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Returning From War: Making Sense of Chaos and Turmoil

By Kernan Manion, MD

A staggering number of marines, soldiers, sailors and airmen1 return from the combat
theater grappling with complex and disabling psychological issues. Stories abound
about the disabling mental trauma that sweeps many young veterans into a veritable
tornadic vortex of nightmarish emotions.

Just as witnessing the terrorist attacks on the World Trade Center left so many stunned
and emotionally flooded, so too (but in much greater intensity) the combat experience
may leave a not insignificant minority of soldiers mentally overwhelmed. Having been on
the medical staff at VA facilities and witnessing the psychiatric approach to returning
soldiers, I believe that our current framework and diagnostic nomenclature is simply
inadequate to identify the cognitive overload and emotional turmoil that overwhelms
these dedicated men and women.

Acute Stress Disorder (e.g. combat stress) and Post Traumatic Stress Disorder are
certainly preeminent concerns. But what is not fully appreciated is that psychological
impairment caused by the trauma of combat is most often intertwined within a complex
tangle of cognitive and emotional overload.

And if one doesn't carefully identify and dismantle the multiple concurrent psychological
components contributing to this overload, there is a very high likelihood that he will stay
entrenched in this disabling psychological quagmire, pigeon-holed with an incorrect
diagnosis, frustrating nearly all attempts at psychological resolution, and face life with a
chronic psychiatric disability.

Let’s say a person returns home with a significant but not life threatening injury. And he
is worried about how fully his function will return. His girlfriend had broken up with him
while he was deployed. It is now a month and a half since being in the combat theater.
He is still easily irritable, has a startle reaction and broods a lot. He tosses and turns in
his sleep. He is still sad about the loss of a close buddy to gunfire.

He recalls also the frightened faces of the families whose houses he raided. He is still
angry at his CO whom he feels did not show wise leadership regarding their patrol
during which he and others were injured. He resents the people who don’t support this
war, and yet increasingly is wondering whether we should have been there at all.

Most likely, he would receive a diagnosis of PTSD which, unfortunately, has become a

1
With no offense intended to any branch of the service and for the sake of brevity in this article, all who
serve in active duty will be referred to as “soldiers.”
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catch-all phrase. But is it really? Most likely not.

There are certainly elements of PTSD. But also grief and “adjustment disorder” (both to
the impact of the injury and unresolved anger at his CO). And hurt and sadness and
anger at his ex-girlfriend. And there is anger at those who do not support this war and
therefore its commander in chief, which is after all HIS commander in chief. And he may
experience doubt about the war effort itself (which, if it becomes stronger, becomes
growing anger at his commander in chief).

Anger is not a “diagnosis”. Nor is hurt or sadness or anxiety or shame. They are healthy
emotions that need to be articulated. But their intensity and confluence can be
disabling!

No medication, no EMDR, no “trauma desensitization” therapy is going to remove the

necessity of naming and talking through each of these issues - in full - and sometimes
repeatedly - with him. Only AFTER sorting all of this out, helping him get over the loss of
his girlfriend and grieve the loss of his buddy and come to closure on his anger at his
CO and decide what he thinks about the war can we really determine if he has a
persistent PTSD.

But without doing this, he will be relegated to life as a “wounded warrior” with an
identified (and probably chronically symptomatic) PTSD disability. And he will still have
not gotten the help he needs to make sense of his experience.

Nearly everyone emerging from the extraordinary experience of combat grapples with
some degree of cognitive and emotional overload. While psychological overload doesn't
necessarily equate with disability, it clearly impedes optimal mental functioning. One’s
mind is like a computer whose working memory (RAM) is jammed with too many files
and commands.

Likewise, a soldier grappling with making sense of the complex and powerful
experiences that occur in a prolonged (and perhaps repeat) combat deployment, he’s
going to be mentally tied up, preoccupied with sorting things out.

