Editor’s Note: As part of the Center for Deployment Psychology’s ongoing mission to provide high-quality education on military- and deployment-related psychology, we are proud to present our latest “Guest Perspective.” Every other Tuesday, we will be presenting blogs from esteemed guests and subject matter experts from outside the CDP. This allows us to offer more insight and opinions on a variety of topics of interest to behavioral health providers.
As these blog entries are written by outside authors, one important disclaimer: all of the opinions and ideas expressed in them are strictly those of the author alone and should not be taken as those of the CDP, Uniformed University of the Health Sciences (USUHS), or the Department of Defense (DoD).
That being said, we’re very happy to offer a platform where we can feature these individuals and the information they have to share. We’d like to make this an ongoing dialogue. If you have questions, remarks, or would like more information on a topic, please feel free to leave comments below or on our Facebook page, and we’ll pass them along to the author.
By Carroll H. Greene III, Ph.D., ABPP, Col (Ret), USAF
“Comfort and prosperity have never enriched the world as much as adversity has.”
― Billy Graham
Combat stress is an issue that concerns all healthcare professionals and military officers who support and facilitate military readiness. When YOU reflect on the phenomenon we call Combat stress, do you consider it:
Combat stress can be all these things and many more, and, most of them have positive effects on the vast majority of our people (Dobbs, 2009). However, a powerful cultural trend is reducing our collective respect for sacrifice, suffering and other adversity. Adversity is the most critical building block of individual and national resilience or strength. Sigmund Freud declared that people make decisions according to the “pleasure principle”, intuitively seeking comfort or pleasure and shying away from discomfort or pain. Avoiding pain certainly has immediate positive implications for survival. But any environment or lifestyle with a predominance of comfort and very little adversity or pain can cause us to become hyper-sensitive and avoidant to even small amounts of hardship. This avoidance is the enemy of resilience. By resilience, I mean the complex characteristic that allows some people to experience significant adversity and yet retain their capacity to function at or near full capability.
Resilience is the product of stress-inoculation – and, stress-inoculation can only occur during daunting stress. The experiences that an individual has had with adversity – at a painful and yet survivable level – make them more likely to develop the resilience required to adapt, overcome, and succeed, in spite of obstacles in the future. In the military, as in civilian life, those people who are awarded decorations that signify their triumph over danger, fear, wounds and physical and emotional pain are not only respected by others – but, also often hold those victories as significant elements of their self-esteem and confidence (Johnson and Boals, 2015). Triumph over adversity breeds personal resilience. This process is at the heart of stress inoculation. Stress inoculation is - the sequential confrontation, of progressively greater stresses, that shapes our confidence and skill to handle later stresses as yet un-confronted. Resilience is about toughness, and it is only developed by progressive exposure to tougher and tougher, painful or stressful, challenges. These challenges can be physical, mental, emotional, or spiritual - and resilience can be developed in any or all of these areas.
It’s no secret that resilience has become increasingly popular as a contemporary topic in medical and psychological research and education. However, we can be seduced – by the attraction of comfort - into believing that educational lectures on resilience can actually increase or create resilience in people who receive them. In fact, only daunting adversity, when combined with positive adaptive beliefs, produces resilience. Consider the following actual situation, in which a Service member builds resilience by facing a frightening situation incorporating elements of personal trauma.
Case #1: Lance Corporal
Anxious about the potential of hostile treatment during Survival, Evasion, Resistance, and Escape (SERE) training interviews, the female Lance Corporal requested to see the SERE psychologist privately. Watching other classmates undergo this high stress process, she had flashed back to incidents during her childhood when she had been degraded and threatened by her abusive father. Her tearful reaction in anticipation of her own time under this pressure was criticized by her classmates, particularly the female Marines who were her peers in her unit.
She explored with the psychologist her motivations to continue - or drop out of - this high-stress training process. She decided that she very much wanted to deploy and carry out the combat support mission for which she had been selected – and this meant she would have to complete the current training. The psychologist offered the clarification that tearfulness itself was not a problem as long as she could produce the responses she had been taught, and on which she would be evaluated.
In the meantime, one of the SERE instructors asked the psychologist whether he should decrease the pressure he planned to put on this student due to her traumatic background experiences and sensitivity. The psychologist advised the instructor to proceed as usual with the training scenario. He also reassured the student that she could stop at any point - if she believed she could no longer “handle” the stress. He also reminded her that she had already handled the worst part with great strength – when, as a child, she had dealt with the REAL pain of threats by her own father.
The next day she was tasked to enter the high-stress exercise which was observed by the class on closed circuit television. During the most stressful emotional pressures, tears rolled down her cheeks and she sobbed and trembled noticeably. The instructor continued to apply highly stressful pressures and focused on her trembling tearfulness as points for ridicule. But, she was able to demonstrate the learning objectives – even as her tears fell. As the scenario went on her sense of efficacy increased, and she became a bolder in her responses.
