Tied Paper For Ind Study - Final

Running head: TRAUMA-INDUCED EXISTENTIAL DIS-INTEGRATION
Beyond PTSD…Trauma-Induced Existential Dis-Integration Model
LeAnn E. Bruce, LCSW, BCD, MAC
University of Louisville, Kent School of Social Work
Submitted to:
Sharon Bowland, PhD
Independent Study
May 31, 2010
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Abstract
With the number of Operation Enduring Freedom/Operation Iraqi Freedom
(OEF/OIF) warriors separating from military service steadily increasing, providers are
struggling to meet the challenge of helping these individuals successfully return home.
Historically, efforts to respond to the needs of previous war veterans furthered our
understanding of war-related trauma and treatment, yet the new generation of combat
veterans continues to echo the complaints of the warriors who came before them. This
rising demand has once again illuminated gaps and revealed limitations in our existing
diagnostic nomenclature. Lacking a comprehensive differential classification, clinicians
are forced to choose between assigning a diagnosis of Post Traumatic Stress Disorder
(PTSD) based on etiological assumptions or resort to assigning multiple ill-fitting
diagnoses in an attempt to address the complex picture of co-morbid complaints.
In response to this observation, a comprehensive exploration of professional
literature including historical and empirical resources, as well as the inclusion of
hundreds of personal narratives of my clients (the true experts), was conducted. From
this, the resulting model, Trauma-Induced Existential Dis-Integration (TIED) developed
as a theory-based, conceptual platform from which to launch discussion and further
exploration of the holistic effects of trauma. It serves as a bridge, allowing us to
transition from a paradigm of pathology with an expectation of symptom
reduction/maintenance to a paradigm of recovery with an expectation of personal growth,
strength, and resilience.
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Beyond PTSD: Trauma-Induced Existential Dis-Integration (TIED)
For nearly a decade, the United States Military has been engaged in combat on a
global scale with the wars in Afghanistan (Operation Enduring Freedom - OEF) and Iraq
(Operation Iraqi Freedom - OIF), among other military operations worldwide. With the
first wave of veterans who trickled into our communities in 2002, clinicians have been
facing the challenge of helping these individuals successfully return home. While our
response in the aftermath of previous wars propelled our knowledge and understanding of
the detrimental effects of war on the individuals who have “borne the battle” (Abraham
Lincoln, in his second inaugural address, 1865 found in van Doren, 1942, p.274), we are
still struggling to meet the complex needs of these exceptional individuals. Since the
inclusion of the diagnosis of Post Traumatic Stress Disorder (PTSD) in the 3rd edition of
the Diagnostic and Statistical Manual of Mental Disorders (1980), the mental health
community has endeavored to develop effective treatment programs and services to meet
the complex needs of returning service members, veterans, and their families. Yet, after
nearly half a century of practice and research following the end of the Vietnam War, and
the emergence of countless treatment programs and evidenced-based modalities, the new
generation of combat veterans continues to echo the complaints of the warriors who came
before them – struggling with the same array of diverse and often debilitating symptoms
that complicate successful reintegration to civilian life. Their complex, atypical
presentation challenges the care providers who are committed to helping these heroes –
and who find that they, too, are continuing to strive to understand, diagnose, and treat this
elusive diagnostic phenomenon.
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Soon after the OEF/OIF conflict began in 2001, we began to see a trickle of
combat veterans leaving military service and returning to their civilian lives. By the fall
of 2008, the trickle had turned into a flood of nearly one million OEF/OIF warriors who
had separated from military service (Defense Manpower Data Center, 2008) and returned
to their families, jobs, and communities. As we turn our attention back to the needs of
our returning troops, we find ourselves repeating the historical ebb and tide of interest in
the topic of post-deployment mental health that was so eloquently described by Kardiner
over 60 years ago. “The public does not sustain its interest, and neither does psychiatry.
Hence, these conditions are not subject to continuous study, but only to periodic efforts
which cannot be characterized as very diligent” (1947, p. 1). Judith Herman refers to
this pattern of alternating periods of intensive interest and indifference as “episodic
amnesia” (1997, p. 7). In keeping with this tradition, the recent resurgence of need has
illuminated the gaps and limitations in our existing knowledge base, paradigms, and areas
of expertise – rekindling our attention and generating an imperative to revisit this topic
once again as our warriors turn to us to guide them on this painful journey home.
Over centuries of inquiry, and decades of formal study, we have made great
strides toward the classification of the myriad of symptoms reported by returning
veterans, and have succeeded in validating the existence of the profound and debilitating
effects of war. However, it is becoming increasingly clear that the complex presentation
of symptoms reported in the early stages of reintegration either do not fully or adequately
meet the existing diagnostic criteria (based on specificity, onset, or duration), or
conversely, the criteria fall short of fully capturing all of the symptoms reported. This
presents a dilemma for the clinician who must assign and support a diagnosis in our
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managed-care, diagnostic-code-driven environment. Lacking precise differential
classification, care providers are currently forced to choose between assigning a diagnosis
of Post Traumatic Stress Disorder (PTSD) based on etiological assumptions, or must
resort to assigning multiple ill-fitting diagnoses in an attempt to address the complex
presentation of co-morbid complaints. Either choice presents both ethical and pragmatic
issues with respect to assessing and treating military personnel. Of primary concern is
the supposition that diagnosis drives treatment – if the diagnosis misses the mark, it
follows that treatment recommendations will be adversely affected. Using an example
from the medical field, a patient suffering from dizziness might have any number of
conditions from diabetes, to high blood pressure or inner ear infection. One would not
want to prescribe antibiotics (to treat an ear infection) if hypertension was the real issue.
Another concern we have seen from our historical perspective is that diagnostic criteria
guides research methodology. Studies are based on specific criteria and how they relate
to differing populations, situations, and interventions. Research can only measure what
it is able to define – that which is not defined cannot be objectively studied. Finally, the
stigma of PTSD and other mental health labels, often assigned during the most vulnerable
period of readjustment and reintegration, can have far-reaching effects on the service
members’ career, financial security, relationships, and already strained sense of personal
identity. Having the ability to obtain a clear and complete picture of this array of
symptoms leading to a comprehensive diagnosis is crucial.
In my work with returning veterans, I have become increasingly troubled by the
feeling that I was missing something crucial in their care, and felt that the symptoms they
were reporting were not fitting into the criteria set forth in the current edition of the
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Diagnostic and Statistical Manual of Mental Disorders-IV-TR (2000). As I wrestled
with these concerns while striving to provide the most effective, informed, and
compassionate care to my clients, I began to talk to other clinicians, who admitted to
having similar concerns. Seeking practice guidance, I began a thorough exploration of
professional literature, historical references, empirical research, and professional practice
wisdom. The personal narratives and insights of my clients (the true experts) through
thousands of psychosocial interviews and therapy sessions were also incorporated. This
exploratory journey led to the development of the proposed model: Trauma-Induced
Existential Dis-Integration (TIED) as a framework from which to better understand the
disconnection. This theory-based conceptual model strives to address identified gaps in
the current diagnostic criteria while providing language needed to generate further
discussion in the field, leading to a more effective understanding of this phenomenon,
and to provide a foundation from which to move toward a holistic approach to treatment.
Furthermore, it serves as a bridge that allows treatment to transition from a paradigm of
pathology with an expectation of symptom reduction/maintenance to a paradigm of
recovery with an expectation of personal growth, strength, and resiliency.
The Evolution of Trauma Theory, Diagnosis, and War
Historical Review.
Ancient Warriors Suffered. The literature confirms that this conundrum is far
from new. Homer, in his epic poem, the Odyssey (800 B.C.E.), chronicles the obstacles
faced by the ancient Greek warrior Odysseus, during his ten-year journey to make his
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way home after the Trojan Wars. In this classic story, Homer illustrates the similarities
between this iconic warrior and modern service members stating,
Even then, however, when he was among his own people, his troubles were not
yet over; nevertheless all the gods had now begun to pity him except Neptune,
who still persecuted him without ceasing and would not let him get home.
(Homer, Book 1)
When Odysseus finally arrives at his home, he is in disguise as a beggar, and even his
wife, Penelope, and closest friends do not recognize him. When he finally reveals
himself to his wife, she is mistrustful of him. This “Greek tragedy” is played out
repeatedly in the homes of many returning veterans whose family members state that they
are not the same person they used to be – that the experiences of combat has changed
them into someone they do not recognize. Using the mythological story of Odysseus’
homecoming as a backdrop in his book, Odysseus in America (2002), Jonathan Shay
provides an insightful analogy to the modern day warrior. Through his work with
Vietnam Veterans, he observed the similarities between generations of warriors and the
inadequacy of our understanding of their experiences and needs. Even before the recent
surge of veterans began pouring into our agencies, he writes,
The American Psychological Association has saddled us with the jargon “Post
Traumatic Stress Disorder” (PTSD) – which sounds like an ailment – even though
it is evident from the definition that what we are dealing with is an injury. …We
do not refer to the veteran who has had an arm blown off by a grenade as
suffering from “Missing Arm Disorder (p. 4).
The literature reveals a long history of our attempts to explain the invisible
wounds of war. Hori, an Egyptian warrior (circa 1000 B.C.), described his feelings
before going into battle, “You determine to go forward…shuddering seizes you, the hair
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on your head stands on end, your soul lies in your hand” (Bentley, 2005). In other early
writings, Herodotus, the 5th century Greek historian reports of an Athenian soldier who
was “wounded in no part of his body,” but completely lost his vision after witnessing his
comrade killed in battle. In another example, Herodotus also writes of the Spartan
warrior, Aristodemus, referred to as ‘the Trembler,” this soldier later committed suicide
by hanging (Bentley). Over the centuries, those who have attempted to identify, explain,
and treat these individuals have postulated multiple theories to explain the phenomenon
based on presumed etiologies. A brief historical overview will illustrate that with each
generation of war, there has been a corresponding generation of “disorders” and
treatment recommendations.
Pre-Civil War. In 1678, Johannes Hofer coined the term “Nostalgia” to describe
a similar condition seen in post-combat Swiss mercenaries. The symptoms they
described included dejection, melancholy, disturbed sleep, insomnia, weakness, loss of
appetite, anxiety, cardiac palpitations, and stupor (Grenier, 2005). Also referred to as
“hypochondria of the heart, sufferers took on a lifeless and haggard countenance and
became indifferent to their surroundings, confused past and present, and even
hallucinated voices and ghosts” (Lambert, 2001). Treatment of the day relied on opium,
leeches, and warm hypnotic emulsions. “In 1733, a Russian army officer allegedly found
another cure for nostalgia among his troops. He buried one nostalgic soldier alive,
quickly cutting the syndrome’s prevalence” (ibid.).
The Civil War era. The diagnosis of Nostalgia prevailed for nearly two
centuries and was instrumental in shaping the initial responses to the wounded warriors
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of the Civil War era (1861-1865). There were over 281,000 walking wounded over the
course of this war (Leland, 2010) and many went on to die from their wounds, illnesses
and other complications in the years after the end of the war. Desertion and alcoholism
were epidemic on both sides of the battle (Cruden, 1973). Those who were broken by
the experiences of battle were considered to be malingerers or cowards and execution
was the recommended course of ‘treatment’ (Meagher, 2007). Documented accounts of
veterans reporting anxiety, breathlessness, paranoia, psychosis, memory problems and a
“sunken countenance” (Dean, 1997) following battle were common. In 1871, Jacob
DaCosta published an article in which he proposed that these veterans’ symptoms were a
result of a physiological condition affecting the heart. He referred to this condition as
Irritable Heart Syndrome although it came to be known later as DaCosta’s syndrome or
Soldier’s Heart (Shepherd, 2000). The psychotic symptoms were dismissed as insanity
and no treatment was specifically recommended. These individuals wandered home to
be cared for by ill-equipped family members and many suffered for the rest of their lives.
This remained the popular theory through the beginning of World War I, although other
names came into being such as Disordered Action of the Heart, and Effort Syndrome
were variations of DaCosta’s Syndrome (Shepherd).
The World War-I era. Service members of World War I (1914-1919)
experienced trench warfare and massive explosions, in addition to mortal hand-to-hand
combat. In addition to the symptoms reported previously, literature from that era
describes reports of a “hollow stare”, violent tremors, psychogenic blindness or deafness,
and paralysis. In 1917, British psychologist, Charles Myers, coined the term “shell
shock” in an attempt to diagnose and understand this collection of symptoms. He
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observed that many soldiers returned displaying hysteria, anxiety, paralysis, blindness or
deafness, nightmares, insomnia, heart palpitations, depression, dizziness, disorientation
and loss of memory (Myers, 1940). Myers believed that the concussive nature of
experiencing the vibrations of explosions were to blame for possible changes within the
brain. Still operating from a physiological perspective and continuing to attempt to
develop a single comprehensive diagnosis for the complex symptoms, Meyer and others
of that era began to include a focus on the psychiatric symptoms. While his theory may
actually been the forerunner to what we now understand to be the effects of Traumatic
Brain Injury, he was instrumental in advocating for efforts to delve into the underlying
psychological and emotional aspects of trauma, but was met with a great deal of
resistance from other theorists and military entities (Shepherd, 2000). On a positive
note, this war began to take a serious look at the aftermath of war on the individual. The
U.S. Army Surgeon General’s Office, Chief Consultant in Psychiatry, Thomas Salmon,
recognizing the prevalence of the emotional wounds of war initiated the first forward
treatment model on the battlefield, an unprecedented tactical move (Meagher, 2007).
However, the stigma of utilizing these services was a barrier to care. Sufferers were still
regarded as weak moral invalids. Lewis Yealland (in his Hysterical Disorders of
Warfare, 1918) proposed treatment of shaming, threats and punishment (Herman, 1997,
p.21). Thomas Salmon wrote, “Distinguishing between mental deficiency and the
mental reactions is one of the problems of the Army” (as quoted in Menninger, 1948).
Menninger observes that this statement, written in 1919 was just as true in 1939. Sadly,
this statement continues to be relevant today as the military wrestles with the onslaught of
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disability claims while trying to rule out pre-existing conditions such as malingering or
personality disorder diagnoses (for which there is generally no compensation).
The World War-II era. Veterans of World War II (1939-1941) continued to be
plagued by shame, guilt, psychosis and memory problems. Menninger states, “for every
four men wounded, there would be one psychiatric casualty” (1948, p. 11); a statistic that
continues to ring true in the most recent research on the incidence and prevalence of
PTSD (RAND, 2008). Awareness that the experience of battle was directly related to
many of the common complaints was increasing. The terms “battle fatigue” and “war
neurosis” (Kardiner, 1941) began to emerge in the wake of World War-I and throughout
World War-II to describe the collection of symptoms reported by veterans when returning
from battle. For Kardiner, the manifestation of symptoms was a result of the
individuals’ struggles to adapt to the painful changes to their “external and internal
worlds” and efforts to control or eliminate these symptoms (Linder, 2004, p. 26).
Kardiner’s work was also instrumental in illuminating the phenomenon that the effects of
war neuroses were “no longer likely to be confined to combatants” (Kardiner, p. v) and
that the symptoms were “the commonest neurotic disturbance of war” (p.3). Echoing the
concerns from the past, he writes,
The importance of this neurosis is due, not only to the severe incapacities which
result from it, but also to the many and complicated forensic problems which it
brings in its wake. The chief of these is the problem of compensation and the
management of the veteran with such a neurosis. (p. 3)
These words, written in the midst of World War-II, continue to be a controversial and
relevant subject of discussion across the Department of Defense and Veterans
Administration disability claim and reintegration processes. While some of the
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terminology has changed, the intent remains the same. Kardiner outlined the struggles of
the field to reconcile the complexity of the symptoms against the prevailing arguments of
whether it was an organic (physiological) or psychogenic (psychological) manifestation.
In addition, he outlined the five broad areas of dysfunction: shock/terror; comatose
symptoms/dissociation; maniacal reactions; delirious reactions; and paralysis and sensory
disturbances (p. 7). Kardiner recognized, nearly 70 years ago, that a significant feature
of post-war dysfunction was that the individual’s “conception of the outer world and his
own capacities to deal with it have undergone a profound change” (1941, p. 232). He
postulated that the goal of therapy was to reconcile the conception of self with the outer
world “in accord with the new actual reality” (ibid.). While Kardiner’s theories were the
precursor of proactive and optimistic treatment, the prevailing attitude of the time
embraced a pessimistic view that this painful casualty of war was something that the
