Staff Perspective: Focus on Peace – An Antidote for Provider Helplessness
I recently sat in on a discussion with Ukrainian providers who were discussing how to handle provider burnout. These were primarily providers who are directly working with fighting troops or providers who work with families who evacuated and have loved ones fighting. One of the providers shared feeling helpless when it comes to being able to help, from a behavioral health perspective, people who are experiencing ongoing war. This feeling was quickly confirmed by the other providers on the call. It got me thinking of the difference between working with patients after an event versus working with patients during an ongoing traumatic/war situation.
From my experience, there is definitely a difference with how to approach behavioral health care. In a combat situation, you can’t “fix” what is wrong. I’d go as far to say that you can’t “treat” them, unless you pull them out of the combat environment. They are in an ongoing life-and-death situation where they are repeatedly exposed to traumatizing experiences. It is similar, if not the same, to helping a patient who is in an ongoing abusive environment. I believe feeling helpless is normal for providers in these cases, given they know that the person they are working with is going to keep experiencing trauma. So how do we as providers cope with our sense of helplessness, knowing that whatever we do our patients are simply going to walk right back into their life-and-death struggle?
I believe the answer is centered around the idea of “finding peace”. When I was embedded with a forward deployed unit during my time in Iraq, I quickly discovered that I couldn’t fix what was “wrong” with those individuals who sought me out. They were experiencing understandable stress that was unfathomable. Depression, extreme grief, and trauma reactions were expected. But what I could do was help them find a sense of peace around whatever they were struggling with, which is what I honestly believe they were looking for in the first place. They didn't want me to “fix” them. They were simply seeking a sense of peace with their turmoil.
My job was to help them find that peace and whatever that meant. Focusing on how to help bring some sense of peace is what I did to combat my own sense of helplessness. I remember thinking how messed up it was, that my job was to keep them together enough so they could get back into the fighting. My job was weapon’s repair, not treating them to get back to actual mental health in the conventional way. I constantly reminded myself, though, that my goal in combat was to actually help them survive to make it home. I’d deal with the fallout of combat and “treatment” then.
What do I mean by helping patients find peace during an ongoing struggle? I found that a sense of peace can be found for a variety of reasons, traumatic experiences and what they discover they are capable of during war being common ones. Sometimes warfighters struggle to understand why they acted a certain way during an incident. Helping them understand their actions in reference to the fight/flight response, their emotional mindset, their training, or simple mission needs and the need to do whatever it takes to save their comrades can go a long way with helping them find peace with their actions. I then normalized their emotional reaction to it, pointing out that their struggle with their actions and what they witness is proof that their humanity and “soul” remains intact. I think this is a common concern that warfighters struggle with – that they are losing their sense of humanity and soul. The look of relief I’ve seen after this discussion is how I know that I’ve helped that person have a bit of peace around this worry of theirs.
Often, I found warfighters struggling with how “senseless” the deaths and overall destruction was, knowing that it wasn’t over and they would continue to experience these things. I remember how disheartened I felt with this came up, because in a very real sense they were right. This is one area where how I dealt with it during combat is close to how I deal with it now, after the fact. The key to finding peace in this case is to help them create meaning from the situation. For example, if someone died, instead of focusing on the senselessness of the death, how do they honor that person’s legacy and make it so their life and possibly death is not meaningless? What was important to the deceased? How did they impact the world in a positive way? How can the individual honor them and continue the deceased’s legacy in the world? I’ve had patients, for example, find ways to comfort others in the way the deceased used to, or volunteer for organizations that were important to the deceased. Regarding the senselessness of the overall war situation and things they see not involving death of a comrade, I help them consider how they can engage in reparation. Perhaps this meant a specific kindness to a civilian in the combat zone. Or more internal, personal actions such as saying a prayer for those negatively impacted.
I also remember helping soldiers find peace regarding their mindset, specifically around being okay with dying. What do I mean by “being okay with dying”? It is important during combat for warfighters to accept that they might die and, in fact, be okay with that fact. Having this mindset allows them to not only do what is needed during combat, but also helps them cope with the anxiety and fear about possible death. This mindset, however, can create conflict between being “okay” to die but knowing they have family back home who need them. One gentleman I talked to was struggling with how he could be okay to die when he had children back home who would miss him if he were gone. We talked awhile about how he had already impacted his children’s lives and his legacy with them, regardless if he returned home or not. He in particular sticks in my mind because I distinctly remember wondering at some point in our discussion if I was helping him at all, feeling helpless as a provider. But then, at the end, he thanked me, stating that our talk had helped a lot. That helped me so much in my discovery about the importance of helping them find peace.