Needless to say, the combat zone does not provide the luxury of psychological space in
which to reflect and “make sense” of the meaning of events. So what happens? Just as
in the mental physiology of an emergency situation, the mind defers processing the data
that the brain’s sensory input “video recorder” captured (incidentally in hyper-speed)
until there is the safety of space and the luxury of time to review it. As the colloquial
psychological phrase so correctly captures it, “you stuff it.” And, as will be discussed
below, if we accept the premise that a key function of the human mind is achieve
coherence about our lives, then eventually the mind must retrieve what has been
“stuffed”, re-view it and make sense of it.

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Have you ever had the experience of dealing with a complex personal emergency
situation in which you somehow managed to function quite superbly but, after it was
over, found yourself recalling each of the events comprising it and wondering “how did I
DO that?” It’s as though you are reassembling a jigsaw puzzle of the whole experience.
In the emergency itself, your mind did not have the luxury off space (nor actually the
availability of the required neuronal circuitry) to “reflectively process” the complex event.
But afterwards – wow! The mind puts its software machine on overtime as it strives to
retrieve every component of the crisis – the events and their environmental and social
setting, cause and effect relationships, fragments of internal and external conversation
that were or were not processed in the emergency …. The mind is AUTOMATICALLY
trying to “make sense” of the myriad sensory data inputs and the person’s multiple
behavioral responses.

I have found it helpful to distinguish amongst types of overload. I refer to the congestion
of psychologically relevant issues, events and situations that have occurred as “chaos”;
the multiple concurrent thoughts we have about each of these as “cacophony”; and the
confluent pooling of predominantly negative emotions associated with each of the chaos
and cacophony components as “turmoil.” Each of these layers of mental processing
(and three others) are discussed more fully in MindSense; this essay focuses
predominantly on the “chaos” and “turmoil” components. Needless to say, intense and
dangerous life experiences like those that occur during the combat experience, are quite
likely to cause “chaos” and “turmoil.”

Chaos and turmoil always mandate "disentangling"; the longer they stay present, the
more distressed (and symptomatic) the individual will likely be.

Chaos and turmoil are not, per se, diagnostic entities. And for that matter, through the
present, the fact of their existence, while obvious, has not been formally recognized.
And I feel that it’s crucial that they be named as they serve as the complex and
individually textured backdrop to any definitive psychiatric syndromes that have
developed.

And because they haven’t been named, there of course isn’t yet a psychiatric
conceptualization of "chaos" or "turmoil." And so, without these concepts, the mental
health community is left with resorting to "best fit diagnosis" amongst the limited array of
DSM 4 diagnoses that might apply to those grappling with psychological overload.

MindSense Model of Mind

The MindSense model of mind (see synopsis) presents a practical and readily
comprehensible model of how the mind works, from processing thoughts and feelings
about experiences through producing a behavioral response. MindSense shows how

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the mind goes through a cascade of discrete steps as it “metabolizes” external events; it
describes the functional physiology of “chaos” and “turmoil”; and identifies what each
individual can – and must – do to dismantle these before they reach critical overload
and become disabling.

In a series of workshops designed for the US Marines, the MindSense model has been
found to be extremely useful especially to those who are in positions serving as peer
counselors, e.g. officers in Wounded Warriors programs. Here, this first level of “mental
health contact” helps the incoming soldier name, take control of and learn to dismantle
his chaos and turmoil edifice.

Chaos and turmoil are like high voltage electricity. Above a certain threshold, they “blow
fuses.” Unresolved, chaos and turmoil lead to psychological dysfunction. Like
Microsoft’s ubiquitous blue screen of death (“fatal error”), chaos’ RAM overload results
in cognitive shutdown. And the affective overload of turmoil itself leads to heightened
pain and therefore to intensification of turmoil itself – it feeds on itself, reaching a point
of nearly complete emotional depletion. The end result of both of these is both “mind
lock” and functional behavioral deterioration. The longer that intrapsychic chaos and
turmoil continue, the more likely that that person will suffer adverse psychiatric illness
(and likely medical illness as well) and maladaptive behavioral sequelae.

