chapter focus attention on the social context highlighting the experience of the veteran and his trauma experience in the military and then after returning home. Direct quotes from veterans will also be presented as evidence to support the identified themes. Major themes within this study include a heightened fear process, compensatory survival behaviors, social disengagement, attachment difficulties, and a shift in attachment bonds.

Veterans go to great lengths to manage their PTSD symptoms through avoidance and compensatory coping mechanisms. Understanding the social context of war and the social context of being back home was key to understanding the broader issues related to how veterans were managing life with PTSD and their efforts to feel normal. Many of the veterans who engaged in trauma therapy experienced a significant decrease in PTSD symptoms and were able to regain a sense of who they were before war. Bessel Van der Kolk’s research on trauma provides further insight into the understanding of veterans’ experiences. “Being traumatized is not just being stuck in the past, it is just as much a problem of not being freely alive in the present” (Van der Kolk, 2014, p. 221).

“Case study research investigates contemporary phenomenon in its real-world context, especially when the boundaries between the phenomenon and the context may not be clearly evident” (Yin, 2014), p. 2). Thus, the focus of this study was to explore how veterans were managing their everyday lives after returning from combat. Data collection spanned 11 months and involved listening to veterans’ trauma experiences as well as how they were adapting to life after returning home.

All veterans included in this study had been in active service in Vietnam, Iraq, or Afghanistan, and had been diagnosed with PTSD. The exclusion criterion for this study was not having a PTSD diagnosis. The veterans ranged in age from 28 to 70 years. Of the 15 veterans included in the case study, two were women. The participants included African Americans and Caucasian males. The two women included in the study were African American. The length and number of deployments varied and were not factors in the analysis. All of the veterans who had been included in this study were informed that information they shared could be used in publications or presentations and that they would not be individually identified in any of the presentations or publications. Direct quotes were used in the development of themes and for the case studies. However, the case studies represent a composite of examples and were not directly attributed to any one veteran.

A multiple case study approach was used using a comparison approach. This inductive approach to data collection involved a replication approach, by which patterns are identified and then compared with cases as the data collection progresses. For example, the DNTA theme was explored in each case reflecting a pattern of replication. This comparison approach helped to assure rigor and increase the reliability of the findings. Focus on the personal and social impacts of DNTA was explored in increased depth and complexity examining why, when, where, and how it occurred. To remain true to the data, this researcher maintained a research journal that included quotes and brief examples of veterans’ experiences. Included were sections on reflections on the data, research memos, and research questions that were emerging from the data, patterns, and theoretical connections. Theoretical evidence and research were critical in the journaling process. The researcher reviewed major works in the areas of trauma and trauma treatment. None of the data included any personal identifying information about veterans. In addition to firsthand accounts from veterans, historical accounts, literature, and films were used to provide confirmatory evidence (Yin, 2014, p. 104). Yin (2014, p. 121) described the “use of multiple data sources as converging the lines of inquiry from different reference points.”

As major themes were identified, data collection continued as a means of verifying the themes and testing out rival explanations.

ETHICAL ISSUES AND RESEARCH METHOD

A critical component in this case study research planning process was the attention to the ethical issues and most specifically, the protection of human subjects. The veterans included in this study were informed that their experiences with PTSD might be used in publications or presentations and that no identifying data would be used in the presentations or publications in order to protect their identity. They could choose to have their experiences included or choose not to have any of their experiences shared and were free to withdraw their consent at any time. As each of the veterans was already working with this researcher and had sought help with his PTSD symptoms, the actual research component added no additional risk in and of itself. The benefits for participants included the ability to share experiences related to PTSD in a safe and supportive environment.

An altruistic benefit for the veterans was in knowing that this information may play a role in helping other veterans in the future and may have an impact on services provided to veterans with PTSD. Participants were informed about the nature of the research and the researcher’s intention to share information with professionals and the public about veterans’ experiences adapting to life back home and dealing with PTSD symptoms in order to help others understand the challenges and the needs of veterans. This approach for maintaining anonymity was to present the multiple case studies as two cross-case analysis, thus not depicting any identifiers from a single case (Yin, 2014). Such case studies are reflective of the aggregate evidence. This approach maintains the integrity of the data and is presented in order to not reflect any single individual veteran’s experience. Given the importance of protection of human subjects, and to some extent the challenges presented in the IRB process, presenting the data as using a cross-case approach and providing exemplary cases were chosen as a credible approach for reporting the significant findings while maintaining the highest level of protection for those participating in the research. Exemplary cross-case studies still adhere to the rigor of case study analysis and meet the general characteristics of case study research, including justifying the relevance and significance of the study, attending to the case and the social context, awareness of and exploring alternative perspectives that might challenge the findings, in-depth and sufficient evidence to support the findings, and presenting the findings in an engaging manner so that the reader is able to “arrive at an independent conclusion about the validity” (Yin, 2014, p. 205).