individual would have to learn to live with (a paradigm that is continues to influence the
prognostic paradigms of the mental health field today).
Psychiatry enters the military environment. William Menninger, a founder of
the Menninger Foundation and Chief Consultant in Neuropsychiatry to the Surgeon
General of the United States from 1943-1946, was instrumental in the development of
standardized classification for mental disorders. Working closely within the military
environment to integrate psychiatric practices into the medical care of soldiers, he
outlined several challenges and obstacles observed during World War-II regarding the
delivery of mental health care for soldiers and veterans. These obstacles included: (a)
lack of plans, (b) unexpected size of the psychiatric problem, (c) few specialists in the
field, (d) line of authority and competing agendas, (e) disposition of treatment, (f) attitude
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toward psychiatric disability and stigma, (g) difficulty in reassigning men (conserving the
fighting force), (h) ineffective officers, (i) misbehavior of soldiers, and (j) position of
psychiatry in medicine (pp. 25-43). Ironically, today’s challenges continue to reflect
these historical observations.
 We have been plunged into a war that was expected to be short-lived, yet has
become our longest sustained military conflict.
 The professional fields and facilities were unprepared for the magnitude and
severity of the injuries that would be returning from this war.
 Due to the efficiency of our forward positioned state-of-the-art med-evacuation
and medical care model, many more individuals are surviving traumatic injuries
than was previously possible – yet are returning with significant impairments and
bio-psycho-social needs.
 The multiple cycles of deployment and numbers of service members rotating
through military service are reaching unprecedented proportions.
 After four decades of peacetime, very few community providers are trained to
treat military trauma specifically.
 Those who work with active duty personnel are subject to the individual’s chain
of command which may have competing agendas and may not view mental
illnesses with the same regard as they would a more obvious physical injury.
 Commanders are tasked with the fulfillment of the mission and keeping the Army
at full fighting strength.
 Officers and other non-medical personnel in the chain of command often are not
properly trained to identify or address mental health issues and often mistake
disorganized behavior as a need for discipline rather than considering the
possibility that the behavior indicates the presences of emotional strain. And,
 Our warriors continue to experience multiple barriers to care.
The need for standard nomenclature. During the period of 1940- 1945, an
interdisciplinary joint sub-committee of the recently formed American Psychiatric
Association convened to develop a standardized classification system to resolve the
discrepancies, inconsistencies and misnomers prevalent across the multiple
interdisciplinary fields. In 1946, the first Standard Classified Nomenclature was
published (Menninger, 1948). The psychiatric portion of this nomenclature
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differentiated the Transient Reactions to Stress from the more pervasive psychoneurotic
disorders. Within the framework of the transient reactions to stress, the term Combat
Exhaustion Disorder (as identified and postulated by the military) differentiated post-
combat symptoms from Anxiety Reaction, Dissociative Reaction (pp. 557-571) or from
the effects of physical trauma (Figley, 1978). This classification system remained the
standard until 1952 when, in the midst of the Korean War (1950-1953), the first
Diagnostic and Statistical Manual for Mental Disorders was published. Providers had
been increasingly aware of the inadequacy of the Standard Classified Nomenclature and
collaborated to revise the classifications and terminology in order to provide clarity and
further standardization (American Psychiatric Association, 1952). Under this new
guidance, the collection of symptoms related to war trauma were referred to as Stress
Response Syndrome under the broad heading of Gross Stress Reactions. Illnesses that
were considered to be pervasive mental disorders were thought to have an organic
etiology and/or caused by damage to brain tissue function (ibid.).
The Vietnam War era. The classification and ideology of the first edition of the
Diagnostic and Statistical Manual prevailed throughout most of the Vietnam War (1964-
1973) in spite of the outcry and lobbying efforts of veterans and military providers,
during and immediately following the Vietnam War. Providers maintained that the
diagnosis and criteria for Gross Stress Reaction was not sufficient to describe or explain
the collection of symptoms they were observing in their veterans clients. While the
psychological effects of war were finally achieving some validation, the symptoms
continued to be viewed collectively and were explained as the result of the individuals’
maladaptive reaction to a situational stressor (war trauma). In an effort to revisit the
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issues and attempt to further clarify the classification system, a new multi-disciplinary
revision committee was assembled and met throughout much of the Vietnam War era.
This committee produced the first substantial revision to the DSM in 1968 at the height of
the Vietnam War (as countless veterans were already returning to communities with the
invisible wounds of war.)
DSM-II: Transient Reactions. In spite of the overwhelming need presented by
returning veterans, the DSM-II regarded combat-related stress as a transient reaction to
the “fear associated with military combat, manifested by trembling, running and hiding”
(American Psychiatric Association, 1968). Regardless of the complexity or severity of
the presenting symptoms (to include psychotic symptoms), this edition defined the
phenomenon as non-specific Adult Adjustment Reaction under the heading of Transient
Situational Disturbance and removed the term, Gross Stress Reaction (Figley, 1978).
This manual broadened the scope of diagnosis to include many different types of trauma
(beyond war-related) and identified several types of reactions to exposure to extreme
emotional stress. Disturbances to mental functioning were referred to as ‘reactions’
rather than specific pathology and were considered to be transient – meaning that there
was an expectation that the symptoms would subside once the stressor was removed.
When the symptoms failed to subside, the individual was diagnosed with Transient
Situational Personality Disturbance and thought to be a condition that was due to
underlying inadequacies of the individual (American Psychiatric Association, 1968).
Linder, through her extensive survey of literature, interviews, and documented accounts
of the historical development of the diagnosis of PTSD, emphasizes that the diagnosis of
Transient Situational Disturbance was the only diagnostic classification available to
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clinicians working with this population in the midst of the reality of increased incidence
of substance abuse, homelessness, violence, and suicides (2004).
The years following the end of the Vietnam War represented a turning point in
our understanding of the existence and effects of war trauma. We owe a debt of
gratitude to our Vietnam veterans, and those who have supported them, for furthering the
development and validation of the diagnosis of Post Traumatic Stress Disorder (PTSD).
Their efforts and sacrifices were instrumental in propelling the field forward with widely
accepted recognition of the “invisible” wounds of battle, validating the profound changes
that may occur within the individual. With over seven million veterans released from the
military after the Vietnam War (Figley, 1978), it was becoming clear to the mental health
providers that a more specific set of criteria was needed to diagnose and treat the myriad
of veterans’ complaints (Keane, 1993, p. 99-100). Matthew Friedman, director of the
National Center for PTSD states that at this time, “People were flooding into clinics,
demanding that we do something for their distress. We had no clinical terminology for
what we were seeing. Their suffering was so raw” (Meagher, 2004, p.19).
A psychiatric social worker at the Boston VA Medical Center, Sarah Haley, began
to notice that she and her colleagues were resorting to “making diagnoses of ‘traumatic
war neurosis’ in the margin of their notes, despite the absence of such a category in the
DSM-II” (Linder, 2004, p. 27). In a paper presented at the annual meeting of the
American Psychological Association in 1977, she and her colleagues presented over
seven years of observations and data compiled through case reviews, and interviews.
This, along with the efforts of the Vietnam Veterans Working Group (V.V.W.G.),
brought to public attention that a “new diagnostic category was needed” (Linder, 2004, p.
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27). The Reactive Disorders Committee was formed to investigate the need for possible
revisions. Still operating from the stance that the symptom constellation was a reaction
to a specific stressors (hence, the name of the workgroup), their intention was to
investigate veteran specific issues. Initially referred to as “post-combat disorder,” these
groups set out to explore and validate the specific existence of a condition shared by
military combat veterans (ibid.).
The Vietnam Veterans Work Group presented the DSM-II revision committee
with criteria that included diagnoses for Brief Situational Psychotic disorder, Brief
Situational Non-Psychotic Disorder, Acute Catastrophic Stress Disorder, Chronic
Catastrophic Stress Disorder, and Delayed Catastrophic Disorder (Figley, 1978, p. xviii-
xix). Their findings revealed this complex constellation of symptoms were not exclusive
to combat veterans but were shared with survivors of other disasters or catastrophes.
The scope broadened, the name changed to Catastrophic Stress Disorder, and the focus
began to shift away from specifically military population and generalized the symptoms
to other groups as well (Linder, p. 28). Within this proposed nomenclature, it is clear that
the group was attempting to provide explanation for many of the complex symptoms,
with special attention paid to the presence or absence of psychotic symptoms as well as
the recognition that individuals have acute, chronic and delayed onset of symptoms
following experiences of extreme stress. With political and social pressure mounting,
there was a sense of urgency to address the identified discrepancies and appease the
providers, veterans, and lobbyists who were demanding a competent, comprehensive
diagnosis. Ironically, the substantiating research came after the diagnosis rather than
before, resulting in a vicious circle conundrum – achieving a valid and reliable diagnosis
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was dependent on availability of empirical data, and without a comprehensive set of
accepted criteria, empirical research was stalled. Amid conflicting theories and lack of
empirical data, the development and inclusion of what was to become Posttraumatic
Stress Disorder was based largely on descriptive and phenomenological data documented
following experiences of “extreme stress” such as war, disasters, and the Holocaust
(Keane, p. 100).
The DSM-III: The birth of PTSD and an Anxiety Disorder. The DSM-II revision
committee on Reactive Disorders was divided over the criteria structure,
symptomatology, and placement of this diagnosis (Linder, 2004). Depending on which
symptom cluster was the focus of attention, some members felt that the constellation of
symptoms was the result of the anxiety and fear produced by a specific overwhelming
stressor or traumatic experience. Other members of the committee argued that this
classification was insufficient and failed to address the highly co-morbid complaints of
depression and dissociative features (flashbacks, numbing, and identity crisis). In the
end, in spite of much debate, and working under professional and political pressure, the
committee settled on placing the diagnosis of Posttraumatic Stress Disorder under the
broad heading of Anxiety disorders in the Diagnostic and Statistical Manual-III
(American Psychiatric Association, 1980), published seven years after the end of the
Vietnam War, and there it has resided ever since. In interviews with committee
members, lobbyists, and providers, following this decision, Linder reports that one
member admitted that “a few issues were left unresolved” (2004, p. 31).
The intention of this edition was to standardize diagnostic classification and
introduced the multi-axial system for comprehensive diagnostic picture. Mayes and
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Horowitz (2005) described this edition as a sweeping revolution to the mental health
field.
In 1980, at one stroke, the diagnostically based DSM-III radically transformed the
nature of mental illness. In a remarkably short time, psychiatry shed one
intellectual paradigm and adopted an entirely new system of classification. The
DSM-III imported a diagnostic model from medicine where diagnosis is ‘the
keystone of medical practice and clinical research’ (Goodwin & Guze, (1996) and
drastically expanded on the described the response to the “distressing event” as
“intense fear, terror, and/or helplessness.” (p. 250).
The DSM-III provided the multi-axial diagnostic structure that we know today.
To the basic premise regarding the etiology of this disorder (as a response to a traumatic
event), this edition established the foundation for the current four-factor diagnosis by
emphasizing the commonly reported presence of re-experiencing, hyper-arousal, and
avoidance (recently, the numbing symptoms associated with the avoidance cluster were
separated for form their own symptom cluster creating a fourth factor.) To address the
other co-morbid symptomatology, this edition also described an array of associated
features including depression, compulsive behavior, memory problems, emotional
liability, and survivor's guilt. It also recognized the potential for delayed onset, and that
impairment could range from mild to severe affecting multiple areas of life (American
Psychiatric Association, 1980). Since the publication of the DSM-III, the new
classification system has shaped our understanding of these clusters of symptoms as a
single phenomenon, and has resulted in a narrowed view of the complexity of this issue.
However, the development and implementation of this set of criteria was a major step
forward and provided the foundation to on which to create standardized screening and
assessment tools and guide further research and treatment recommendations.
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Immediately after the publication of the DSM-III, providers began to identify the
need to expand the language and clarify the criteria. DSM-III-R (published in 1987)
maintained the conception of the disorder as being caused by a traumatic experience
(etiology) and provided little change to the overall diagnostic structure or fundamental
criteria, but expanded the language and examples to illustrate the basic criteria, added
qualifying traumatic event as being “outside the range of unusual human experience,”
added language that expanded the view of intrusive recollections to include dreams and
“in rare instances, dissociative states,” and added impulsivity, headache and vertigo to the
list of associated features. Also added to this revision is a section that mentions
Psychoactive Substance Abuse Disorders as a common “complication” (American
Psychiatric Association, 1987).
DSM-IV emerges: Controversy continues. In 1993, just prior to the publication
of the Diagnostic and Statistical Manual-4th edition, Dr. Elizabeth Brett an advisor to the
revision committee commented that, “PTSD sits uneasily in its present classification as
an anxiety disorder” (1993, p. 191), and cited two reasons that the classification of this
disorder should be revised. First, she points to the intense historical controversy over
whether PTSD was an anxiety or dissociative disorder, and second, the unanimous vote
of the DSM-IV advisory subcommittee on PTSD to classify the diagnosis under a new
stress response category (Brett). Furthermore, multiple studies investigating the co-
morbidity of PTSD with other diagnoses such as anxiety, depression, and substance
abuse, indicate that PTSD and anxiety are likely to co-occur based more upon the nature
of the stressor, but that the relationship between PTSD and anxiety is “modest at best”
(Brett, p. 194). In spite of the findings and advisory committee recommendations, the
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current revision of the Diagnostic and Statistical Manual-IV was published, maintaining
PTSD as an anxiety disorder. With regard to PTSD criteria, the DSM-IV does offer even
greater expansion of the criteria, and language to further define and differentiate between
specific criteria. In addition to the classification structure and language in the DSM-III-R,
the DSM-IV emphasizes the assumption that the experience of trauma is unique and
subjective and can be actual or perceived. Language related to associated features was
added to include potential dissociative states, diminished interest in activities, feelings of
detachments from other people, issues with intimacy, tenderness and sexuality, guilt,
interpersonal conflict, divorce, and loss of job. Also mentioned for the first time, were
symptoms that alluded to something far beyond anxiety – feelings of ineffectiveness,
shame, despair, or hopelessness; feeling permanently damaged; a loss of previously
sustained beliefs, or a change from the individual's previous personality characteristics
(American Psychiatric Association, 1994).
Emerging Contemporary Theories.
Many theories have attempted to address the disconnections and discrepancies
that have frustrated providers and patients alike. One of the leading theorists to focus her
attention on the symptoms that tend to fall out of the PTSD criteria and has continued to
advocate for more concise diagnostic criteria is Judith Lewis Herman. Based on her
research and extensive clinical work with trauma survivors, Herman observed that not all
traumas are the same - so not all “victims” present in the same way. In her book, Trauma
and Recovery (1997), Herman states that the existing diagnostic criteria for PTSD “do not
fit accurately enough” (p. 118). She believed that “there is a spectrum of traumatic
21
disorders, ranging from the effects of a single overwhelming event to the more
complicated effects of prolonged and repeated abuse” (p. 3) and that the presentation of
individuals who had experienced prolonged, persistent or repeated trauma or abuse was
qualitatively different than those who had experienced a single traumatic event (ibid.).
She sought a theoretical model that would tie the extraneous PTSD symptoms to specific
trauma etiology. Much of her theory was based on her work with battered women and
abused children and grounded in developmental and feminist theory with a focus on the
pervasive effects of experiencing oppression, victimization, dependency and helplessness
on the development and core stability of the individual’s personality and sense of self.
The introduction of this theory has been instrumental in bringing attention and awareness
to the multi-faceted changes that occur in the individuals’ life, internally and externally.
Herman began to look beyond the anxiety response assumptions to examine the profound
transformation that occurs in the individual. She asserts that traumatic experiences can
breach attachments with others, shatter constructs of the self, destroy sense of safety in
the world and ability to trust, undermine and violate existing belief and faith systems that
give life meaning, and lead to a state of existential crisis (p. 51). She further asserts that,
The lack of an accurate and comprehensive diagnostic concept has serious