Another soldier I recall talking to in the warzone was angry about what he perceived were the political reasons we were in Iraq in the first place. We know from research that soldiers can really struggle if they do not support the reason for the mission, so it is important to help them find peace on this topic. How did I do it? This soldier came in yelling about the politics, the stupidity of it all, and wondering why he continued to go out on convoys every day “just to get blown up”. He argued that he shouldn’t be going out to fight anymore for the political reasons he cited. I pushed right back at him, stating that it wasn’t about politics and the reason he went out there every day was because there was no way he was going to let his guys go out there without him. He calmed right down, stating I was right. I had refocused the purpose of why he fought from politics to thinking about his colleagues and doing what he could to protect them. A key saying with the military is that the reason they fight is because of the person to their left and to their right. No warfighter in the history of warfare has ever fought for a political cause – politics is just what gets them to a location, but it isn’t why they fight. They fight for each other. Period. So if you have a person struggling with the mission reason, refocus them onto their comrades. In this, they will find peace for why they fight.
Helping warfighters find peace isn’t always about what is happening in the combat zone. Sometimes what is weighing heavily on them has to do with things back home. In those cases, it was a lot like the therapy I’d do outside a warzone, if not exactly the same. But it had a different spin on how important it was – in a warzone it can be very dangerous if a soldier’s mind is being distracted by concerns at home. And if some of their depression or stress can be “fixed” because it isn’t related to ongoing war/trauma, then it feels even more important to remove that load given the expected emotional stress that war creates. It is like being able to lighten the load where you can, so that the added load won’t tip them over the edge.
One soldier I worked a lot with while deployed struggled with his connection with his wife. They had a lot of problems in their relationship, and he honestly didn’t know if he still loved her. We worked a lot on understanding his struggles with attachment in general and how this impacted his marital relationship. We also worked on communication skills, so he could better talk with his wife about their problems. When he came back from R&R (a two-week “vacation” from combat), he reported having talked with his wife and working a lot of their difficulties out. For the first time, he was looking forward to the end of deployment and returning home, excited to continue working on his marriage. His actual quote – “I don’t know if we will make it, but I know I love my wife and I’m going to try.” I remember this quote with tears, because two days after he said this, he died. I struggled a lot afterwards with how I felt about this. Yes, it was horribly sad that he never got home, but it was more than that. I finally realized that there was an emotion I don’t think we have an English word for, combining grief and satisfaction, perhaps? I realized that the day he died, he knew he loved his wife and she loved him. Remembering his smile, I know that in this, at least, he knew peace.
Focusing on helping patients find peace isn’t just about ongoing war and trauma. It is something I think we can focus on after the trauma is over as well – finding peace with their history and experiences. Nothing will “make it okay”, but they can be okay with living with it. I hope that my thoughts above will not only help providers in active combat but also those working with anyone who has experienced trauma. I truly believe that it is normal to sometimes feel helpless when working with people experiencing ongoing trauma. It is also normal to sometimes feel helpless with those not in active trauma situations, given the intensity of what patients sometimes experience. The key is to know we aren’t alone in this feeling, and to know that this sense of helplessness is probably coming from our drive to “fix” things and do a treatment that will take away a mental health diagnosis and the person’s overall struggle. When we feel helpless, we need to adjust what we are focused on. My default is to consider how to help the person find peace with their situation and experiences. I believe that much of the time, this is what they are truly looking for anyway, not to have their situation “fixed” but to be at peace with it.
The opinions in CDP Staff Perspective blogs are solely those of the author and do not necessarily reflect the opinion of the Uniformed Services University of the Health Science or the Department of Defense.
Debra Nofziger, Psy.D., is a Senior Military Behavioral Health Psychologist and certified Cognitive Processing Therapy Trainer with the Center for Deployment Psychology (CDP) at the Uniformed Services University of the Health Sciences in Bethesda, Maryland.