MAJOR THEMES

Research themes were gleaned from the following data: veterans’ experiences related to combat trauma and veterans’ experiences after returning home, historical accounts of veterans’ war time experiences, research in the area of trauma and combat-related trauma, trauma theory, and films depicting combat trauma and veterans’ lives after returning from war.

Theme One: Heightened Fear Response

The first theme that was universal among the veterans experiencing combat-related PTSD was “a heightened fear process.” As discussed by Foa and Kozac (1986) and Foa, Hembree, and Rotherbaum (2007), fear in the presence of true danger is a normal protective response. However, the response becomes maladaptive or pathological when the individual experiences the following responses: (a) when the fear response does not accurately represent the world, (b) when avoidance behavior is employed in the presence of harmless stimuli, and (c) when nonharmful stimuli evoke a sense of threat and fear. The following examples illustrate veterans’ experiences with heightened fear process.

Veterans could identify that their fear was not rational but at the same time they could not overcome it. Transitioning from a context of combat where danger was an everyday norm, the fear response for these veterans seemed “over learned.” Benign situations in everyday living triggered their fear and avoidance. For many of the veterans, this exaggerated fear response had resulted in a narrowing of their social connections resulting in difficulties with relationships both at home and at work. Some coped by choosing occupations that were more dangerous in that these jobs literally required that they be “on guard.” Examples included correctional officers and police officers. Others restricted their sphere of social interaction to manage their fear and anxiety by working in jobs that were more isolated.

Veteran Quotes: Heightened Fear Response

    When I got home from Afghanistan I got a job as a correctional officer. It was normal to be on guard and not trust anyone. It was part of my job to look for potentially dangerous situations.

    I never take a train or bus because you never know ….it just is not safe.

    I only go to the movies if I can sit in the last row, last seat near the exit. If that seat is not available I just leave the theater. I could never sit in the middle of the theater, I would be looking around and would not be able to even watch the movie.

    If I go to a restaurant, I sit by the door and I have to face the entrance. I will not eat at a restaurant if I cannot sit near the exit and see the entrance.

    I cannot be in any crowds … I do not go to large department stores, the mall, sporting events or event home improvement stores. When I am in a room I take a mental inventory of everyone in the room. I look for any potential weapons that could be concealed. I watch everyone’s behavior and try to determine who might pose a risk.

    I do not like to go too high.

    I am OK when I am sitting in a room with other veterans, then I feel safe.

    I can be with a small group of family but even a large family group makes me nervous. I cannot go to church and I am engaged to be married and I cannot imagine a big wedding.

    My wife wants me to go with her to the mall but I have to sit in the car. It is too stressful and I would never consider going into stores around the holidays.

    When I was in Iraq you never knew who the enemy was. It could even be a kid and you could not trust anyone. I have not been able to get over that feeling. I cannot work and I am home most of the time. You know, PTSD comes with its little friends, depression and anxiety.

Theme Two: Compensatory Survival Behaviors

Another overcompensating approach used by veterans was employing survival behaviors in everyday situations. Compensatory survival behaviors incorporate hypervigilance. Many of the veterans had created anticipatory protective systems aimed at survival, where they focused on surveillance of their surroundings and ever vigilant attention to detect any potential threat. Their survival instinct remained on high alert. A tremendous amount of time and energy was dedicated to survival behaviors depleting energy from creating a meaningful life. And, as noted by Ogden and Fisher (2015), survival is not living.

Veteran Quotes: Compensatory Survival Behaviors

    I protect my home. I dug a fox hole in the backyard for protection.

    When I sleep I have a knife under my pillow.

    I never take the same route to or from work. You never know who is following you.

    Whenever I see someone who is Asian walking down the street I make sure I cross the street. I do not trust “gooks.”

    I had a repair man come to the house the other day. I was in the living room with my 6 year old son. Before I let him into the house I frisked him.

    When I take my son to the inside playground I look for all the exits. One playground had Plexiglas walls and only has one entrance/exit. I bring a glass cutter just in case I need to get out if the entrance is blocked.

