Increasing attention amongst clinicians is rightly being paid to tailoring interventions in a way that takes in to account the cultural and historical context of their clients, in particular those of minority communities. In the same way it is important for clinicians to understand the context of military training and culture when thinking about PTSD with military and veteran clients.
Much is made of the military 'breaking down' recruits before 'building' them back up again into soldiers and there is indeed much truth to this trope. From a behavioural perspective military training, in particular initial recruit training (basic, or phase one training, as it is known in the UK), significantly shapes and reinforces desired behaviours in soldiers and, as I will outline below, while it is very effective in doing so it can also have longer term unintended consequences for service people.
Identity:
It is common for veterans, to strongly identify as such in contrast to identifying as civilians once they have left service. Indeed, many veterans will make a point of describing themselves explicitly as Ex-Army/Royal Navy/Airforce/Royal Marines rather than identify as a civilian. This is by no means an accident and it has implications for the meanings they make of their experiences, both in and out of service, which we should, as clinicians, be open to recognising.
Understanding how that identity comes about can be useful. When a recruit arrives at phase one training, they are very much at the bottom of the hierarchy - outranked by everyone including the Commanding Officer's Labrador and Regimental Mascot (this isn't a joke, the British Army has animal mascots who hold rank!). They are treated 'robustly', which includes punishments and shouting to get them to conform to the wishes of their commanders. All of this happens at a fast pace, and high stress levels are maintained throughout, with little down time (even once lessons for the day are completed recruits can expect a full evening of prepping kit, cleaning and other duties, ready for the next day).
Failure to meet the required standards (or to conform), which every recruit will do at some point either individually or collectively, results in a 'robust' response from the trainers and punishment. As recruits adjust their behaviour, to meet the required standards, and conform to what is expected, punishments reduce and the behaviour change is reinforced through negative reinforcement (if a behaviour results in taking away something unpleasant such as punishment, then that behaviour is more likely to be repeated.) The cumulative effect over the course of training is that recruits conform to the desired way of behaving as a result of repeated reinforcement.
None of this is surprising, but what also happens as part of this process is a fundamental change in the identity of the recruit. It is important to note that most recruits, especially in combat arms, join at a young age, when they are still transitioning into adulthood, and are still developing a sense of their own identity. The desire to fit in, to be approved of, to gain a sense of purpose, and to have status, are all powerful drivers that recruit training is able to use to encourage the types of changes it is designed to achieve.
As mentioned, at the beginning of training recruits exist at the bottom of the hierarchy but, as they progress (i.e., meet the expectations of their trainers, and the military), they gain increased privileges, receive less punishment, and take a step up in relation to recruits behind them in training. Throughout the training 'values and standards' are commonly referred to, often by contrasting them with the perceived failure of the recruit, or with a perceived lack of such values in civilians. Indeed, it is not uncommon to hear civilians spoken of negatively, framed as they are, in opposition to the desired qualities of the service person. The message is clear, there is a correct way to be, and it is the way the military wants you to be. Failing to meet the standards required is not framed as merely the failure to acquire a particular skill but as a failing of the individual as a person. To be 'not good enough' as a serviceperson is to be less as a person. As we might imagine, this has the potential to activate powerful feelings within most people who neither wish to be proven 'not good enough' or to be rejected by the group. It is natural for recruits, as with all humans who have evolved to be social animals, to have a strong desire to escape such uncomfortable thoughts and feelings by fitting back into the group. As such, the desire to fit in and be accepted encourages the recruit to conform to demands of the military and adjust their behaviours and attitudes as part of the process.
Naturally, conforming to the demands of the training team, with benefits that brings in terms of reduced punishment, increased status and respect, and in fitting in with the group, also accords with the view of the 'right' way to be. We can see the dual impacts of negative reinforcement (changing behaviour to escape pain) and positive reinforcement (the gaining of respect, status, pride etc) act as powerful tools to encourage the recruit to identify as a serviceperson in preference to their previous civilian identity.
By the end of training, marked by a ceremonial 'Pass off Parade' in front of invited family, friends and local dignitaries (at the Royal Military Academy Sandhurst, where Officers are trained, those dignitaries are not infrequently Prime Ministers and Royalty). The message sent is that serviceperson is now part of the club (albeit, on the bottom rung), set apart from the civilian population with whom they contrast themselves.