consequences for treatment. Attempts to fit the patient into the model of existing
diagnostic constructs generally result, at best, in a partial understanding of the
problems and as fragmented approach to treatment. (pp 118-119)
Complex PTSD. With every edition of the Diagnostic and Statistical Manual since
the publication of the third edition, Herman and her colleagues have been calling for
formal recognition and inclusion of the diagnosis of Complex-PTSD (a form of PTSD)
stating that, “it is time for the disorder to have an official, recognized name” and that “the
22
naming of the syndrome of Complex Posttraumatic Stress Disorder represents an
essential step toward granting those who have endured prolonged exploitation a measure
of the recognition they deserve” (p. 122). Herman proposed seven areas of diagnostic
criteria for Complex-PTSD as outlined in table 1, below (1997, p. 121).
1. A history of subjection to totalitarian control over a prolonged period

2. Alteration of affect regulation
3. Alteration in consciousness
4. Alteration in self-perception
5. Alteration of perception of perpetrator
6. Alteration to relationships with others
7. Alteration in systems of meaning
Table 1
With regard to diagnosis guiding treatment, Herman (1997) states that Complex-
PTSD warrants specific therapeutic interventions. Recognizing that the symptom clusters
outlined above result in profound changes to the sense of self, shattering of safety and
trust, breakdown of relationships, and sense of grief and loss, she recommends a specific
3-step therapeutic intervention process (p. 156). Herman emphasizes that the first
essential step in treatment for individuals who have endured repeated or prolonged abuse
or trauma was to establish a sense of safety and a secure, supportive relationship (pp.
155-174). Second, she believed that it was vital to allow the individual to mourn and
remember through the telling of the traumatic story in detail so as to process and integrate
it into the present (p. 175-195). Finally, the third step is to encourage reconnection with
others and to find a “survivor mission.” (p. 207). This is a prime example of how
differentiating the nature of the diagnosis can shape and inform the nature of the therapy.
Conversely, if one operates from an erroneous or inaccurate set of assumptions with
regard to the diagnosis, the course of treatment will be adversely affected.
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DESNOS: an Alternative View. From the inception of the diagnosis of PTSD as an
anxiety disorder in the DSM-III (1980), many theorists and investigators continued to
voice their concerns about the “other” symptoms. One such investigator, Bessel A. van
der Kolk, a Harvard professor and colleague of Judith Herman, believed that the “PTSD
criteria captures only a limited aspect of post-traumatic psychopathology” with regard to
psychological functioning (Luxenberg, 2001, p. 373). Van der Kolk, working to develop
an alternate classification system during the development of the DSM-III and thereafter,
proposed the following diagnostic classification structure that came to be known as
Disorders of Extreme Stress – Not Otherwise Specified by the DSM-III revision
workgroup. DESNOS addresses disturbances or alterations in six domains of life as
shown in table 2 below (p. 375):
1. Alteration in regulation of affect and impulses

2. Alteration in attention or concentration
3. Alterations in self perception
4. Alterations in relations with others
5. Somatization
6. Alterations in systems of meaning
Table 2
Similar to Judith Herman’s classification structure, both C-PTSD and DESNOS
observe changes or alterations in mood/affect regulation, concentration, self perception,
relationships, and personal systems of meaning. To this, DESNOS adds the domain of
Somatization – a significant observation for providing a holistic and comprehensive
diagnosis for military personnel who often report multiple somatic complaints that tend to
have no physiological origin (fatigue, generalized pain, digestive problems, erratic heart
rate, and sexual dysfunction, among many others.) Also, a differentiating factor between
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C-PTSD and DESNOS is Herman’s assumption of the etiology of prolonged or repeated
abuse in which the victim reports feeling helpless and/or controlled by the abuse or
abuser. While also strongly associated with experiences of prolonged trauma or stress,
“DESNOS is not officially predicated on a specific traumatic experience,” (p. 375) and
therefore is much more generalizable to many populations stating that it can be the result
of any “history of interpersonal victimization, multiple traumatic events, and/or traumatic
exposure of extended duration” (p. 375).
During the field trials for the DSM-IV, the Structured Interview of Disorders of
Extreme Stress (SIDES) assessment tool was developed and validated. Through this
process, ample evidence was collected to indicate the existence and prevalence of these
symptoms and DESNOS was considered for inclusion as a stand-alone diagnosis or sub-
category of PTSD. However, as a compromise of opinions related to conflicting trauma
theories, the DESNOS name was omitted and the symptoms became known as the
“associated features” of PTSD – giving us a catch all to throw everything that doesn’t fit
under the specific classification structure of PTSD. Subsequent research has shown that
DESNOS and PTSD are highly co-morbid, but it is possible for DESNOS symptoms to
occur with or without meeting the diagnostic criteria for PTSD, and even in the absence
of specific traumatic experiences (Ford, 1999). Ford’s study interviewed 85 veterans
who had been admitted to a specialized PTSD residential rehabilitation program, found
that 58% of the overall respondents met the criteria for DESNOS, 31% met the criteria
for both PTSD and DESNOS, while 28% were diagnosed with PTSD alone, 28% with
DESNOS and 13% met the criteria for neither (ibid.). While this is a small initial study,
in conjunction with the field trials and continued research, there seems to be evidence to
25
suggest that the DESNOS symptoms may be related to, but extend beyond PTSD. Of
current interest is that the existing revision committee for the DSM-V edition (projected
to be published in 2012) is once again considering the inclusion of the DESNOS criteria.
The proposed criteria can be reviewed at www.DSM5.org.
Application of C-PTSD and DESNOS for military populations. As the theories
simultaneously evolved, the terms C-PTSD and DESNOS have become interchangeable
and synonymous in the field and in literature with regard to alluding to the “left-over”
symptoms. However, there are subtle but significant nuances between the two with
regard to specific etiology, theory, assessment, treatment recommendations, and utility to
specific populations – especially for the military. Many clinicians report that they are
familiar with the term Complex PTSD and often use this term to denote a client’s
presentation that is complex and confounded by atypical symptoms without regard to the
specific etiology criteria of multiple traumatic events or prolonged trauma experience.
They mistakenly refer to patients who display a complex array of symptoms as having
complex-PTSD. Many clinicians tell me that they have never heard of the term DESNOS
at all. Much of the research for both C-PTSD and DESNOS has been conducted on
abused children, battered women and adults in captive situations in which they were
regarded as helpless and controlled. For the military population, it is difficult to apply
the criteria for C-PTSD specifically because of the victim stance assumed by the patient
and the reliance on the state of helplessness as a criterion. Many service members are
offended by the suggestion that they were a victim of their circumstances or that they
were helpless. They describe themselves as a highly trained and skilled volunteer
fighting force who chose to step up to defend our country. They do not ascribe to the
26
passive, helpless victim stance, nor does this generally apply to this population as a
whole. While military personnel have certainly endured prolonged stress before, during,
and after deployment, and may have experienced one or more traumatic event(s), being
identified as helpless would further undermine their already strained sense of self and
purpose as a warrior and deter them from diagnosis and treatment. Both C-PTSD and
DESNOS are predicated on developmental theory, predominately influenced by research
on the effects that child abuse and trauma have on psychosocial development. With
regard to the influences of developmental theory, there are some specific distinctions to
be made for the adult military population. It can be generally assumed that the service
member is an adult who was functioning well enough to make the decision to join the
military knowing that deployment was possible, complete basic and advanced level
training, and is able to work and live with others in a high pressure environment. One
might assume that, for the most part, the basic ego (i.e. self or personality – depending on
one’s preferred theory) is formed and relatively stable. This is not to say that individuals
with pre-existing mental health issues, previous abuse, and other psychosocial stressors
are not present in this population. But, it is an assumption that even with these previous
issues; the individual who has reached this milestone has done so by developing and
demonstrating a functional equilibrium and are performing adequately below their
threshold of stress prior to deployment. However, as we will discuss in greater detail
later, the experience of extreme stress or trauma can overwhelm this equilibrium and
push beyond the threshold, breaking down the fundamental developmental tasks already
achieved.
27
The military has initiated multiple levels of assessment and screening instruments in
an attempt to identify individuals who may not be able to deploy on the basis of physical
or mental issues. Behavioral health screenings and self assessments such as the Pre and
Post Deployment Health Assessments (PDHRA) are in place to try to identify individuals
who may be experiencing psychiatric symptoms or are under excessive emotional strain.
Intervention is then initiated to explore these issues further and make treatment
recommendations (Department of the Army, PDHRA Fact Sheet). Of course, this is not
an infallible system and is largely based on self report. The validity of the responses is
influenced by multiple factors such as fear of stigma, loss of financial security, career,
letting down their battle buddies and personal desire to serve.
Historical Summary
This brief historical review is far from comprehensive, but effectively illustrates
the evolving paradigms and recurrent trends that have dominated and divided the mental
health field for decades with regard to the symptomatology, etiology, and classification of
trauma-related manifestations following war experiences. Over the years, theorists have
continued to seek one over-arching classification to explain this phenomenon and have
debated as to whether this disorder has a physiological, emotional, situational, or spiritual
source. Even today, the pendulum continues to swing to and fro between those who
regard this single phenomenon as an anxiety-based disorder and those who advocate for
its inclusion as a psychosis or dissociative condition. The field has been largely polarized
on this issue as it tries to reconcile the diversity and complexity of symptoms so
commonly reported by survivors of traumatic experiences. Throughout this extensive
historical review, I was shocked at just how closely the observations and struggles from
28
decades past paralleled my own clinical observations today and was disheartened that the
complaints of today’s warriors echoed verbatim the words of their predecessors.
Current Clinical Observations
In my practice, I have witnessed the personal, emotional, social, and spiritual
struggles affecting our warriors and their families. For years, I have worked with soldiers
who were identified as having psychosocial and emotional difficulties after deployment
through my work with the Army Family Advocacy, Army Substance Abuse, and
Behavioral Health programs. Overwhelmingly, the vast majority of the respondents
admitted to suffering from a variety of somatic, emotional, cognitive, and behavioral
complaints. I began to compile a comprehensive list of commonly reported symptoms
(see appendix A) in an attempt to differentiate between PTSD and other mental
conditions such as Combat Stress Reaction, Acute Anxiety Disorder, Adjustment
Disorder, and other diagnoses (see appendix B). After I began working with all returning
service members assigned to the Fort Knox Warrior Transition Battalion through the
Veterans Health Administration (rather than only those who were identified as having
significant mental health problems – resulting in a referral for intervention), it became
obvious that this array of symptoms was not exclusive to individuals who were seeking
mental health services or reporting specific dysfunction, nor was it exclusive to those
soldier who reported experiencing combat. Many of the symptoms reported were
common to nearly all returning warriors that I interviewed. Most of the soldiers I met
had varying degrees of nearly all of the complaints on the list; making this a norm for this
population rather than criteria for pathology.
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“Normal Reaction to Abnormal Event”
In the first months after returning from a combat zone, service members often
face a variety of stressors as they struggle to overcome these diverse clinical phenomena.
In the early stages of reintegration, these must be recognized and validated as a normal
and necessary part of transition and transformation, while closely monitoring the severity
and intensity of these symptoms. With appropriate command, family, and community
support, and personal resiliency skills, many of these complaints resolve over time as the
person readjusts to the new demands of being non-deployed or to returning to civilian
life. Studies indicate as many as 80% successfully readjust and go on to embrace
rewarding and fulfilling lives after combat while others (20-25% depending on the
study), find that after the initial adjustment period, they continue to experience the
criterion symptoms of PTSD that warrant diagnosis and treatment (RAND, 2008). There
is a large body of evidence indicating that many of these symptoms respond to
recommended therapeutic modalities including psycho-education, support programs,
cognitive-behavioral counseling, and symptom-specific medication. The VA and DoD
have collectively adopted several evidence-based treatment options as industry standard
recommendations for working with this population. In 2002, the Veterans
Administration and Department of Defense came together to publish Clinical Practice
Guidance for the Management of PTSD. In this manual, several forms of cognitive-
behavioral trauma therapy including Cognitive Processing Therapy, Acceptance and
Commitment Therapy, and Exposure Therapy, were listed as recommendations.
Conventional treatment involves a combination of psycho-pharmacology aimed at
reducing the anxiety-based symptoms (panic attacks, nightmares, sleeplessness,
30
hypervigilance/startle reaction), along with individual or group therapy to provide
support, education and treatment. The goal is to increase the development of skills to
cope with the symptoms of anxiety (breathing and relaxation exercises, thought-stopping,
trigger reduction) through a variety of methods aimed at desensitizing the traumatic
experience until the pairing of the memory and the intensity of emotional responses are
lessened. For several decades, the mental health field has embraced the existence of
Cognitive-Behavioral Theory’s “thought-feeling-behavior” feedback loop as a treatment
standard and many variations of intervention have emerged based on these assumptions.
The efficacy of unraveling the connection between emotions, thoughts, and actions for
symptom reduction is supported by ample research. These modalities are reported to
offer some relief and sense of personal control – especially during the adjustment phase
of post-deployment. Nearly any CBT-based study will reveal a clinically significant
positive response for those participants who complete the study/intervention with regard
to PTSD–specific symptom reduction. As such, the research indicates that triggers,
intrusive thoughts, and other anxiety-based components of PTSD respond to many types
of evidence-based CBT modalities and psychopharmacology. However, symptom
reduction does not always equate to recovery and many equally debilitating symptoms
(DESNOS) remain un-identified, undiagnosed and untreated – often overshadowed by
the more overt PTSD symptoms.
While many individuals report a reduction of symptoms or dysfunction, a sub-
group of this population does not seem to respond well to conventional treatment nor do
their “symptoms” fit neatly into the existing classification schema. Their constellation of
symptoms are more elusive, pervasive, and debilitating and are found to be most
31
insidious - leading to despair, dysfunction, and increased risk of drug abuse, domestic
violence, and thoughts of suicide. While working with these individuals, I found the
existing diagnostic criteria to be inadequate as the symptoms continued to defy accurate
diagnosis within the framework of our current nomenclature. Due to the high co-
morbidity within the post-combat symptoms themselves and with numerous other DSM-
IV-TR diagnoses and classifications, providing an accurate diagnosis became
problematic. In the military and Veterans Affairs environment, by the time patients
arrive at my office, they may already have been diagnosed by a number of other
providers and have a “problem” list filled with co-morbid and conflicting diagnoses. To
complicate matters further, I observed that many of these individuals often present with a
primary concern of having a sense or feeling of disconnection or that they have become
fragmented at the core of their being. Their mantra: “I am not the person I used to be.”
Symptoms that fall through the cracks of the system
In an attempt to provide an ethical, substantiated differential diagnoses, I filtered
the compiled list of symptoms through the criteria for PTSD, and was left with a
confounding array of symptoms and complaints. Also unexpected was my discovery that
some clients, who were clearly suffering emotionally since their deployment, did not
meet the criteria for PTSD at all, but primarily complained of these extraneous
symptoms. Once the classic PTSD symptoms are accounted for, it became clear that the
remaining symptoms clusters closely resemble the proposed DESNOS criteria and lean
heavily toward the elusive dissociative features. A glance at the ‘left over”
symptoms/complaints below will illustrate why the field continues to be divided over the
classification of this phenomenon as either anxiety or dissociative disorder and why so
32
many service members are being diagnosed with a multitude of mental conditions.
Furthermore, some patients consider these symptoms to be much more debilitating and
disturbing than their reported PTSD symptoms (see table 3).
Disconnection with oneself Withdrawn from others, society