A male Staff Sergeant who was picked to facilitate the class critique of her performance commented, “You know…what I noticed is that the instructor focused on criticizing her crying and shaking, and he was distracted by it. He didn’t even notice that he wasn’t accomplishing his task (interviewing) because he was focused in on her physical behavior and trying to shame her.” Other students agreed that her behavior seemed disarming to the instructor. Most concluded that she had accomplished her training objectives, and they congratulated her when she finished. This student’s confidence increased noticeably after this experience, and she went on to perform well in completion exercises, later graduated, and pursued her mission in the combat theater. This story is typical and illustrative of the way that adversity, when properly met with effective motivation and positive attitude, results in personal growth and strength. The only path to resilience lies right through the center of significant adversity.
“Nothing in the world is worth having or worth doing unless it means effort, pain, difficulty… I have never in my life envied a human being who led an easy life. I have envied a great many people who led difficult lives and led them well.”
― Theodore Roosevelt
Resilience Undercut by the Medical Model and Media
Our health care system, based on what is often referred to as the “medical model” of service, does a great job of scanning for, detecting, naming, and treating disease and dysfunction. However, a medically conditioned orientation can automatically limit our focus to the reduction of pain and discomfort. Actually using discomfort to produce strength may not enter our awareness when we are conditioned to a medical perspective. While generally useful in the healthcare setting, a heavy focus on reduction of discomfort actually undercuts the process that develops resilience. As professional experts in human behavior we should be developing attitudes that subtly help patients consider and actualize the strengths that derive from the positive effects of adversity.
A time-tested dynamic – sometimes described as “self-fulfilling prophecy” – has repeatedly shown that people will respond strongly to suggestions from, or the expectations of, those they respect (Rosenthal and Jacobsen, 1966). To facilitate individual and collective strength, leaders should publicly proclaim and champion the strength and growth that result from adversity and pain, when it is met with positive attitudes and actions. The most resilient people believe in the importance of regularly exposing themselves to adversity – and, embracing the pain and struggle inherent in difficult challenges. Some combat troops use the phrase, “Embrace the suck!”
Despite these well-established facts, our information media routinely carry reports of Service members and negative outcomes such as suicide, homicide, family abuse, denial of access to care, and soldiers abandoned by healthcare systems. Incidents representing a small minority of Service members’ behaviours and experiences are sensationalized on the vast majority of information media outlets. The public and our own military members frequently draw their assumptions about the stress of deployment, combat, related dysfunctions - and their prevalence - from these illustrations. We see few—if any—media reports of:
It is a BIG mistake for us to allow the “negative news” formats, prevalent in these venues, to set the tone for our focus - or approach - to leadership of our patients and our forces. Yes – like it or not – healthcare professionals are seen as leaders.
And, the incorporation of positive suggestions and expectations into our interpretations of our patient’s pain and struggles should be commonplace. These suggestions must be offered with sensitivity - and they may not always generate warm appreciative thanks in return. But, our responsibility is to make patients better – not just keep them happy. Courage is a requirement. A small percentage of patients will actually struggle against these positive projections. A few are frightened by the thought of losing their claim to their newly positive – sometimes heroic - identity that accompanies their self-image of victimization – and, their focus on the uncomfortable (therefore bad!) results of their experiences. This secondary gain is in itself a seductive pattern for some. But, many of our patients – who are lost in their negative assumptions - have just never learned that it is possible to find new positive outcomes in their discomfort.
In order to respect and support our warriors effectively, we must relegate media promulgated negativistic sensationalism to the tiny realm of personal amusement, or totally ignore it! The problem is not the exposure of some problems in the healthcare system and in our Service member’s adjustments – it is the unspoken suggestion that such results are the norm.
Some medical professionals are actually surprised by the fact that “combat stress” produces predominantly positive outcomes and enhanced resilience for the vast majority of our Service members. But, for most of us who have lived careers in the military and in medical settings – the benefits of pain and sacrifice are not unknown. In the dialogue below, we can see how a clinician might incorporate positive suggestions regarding adversity into a therapy session.
Case #2: MSgt Bailey
Dr. Smith: “MSgt Bailey, how have your flashbacks been beneficial for you?”
MSgt Bailey: “What do you mean…how could they be positive?”
Dr. Smith: “Well, for example, have they made it hard for you to forget the men who died there?”
MSgt Bailey: “Of course. I end up thinking about them every time I have one.”
Dr. Smith: “That’s what I mean. So, the flashbacks have reminded you regularly of their sacrifice.”