Identity continues to be reinforced throughout service. Regiments, Corps, and units all have their own identities that compete against the others to be the best. It is common to hear banter between various members of regiments as to who is the best/worst but, importantly, what constitutes the best is still a version of adherence to the model of military virtue. That competition extends to other nations armed forces with whom the dominant narrative is always to compare ourselves positively. Likewise regimental and military history is presented in the best possible light, again with the intention to reinforce a positive identity that accords with a sense of purpose in which the British Armed Forces and the individual service person, is unquestionably presented as a force for good in the world. At this point, it should be made clear, I'm not taking a position on the rights or wrongs this but simply to notice the function of history and narrative in fostering identity.
More directly, many service people have powerful direct experience of serving in close proximity with their comrades on operations which fosters a strong sense of purpose, loyalty and duty even in, and often because of, the harsh conditions they endure together. Sebastian Junger's book, Tribe speaks to the impact of this kind of experience and how even traumatised veterans often wish themselves back to war because of the sense of belonging and purpose they felt while serving.
What should be clear at this stage is that serving in the Armed Forces has the potential to have a significant impact on individuals' identity and their understanding of their place in the world. It can also point to why many people struggle with their transition into civilian life where the cultural expectations are quite different from those they have been used to it and why loss of identity at transition, especially if unexpected due to medical discharge, is often particularly distressing. Also, when considering identity, we can also begin to think about how an identity, which fosters a particular view of self, the military and the world, may be a complicating factor when reality jars with that view - such as in the case of moral injury, where there is a perception that the moral values associated with either the organisation, self, or both, have been violated in some way
Mental Toughness:
Returning to training, we can see, even by the end of the initial training recruits have likely had their identity reshaped significantly. However, the process doesn't end there.. Culture plays an important role in shaping how service people learn to respond to their thoughts and feelings. The ability to 'get a grip' and 'crack on' with the job is understandably highly prized given service people are required to continue to function in high risk, high stress, and potentially lethal situations, on operations. Learning to suppress emotions effectively can be useful in those situation (even if, of course, it can cause difficulties later on) and so, much of military culture encourages this response while at the same time stigmatising displays of emotion that are framed as weakness or vulnerability. Open displays of strong emotion, beyond anger, such as crying, or fear, are strongly discouraged at both the group level, where suspicion is raised as to impact on operational effectiveness, and at the individual level, where these experiences are frequently seen as a threat to an identity based on strength.
Of course, emotional suppression is not unique to the Armed Forces, but it is perhaps uniquely tied to identity in this context. Service people are encouraged to identify with a clear archetype of masculinity (how that leaves female members of the service is a question in itself and has been a significantly, and glaringly, under studied part of the service experience) which is defined, at least in part, as strong, capable and 'stoic'. Specifically, this archetype is framed to position behaviours that do not fit the mould as weakness. It is in that context that service people find emotional suppression normalised as expression of emotions become potentially threatening, both in terms of being stigmatised by the group, and in terms of a threat to individuals' personal identity as service people (an identity which, as we have seen, is already framed in such a way that departure from it is deemed as failure).
All of this can function well and not cause serious problems for many people as long as their ability to manage their emotions is not overwhelmed. It does however have inherent risks baked into it as an approach for managing emotions, given the high stress, and potentially traumatising, situations service people encounter. Following these events, the service person may find their ability to suppress their emotions has indeed been overwhelmed meaning they now risk a threat of being stigmatised and rejected by the group and a threat to their own sense of self based, as it is, on the ideal of 'mental toughness', from which they now find themselves apparently departing. Indeed, the common response to double down on suppression and emotional avoidance in the face of these threats may well contribute to the development of a full-blown trauma diagnosis such as PTSD as well as contribute towards its maintenance.
Fight, not Flight or Freeze:
Thinking further about being overwhelmed by distress, it is worth noting that three of the main symptoms of PTSD are an increased startle response (i.e., sudden reaction to threat - e.g., the classic example of diving for cover when a car exhaust backfires in the street), hyperawareness (looking out for danger) and difficulty controlling emotions (emotional dysregulation), especially in relation to anger and irritation. What is unique in the military is that it probably the only occupation where these symptoms are intentionally trained because of their desirability in combat.