Disconnection with others Loss of time
Guilt, Remorse, Shame Auditory/Visual hallucinations
Grief De-realization
Rage Hopelessness (general)
Cognitive distortions Suicidal Ideation
Feelings of worthlessness Surreal Feelings
Increased risk of substance abuse Fear of the Self
Table 3
Clearly, this symptomatology encompasses a multitude of “disorders” from
anxiety, depression, psychotic disorders, to personality disorders, In fact, with the
complexity of their presentation, our service members are being diagnosed with
everything from personality disorders (which can be a non-compensated “career-ender”)
to bi-polar disorder and even schizophrenia or schizoaffective disorder – regardless
whether they meet the onset or etiological criteria or not. According to the National Co-
morbidity Study conducted by Kessler and his colleagues (1992), “individuals who have
been diagnosed with PTSD are eight times more likely to have three or more additional
diagnoses” (as cited in Luxenberg, 2001). Bessel A. van der Kolk observes this high
incidence of co-morbidity and overlap of disorders in trauma patients resulting in
DESNOS symptoms being either misdiagnosed, regarded as atypical symptoms, or being
given multiple diagnoses. “Not uncommonly, patients have arrived at our center with
histories of treatment–refractory conditions that have been defined by some ill-fitting,
conventional diagnosis made in an effort to account for chronic and severe affect
33
dysregulation” (Luxenberg, 2001, p.384). This hodge-podge of diagnoses are missing the
mark and resulting in disparities in treatment, prognosis, and even compensation, having
long-lasting and far-reaching ramifications for the patient.
Still Seeking Answers
If what we have is working, why? While great strides have been achieved in the
assessment, diagnosis, and treatment of post-combat disorders, a quick glance at the
generations of service personnel and veterans who fill military or Veterans Affairs
waiting rooms will illustrate that we have yet to conquer this phenomenon. Data suggests
that of all individuals who return from a combat zone, between 17-25% will meet the
diagnostic criteria for PTSD and only about 20% seek treatment. Of those who seek
treatment, only 17% complete their course of treatment and only 50% of those report that
they feel they have recovered (RAND, 2008). That equates to about 8-9% of all
returning services members who reported significant initial dysfunction feel that they
have recovered. Multiplied by the nearly one million service members who have already
returned from deployment and left military service, the numbers of veterans in our
communities who may be dealing with psychic and spiritual pain are staggering. What of
the individuals who are suffering but do not meet the existing criteria for PTSD? What of
the patients who prior to deployment were mentally and emotionally stable, but since
their return have a collection of mental illnesses on their permanent medical record? If
we have the answers, why do so many avoid seeking treatment or drop out of treatment –
stating that we just do not understand? Are we failing them? According to a recent
article examining the utilization of mental health services through the VA medical
centers, of the 49,425 OEF/OIF veterans with newly diagnosed posttraumatic stress
34
disorder, only 9.5% attended a minimum of 9 therapy sessions in the first year of
diagnosis (Seal, 2010). Recent statistics estimate that suicide accounts for as much as
20% of all military personnel deaths in the U.S., and for every death at least five others
were hospitalized for suicide attempts (Jaroncyk, 2010). In addition, a study of 407
OEF/OIF veterans referred to the Veterans Affairs mental health care revealed that 47%
reported that they had experienced suicidal ideation prior to seeking treatment and that
3% had made a previous suicide attempt (Jakupcak, et. al.., 2009). Why are so many of
our service members surviving combat only to end up taking their own lives later? Of
course, the answer to that question is multifaceted, but I believe that it is safe to assume
that it is not just about having a traumatic experience. It is more than that. It is about the
transformation that takes place throughout the entire experience of becoming a warrior
and trying to return to being a civilian. In a recent article, suicide expert and former U.S.
Air Force Captain, Craig Bryan comments,
We [the military] train our warriors to use controlled violence and aggression, to
suppress strong emotional reactions in the face of adversity, to tolerate physical
and emotional pain and to overcome the fear of injury and death. Such
conditioning cannot be dulled without negatively affecting the fighting capability
of our military. While required for combat, these qualities are also associated
with increased risk for suicide. Service members are, simply put, more capable of
killing themselves by sheer consequence of their professional training.
(Thompson, 2010)
We cannot continue to allow the needs of our service members to go unaddressed. With
the prevalence and expectation rising, and the limitations of our anxiety-based conceptual
model surfacing, it is clear that we are poised to take our understanding of this
phenomenon to the next stage of development.
35
PTSD as an Anxiety Disorder. As our concept of PTSD as an anxiety disorder
has evolved over time, the dissociative and pervasive identity features so common in
many veterans’ presentations seem to have fallen by the wayside as we continue to labor
under the misconception that all of the elements of the presentation can be captured with
one set of criteria. Those who attempt to provide a comprehensive diagnostic picture
must resort to deconstructing the individual into various fragmented parts in order to
justifiably treat the vast range of complaints. This reductionistic approach is in direct
opposition to the goal of providing holistic intervention, reintegration, and treatment for
our returning service members. The individual may already be fragmented by the
transformative experience of war. Continuing to deconstruct and compartmentalize their
symptoms into multiple ill-fitting pathological entities perpetuates this state of
disintegration. The fragmented core identity begins to be defined through the
deconstructed “pieces” of their symptoms clusters and through the telling and retelling of
their “traumatic experience” (or lack thereof.) It is time both revisit the past while
embracing the future. It is time to reconcile the age-old dilemma of addressing both the
anxiety and dissociative aspects of this diverse phenomenon while moving toward a
holistic treatment approach leading to lasting recovery and growth.
While so many of these symptoms are commonly reported by survivors of trauma,
especially those who have endured a prolonged, high-stress or traumatic experiences,
and are very common among combat survivors, what is lacking is an explanation of why
these symptoms seem to “hang together” and defy appropriate classification under other
current DSM IV system. These “left-over” symptoms are clearly debilitating in their own
right and deserve a more prominent place in the diagnostic picture. Many are not clearly
36
associated with anxiety or fear and are more appropriately aligned with dissociative
issues and other mental/emotional conditions, yet they do not quite fit those existing
categories either. It is time to once again embrace the opportunity to take critical look at
our understanding as our service members and their families look to us for help. We are
forced to go beyond our comfort zone of existing knowledge and accepted paradigms to
question the etiology, progression, diagnosis, theory, and treatment modalities currently
utilized in practice. We must engage in defining and refining our nomenclature,
concepts, theories, and approaches in an attempt to ease the suffering of these brave
individuals.
“What doesn’t kill you…” Working with returning troops, I have had the
unique privilege to assess whole units of returning service members rather than only
those who have been identified as seeking mental health services. This has been vital in
the evolution of my current perspective. Far from all being “broken” or debilitated by
their combat experience as one might assume, I have found large numbers of our service
members to be a warm, connected, compassionate, and highly skilled group of
individuals who voluntarily dedicated themselves to the mission of serving and protecting
our country. While they have all endured much sacrifice and hardship, many continue to
be strong, resilient, capable, and are able to integrate these difficult experiences into their
new identity. However, during the first several weeks, or even months, following
deployment, nearly all of the soldiers report having residual effects of their experience
(nightmares, flashbacks, hyper-vigilance, poor concentration, irritability, questioning
meaning) yet our existing diagnostic protocol regards these symptoms as diagnostically
pathological if the symptoms continue to occur beyond one month after they return from
37
deployment. While nearly all returning soldiers report having many of these symptoms
in greater or lesser degree, a segment of this population report having severe, intense or
debilitating symptoms that reach far beyond the classic PTSD anxiety symptoms and
state that they feel as if a profound change has occurred in the core of their identity.
Since many returning warriors seem to have endured the experiences of war with their
sense of ‘self’ intact, then the question becomes, “what allows some to be able to
overcome the suffering while other seem to become fragmented?” Throughout hundreds
of clinical interviews, I began to ask my clients to tell me what gives them (or others) this
ability? What helps them endure the pain? Overwhelmingly, their answers revealed a
reliance on a strong personal sense of purpose or meaning in the experience. A pattern
began to emerge between the soldiers who exhibited severe, complex symptoms and
appeared to be unresponsive to treatment and those who, in spite of experiencing many of
the same events and stressors and suffering from PTSD symptoms, appeared to be better
able to cope and reintegrate.
The Purpose of Meaning. The difference between the two groups seemed to
stem from whether the individual’s sense of ‘self’ remained intact or had become
fragmented or strained. In spite of having similar combat experiences, and even
exhibiting similar PTSD symptoms, some were able to retain a sense of who they are in
the world, what it means to be a warrior, a personal sense of purpose in life and in the
mission, a connection with their core values, and ability to connect with others. For
some, the mission even served to enhance and strengthen their deep sense of life meaning
and a framework for making sense of their traumatic experiences. If you ask them why
they went to battle, they will point to the flag, tell you stories about their battle buddies,
38
and will show you the pictures of their family as well as of them with smiling children in
the streets of Iraq or unloading school supplies in Afghanistan. Aside from the politics of
war, they report having found their own personal sense of meaning that helps them make
sense of, and overcome, the stressors and sacrifices.
For others, I observed that their ability to remain connected with their core selves
had been strained. In interviews, they were visibly shaken and withdrawn. The ‘hollow
stare’ that I had read about was staring back at me from across the desk as they echoed
the same words their fathers, grandfathers, and great-grandfathers had uttered before
them: Why? Why war? Why killing? Why me? What does it all mean? What
difference does it make? What difference did I make? These soldiers appeared to be
much more preoccupied with this existential questioning and self exploration than on
processing any traumatic event (if they had one – and many did not). For some, the
entire deployment fostered an opportunity for wrestling with these “meaning of life”
concepts. In our sessions, these individuals have given me the honor of having the
deepest and most profound philosophical discussions I had ever experienced in my
previous twenty years of clinical trauma work. These individuals seemed to have
returned with a fragmented sense of personal identity as they question who they are at the
core of their being (in comparison to who they once were). Many of the individuals
struggle to put their questions and suffering into words. They report feeling as if they
have lost their sense of self and that everything they previously knew is dis-integrated;
previous assumptions, values, belief system, connections with the past and present,
connections with others, connection with their feelings – everything and everyone seems
foreign to them. It is a common experience for them to state that when they look in the
39
mirror, a stranger is staring back at them. Some will speak as if a part of them is gone,
dead or missing and they feel an intense sense of loss (and are grieving) this part of
themselves. Nothing seems to matter or make sense and they struggle to find meaning in
all facets of their lives. Beyond complaining about anxiety-based symptoms, they are
disturbed by the feelings of disconnection within themselves and with those around them.
These warriors describe having had a significant shift in their core sense of “self,’ a
pervasive feeling that they are not the person they used to be. More than emptiness, they
describe a hollow feeling as if their very soul is missing or detached. Their families often
corroborated this phenomenon stating that one person left but another returned. Far from
isolated cases, the mantra “I’m not the person I used to be” rang so frequently in the
client’s stories that I realized that I needed to explore this further and began to shift my
clinical focus from the “trauma” to the “transformation”. I began asking my clients to tell
me about this experience and to describe this phenomenon. Through these discussions, I
discovered that, rather than an anecdote, this was actually a central theme in the
dysfunction and readjustment and that neither they, nor I, could adequately explain or
address this. Yet, when given the opportunity, this is what they wanted to discuss, more
than their startle reaction or nightmares. This phenomenon was clearly beyond a simple
emotional response to trauma. This was a deep, pervasive and profound change in the
innermost being of the individual and conventional therapy and medication management
was insufficient to heal this wound. This exploration required a willingness to delve into
the existential domain with the client – to join them on their journey of reintegration and
recovery.
40
The Boredom Factor? Listening to my clients taught me that there is more to
war than isolated traumatic events. In fact, many describe their experience in “theater” as
“long periods of mind-numbing boredom, interrupted only occasionally by sheer chaos.”
The mental health field is quite familiar with exploring the moments of “sheer chaos” –
those defining moments of trauma and tragedy associated with the war experiences.
These are the moments that are remembered and relived – often with accompanying
PTSD symptoms and, the moments on which most contemporary research and treatment
modalities focus. But, what does the other “99%” of the time do? Do the hours
described as “mind-numbing boredom” play a role in the subsequent struggles to re-
integrate? In The Will to Meaning, Viktor Frankl cites boredom and apathy as the “main
manifestations of existential frustration” in our time (1988).
Consider the roller coaster of emotions experienced throughout the total
deployment cycle. One deployment affects about 18 months of the service members’
lives. Upon receiving orders, they experience anticipatory stress during preparation and
mobilization training prior to the deployment. They must prepare mentally, emotionally,
and physically for the demands of the mission. They must also prepare their families for
their absence and the possibility that they may not return. Each deploying service
member must submit a Family Care Plan prior to departure that providers for the care and
provision for the family’s needs during their deployment and in the event of their
untimely death. Everything must be in order before the warrior deploys. Then, there is
the deployment itself, with the emotional, mental, and physical strain, during which time,
the abnormal must become normal – their survival depends on adjusting to these new
demands. Finally, there is the stress of post-deployment and reintegration upon their
41
return. This is when the normal seems abnormal. During all of that time, the warrior
experiences anticipatory anxiety, excitement, new experiences, existence in a harsh,
demanding environment of extreme temperatures, adjustment to a different time zone,
lack of sleep – impaired sleep cycles, sensory deprivation (“everything is beige”),
mundane routines, long hours of “duty,” disconnectedness from their friends, family
members, and previous existence. The “boredom” experienced in this surreal
environment provides many long hours in which to become self-absorbed, contemplating
one’s own purpose and existence. Long hours of standing guard and long hours of
sleepless nights provide the time to wrestle with profound issues such as life/death,
politics/patriotism, good/evil, mission/family, and choice/purpose and can bring an
individual face to face with his or her own internal reality. The acute awareness of one’s
own mortality, the very real danger to the soldier and unit, paired with the endless hours
of reflection in a surreal environment, is the perfect incubator for questioning one’s own
past, present, and future. In addition to the strain and injuries to the body, strain on the
mind, the combination of time + terror can lead to a dis-integration of the core self. As
Charles Figley observes,
The survivor of combat returns home from a world in which military reality
eclipsed civilian reality. Death is a new “reality principle. A soldier can stay
alive only by transfiguring his ego and permitting everyday reality to “slide
through a membrane” (in the words of one veteran). His perception of events is
completely changed as he takes on the paranoid posture of combat. His styles of
feeling, thinking, and action are transformed as he restructures his personality.
All that is needed to achieve “reality control” is “doublethink” (Orwell, XX) and
endless series of victories over your own memory. When he comes back, the
veteran must penetrate through this membrane of reality again. (1948, p. 51)
42
Not Exclusive to Combat Veterans. This transformational experience of
reflection, contemplation, and is not exclusive to those who return struggling with their
sense of fragmented identity. Interviews with soldiers who appeared to be quite resilient
upon their return also reported that they had similar experiences while in theater. Many
reported that they had times that they began to question their role, relationships,
existence, purpose and meaning. Most returning soldiers report that they had many
moments when they privately asked themselves, “Why am I here? What purpose are we
serving? Who cares? What if we are the bad guys? What difference are we really
making? However, when asked how they dealt with this, the ones who seems to have
reconciled these questions reported that they sought relief and answers through their
relationships with family and battle buddies, connection with the divine, and their sense
of purpose in knowing that they were an integral and vital component of the mission and
that their colleagues were counting on them. Even though the experienced periods of
existential crisis in theater, they possessed the skills and/or support to reconcile their
existential questions gradually, and that they were able to retain their connection with
their sense of personal purpose and find meaning in the experience. Many have even
reported that while they are disturbed by some of the memories of the experience, they
feel that they are a stronger or better person having had the experience. Accompanying
the warrior into combat is the shadow of the original self. Previously held core beliefs,
values and interpersonal connections have had to be transformed to assume the persona
of the warrior. The warrior embraces life and death, the safety and honor of the country,
and their society and family are worn close to the heart. The task of the warrior is to rise
beyond the mundane to embrace mythical proportions as they reflect on these larger-than-
43
life subjects. In the field of mental health, “No formal help is available for this task.
Once again, outer reality is not congruent with remembered inner reality. As [the
warrior] faces the renewed clash between the two reality-perception systems, the warrior
experiences “perpetual dissonance.” (Figley, 1978)
A Paradigm Shift
Return to the Holistic Model of Care. History clearly bears witness to the bio-
psycho-social-spiritual struggles of returning warriors. Biological/Physical health issues
and injuries must be treated, mental and emotional stresses must be eased, and warriors
must face social reintegration back into civilian life of family and community. To treat
the physical wounds, we have a complex network of health care professionals, screenings
and state-of-the-art medical treatment. Multiple research-based psychological assessment
tools and treatment modalities and medications have been developed to manage the
symptoms of emotional/psychological issues. For social reintegration, numerous Federal,
State and local programs and outreach services have been implemented for the service
member or veterans and family members. What seems to be lacking with regard to our
intention to provide holistic care is discussion and valid intervention to address the needs
and injuries to the spiritual domain? What language do we have to help identify,
recognize, discuss, and treat the psycho-spiritual changes that so many of our returning
warriors report as being the most prevalent disturbance to their successful reintegration?
Traditionally, the mental and physical health care fields have taken a “hands-off”
approach to the spiritual domain by relegating this realm to clergy. But, the time has
come to re-integrate this domain of human existence back into the holistic treatment
model. This paradigm shift is being felt across treatment fields with respect to treating
44
combat warriors and veterans. Directives and treatment manuals originating from the
Department of Defense and the Veterans Health Administration, National Center on
PTSD (Friedman, 2000), among other sources are recommending that post-deployment
intervention and treatment adhere to a whole health, patient-centered, recovery model of
care. While this is a welcome departure from the previous decades influenced almost
exclusively by Cognitive and Behaviorist theories, where fragmenting and deconstructing
human experiences prevailed, we are still very early in this shift. The directives and
recommendations represent an intention at best, and often fall short at this time in guiding
the therapists in the field to provide integrated care in a fragmented and constantly
changing environment. This push toward a holistic model of care has resulted in the
creation of the DoD Comprehensive Transition Plan for Warrior’s in Transition
(Department of the Army, 2009) and the Veterans Administration Patient-Centered Care
model (Lukas, 2004), and OEF/OIF Care Management programs. These efforts provide
examples of this shifting paradigm and movement toward innovative and progressive
models of care that embrace a comprehensive and multi-dimensional continuum of care
for returning service members. These initiatives recognize that injury and disintegration
can occur across multiple domains such as housing, vocational, educational, financial,
social, physical, cognitive, emotional, interpersonal, and spiritual. While we are
sufficiently experienced at assessing and addressing environmental and psychosocial
needs, we are much less adept in our efforts to identify, discuss, and reach the core of the
individual through providing holistic responses to the changes wrought by trauma or
extreme stress. If considered at all, the spiritual domain is often isolated and relegated to
the work of the clergy. However, the spiritual domain (when seen as the core of the
45
individual) is intertwined and inseparable from the whole, each layer being influenced by
every other layer, and therefore, cannot (and should not) be isolated. Rather, this domain
is best regarded as a vital, integral component of the whole being.
The Spiritual Domain (Structure). Attempting to “define” this domain is a
quagmire of contrasting, conflicting, and confusing theories. The concept of spirit or soul
has been a subject that scientists, clergy and philosophers have been contemplating
throughout time as we struggle to grasp the full nature of our “being human.” Earliest
accounts of this debate come from the Ancient Greek philosophers who used the same
word for 'alive' as for 'ensouled'. Plato (428?-348? BC) considered the soul to be the
‘essence’ of the individual and conceptualized it as having three components: the Logos
(reason/meaning), the Thymos (emotion), and the Eros (drive/desire). Plato believed that
optimum health resulted from all three domains to be in balance. Following Plato,
Aristotle (384-322 BC) continued to refer to the soul as the core or "essence" of a living
being, but rather than seeing it as a separate domain, believed it to be an integral part of
the being (Soul in Wiki, 2010). Continuing to wrestle with this issue, Rene Descartes
(1596-1650) wrote,
I regard the human body as a machine so built and put together of bone, nerve,
muscle, vein, blood and skin…I knew then that I was a substance, whose whole
essence or nature is, but to think and who to be, hath need of no place, nor
depends on any materiall [sic] thing. So that this me, to wit, my soul by which I
am what I am, is wholly distinct from the body and more easie [sic] to be known
that it. (Trimble, 1981)
Expanding on these themes and theories, noted Austrian psychologist, Viktor
Frankl, viewed human beings as being comprised of three domains: the Physical Self
46
(Soma), The Mental Self (Psyche), and the Spiritual Self (Noos). He regarded the Soma
and Psyche as “what we have” but the Noos is “what we are” (Frankl, 1969). According
to this model, the Noos is the unique essence of the being that holds all of the values,
beliefs, experiences, preferences, hopes, dreams, and goals. Fig. 1
The NOOS* represents the inner world of the individual –