If we don't definitively name and address the ubiquity of chaos and turmoil and review
our grossly inadequate approach to addressing them, then these many affected
soldiers:
will be subjected to misdiagnosis and therefore mistreatment;
will needlessly suffer psychologically for a prolonged period of time;
will suffer chronically disabling psychiatric disorders – PTSD, Major Depression;
Generalized Anxiety and Panic Disorder et al.
will have seriously adverse behavioral sequelae: suicide, homicide, interpersonal
violence; high risk, dangerous and impulsive behavior; broken marriages and
families; alcoholism and drug addiction et al.;
and they will have been will be falsely assessed as disabled, (and/or falsely label
themselves as more disabled than they really are) and this will be, perhaps most
importantly, the greatest squandering of human life.

Optimal approach
First, military mental health needs to incorporate a broader conceptual approach at
assessment, encompassing MindSense’s concepts of chaos and turmoil. Perhaps the
academic psychiatric community, the authors of the Diagnostic and Statistical Manual,
need to consider a new general diagnostic category of “mental / emotional distress”,
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defining its particular context, e.g. combat; repeat tours of duty et al.

A MindSense training program could be tailored to the needs of various groups within
the military – officers and leaders; peer support and counseling personnel; and
professional mental health personnel. And the MindSense program could be made
accessible to all via online training as part of a more comprehensive "mental fitness and
psychological resiliency training."

The outcomes with the MindSense approach are many:

Soldiers who serve as peer counselors will be much better equipped to help
incoming soldiers sort out issues.

The individual soldier will be better able to psychologically dismantle his/her

stress edifice. There will be a speedier return to healthy mental functioning.

Soldiers will be more fit for resuming the roles they are committed to. (Clearly,
this is most crucial given the extensive reality of re-deployment.)

There will be less mislabeling of general psychological overload as one or

another particular diagnosis (e.g. PTSD).

With chaos and turmoil effectively dismantled, there will be less overall incidence
of acute and chronic psychiatric disability. Soldiers and their families will enjoy a
better quality of life.

There will be less incidence of adverse dysfunctional behaviors on civilian

populations, not only preventing harm to communities from distressed soldiers
but sparing costly crisis management resources (and embarrassment) to military
institutions resultant from such dramatic and public displays of soldier
dysfunction.

Mental Health clinicians will have a more adaptable conceptual approach, and
yet will still be able to maintain emphasis on the appropriate discernment and
treatment of bona-fide mental illness (e.g. PTSD, Major Depression, addiction;
psychosis ...)

the MindSense approach is ultimately more cost effective, diminishing the

prolonged symptoms that emerge due to inadequate diagnosis and fragmented
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mental health care.

MindSense offers a sound and practical framework for development of a more
comprehensive peer support program.

Unlike any current conceptual framework in the arena of mental health,

MindSense actually offers a vision of “emotional fitness, proactive mental health
and psychological resiliency." The MindSense approach would foster developing
training programs that are not primarily "reactive", exclusively geared toward
diagnosing and treating emotional illness, but "proactive", teaching practical
concepts and tools for achieving and maintaining mental health and
psychological resiliency.
And, lastly, implementing the MindSense training program enables our military
institutions to demonstrate in a powerful way both that "we genuinely care about
your emotional health and well-being” and that they really endorse efforts that
strengthen and foster soldiers’ mental health and psychological resiliency.

We all need to do our “psychological work” on an ongoing basis. Those returning from
theaters of combat grappling with psychological overload need especially the
opportunity to safely “unload” and disentangle the complex weave of their distress so
that they can heal and resume fully functional lives. MindSense’s unique conceptual
framework offers our soldiers a more humane and accessible approach to psychological
health and well-being.

© Kernan Manion, MD 3/17/07

kernan@WorkLifeDesign.org

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