Many people will be aware of the fight, flight or freeze response to threat. Essentially an automatic response to sudden danger, the body can launch in to fight to deal with threat, flight to run away from it, or else freeze in the hope the danger leaves it alone. An e.g., is walking through the woods and suddenly seeing a snake where you are about to put your foot. Most people are very likely to suddenly leap back out of the way of the danger without consciously thinking about it. Whatever the response, it is reactive and sits outside of conscious choice, but is, nonetheless, very much open to being trained over time and this is exactly what military training seeks to do.
The reality of service in the armed forces is that any service person could find themselves in a life-or-death situation, including combat. To prepare for this the military utilises, as a core component of training, drill. Drills are automatic and trained responses in which service people carry out practiced responses in response to external stimuli, such as a shouted command. Starting with coming to attention at a word of command, through foot drill in which movements are directed by sudden commands while marching in a group, and culminating in combat drills, service people's responses to both words of command and situations are conditioned with specific responses.
The simplest combat drill is the Immediate Action (or I.A.) drill. If contact with enemy is made (i.e., suddenly coming under fire) while on a foot patrol, the soldier will shout out the contact and direction, open fire, and move forward, ideally into cover. In this kind of situation, running away without returning fire is likely to get you, and your patrol killed, as will freezing. A fight response is required, in which the soldier will take a sudden aggressive action that increases their immediate chances of survival. It is for this reason that the military spends time conditioning the fight response, in preference to flight or freeze. It does this repeatedly in realistic conditions, including live firing and with explosions to simulate, as closely as possible, the conditions the fight response will be required in, and which require service people to attend closely to threats in that environment. Of course, to be effective in a fight the response does not just need to be instant, it needs to be aggressive, which is why throughout training service people are encouraged, with equivalent aggression by their training teams, to respond with aggression. Again, this is done repeatedly to reduce hesitation and reinforce a consistently aggressive response to threat.
Having trained repeatedly, and exclusively, an aggressive fight response to threat, this can then become the primary response over flight and freeze to any sufficiently threatening stimuli. If the service person then goes on to use this response on operations in reaction to genuine danger, then they will have learned, through personal experience that it works by virtue of having survived. That is an understandable powerful reinforcement of the fight response to threat.
This doesn't mean that all military personnel and veterans are all potentially dangerous, but it does mean that anger and aggression can often be the most obvious and outwardly challenging symptoms in service people who have been traumatised. When we consider that following trauma individuals frequently feel unsafe and under threat, anger and aggression as the primary response to that sense of threat is understandable, especially when note that it has been specifically trained in preference to any other response. When we also consider, as we have seen, that military personnel are encouraged to see distress as a sign of weakness, then we can see how their own painful thoughts and feelings can themselves become a threat by the challenge they represent to their identity. In the context of this threat, difficulties with anger and aggression can make sense, both as ways to push out those feelings, to escape the notion that they are weak, and as ways to reassert strength and safety. The difficulty is, of course, that these strategies do not tend to be effective in the long term and can cause significant difficulties in the service person or veteran's life.
Bridging the gap between lived experience and clinicians:
There is, of course, far more to be discussed regarding the relationship between the context of military service, training, culture, and PTSD than can be covered in this blog but hopefully encouraging clinicians to be alive to the specific contexts within which service people and veterans experience their trauma will be helpful in bridging the gap between the lived experience of service people and clinical intervention. There are good treatments available for trauma, and excellent clinicians within the NHS and beyond, to provide them. Often the missing piece is the understanding of the experience of service life that can lead to veterans not presenting or dropping out of mainstream services. Thankfully, there is now a veteran specific pathway in the NHS, but veterans will in many cases continue to be seen by appropriately by mainstream services which means wider understanding of service and veterans issues remains essential.
If you work with service people or veterans and would like to discuss any aspect further than feel free to contact.
Christian Hughes is a Psychotherapist, and former uniformed military mental health clinician, specialising in Acceptance and Commitment Therapy, Compassion Focused Therapy & CBT, with expertise in trauma & PTSD and a special interest in Moral Injury.