the “core self” and holds the unique set of values,
preference, beliefs, ideals…
The SOMA* represents the body – the outer physical layer

that interacts with the external world.
SOMA
PSYCHE
PSYCHE
The PSYCHE* represents the mind – this layer connects
NOOS
with both the inner and outer worlds and through cognition,
and emotion strives to achieve coherency** between the
two.
Figure 1 (*Frankl, 1996) and (**Wilson, 2004)
The three domains proposed by Frankl, and how they respond to trauma or injury
are reviewed in briefly below.
Soma: the physical domain. Soma relates to the individual’s physical being – the body.
This domain may be injured, become ill, or be suffering from pain or discomfort or
disease. It can be affected by multiple chemical changes (cortisol, adrenalin, etc.) that
occur in response to trauma or extreme stress. It is responsive to changes in exertion,
sleep, nutrition, and hydration. For service members (and others), these injuries are often
observable, can be more easily diagnosed and validated with testing, often do not carry
negative stigma, and respond well to conventional multi-disciplinary medical treatment
47
and medication. In some cases, for the military, awards and recognition are given to
individuals sustaining such injuries.
Psyche: the mental domain. According to Frankl, the psyche, or mind, contains the
awareness thoughts, and emotions experienced as the individual struggles to reconcile
their feelings, make choices/decisions, and to understand their experience. This is the
domain in which tasks are planned and carried out, the person is able to rationalize the
here and now, rises to the demands of family, bills, new jobs, and copes with memories
and thoughts of the experience. It is this domain that stores memories and feeling related
to traumatic events, and the part that responds to Cognitive-Behavioral methodology such
as Cognitive-Processing Therapy, Prolonged Exposure, and Eye Movement
Desensitization and Reprocessing treatment.
Noos: the spirit. For Frankl, the Noos represents the specifically human dimension that
makes us “who we are.” It is the unique inner realm containing our values, beliefs,
freedom of choice, creativity, ethics, conscience, love, inspiration, personal identity, self
worth, drive for our “search for meaning” and purpose (Graber, 2004, p.71). When this
domain becomes wounded, disconnection from these personal virtues can result, leading
to what Frankl called the existential vacuum or noogenic neurosis (Frankl, 2006, p. 101).
Frankl considered these three “dimensions” as inseparable and unified to form a
whole being. He stated that “if one is disregarded, we do not get a complete human
being, but a shadowy two-dimensional projection” (Graber, 2004, p.68). To truly adhere
to a holistic model of care, we must recognize and address the assaults and injuries to
each of these domains. The belief in the existence of a spiritual domain, as differentiated
48
from the physical or mental, is universal among many cultures and disciplines, although
there are as many terms and theories to explain this concept as there are theorists. Also
universal is the belief that that each of these human domains, including the spiritual, may
become strained, wounded or broken. Many theorists and providers who have worked
extensively with trauma survivors including military veterans have arrived at similar
conclusions, but have a number of ways of explaining this phenomenon.
Multiple Theoretical Veiwpoints Exist. In War and the Soul (2005), Dr.
Edward Tick details his theory derived from his extensive work with Vietnam veterans
stating that, “every vital human characteristic that we attribute to the soul may be
fundamentally reshaped…war invades, wounds, and transforms our spirit” (2005, p.1).
Focusing on post-war related symptoms, Tick asserts his stance that, “PTSD…is best
understood as an identity disorder and soul wound, affecting the personality at the
deepest levels” (p.5). He refers to this transformation of the personality as a ‘psycho-
spiritual death’ and contends that the pathology we see in many returning veterans is a
result of their becoming “disconnected” from their soul. According to Tick, the soul
holds awareness, experience, creativity, ethics, aesthetic values, love, and is that which
distinguishes good from evil. With a strong influence of Native American traditions,
Tick emphasizes the need to recognize the soul wounds as having specific needs for
rebuilding a sense of safety and trust.
The Constructivist paradigm. The Constructivist Self Development Theory,
based heavily on the work of Piaget, states that humans actively create “increasingly
complex cognitive structures” over their lifespan - developing schemas (or cognitive
maps) that allow the person to organize their experiences in accordance with assimilation
49
and accommodation of new information. Horowitz defines schema as an “organized
composite of multiple features that persists unconsciously to organize mental processes
(p.257). Individuals have multiple schemas with regard to their sense of personal
identity, sense of relationships, and about the world around them (p. 10). Constructivist
theory regards the “self” as the “seat of individual identity and inner life” (McCann,
1999, p. 14). Traumatic experiences are ‘encoded’ in the construction of the self as a
means of survival but can overwhelm their existing belief system, disrupt all parts of the
self, and shatter existing schema (p. 17). Trauma shatters the person’s view of self and
the belief in a “meaningful, orderly world” (p. 61). Even vicarious trauma can shatter
existing schema. For most Americans, seeing the planes crash into the Twin Towers, and
hearing the reports as they unfolded that that morning of September 11, 2001, shattered
our collective sense of invincibility, safety, and our position in the world. For the first
time in our generation, we felt vulnerable. Individually and collectively, not only did our
world view change, but our sense of self changed as well. We were thrust into an
emotional, social and existential crisis in which our moral values and beliefs came to the
forefront and demanded resolution. For nearly ten years, we have experienced changes to
our ‘selves’ as we work to resolve our personal attitudes, feelings and beliefs about
terrorism, privacy, freedom, security, safety, politics, war, cultural, religion, and
patriotism.
From a Constructionist perspective, therapy is focused on assisting the individual
to restore positive schemas while integrating the traumatic memories, leading to
transformation of the ‘self’. Further, McCann states, “we want to acknowledge that
trauma can also alter schemas in positive, growth-producing directions providing a means
50
to allow the individual to engage in a “healthy questioning of beliefs about the meaning
and direction of one’s life, discovered ability to maintain a sense of competence under
trying circumstances, heightened sensitivity to horror and dehumanization, and the
development of strong convictions” (Koss & Burkhart quoted in McCann, 1990, p33).
Elaborating on the previous example of our collective trauma of 9-11, some could say
that we, as a country, have shown our resilience and strength in the face of trauma, that
we became united in our efforts to grieve and to heal. As our schemas about the world
changed, so did our values and finally our behavior/choices followed. “In the aftermath
of war/trauma, survivors often review and judge their own conduct and their experiences
– survivor guilt and inferiority are almost universal” (Lifton, 2005). Dealing with this
evaluation of the self and the world leads to an “inner revolution” of the self (p. 286). In
his work with Vietnam veterans, Lifton comments, “
I was struck by the emphasis of the men, in this reconstructing themselves, placed
upon responsibility and volition. While freely critical…they inevitably came
back to the self-judgment that they had, themselves, entered willingly into these
processes…[implying] that they had chosen the military and the war, rather than
the military and the war choosing them..All relationships and above all work
experiences tended to be reexamined in terms of volition and autonomy. (p. 287)
Shattered schema. Ronnie Janoff-Bulman describes this concept as our
“assumptive” world, “Most generally, at the core of our assumptive world are abstract
beliefs about ourselves, the external world, and the relationship between the two (1992,
p.51). Generally, she asserts that human beings seldom consider these assumptions until
they are “stretched too far” in a time of extreme crisis when these core values are
challenged and shattered resulting in disillusionment (p 52).
51
One assumption is that the events in the world are meaningful, that they make
sense…the goal of therapy is to rebuild these assumptions and find benevolence,
meaning and self worth (p. 116) … Recovery occurs when the individual is able
to not only accept but also transform the traumatic experience through
discovering personal meaning through the concept of purpose (p. 134).
The survivor may even come see the event as a powerful life lesson. Judith Lewis
Herman (1997) adds, “The belief in a meaningful world is formed in relation to others
and begins early in life…traumatized people suffer damage to the basic structures of the
self. Their sense of self has been shattered and can only be rebuilt as it was built initially,
through connections with others (p.61).
“What breaks?” Shay asks, “When a soldier is broken by combat, what breaks?”
(1994, p. 165). Examining this issue from a mythological perspective, Shay describes
multiple areas of the human being that are prone to “breaking” including feelings of
emptiness, hopelessness, and “suffocating despair.” He states that the “broken spirit”
will often a display hostile, mistrustful attitude toward world, disconnection with others,
chronic on-edge feeling, and impending feeling of doom. Shay warns that these
symptoms can be mistaken as borderline or antisocial personality disorder. While he
believes that “normal is not possible,” recovery is possible as “survivors of severe trauma
adopt their own lives – including their limitations – with passion and existential
authority” (p. 185).
The broken spirit. According to Wilson, “The broken spirit is a metaphor for the
fracturing of the soul, self, and identity” (2004, p.110). While the concept has had many
names (soul, self, life energy), the spirit is the “core, inner sanctum of the ego and the self
of a person” (p. 110). Wilson contends that when this human domain becomes
fragmented, it results in the loss of coherency and continuity in the being. What is
‘broken’ is the sense of connection with the “critical dimensions of [human] existence”
52
(ibid.). These include one’s connection with the self and others, nature and the sacred,
hopes for the future and sources of meaning in life. “Disintegration” of these virtues (to
borrow a term from Erikson, below) occurs when the self is shattered by trauma or
extreme stress.
The structure of the self unravels, dismantles, and reverts to regressive forms of
primitive ago functioning at a rudimentary survival level. What remains are
fragmented pieces of the self that can be devoid of energy, hope, trust and viable
system of meaning (p. 119).
Wilson viewed the dialectic between cohesion and fragmentation as a continuum
for the posttraumatic self (p. 114). Following trauma, the individual will fall somewhere
along this continuum from extreme fragmentation of the self to higher levels of cohesion.
Wilson outlined several possible manifestations of this continuum from the “empty self”
characterized by significant disintegration of the identity, to the “cohesive self” which is
characterized by ability to “spring back” from trauma demonstrating resiliency. In
between, there are several variations of the “fragmented self” which is characterized by
“traits of identity diffusion, fragility, and strong feelings of discontinuity within
themselves and with others and are prone to dissociation.” Finally, the “integrated
transcendent self” denotes the person who has been fragmented by their experience, but
has healed and transcended the trauma through engaging in self reflection and efforts
toward self actualizing (p. 123). Frankl (1994) described this as “active transcendence”
in which the “old self” is shed and replaced with a new, more vital and functional, self (p.
131) which, once reassembled can become a new form of strength and beauty (p.112).
53
Developmental theory. Earlier we discussed developmental theory with regard to
assumptions about the initial identity or ego development processes that have been
completed by the adult service member prior to experiencing deployment stress.
Revisiting this issue from a different perspective (not with regard to initial identify
formation but of developmental disintegration) Erik Erikson’s Stages of Identity
Development (1980) provides a significantly relevant framework for understanding the
formation and transformation of the identity across the lifespan as well as a contextual
model for examining the disintegration of the Core Self.
At the point of early adulthood when most military personnel join the service, most
have navigated through the first five or six developmental stages and have achieved some
degree of the underlying virtues of those tasks (table 4). However, many are still in the
process of working through the stages associated with establishing industry
(competence), identity (self) and intimacy (relationships). The military can provide
opportunities for the individual to find a sense of purpose, bond with others and achieve a
sense of belonging and sense of self. However, experiencing extreme stress can
undermine and unravel the developmental tasks previously attained, shattering the
existing schema and resulting in developmental regression. In returning military
personnel, we often see signs of a breakdown of the fundamental virtues of previous
developmental stages.
STAGE TASK VIRTUE IN CRISIS
Stage 1 Trust vs. Mistrust Hope Develop mistrust, paranoid

world view, loss of hope in
future
Stage 2 Autonomy vs. Shame Will Shame and doubt debilitate
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the individual’s ability to

move forward
Stage 3 Initiative vs. Guilt Purpose The person is unable to

connect with individual
purpose or meaning
Stage 4 Industry vs. Inferiority Competence Individual feels incompetent,

inferior undeserving and
judges self harshly
Stage 5 Identity vs. Role Confusion Fidelity Feels betrayed by group
Stage 6 Intimacy vs. Isolation Love Unable to connect with others

or feel belongingness
Stage 7 Generativity vs. Stagnation Care Self-absorption stagnates

development and healing
Stage 8 Integrity vs. Despair Wisdom Unable to find meaning in