I recently sat in on a discussion with Ukrainian providers who were discussing how to handle provider burnout. These were primarily providers who are directly working with fighting troops or providers who work with families who evacuated and have loved ones fighting. One of the providers shared feeling helpless when it comes to being able to help, from a behavioral health perspective, people who are experiencing ongoing war. This feeling was quickly confirmed by the other providers on the call. It got me thinking of the difference between working with patients after an event versus working with patients during an ongoing traumatic/war situation.
From my experience, there is definitely a difference with how to approach behavioral health care. In a combat situation, you can’t “fix” what is wrong. I’d go as far to say that you can’t “treat” them, unless you pull them out of the combat environment. They are in an ongoing life-and-death situation where they are repeatedly exposed to traumatizing experiences. It is similar, if not the same, to helping a patient who is in an ongoing abusive environment. I believe feeling helpless is normal for providers in these cases, given they know that the person they are working with is going to keep experiencing trauma. So how do we as providers cope with our sense of helplessness, knowing that whatever we do our patients are simply going to walk right back into their life-and-death struggle?
I believe the answer is centered around the idea of “finding peace”. When I was embedded with a forward deployed unit during my time in Iraq, I quickly discovered that I couldn’t fix what was “wrong” with those individuals who sought me out. They were experiencing understandable stress that was unfathomable. Depression, extreme grief, and trauma reactions were expected. But what I could do was help them find a sense of peace around whatever they were struggling with, which is what I honestly believe they were looking for in the first place. They didn't want me to “fix” them. They were simply seeking a sense of peace with their turmoil.
My job was to help them find that peace and whatever that meant. Focusing on how to help bring some sense of peace is what I did to combat my own sense of helplessness. I remember thinking how messed up it was, that my job was to keep them together enough so they could get back into the fighting. My job was weapon’s repair, not treating them to get back to actual mental health in the conventional way. I constantly reminded myself, though, that my goal in combat was to actually help them survive to make it home. I’d deal with the fallout of combat and “treatment” then.
What do I mean by helping patients find peace during an ongoing struggle? I found that a sense of peace can be found for a variety of reasons, traumatic experiences and what they discover they are capable of during war being common ones. Sometimes warfighters struggle to understand why they acted a certain way during an incident. Helping them understand their actions in reference to the fight/flight response, their emotional mindset, their training, or simple mission needs and the need to do whatever it takes to save their comrades can go a long way with helping them find peace with their actions. I then normalized their emotional reaction to it, pointing out that their struggle with their actions and what they witness is proof that their humanity and “soul” remains intact. I think this is a common concern that warfighters struggle with – that they are losing their sense of humanity and soul. The look of relief I’ve seen after this discussion is how I know that I’ve helped that person have a bit of peace around this worry of theirs.
Often, I found warfighters struggling with how “senseless” the deaths and overall destruction was, knowing that it wasn’t over and they would continue to experience these things. I remember how disheartened I felt with this came up, because in a very real sense they were right. This is one area where how I dealt with it during combat is close to how I deal with it now, after the fact. The key to finding peace in this case is to help them create meaning from the situation. For example, if someone died, instead of focusing on the senselessness of the death, how do they honor that person’s legacy and make it so their life and possibly death is not meaningless? What was important to the deceased? How did they impact the world in a positive way? How can the individual honor them and continue the deceased’s legacy in the world? I’ve had patients, for example, find ways to comfort others in the way the deceased used to, or volunteer for organizations that were important to the deceased. Regarding the senselessness of the overall war situation and things they see not involving death of a comrade, I help them consider how they can engage in reparation. Perhaps this meant a specific kindness to a civilian in the combat zone. Or more internal, personal actions such as saying a prayer for those negatively impacted.
I also remember helping soldiers find peace regarding their mindset, specifically around being okay with dying. What do I mean by “being okay with dying”? It is important during combat for warfighters to accept that they might die and, in fact, be okay with that fact. Having this mindset allows them to not only do what is needed during combat, but also helps them cope with the anxiety and fear about possible death. This mindset, however, can create conflict between being “okay” to die but knowing they have family back home who need them. One gentleman I talked to was struggling with how he could be okay to die when he had children back home who would miss him if he were gone. We talked awhile about how he had already impacted his children’s lives and his legacy with them, regardless if he returned home or not. He in particular sticks in my mind because I distinctly remember wondering at some point in our discussion if I was helping him at all, feeling helpless as a provider. But then, at the end, he thanked me, stating that our talk had helped a lot. That helped me so much in my discovery about the importance of helping them find peace.