Theme Three: Social Disengagement and Attachment Difficulties

Many veterans described how they had difficulty enjoying themselves and had a hard time being around people. They often stated that they felt awkward and were irritable. After returning from war they said that they saw the world differently. They had experienced the death of fellow soldiers and in some ways felt out of place back home. They had difficulty trusting others.

Veteran Quotes: Social Disengagement

    My wife said she did not know me when I came home. She said to me that my husband did not come home. I don’t feel close to her anymore. I can sit next to her on the couch and I feel nothing. She asked me for a divorce.

    I learned from the Vietnam veterans: Do not trust anyone (DNTA). There are very few people I trust. I don’t like to be around anyone I do not know. I just avoid those places.

    (Quote from the movie American Sniper [Cooper, Eastwood, Lorenz, Lazar, & Morgan, 2014] wife speaking to her husband). “You have to make it back to us …. You are not here …. I need you to be human again.”

    I am on edge most of the time. I need to be aware of my anger. On a scale of 1–10, if my anger hits a 5 it goes straight to a 10 and I cannot control myself. This has been a big problem with work and family. I don’t know how to be around people anymore.

Theme Four: Shift in Attachment Bonds

There are basic survival needs that include a need for safety and belonging. In healthy attachments, young children form attachment to caregivers to feel safe and secure. This process is referred to as the social engagement system. In times of war and danger, soldiers also search for attachments for security and protection. In the face of persistent danger, new attachments and bonds are often developed with fellow soldiers, brothers, and sisters creating a sense of loyalty and duty to protect. The phrase used, “I have your back” is reflective of the attachment bonds. Many veterans will even seek redeployment to be back with their fellow soldiers with whom they feel bonded and feel a duty to protect.

The opposite of these attachments has also been observed among veterans returning home who do not rekindle bonds with family or with other veterans but rather isolate themselves. Many of these veterans are represented in the homeless population.

Veteran Quotes: Shift in Attachment Bonds

    I was leading a group of men and it was my responsibility to keep them safe. I watched two of my men blown up. I should have been able to prevent it. I still have nightmares of that day and it was 40 years ago.

    My buddy was killed. He talked about going home. He was going to get married. He had a life ahead of him and was going to build a house and had a business to return to. I did not have any of these things. Why did he have to die? Why wasn’t it me?

    My buddy and I were on watch. We worked around the clock and each of us took turns sleeping. It was his turn to do watch and during his watch a truck passed a bit in the distance and they shot him in the head. I watched him die. I should never have gone to sleep. I should have been watching out for him. They understand the way no one else can.

    I only share my experiences with other veterans. They know what it was like. No one else really understands or cares.

    (From the movie American Sniper [Cooper et al., 2014], in response to thinking about his experience.) “The thing that haunts me is the guys I could not save.”

    From the move Deer Hunter (Cimino, 1978), the extreme form of severed attachments and psychological numbing was portrayed by the Vietnam veteran played by Christopher Walken. While in Southeast Asia, Walken’s character is captured by the Vietcong. As prisoner of war (POW) he and his fellow POWs are forced to play a form of Russian roulette. A revolver with one bullet is passed back and forth between two prisoners and the spectators bet on which of the prisoners will blow his brains out: A terrifying experience. Walken is frozen in fear and unable to pull the trigger. However, after returning home he does not return to his home town, friends, or family but continues to engage in Russian roulette which eventually leads to his death.

Case Exemplars

The following examples have been constructed from the data using a cross-case approach. As discussed earlier, a cross-case approach uses data from multiple cases to construct a representative case. In doing so, it further protects the identity of participants. The names have been changed but the details depict actual experiences and common patterns. Both of the cases represent veterans who were in individual therapy to manage symptoms of chronic PTSD. The context of these cases includes the trauma experience while deployed and then living with PTSD after returning home.

Case One: Veteran Who Served in Iraq for 2 Years

John is a 39-year-old Iraq veteran. He described his time in Iraq as a time filled with anxiety and fear. John described experiences walking down the street seeing men, women, and children, and never knowing who might be the enemy. Being on guard was an everyday, sometimes every minute experience. “I never knew friend from foe.” He stated that before his deployment he had learned from the older veterans, DNTA, meaning, “Do not trust anyone.”

John has been home for 10 years. He thought things would be back to normal when he returned home, but that could not be further from the truth. At that time, he was married and had two sons who were 5 and 7 years of age. Within 2 years he experienced a divorce. Life was not “normal.” He stated that his wife complained that her husband never came home. John had gravitated to work that used his military training. The year he returned he started a job as a correctional officer. He said:

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