experiences
Table 4
For the warrior who has experienced extreme stress or trauma, the core of their being
where these virtues reside, becomes fragmented and development regresses to earlier
stages. Of veterans, psychologist Erik Erikson stated, “What impressed me most was the
loss in these men of a sense of identity. They knew who they were; they had a personal
identity. But it was as if, subjectively, their lives no longer hung together – and never
would again. There was a central disturbance of…ego identity” (Erikson, 1963, p. 42).
A rose by any other name… There have been many attempts to identify and
describe the elusive domain of human existence we identify as the spiritual domain and
differentiate this facet of being from the physical and mental domains. The review of
existing literature, both professional, and general, use the terms spirit, psyche,
personality, soul, schema, ego, and self, interchangeably. To further confuse matters, the
55
terms soul or spirit carry deep religious connotations which lead to a much different
discussion entirely. In the interest of clarifying this ambiguous terminology, for the
purpose of this treatise I will refer to this domain as the “Core Self.” The Core Self will
refer to the vital, dynamic, interconnected component of the whole being that represents
the Noetic (spiritual) domain of the individual. While ever changing and evolving as new
experiences are integrated, this domain represents a manifestation of the individual’s
accumulated experiences, past and present. Within this realm is held the individual’s
unique compilation of values, beliefs, faith, trust, preferences, motivation, love, esteem,
goals, ambition, and world view.
Trauma-Induced Existential Dis-Integration Model (TIED)
Clinical Development of the TIED Model.
The spiritual domain. Many theorists not only acknowledge that the spiritual
domain exists and have made attempts to describe it, they also suggest that this domain
can be injured or wounded, resulting in an array of emotional, social, and behavioral
outcomes. In my own quest to understand the phenomenological effects of war on the
soldiers and veterans with whom I work, I arrived at similar conclusions. I have
witnessed the way that the war experiences can injure individuals at the very core of their
being through my clients who have shared their struggles to understand the profound
changes that they feel in themselves. The prolonged experience of engaging in war can
lead to a wounding of the core self. While many refer to these wounds as PTSD, I have
come to believe that this wound is separate and distinguishable from the diagnosis of
56
PTSD and I propose that this phenomenon is a separate, but highly co-morbid, condition
that arises in response to the same etiological conditions. While PTSD is an anxiety-
based condition that manifests as a result of experiencing extreme trauma, I believe that
what we have been missing is separate, spiritually-based condition that manifests as a
result of other aspects of the war experience. With several years of validated research to
support the criteria of PTSD, it is clear that many of our warriors today suffer from
reliving their traumatic experiences, hyper-vigilance, avoidance, and numbing related
specifically to traumatic events of combat. They suffer from nightmares, endure
flashbacks, and report that they are unable to shake the feeling of intense anxiety as if
they are “on guard” nearly all of the time. However, the diagnosis of PTSD by itself does
not accurately or effectively encompass all of the symptoms reported by returning service
members. Even though being deployed to a war zone (with the awareness of the potential
of trauma/mortality and focus on the mission) could certainly be regarded as a prolonged
stressor, meeting the criteria for consideration of the diagnosis of Complex-PTSD, many
warriors reports that they did not have a traumatic “event” during the deployment, yet
over 50% of patients seeking treatment have exhibited the DESNOS symptoms upon
their return (Ford, 1999). To address the leftover symptoms we must turn our attention to
humanistic and existential theory to delve further into examining the effects of trauma
and extreme stress on the core self and to provide a framework for understanding our
clients when they talk about feeling as if their very soul has become fragmented. Much
like the age-old “Nature vs. Nurture” argument, the field has been divided for generations
between regarding this constellation of symptoms as an anxiety-based or dissociative
disorder. When backed into a corner without many options, one tends to feel the need to
57
choose sides. Yet, as we step back to observe the whole picture (i.e. the whole person),
we begin to see that this is a complex three-dimensional issue, affecting every domain of
the individual – body, mind and soul. It is impractical to continue trying to merge all the
symptoms together under one diagnosis? What if we looked at it through two lenses
instead of one? When I started exploring this as two distinct, yet highly co-morbid
conditions, the components of the proposed model, Trauma-Induced Existential Dis-
Integration, began to fall into place.
Franklian Psychology. The underlying framework for this model is based
heavily on the tenets of Franklian Psychology (also known as Logotherapy). Developed
throughout the 20th century by Viktor Frankl, Logotherapy (Logos referring to
“meaning”) is often referred to as the Third Viennese School of Psychotherapy. In
contrast to Freud’s Psychoanalytic theories which postulate that human beings are
motivated by their quest for pleasure, or Adler’s theories which emphasize a quest for
power, Frankl states that our greatest motivator is our quest for personal purpose or
meaning. Franklian Psychology rests on three basic ‘pillars’: life has meaning under all
circumstances; human beings are motivated by the search for their own unique meaning
in their lives; and, human beings have the freedom (and responsibility) to discover
meaning in all that they do or experience – even in the face of great suffering (Frankl,
1988, p. 16). One of the assumptions present in Frankl’s theory is the observation that
suffering is inevitable; it is one characteristic of being human that we all share no matter
what our socioeconomic status, or culture. Statistically, 50 % of us can expect to survive
at least one traumatic event over the course of our lives (Meagher, 2007, p. 21). All
human beings will, at some time in their lives, experience what he called the “tragic
58
triad” of pain, guilt, and death (Fig 2). “There is no human being who may say that he
has not failed, that he does not suffer, and that he will not die.” (Frankl 1988, p 73).
Pain TRAGIC TRIAD can

lead to
Existential Vacuum
Guilt Death
& Despair
Figure 2
Suffering is inevitable: an opportunity for meaning. The assumption that all humans
suffer is an ironically comforting quality that allows a therapist who may not have
experienced war to emotionally identify with the client’s experience of trauma, and can
connect with regard to the client’s suffering since that is something we all share. It levels
the playing field, so to speak, and connects us with all others. It also normalizes
suffering as a uniquely human experience and validates the feelings associated with our
suffering. Another assumption made in Franklian Psychology is the belief that humans
are able to reflect on their suffering and strive to discover personal meaning in the
experience. Whether the traumatic event is sudden and unexpected, or prolonged,
Logotherapy recognizes that a person who has endured a profoundly stressful experience
may be injured in body, mind, and/or the spirit (noos). The third assumption inherent in
Logotherapy is the belief that human beings (in general) have within them, the ability to
rise above, overcome, and even grow from their adversity. We have built in ability to
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adapt to our changing environment and to the stresses and circumstances of like out
adaptability acts as protection. (Meagher, 2007, p. 22). Franklian psychology
emphasizes the quest for meaning and enrichment of the strengths of the individual to
overcome tragedy, specifically addressing the injuries and healing of the spirit (noos).
Frankl differentiates between the emotional discomfort of searching for meaning which
he views as being a desired human trait, and the pathological emptiness or void he calls
the “existential vacuum.”(1988).
Struggling for a meaning of life, or wrestling with the question of whether there
is a meaning to life, is not in itself a pathological phenomenon. There is no need
to feel ashamed of existential despair because of the assumption that it is an
emotional disease, for it is not a neurotic symptom but a human achievement and
accomplishment (ibid., p.91).
I found this theory is especially relevant and applicable to understanding and addressing
the needs of our returning warriors, for whom a strong sense of personal meaning is so
prevalent in their lives. According to Frankl, emotional illness and depression is a result
of the individual’s inability to find or create their own sense of meaning in life, leading to
an internal emptiness and disconnection with one’s sense of personal meaning. The loss
of this personal connection with personal meaning or purpose causes a chain reaction of
existential crises, which leads to a shattering of the Core Self. What was once a cohesive
structure becomes fragmented or dis-integrated. This dis-integration affects the
individual’s sense of who they are as a person (or who they once were); their individual
sense of purpose, and ultimately their ability connect with others or find meaning in their
new lives. According to Franklian theory, it is this ability to remain connected within
one’s self in the face of adversity that leads the individual toward resiliency, recovery and
growth. He postulates that not only do all human beings share the experience of pain and
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suffering, but that we all have the capacity of overcome the suffering through an
individual sense of meaning and purpose. Through his work with suicidal and
despondent patients who had lost all hope or desire to continue living, Frankl developed a
strong belief in the resiliency of human beings to overcome tragedy and adversity
through this ability to create or find our own personal sense of meaning from these
challenging experiences in life. It is through embracing this sense of personal meaning or
purpose that provides the strength and determination to endure suffering and the
opportunity to grow as a person (Graber, 2004). Frankl’s theories were put to the test
when he, himself, was imprisoned in German concentration camps for three years during
the Holocaust. His determination to see his parents and wife again and to publish his
manuscript to bring his theories to the public fueled his determination to survive, even as
those around him were giving up. As the great philosopher, Nietzsche, declares “He who
has a ‘why’ to live can bear almost any ‘how’” (2010).
Tragic optimism. Frankl believed that the path to healing this disintegration of
the Noos was through reintegrating the parts of the self through meaning-making. He
postulated that there were three primary ways that human being create or find meaning in
their lives. First, the path to meaning making was through looking outside of, and
beyond the ‘self.’ In fact, self-absorption was considered to be detrimental to finding
meaning and leads to pathology and despondency. It is through reaching outside of the
self through work, love, and/or experiencing nature/beauty, that we find our sense of self.
He referred to these components as the Triad of Optimism (fig, 3) (Frankl, 2006, p.111).
The Triad of Tragic Optimism:
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Meaning-Making
Love
Growth & Resilience
Work Beauty Re-Integration
Figure 3
The Triad of Tragic Optimism provides the means to discover or create personal
meaning. From this perspective, human beings actualize their “potential meaning in life”
by focusing on a “cause to serve or another person to love” rather than by focusing on the
self. Logotherapy encourages de-reflection (looking outside oneself) rather than hyper-
reflection (looking within the self) and believes that “self actualization” is not a goal - it
is a by-product derived from the activity of creating meaning. Frankl refers to this as the
“transcendence of human existence” (2006, pp. 110-111).
Work. Personal meaning can be created or discovered through work or
generatively. Whether it is a job, a volunteer position, or creating something that is
meaningful, finding meaning through work or creation allows the individual to give
something of themselves to the world. The creation of this ‘work’ gives their life purpose
and meaning and helps sustain in the difficult moments. For Frankl, he experienced this
first hand as he fought to retain his manuscript during his containment in the
concentration camps of Auschwitz. He was motivated to bring his theories to the world
to help others and this ‘purpose’ often helped him endure the pain and suffering of the
concentration camp (2006).
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Love. Another path to life meaning is through love and our relationships with
others. Our lives have meaning because we know that we are connected to another
person. We matter to someone else. Often we can endure suffering in order to see our
loved ones again or to be strong for them. Frankl also stated that his desire to see his
wife and parents again gave meaning to his struggle to survive each day in the
concentration camps. Our own personal life meaning is discovered through our
relationships and that knowledge that other people need us. I have spoken to many
suicidal clients whose only reason for not attempting suicide is that it would hurt a loved
one (Frankl, 2006, p. 110).
Beauty. The third path to meaning in the Triad of Optimism is what Frankl
referred to as Aesthetics, also referred to as beauty or nature. This realm is personal and
unique. It represents the moments in life when we feel connected with nature and all
things. It may be through an increased awareness of the divine, or of our interconnected
relationship with nature seen through a beautiful sunset. Meaning turns suffering into
human achievement and accomplishment, motivating and empowering one to take
responsible action and leads to the concept of posttraumatic growth and resiliency (2006,
p.111).
Trauma-Induced Existential Dis-Integration.
While the literature review presented thus far represents only a fraction of the
available material related to trauma, I feel that it is sufficient to establish the foundation
from which to discuss the need and development of a new conceptual framework. As we
have seen, attempts to define the post-trauma phenomena have had a long and varied
history, and have been riddled with controversy and confusion. Throughout generations,
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service members returning from war and/or combat have reported similar symptom
clusters regardless what professional paradigms were prevailing at the time. Even today,
with decades of research validating the existence of PTSD, our warriors continue to
suffer with the same of debilitating symptoms as in previous generations and are still not
adequately defined, addressed or treated under our current guidance. We are a country at
war, and the numbers of service members who have already returned from war, and the
number who will be returning, are staggering. We have learned much over the years and
generations of previous wars, but it is time to take our knowledge to the next level. I
believe we must take a serious and intentional look at the symptoms that “do not fit” our
current classification system, and attempt to understand how and why these symptoms
continuously “hang together.” Paradigms are changing and emphasizing a move toward
holistic treatment. Can we address the needs of our returning service members from a
holistic perspective and fill the gaps we are seeing in the field and translate to more
effective treatment?
The proposed model, Trauma-Induced Existential Dis-Integration provides the
framework needed to address the indentified gaps in our existing nomenclature and
elevate our understanding of the existential effects of extreme stress and trauma on the
individuals who experience it. Integrating practice wisdom, clinical observation, and
multiple evidence-based theories, the proposed model provides a platform from which to
examine the elusive symptoms of extreme stress that are beyond the scope of PTSD,
while integrating these symptoms into an etiologically-based therapeutic model. Finally,
the model seeks to provide within its framework, the implication for treatment that
embodies an expectation of transformation, growth, and recovery – taking treatment into
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the realm of holistic care. Within the name, lies the framework for etiology, diagnosis,
and treatment and provides the nomenclature that will facilitate discussion and further
inquiry.
Trauma-Induced (Etiology): In accordance with the etiological assumptions for
Disorders of Extreme Stress – Not Otherwise Specified (DESNOS), TIED is often seen in
people who have endured extreme, prolonged or severe trauma or stress-laden
experiences. However, it can be noted that people can experience TIED without a
specific trauma event and that enduring extreme stress can bring about the phenomenon
of TIED. While this essay specifically focuses on the application of this theory to the
military population, war is not the only environment that may produce this phenomenon,
but is certainly conducive to the development of this condition. It is noted that this
phenomemon can be found in a variety of populations and people across the lifespan. A
hallmark feature for TIED is that an external experience triggers an internal existential
crisis during which the person begins to question their very existence, life meaning, and
future. This experience can involve an increased awareness of one’s own mortality,
facing death, danger, or significant life change.
Existential (Symptmatology): Based on the structure of the whole being as
postulated by Aristotle, Frankl, and others, TIED recognizes the existence and
importance of the Noos, or spiritual domain as a viable human entity referred to as the
“Core Self.” TIED recognizes that this domain can be wounded by experiences of
extreme stress which leads to an existential crisis or “vacuum” – shattering the previous
sense of self at the core of one’s being (values, feelings, beliefs, choices, purpose) and is
related to the person’s sense of who they are, why they exist, why they made certain
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choices, whether or not they matter, or make a difference. Existentialism is the branch of
philosophy conceptualizing the individuality of each person’s quest to understand life and
his or her place in it through deriving meaning from life events. Based on my own
clinical observation, psycho-social assessments and attempts to diagnose returning
service members, along with the work of others such as Herman and van der Kolk, the
diagnostic criteria for TIED is similar to the symptoms outlined in the DESNOS criteria
which has been validated by multiple studies. While DESNOS covers a wide variety of
symptoms, TIED specifically focuses on the following symptom clusters;
1. alteration in regulation of affect and impulses – (Irritability, risk-taking,

impulsive purchases, attempts to replace the lost meaning),
2. alteration in attention or concentration - (Hyper-reflection on self, obsessive

focus on changes to self, depersonalization),
3. alterations in self perception – (Feeling permanently changed or damaged,