Another soldier I recall talking to in the warzone was angry about what he perceived were the political reasons we were in Iraq in the first place. We know from research that soldiers can really struggle if they do not support the reason for the mission, so it is important to help them find peace on this topic. How did I do it? This soldier came in yelling about the politics, the stupidity of it all, and wondering why he continued to go out on convoys every day “just to get blown up”. He argued that he shouldn’t be going out to fight anymore for the political reasons he cited. I pushed right back at him, stating that it wasn’t about politics and the reason he went out there every day was because there was no way he was going to let his guys go out there without him. He calmed right down, stating I was right. I had refocused the purpose of why he fought from politics to thinking about his colleagues and doing what he could to protect them. A key saying with the military is that the reason they fight is because of the person to their left and to their right. No warfighter in the history of warfare has ever fought for a political cause – politics is just what gets them to a location, but it isn’t why they fight. They fight for each other. Period. So if you have a person struggling with the mission reason, refocus them onto their comrades. In this, they will find peace for why they fight.
Helping warfighters find peace isn’t always about what is happening in the combat zone. Sometimes what is weighing heavily on them has to do with things back home. In those cases, it was a lot like the therapy I’d do outside a warzone, if not exactly the same. But it had a different spin on how important it was – in a warzone it can be very dangerous if a soldier’s mind is being distracted by concerns at home. And if some of their depression or stress can be “fixed” because it isn’t related to ongoing war/trauma, then it feels even more important to remove that load given the expected emotional stress that war creates. It is like being able to lighten the load where you can, so that the added load won’t tip them over the edge.
One soldier I worked a lot with while deployed struggled with his connection with his wife. They had a lot of problems in their relationship, and he honestly didn’t know if he still loved her. We worked a lot on understanding his struggles with attachment in general and how this impacted his marital relationship. We also worked on communication skills, so he could better talk with his wife about their problems. When he came back from R&R (a two-week “vacation” from combat), he reported having talked with his wife and working a lot of their difficulties out. For the first time, he was looking forward to the end of deployment and returning home, excited to continue working on his marriage. His actual quote – “I don’t know if we will make it, but I know I love my wife and I’m going to try.” I remember this quote with tears, because two days after he said this, he died. I struggled a lot afterwards with how I felt about this. Yes, it was horribly sad that he never got home, but it was more than that. I finally realized that there was an emotion I don’t think we have an English word for, combining grief and satisfaction, perhaps? I realized that the day he died, he knew he loved his wife and she loved him. Remembering his smile, I know that in this, at least, he knew peace.
Focusing on helping patients find peace isn’t just about ongoing war and trauma. It is something I think we can focus on after the trauma is over as well – finding peace with their history and experiences. Nothing will “make it okay”, but they can be okay with living with it. I hope that my thoughts above will not only help providers in active combat but also those working with anyone who has experienced trauma. I truly believe that it is normal to sometimes feel helpless when working with people experiencing ongoing trauma. It is also normal to sometimes feel helpless with those not in active trauma situations, given the intensity of what patients sometimes experience. The key is to know we aren’t alone in this feeling, and to know that this sense of helplessness is probably coming from our drive to “fix” things and do a treatment that will take away a mental health diagnosis and the person’s overall struggle. When we feel helpless, we need to adjust what we are focused on. My default is to consider how to help the person find peace with their situation and experiences. I believe that much of the time, this is what they are truly looking for anyway, not to have their situation “fixed” but to be at peace with it.
The opinions in CDP Staff Perspective blogs are solely those of the author and do not necessarily reflect the opinion of the Uniformed Services University of the Health Science or the Department of Defense.
Debra Nofziger, Psy.D., is a Senior Military Behavioral Health Psychologist and certified Cognitive Processing Therapy Trainer with the Center for Deployment Psychology (CDP) at the Uniformed Services University of the Health Sciences in Bethesda, Maryland.