Page 67 - Total War on PTSD

For Veterans who have been to Iraq or Afghanistan, for instance, common triggers can include loud noises, sewer smells, diesel fuel, heat, crowds, driving, potholes, debris, and even Middle Eastern Individuals, just to name a few. Ambiguous situations, environments that are overstimulating, or unplanned events can also be quite anxiety provoking for combat Veterans. It is essential in treatment that combat Veterans understand and come to recognize triggers in their environment, so they can learn to modulate their anxiety response. Combat Veterans often externalize their reaction to the environment, believing others are causing them to be angry or anxious. They may also focus on negative aspects of their environment when they are anxious, causing them to feel irritated and more empowered. Although this is not a healthy cycle, feeling angry is a much more familiar feeling to the combat Veteran and comparatively, they will feel more comfortable in an angry state than when they feel anxious or vulnerable. Until the Veteran starts to learn it is not others causing their discomfort or irritability, they will not gain an internal sense of control over their emotional reaction.
In treatment, combat Veterans are assigned to go to avoided or feared environments that should include social scenarios, places that have specific triggers identified by the Veteran, and public places that are busy or crowded. The Veteran should work on learning to be in the moment and focusing on “what is” happening, as opposed to “what if” scenarios that fuel their anxiety. They need to work on disengaging from safety behaviors, such as having their back to the wall, sizing up people, and watching exits. Ultimately, they need to be willing to give up their basic need for a sense of control and to recognize they can still be safe even If they are not constantly vigilant or “battle-ready.” They will need to place effort into learning to refocus on positive aspects of their environment, as opposed to looking for potential threats or negative aspects. Throughout the course of treatment, we explore how combat Veteran walked around in the world prior to their deployment vs. after returning from combat, focusing on helping the combat Veteran see how their perspective was changed due to these experiences and whether they can safely give up their sense of control slowly over time. Again, the combat Veteran can feel highly uncomfortable with letting go of control, as they will feel they are being complacent and have been inculcated with the belief “complacency kills.” Veterans will need to recognize the cost of their vigilance, including never actually enjoying environments, how their negative anticipatory thinking
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