Feeling that no one can understand, changes in Core Self virtues),
4. alterations in relations with others – (Dis-connection or discomfort

emotionally connecting with others, mistrust, paranoia, and
5. alterations in systems of meaning – (Strained or lost sense of meaning or

purpose, despair, hopelessness, loss of previously sustained beliefs).
Ample research is available to suggest the existence and prevalence of these symptoms
clusters among returning veterans in conjunction with the centuries of anecdotal reports
from previous eras of soldiers throughout time. TIED recognizes these symptoms as
central to the individual’s discomfort and not “associated features” of another diagnosis.
In addition, while it is important for this constellation of symptoms to have a specific and
unique identity, it should be noted that experiencing these symptoms does not,
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necessarily suggest the presence of pathology. The presence of a degree of tension
created in the moments in life that offer the greatest opportunity for meaning-making and
growth is considered by Frankl to be a healthy and natural sign of growth and resiliency.
All too often, the “normal emotional reaction” to the “abnormal” events of war,
separation, deployment, is considered to be pathological. However, while the discomfort
of this life crisis or existential vacuum may be normal, the person often needs guidance
and reassurance to navigate through this process of re-integration. In addition, if the
person becomes stuck or stagnate in this existential vacuum, it can lead to serious
pathological problems such as depression, identity diffusion, and suicide. For the
individual, this is a process that spans a continuum between “normal/functional” to
“pathological/dysfunctional.” Pathology is based on the intensity and severity of the
individuals’ feelings of being disconnected from their core self and sense of purpose.
Dis-integration (Normal, Pathological & Recovery): The concept that what
was once whole or connected is now fragmented and lacks cohesion or integration. This
dis-integration happens on many levels from the core of the being, to a connection with
the self, others, society, or higher sense of purpose or divinity. According to Dr. Charles
Figley, this injury is permanent in the sense that that the pieces will not go back together
exactly the way they were before (2007). Healing comes from the re-integration of the
fragmented components of the self to help the person become “whole” again. TIED
recognizes that the new self will be permanently changed by the experiences. This
change can be positive and can result in the individual becoming stronger and more
resilient than before. The goal of therapy is to support the client as he or she re-integrates
these fragments while deriving meaning from the experiences.
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Face Validity - Addresses Clinical Observation. Trauma-Induced Existential
Dis-Integration attempts to provide a diagnostic and treatment structure to address the
clients’ primary question, “who am I now?” A hallmark characteristic of this syndrome,
it is an indicator that the individual is trying to convey his or her awareness of the
profound changes and/or feelings of disconnection with one’s core self and need for re-
integration. TIED recognizes that this is not the realm of the cognitive, or the physical, it
is the realm of the spiritual self and can only be reached through exploration of existential
theory, particularly with Franklian Psychology, this model addresses this transformation
and sees it as a continuum from pathology to recovery.
Theoretical assumptions. Embedded within the Trauma-Induced Existential
Dis-Integration model are the following assumptions adopted from other theories or
models presented. It assumes the existence of the Spiritual Domain as a very real, vital
and integral component of the whole. This domain is referred to at the Core Self. The
Core Self is the unique part of the human being that can be likened to the personality,
persona, ego or identity. Simply stated, it is who they are and who they know themselves
to be. The Core Self can be shattered or wounded by severe stress, trauma or extreme life
event. We assume that, prior to the experience of extreme stress; the Core Self was
integrated and functional (at least in the environment in which they were accustomed).
When the Core Self is wounded, it becomes dis-integrated, (as in, “no longer
integrated”). All of the Core traits that once formed a cohesive structure that was known
and comfortable to the individual are no longer integrated or cohesive. Fragments remain
of the Original self, along with fragments of new elements created from the new
experiences. The glue that holds the self together, or allows for resiliency during periods
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of great stress or trauma is the individual’s ability to create or discover meaning in these
experiences. An overwhelming of this process leads to an existential vacuum, which can
lead to despair and manifest into symptoms of extreme stress as outlined above.
Another assumption on which this model is based is that all humans will
experience periods of suffering in their lives and that we all have the potential capacity to
endure, survive, and even thrive in the face of great danger or adversity. This, of course,
has been proven time and time again by everyday people. From war, the Holocaust,
crime, and natural disasters, people have a strength and determination to survive. TIED
assumes that the goal of treatment is to help the individual navigate their way through
this journey and reintegrate the fragments of the self with the new experiences leading to
transformation and growth.
Application: What does this mean for our military? Among returning
warriors, there exists a duality between those whose sense of Core Self remains
“integrated” as opposed to those who return “dis-integrated.” While both groups often
report having similar experiences during deployment, and both groups may report having
combat-related symptoms and readjustment challenges, the individual whose Core Self
remains “integrated” has an intact sense of self, ability to remain connected with others,
and has retained, or developed, a personal sense of purpose or life-meaning. Far from
being rigid, these are individuals who have integrated their life questions and war
experiences into a new sense of self. They appear to be much more resilient and able to
successfully reintegrate back into civilian life in spite of predicable anxiety and
readjustment issues. Whereas, the individual who returns with a fragmented, shattered or
“disintegrated” Core Self has much more difficulty deriving personal meaning from their
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traumatic experience, becomes withdrawn and has disconnected from others, and has
difficulty re-integrating back into civilian life. These individuals display a high co-
morbidity with PTSD, Major Depressive Disorder, and other emotional/behavioral
conditions. They can be difficult to engage, have atypical responses to medication
management and traditional therapies, and express a myriad of bio-psycho-social
complaints. I have witnessed individuals in this group drift in and out of multiple
treatment facilities and attempt numerous treatment modalities including a vast array of
medications, with little or no reported relief. As Dr. Tick astutely observes, “You cannot
medicate the soul” (2005, p. 116). This group often displays an increased risk for
dysfunction within multiple areas of life including interpersonal, emotional, vocational,
substance abuse, homelessness, and suicide. There are several aspects of military
services which lend our warriors to being more susceptible to this existential vacuum.
This is a volunteer fighting force. The warriors have chosen to serve and oftentimes, to
deploy. For some, this is a point of comfort and sense of personal choice and power, for
others this can increase the sense of guilt, remorse, and self doubt. Our soldiers are
highly trained, professional, intelligent warriors who have a deep sense of individual and
collective purpose and meaning to all that they do. These choices, strengths and
adaptability allow the Core Self to change and transform in order to survive. This
transformational process, with emphasis on the changes to the Core Self is outlined below
and summarized in table 5 on page 77.
Original Core Self. Prior to the experience of extreme stress or trauma (i.e. prior
to deployment), the individual is functioning with his or her Original Core Self intact.
Within this Core Self lies the sum total of the person’s existence to this point. Past
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experiences, previous learning, accomplishment of developmental tasks, previous abuse
or trauma, instilled values, belief system, hopes, dreams, preferences, motivations,
esteem, doubts, sense of self in the world and sense of meaning - all reside in a relatively
cohesive entity. While this entity is far from perfect, we will assume for the warrior
population, that it is generally stable and functioning, even with any possible deficits
such as previous trauma, abuse, or psychosocial issues. This persona often becomes the
baseline to which later variations of the “self” will be compared. When they state, “I am
not the person I used to be,” they are holding the memory of this “self” in their mind, as
are their family members who cling to unrealistic expectations that the warrior will return
to the person they once had been. When preparing to go into battle, the Original Core
Self must transform from their civilian persona to the warrior persona in order to survive
and fulfill the mission. This transformation is adaptive and functional for survival yet,
ironically it is this powerful transformation, under the pressure of life and death
circumstances that creates such difficulties when a service member returns and tries to re-
integrate into their civilian life.
Warrior Self. During the preparation for deployment the transformation from
civilian to warrior begins. First, there is the process of anticipatory separation from their
loved ones. They begin to plan and talk about their departure, and must face the
possibility that they may not return. They start emotionally separating long before the
“geographic” separation occurs. As they enter pre-deployment training cycles, they
begin to connect and bond with their “battle buddies” as the group motivation toward
fulfilling the mission is instilled. The bonds and connections that define the Original
Core Self, are loosened in order to assimilate and accommodate new demands. They
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must transform to become an integral member of the group, troop, or battalion – the
American Uniformed Services. This is an immensely powerful transformation since,
with this warrior identity, comes intense pride, patriotism, and purpose. The values of
life, death, freedom and safety lie in their hands. The individual must allow the
connection with their previous values, beliefs, and tendencies of the Core Self, to be
loosened in order to take on the values of the group and develop cohesion and the
collective identity. The warrior’s life, the lives of their troop members and innocent
civilians depend on successfully making this transformation. When this happens, they
become more than just a member of a group, they become a part of something greater
than themselves. Something mythical, timeless – they become warriors. This great sense
of purpose is something outside of themselves that they are willing to suffer, sacrifice and
die for. Their affiliation as a member of this group is seen and reinforced through the
powerful symbolic images of their uniform, the American flag, insignia, and their shared
credo (see appendix C). Throughout the deployment, they have the mission of holding
the country’s security, pride, and future, and the very life and death of countless battle
buddies and civilians, in their hands. The values and beliefs of the Core Self and
previous connections with others are challenged, strained and even broken for the
individual to survive this abnormal life experience. This transformation challenges even
the most basic values forcing the individual to overcome ingrained human resistance to
kill by instilling a “mission first, kill or be killed” belief system (Grossman, 1996, p. 29).
This transformation is based on survival. There is an increased awareness that there is a
real element of perpetual danger and the warrior must be ready to put mission first and be
willing to die for the cause. Meaning and purpose of the group is greater than the
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individual. Inside the individual, however there is a conflict between the values and
beliefs of the Original Self, and those adopted by the Warrior Self. Tim O’Brien, a
combat veteran, describes this duality of within,
War has the feel – the spiritual texture - of a great ghostly fog, thick and
permanent. There is no clarity, everything swirls. The old rules no longer
binding, the old truths no longer true. Right spills over into wrong. Order blends
into chaos, love into hate, ugliness into beauty, law into anarchy, civility into
savagery. The vapors suck you in. You can’t tell where you are, or why you’re
there and the only certainty is overwhelming ambiguity. In war you lose your
sense of the definite, hence your sense of truth itself, and therefore it’s safe to say
that in a true war story, nothing is every absolutely true (O’Brien, 1980 as quoted
in Herman, 1997, p.53).
This quote provides a glimpse into the internal conflict and profound opportunity for
deep existential and philosophical questioning as everything they once knew to be true
begins to come apart. There is no external certainty, and therefore, no internal certainty
or cohesion. The existential experience can be similar for those who engaged in combat
and in those who were there “in support” and did not experience battle or traumatic
experiences. The mere fact that they were separated from their previous life and
relationships, and serving the same mission, still aware of their own mortality, and having
the time to ruminate on their life, purpose, goals and existence. I believe this helps to
explain why we often see a similar constellation of symptoms in those who did not
experience combat or trauma and therefore, would not meet the diagnosis of PTSD. They
may not exhibit symptoms of anxiety, but may return with many of the DESNOS
symptoms discussed earlier.
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Dis-Integrated Self. Upon return from the deployment experience, the individual
carries with them fragments of the Original Core Self as well as fragments of the Warrior
Self but, neither of these adequately fit their new environment. The grip held on the
values, beliefs, and motivations of the Warrior Self must now loosen in order to
transform to meet new demands and to be able to reintegrate into civilian life. Previous
relationships must be renewed and the person must often (especially in the case of
National Guard and Reservists) return to previous neighborhoods and jobs. The person
struggles to re-integrate these pieces of the “selves” into a cohesive structure that meets
the demands of the new reality. Their experiences and new knowledge must be
integrated into this new self as well. Horowitz explains this as a “failure to re-schematize
inner cognitive maps of self and the world to accord with a new reality…enduring
preexisting attitudes are in sharp discord with the experiences produced by traumatic
events” (Horowitz, 1997) leading to what he calls “Stress alarm” (Horowitz 1999, p. 10).
Traumatic events impact on identity and may lead to a variety of self concept
disturbances such as identity diffusion (a chaotic sense of self –fragmentation) or
depersonalization. Feeling disconnected and confused, individuals begin to judge
themselves, their actions and experience harshly – leading to guilt and remorse. They
may lose their connection with the powerful feelings of purpose and meaning that they
felt while “in country.” Upon return, they may have felt let down or even betrayed by the
group, unit, military or country and began to question what purpose their sacrifice served.
They may express that they think they may be “going crazy” and are sometimes afraid to
tell people for fear that these thoughts will be confirmed. They wrestle with values that
are so powerful and overwhelming that they feel no one could possibly understand.
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Often, they have unrealistic expectations that they are supposed to return to the Original
Self, and when this does not happen, they feel a great deal of self doubt and fear about
who they are, or who they are supposed to be. Much of this transformation process is a
normal and natural part of being human. We are constantly learning, growing and
changing – gradually meeting the tasks of development. But, for these individuals, too
much has happened too fast, under extreme conditions. This loss of self and purpose
leads to what Frankl called the existential vacuum. This is characterized by hopelessness
and despair. When the individual sees their goal as returning to the Original Self
baseline, they will become fixated on the unrealistic attainment of this goal. This is often
reinforced by family members who were expecting the person to go back to being the
Original Self as well. A person fixated on themselves becomes hyper-reflective (focused
on their internal pain and suffering) which is in direct opposition to the path to healing
described by Frankl (1994, p.123). According to Logotherapy, the goal of treatment is to
find or create meaning by de-reflection (making connections outside of the “self” through
the Triad of Tragic Optimism). To begin to re-integrate the fragmented pieces of the self,
the person must become reconnected through reaching beyond themselves through their
work, experiences or relationships. Herman emphasizes that “A secure sense of
connection with caring people is the foundation of personality development. When this
connection is shattered, the traumatized person loses her basic sense of self (p. 52).
According to Lt. General Eric Schoomaker, “Army leaders say that broken personal
relationships seem to be the most common thread linking suicides. "The one
transcendent factor that we seem to have, if there's any one that's associated with
[suicide], is fractured relationships of some sort" (Thompson, 2010). Clearly, the dis-
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integration occurs first within the individual and then with the relationships, community,
work and finally, the self is dis-integrated with the world.
Re-Integrated Core Self. Many individuals have described experiencing a
profound, life-changing process during deployment or in the months of adjustment
following their return. Some turn to family, friends, clergy, or re-adjustment counseling
centers for support and assistance during this process. In addition to this existential pain,
many may also be suffering from PTSD and other emotional challenges and physical
injuries and pain. War wounds all part of the being and all must be addressed in a
holistic model of care. These domains of body, mind and spirit (or Core Self) are
inseparable and intertwined. It is imperative that all three be considered in the holistic
treatment model.
Focusing on the Core Self (spiritual) domain, re-integration involves accepting
and embracing the fragments of both the Original Self and Warrior Self while realizing
that the end result of re-integration is a New Core Self. As Figley points out, the pieces
will not go back exactly the way they were, but can be whole again (Figley, 2007). It is
important for the individual to let go of the unrealistic goal of returning to the Original
Core Self in order to be able to move forward. New values, thoughts, feelings and beliefs
are re-integrated into a new cohesive structure and the person develops a connection with
new sense of life meaning or purpose. According to Frankl, the goal of treatment is
aimed at helping the individual discover or create meaning from their experiences and not
to fear the changes, but to embrace the New Self. Once the internal fragments are re-
integrated, the person is then able to genuinely connect with others. Conflict between
original self, warrior self, and new self has been resolved. The individual can become
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stronger and more resilient than they had ever been before and may have better insight
and coping skills to deal with future stressors. There is a long tradition of this belief that
human beings have the potential to become stronger by overcoming adversity. Ernest
Hemmingway wrote, “The world breaks every one and afterward many are strong at the
broken places” (2010). Once re-integration is complete, the Core Self returns to a state of
homeostasis in which he or she is more at peace with their new identity and has
successfully assimilated the new knowledge and experiences into a new Core Self.
Transformation Model:
Table 3
Original Self: Individual core-self is in homeostasis (below stress threshold)
Individual sense of core-self intact (I know who I am, what I feel,

value & believe)
Individual sense of purpose intact (I know what I do and why)
Relationships (connections with others) are in homeostasis
Warrior Self: Individual identity is replaced with group identity (unit identity)
The group identity and purpose becomes greater than oneself
Individual values and beliefs begin to be questioned if they conflict

with group
Faces the "Tragic Triad" daily (Guilt, Pain, Death) = Existential

Vacuum
Dis-Integrated Self: Core assets of the self are questioned (values, beliefs, feelings,
purpose)
Conflict between new thoughts, feelings, beliefs with original

self/warrior self
Fragmented sense of meaning and purpose
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Discomfort engaging with others
Re-Integrated Self: Conflict between original self, group self, and new self has been
resolved
Experiences have been reframed through meaning-making
The new values, thoughts, feelings and beliefs have been reintegrated
Person has developed connection with new sense of life meaning or