MSgt Bailey: “Of course. My injuries are nothing compared to their sacrifice. That’s a humbling thought!”
Dr. Smith: “So the flashbacks serve to humble you and remind you of the sacrifices of others.”
MSgt Bailey: “Hmm…guess I hadn’t thought of it that way. I had just thought they were bad because they are so uncomfortable.”
Dr. Smith: “Actually, pain and discomfort always have many positive benefits.”
The establishment of positive focus and expectations is critical to excellence in patient care – and, the ability to help patients find this focus can be developed. But, it requires us to re-orient our attitudes to discomfort and distress. From the beginning of care, positive interpretations can be suggested, as demonstrated in this exchange.
Case #3: Mr. Sargent
Nurse: “Mr. Sargent, you told me you retired in 2012 and that you had deployed to Afghanistan and Iraq on multiple occasions. Which deployment did you enjoy the most?”
Mr. Sargent: “I haven’t heard that question before! They were all tough…but, I guess I most enjoyed the second tour in Iraq.”
Nurse: “What was most enjoyable about that tour?”
Mr. Sargent: “Well… I’m not sure, but I guess it was my first tour as an E-6. I was in charge of a team that was really good. These guys knew what they were doing. But, I lost one of those guys halfway through the tour.”
Nurse: “How did he die?”
Mr. Sargent: “Well, I feel responsible still”
Nurse: “In what way?”
Mr. Sargent: “I assigned him to drive…and he was killed when we ran over an IED. Just a one-in-a-million shrapnel hit. Nobody else aboard had serious injuries.”
Nurse: “So whoever was driving might have been killed?”
Mr. Sargent: “Probably.”
Nurse: “I bet, if you can handle losing one of your team, you could handle most anything else life can throw at you? It’s tough that the only way we can get stronger is to go through the pain.”
Mr. Sargent: “Yeah…I guess so. Hope I never have to do it again though.”
Many of our Service members experience uncomfortable personal effects from their combat service. However, the vast majority, despite these discomforts, find the effects of their experience are predominantly positive in their impact on strength and success. Elder and Clip (2006) found that Service members of heavy combat generally became more resilient and feel less helpless over time when compared to other men. Jennings (2006) found that, “Stress, even extremely traumatic stress, may pose both risks and benefits.” It is not the event – but, our interpretation of, and response to, the event that are the most powerful factors determining whether the experience will produce future strengths. But without the event, and its stressful impact - there can be no strengthening of resilience. Pain, sacrifice and discomfort - accompanied by a positive attitude about the power of adversity - are the beginning of enhanced resilience. If we are to provide significant support to the resilience of our forces, we must be able to recognize and promote the qualities and values that make our force – and our nation - strong in the face of threats.
Carroll H. Greene III , Ph.D., ABPP, Col (Ret), USAF, was born in Norfolk, VA and grew up in the Richmond, VA area. He graduated from Virginia State and Virginia Commonwealth Universities. His Bachelor’s and Master’s degrees are in psychology and his Ph.D. is from the Counseling Psychology program at Virginia Commonwealth University. He is certified by the American Board of Professional Psychology and the American Academy of Clinical Psychology. Dr. Greene is also certified as a SERE/RT Psychologist by the Joint Personnel Recovery Agency (JPRA) and is licensed as a Psychologist in North Carolina, Virginia, and Florida. He currently is the Command Psychologist for the Marine Corps Special Operations School and has worked as a psychologist in public, private and military settings since 1975. In 1993 he was the first psychologist to be assigned to the newly established Air Force Special Operations Command (AFSOC). From that time until he retired in 2009, he served at several locations as the senior operational and clinical psychologist for that branch of US Special Operations Command (USSOCOM). He has developed and managed many programs for the selection, training and support of elite forces. During deployments for Operations Enduring Freedom and Iraqi Freedom he supported uniquely sensitive joint and combined special operations missions. He and his family live in Surf City, NC.
Dobbs, D., The Post-Traumatic Stress Trap, in The Scientific American, April, 2009, pgs. 64-69.
Elder, G.H. and Clipp. E.C., Combat Experience and Emotional Health: Impairment and Resilience in Later Life, Journal of Personality, Vol 57, 2, pgs. 311-341.
Jennings, P.A., Aldwin, C.M., Levinson, M.R., Spiro, A. and Mroczek, D.K., Combat Exposure, Perceived Benefits of Military Service, and Wisdom in Later Life, Research on Aging, Vol. 28, No. 1, 115-134.
Johnson, S. and Boals, A., Refining our ability to measure post-traumatic growth., Psychological Trauma: Theory, Research, Practice and Policy, 7 (5), 422-429.
Rosenthal, R. and Jacobson, L.F., Pygmalion In The Classroom, 1968, Springer, Netherlands