purpose
Person is able to connect with others
The individual is stronger and more resilient and has better coping
skills to deal with future stressors
Identity (Self) returns to homeostasis
Implications for Treatment and Recovery
By reintegrating the spiritual domain back into the realm of the whole being and
truly offering a holistic model of care, we open many new doors to therapeutic
interventions that were once just out of our reach. I have experienced in my own practice
how powerful addressing this realm can be in a traditional therapeutic relationship. The
following points are ones I have discovered and lead my pracctices.
 Letting the patient know that we understand and share their pain, questions and
confusion is a wonderful step to leveling the playing field. We all suffer. We all
face adversity.
 Normalize this experience, let them know they are not alone (and that they are not
going crazy)
 Encourage exploration of these existential questions
 Focus on the strengths, and the future (time really does heal)
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 Let them know that they are on a transformational journey and this is not the end,
it is just a temporary oasis
 Most of all, help them find meaning in their suffering, and a new purpose in life
Addressing these questions, giving it a language of its own and the permission to talk
about the changes to the Core Self), allowing them the opportunity to get to know
themselves again and possibly not fear this transformation or cling to unrealistic
expectations. This can lead to the concept of Post-Traumatic Growth (PT-G).
Post-Traumatic Growth & TIED. Throughout time, human beings have proven
themselves to be resilient fighters and survivors of war, the Holocaust, natural and man-
made disasters, accidents, loss, and personal adversity. Throughout history, we have
risen to the demands of life with immense strength and determination. Where does this
strength come from? Do we strive for pleasure as Freud suggested, or for power as Adler
postulated? Ask a survivor of trauma or adversity what it was that helped them face the
suffering and they will tell you, in some variation, that they had some connection deep
inside the core of their being that allowed them to endure. Many will tell you that they
thought of loved ones or had to be strong for others. Through these connections, they
found meaning in their difficult experiences. More than just enduring the experience,
many people report that, while they would not have chosen to have the trauma, they feel
that they are in some ways better for having had the experience. Research on this human
resiliency and concept of Post-Traumatic Growth is starting to emerge. According to
research conducted by Calhoun and Tedeschi (1999), posttraumatic growth refers to
79
positive psychological and personal changes that are produced as the result of an
individual’s struggle with a difficult life circumstances that challenges their
understanding of the world and their place in it. These are not merely intellectual or even
emotional effects, and that is what makes them so powerful for many trauma survivors.
Posttraumatic growth is not simply a return to baseline from a period of suffering; instead
it is an experience of improvement that for some persons is deeply profound. According
to Calhoun, the clinician's role is to assist in the facilitation of meaning-making, and
reconstruction of schemas. Calhoun and Tedeschi (1999) have created a 21-item
assessment tool to help identify the qualities that are associated with Post Traumatic
Growth. These qualities include; relating to others, personal strength, spiritual change,
and appreciation of life.
Resiliency. Another concept that is emerging in discussion, policies and
programs is the concept of resiliency. Research is also emerging with regard to using
resiliency programs as a preventative or protective measure within the military. Warrior
Resiliency and Family Resiliency programs are being implemented for deployed soldiers
and their family members with components being implemented before, during and after
deployment. This is being met with positive enthusiasm.
Logotherapy. Franklian psychology provides a uncomplicated framework of theory and
therapy that specifically addresses the importance of meaning and purpose as a central
motivation in life. According to Frankl, having meaning and purpose in one’s life gives
us a reason to live and endure hardships. Therapists are able to implement Logotherapy
within their existing therapeutic programming by offering their patients opportunities to
discover meaning through multiple therapeutic techniques and strive to reconnect with
80
others. These activities help the person focus on the future and re-integrate the
fragmented parts of the self.
Conclusion
The subject of post-deployment mental health has been a difficult and elusive
topic for generations. In my practice, and research, I have found myself traversing the
same paths as theorist, researchers and philosophers before me. In my review of the
literature I was shocked to find that others have been trying to resolve the issues related
to the diverse and debilitating symptoms that can destroy a person at the core of his or her
Core Self. Struggling to find a framework in which to synthesize the symptoms that do
not fit the PTSD or other mental health diagnoses, and to try to understand what holds
these common symptoms together, the proposed model began to evolve.
The concept of Trauma-Induced Existential Dis-Integration (TIED) not only
provides a framework for the identification of individuals who may be at higher risk for
dysfunction (by examining the pervasive symptoms of existential crises). It also provides
an effective nomenclature by which we can discuss, research, and study the phenomenon.
In addition, embedded within the framework is the key to treatment and opportunity for
recovery by focusing on meaning-loss, meaning-making. This model goes beyond
anxiety, beyond behavioral conditioning, and beyond the physiological neuro-chemical
reactions to reach into the inner core where the shattered, dis-integrated ‘self’ resides. If
we are to successfully provide “holistic” treatment, the injuries to this part of the
individual must be recognized, brought to light, and proactively treated. Once an
individual is able to heal the fragmented and dis-integrated parts of the self and able to
81
derive meaning from his or her experiences, the person is also better able to grow
stronger and more resilient from this experience leading to the concept of Post-Traumatic
Growth. Once the pieces of the inner self are re-integrated, the person can more wholly
connect with others and find meaning in life experiences.
Implications for Future
Research. While this model is an example of evidence-based theory meets
practice wisdom, empirical research needs to be completed to further validate the criteria
and establish the validity of the theory that these symptoms are a manifestation of a
wound to the “soul.” We are doing a great injustice to these individuals to misdiagnosis
them as having PTSD (in the current understanding of this anxiety –based disorder)
Standardize nomenclature. When the diagnostic criteria for PTSD was finally
accepted and included in the DSM-III, it provided the language and criteria to standardize
the concept PTSD giving the field a common set of criteria with which to study the
phenomenon. The primary criteria has been validated time and again and has been used
to further the development of screening and assessment tools, and treatment modalities
with research on symptoms reduction. It is crucial to have an accepted name for this
condition that accurately describes the etiology, symptomology, progression and potential
treatment modalities and guide further research.
Develop screening tool. Many of the symptoms of DESNOS/TIED are very
disturbing and debilitating to the individual and can lead to severe despair, hopelessness
and suicidal ideation. Having a validated, effective screening tool would be helpful to
82
identify individuals who may be at risk and to help to determine the efficacy of programs
or treatment modalities.
Treatment guidelines. Once the existence of TIED are effectively validated,
screening and assessment tools are in place, research to determined effective treatment or
interventions can be developed to provide treatment guidelines that allow for holistic
care.
Prevention efforts. Understanding this transformational process as a journey can
link with other treatment and intervention programs to prepare individuals for the
experience of change to the Core Self. Resiliency training is starting to provide this care.
Specific to social work. Social work is accustomed to considering the person-in-
environment and are familiar with the need to treat the whole person. Social workers can
operate in the holistic realm; we focus on strengths, self-determination and personal sense
of meaning. Social workers have the unique opportunity and responsibility to help
define, identify and change the system to embrace a holistic approach. We must advocate
for the needs of our clients to be met through listening to their needs and developing and
implementing models of care that meet their needs. We need to help change the
expectations in the field from a paradigm of pathology to a paradigm of recovery.
Limitations
Work in progress. This is a work in progress. A thorough historical overview
has been completed that reveals a long history of wrestling with the diverse of elusive
83
needs of returning veterans. This is just a beginning and will hopefully continue to
evolve into a solid, validated theoretical and therapeutic model.
Theory-based but not empirically supported. While the basis of the model is
based on validated, empirically based models and classic theory, the model itself has not
been subject to empirical validation and study.
Meant to generate discussion. At this point, this postulated theoretical model
has been presented and circulated through many avenues (professional conference, group
therapy sessions, and individual and family sessions, as well as being reviewed by
professionals in the field. This is meant to generate discussion and obtain feedback from
professionals and clients alike. Anecdotal feedback supports a high level of face-validity
and support for the model. It is well received by clinicians, administrators, and clients. It
is easily understood and clients appear to be appreciative of the efforts to tell their story.
Not an either or, but a yes-and…. It should be understood that I am not proposing to
change or eliminate the diagnosis of PTSD. I believe that we have a great deal of
validated research to support the PTSD (trauma-related anxiety disorder) criteria. I am
suggesting that we take a closer look at the symptoms that really do not fit in that
category and recognize the limitations of this diagnostic criteria to be an all
encompassing diagnosis for trauma experiences. As recognized by Judith Herman, what
we are seeing are, “Two co-morbid manifestations of the same etiology effecting
different part of the “self” “All are, in the end, inseparably connected (Herman p.32).
Summary. In my research, practice, and interviews, I found a common thread
among the individuals who were describing this pervasive sense of emptiness and dis-
84
integration at the core of their being. These individuals reported having lost (or were
questioning) a sense of purpose and meaning in their lives. Nothing had meaning – they
had no purpose. Their sense of purpose and meaning in all things had broken down. In
some cases, they looked OK on the outside because they knew how to “go through the
motions,” but on the inside they were coming apart. They had no cohesion in the core of
their self (values, beliefs, thoughts, schema) were dis-integrated. Their sense of
relationships and connections were dis-integrated. Their very connection to the world
around them and their sense belonging to it was dis-integrated. In my practice, I have
found that the Trauma-Induced Existential Dis-Integration Model provides a framework
for building a bridge between the trauma dis-integrated state and recovery through the
activities of meaning-making and reintegration of the core self.
While change is slow, it is it inevitable. Lessons learned from Vietnam include an
awareness of how deeply the wounds of the soldiers can spread to wound their families
and our society for generations. We are still feeling the generational effects of our poor
response to the reintegration and trauma needs of the Vietnam veterans and their families.
We have learned that early intervention and support is a key factor in successful
reintegration. Pretending there isn’t an issue won’t make it go away, and we either deal
with it now or deal with it later. Also changing is the realization that we have come a
long way, but we clearly have gaps in our understanding. It is hoped that this model will
serve to generate a forum and foundation for future study and research, and discussion
and provide a glimpse into what the future could hold for true holistic treatment and
recovery from trauma.
85
“Life does not owe you happiness – it offers you meaning” ~ Viktor Frankl
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91
Appendix A
Compiled List of Common Symptoms
DESNOS Diagnostic Criteria
92
Compiled List of Common Symptoms Reported by Returning Warriors
Classic PTSD Associated with PTSD and other disorders * = DESNOS
Disconnection with oneself * Anxiety in Crowds
Disconnection with others * Trust Issues *
Guilt * General Anxiety/Worry
Remorse * Racing thoughts
Shame * Impatience
Grief * Low Tolerance Level *
Rage * Irritable *
Cognitive distortions and changes * Mood Swings *
Feelings of worthlessness * Recklessness *
Increased risk of substance abuse * Crave/Seek Stimuli *
Withdrawn from others, society * Adrenaline Rush
Loss of time * Euphoria
A/V hallucinations Risk Taking *
Derealization * Anger & Rage *
Hopelessness (general) * Physical pain & ailments *
Suicidal Ideation or attempts * Denial *
Surreal Feelings * Appetite Changes *
Sleep Problems Fear of self
Nightmares Poor Memory/forgetful *
Flashbacks Easily Frustrated *
Hypervigilance Panic Attacks
Avoidance of Stimuli Obsessive checking
Driving/Road Anxiety/Rage * Sexual difficulties
93
Disorders of Extreme Stress – Not otherwise Specified (DESNOS) CRITERIA:
I. Alteration in regulation of affect and impulse control: (A and one of B-F required)
a. Affect regulation
b. Modulation of Anger
c. Self-Destructive
d. Suicidal preoccupation
e. Difficulty Modulating sexual involvement
f. Excessive risk-taking
II. Alterations in attention or concentration
a. Amnesia or
b. Transient dissociative episodes and depersonalization
III. Alterations in self perception (two required)
a. Ineffectiveness
b. Permanent damage
c. Guilt and responsibility
d. Shame
e. Nobody can understand
f. Minimizing
IV. Alterations in relations with others (one required)
a. Inability to trust
b. Revictimization
c. Victimizing others
V. Somatization
a. Digestive system
b. Chronic pain
c. Cardiopulmonary
d. Conversion symptoms
e. Sexual symptoms
VI. Alterations in systems of meaning
a. Despair and hopelessness
b. Loss of previously sustaining beliefs
94
Appendix B
Differential Diagnosis Matrix
95
Differential Diagnosis Matrix
TIED
Mood D/O
PTSD (20%)
ADJUSTMENT DISORDER
ADJUSTMENT (100%)
COMBAT STRESS (100%)
96
Appendix C
Soldier’s Creed
97
The Soldier’s Creed
I am an American Soldier
I am a Warrior and a member of a team. I serve the people of the United States and live
the Army Values.
I will always place the mission first.
I will never accept defeat.
I will never quit.
I will never leave a fallen comrade.
I am disciplined, physically and mentally tough, trained

and proficient in warrior tasks and drills. I always maintain my arms, equipment and
myself.
I am an expert and I am a professional.
I stand ready to deploy, engage, and destroy the enemies of the United States of America
in close combat.
I am a guardian of freedom and the American way of life.
I am an American Soldier.
ARMY VALUES
Loyalty
Bear true faith and allegiance to the U.S. constitution, the Army, and other soldiers.
Be loyal to the nation and its heritage.
Duty
Fulfill your obligations.
Accept responsibility for your own actions and those entrusted to your care.
Find opportunities to improve oneself for the good of the group.
Respect
Rely upon the golden rule.
How we consider others reflects upon each of us, both personally and as a professional organization.
Selfless Service
Put the welfare of the nation, the Army, and your subordinates before your own.
Selfless service leads to organizational teamwork and encompasses discipline, self-control and faith in the system.
Honor
Live up to all the Army values
Integrity
Do what is right, legally and morally.
Be willing to do what is right even when no one is looking.
It is our "moral compass" an inner voice.
Personal Courage
Our ability to face fear, danger, or adversity, both physical and moral courage.
98

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Running head: TRAUMA-INDUCED EXISTENTIAL DIS-INTEGRATION

Beyond PTSD…Trauma-Induced Existential Dis-Integration Model

LeAnn E. Bruce, LCSW, BCD, MAC

University of Louisville, Kent School of Social Work

Sharon Bowland, PhD

May 31, 2010

With the number of Operation Enduring Freedom/Operation Iraqi Freedom

diagnostic nomenclature. Lacking a comprehensive differential classification, clinicians

(PTSD) based on etiological assumptions or resort to assigning multiple ill-fitting

diagnoses in an attempt to address the complex picture of co-morbid complaints.

In response to this observation, a comprehensive exploration of professional

literature including historical and empirical resources, as well as the inclusion of

this, the resulting model, Trauma-Induced Existential Dis-Integration (TIED) developed

as a theory-based, conceptual platform from which to launch discussion and further

exploration of the holistic effects of trauma. It serves as a bridge, allowing us to

transition from a paradigm of pathology with an expectation of symptom

reduction/maintenance to a paradigm of recovery with an expectation of personal growth,

strength, and resilience.

Beyond PTSD: Trauma-Induced Existential Dis-Integration (TIED)

that complicate successful reintegration to civilian life. Their complex, atypical

elusive diagnostic phenomenon.

this pattern of alternating periods of intensive interest and indifference as “episodic

strides toward the classification of the myriad of symptoms reported by returning

meet the existing diagnostic criteria (based on specificity, onset, or duration), or

managed-care, diagnostic-code-driven environment. Lacking precise differential

of Post Traumatic Stress Disorder (PTSD) based on etiological assumptions, or must

resort to assigning multiple ill-fitting diagnoses in an attempt to address the complex

follows that treatment recommendations will be adversely affected. Using an example

symptoms leading to a comprehensive diagnosis is crucial.

In my work with returning veterans, I have become increasingly troubled by the

Diagnostic and Statistical Manual of Mental Disorders-IV-TR (2000). As I wrestled

compassionate care to my clients, I began to talk to other clinicians, who admitted to

having similar concerns. Seeking practice guidance, I began a thorough exploration of

professional literature, historical references, empirical research, and professional practice

exploratory journey led to the development of the proposed model: Trauma-Induced

Existential Dis-Integration (TIED) as a framework from which to better understand the

disconnection. This theory-based conceptual model strives to address identified gaps in

discussion in the field, leading to a more effective understanding of this phenomenon,

Furthermore, it serves as a bridge that allows treatment to transition from a paradigm of

pathology with an expectation of symptom reduction/maintenance to a paradigm of

recovery with an expectation of personal growth, strength, and resiliency.

The Evolution of Trauma Theory, Diagnosis, and War

between this iconic warrior and modern service members stating,

homecoming as a backdrop in his book, Odysseus in America (2002), Jonathan Shay

surge of veterans began pouring into our agencies, he writes,

generation of war, there has been a corresponding generation of “disorders” and

a similar condition seen in post-combat Swiss mercenaries. The symptoms they

described included dejection, melancholy, disturbed sleep, insomnia, weakness, loss of

quickly cutting the syndrome’s prevalence” (ibid.).

the experiences of battle were considered to be malingerers or cowards and execution

was the recommended course of ‘treatment’ (Meagher, 2007). Documented accounts of

veterans reporting anxiety, breathlessness, paranoia, psychosis, memory problems and a

result of a physiological condition affecting the heart. He referred to this condition as

Irritable Heart Syndrome although it came to be known later as DaCosta’s syndrome or

and no treatment was specifically recommended. These individuals wandered home to

were variations of DaCosta’s Syndrome (Shepherd).

The World War-I era. Service members of World War I (1914-1919)

experienced trench warfare and massive explosions, in addition to mortal hand-to-hand

describes reports of a “hollow stare”, violent tremors, psychogenic blindness or deafness,

shock” in an attempt to diagnose and understand this collection of symptoms. He

deafness, nightmares, insomnia, heart palpitations, depression, dizziness, disorientation

brain. Still operating from a physiological perspective and continuing to attempt to

treatment model on the battlefield, an unprecedented tactical move (Meagher, 2007).