By C. Alan Hopewell, PhD, MP, ABPP, BSM, MAJ (RET) Robert Klein, PhD, CPT US Army and Michael Adams, PhD, LTC (RET) 

*This is an article from the Winter 2024 issue of Combat Stress

Fort Hood is a United States Army Post located in Killeen, Texas. This post was originally named for Confederate General John Bell Hood, but has since been renamed Fort Cavazos after General Richard E. Cavazos, a native Texan and four-star general. However, since all of the research reported here was conducted at Fort Hood during the Global War on Terror (GWOT,) the name Fort Hood will be referenced. The main cantonment of Fort Hood had a total population of 53,416 as of the 2010 U.S. census and at the time of this original research, was the most populous U.S. military installation in the world.1 In April 2014, the Post’s website listed 45,414 assigned soldiers and 8,900 civilian employees covering an area of 214,000 acres (87,000 hectares). 

In 2001, the War on Terror became a prime focus of post activities. Fort Hood transitioned from an open to a closed post with the help of military police from Army Reserve units. The post is also the headquarters of III Armored Corps and First Army Division West and is home to the 1st Cavalry Division and 3rd Cavalry Regiment, among others. During GWOT and the time period of research conducted, the 4th Infantry Division was also stationed at Fort Hood, making it the largest military deployment platform in the world.1 As a consequence, the outpatient psychiatry/ behavioral health operations were the largest in the world at the time. During the height of the Iraqi Surge, more than 400 Soldiers were seen or were attempted to be seen per day at the Carl R. Darnall (CRDAMC) Resilience and Restoration Center (the post outpatient clinic for psychiatry and behavioral health), more patients than were seen at the CRDAMC Emergency Department per day. During the research period reported in the article, CRDAMC was upgraded in its designation to an Army Medical Center and a special Washington D.C. commission coordinated by the senior author resulted in essentially tripling the staffing of the CRDAMC Resilience and Restoration Center. 

 The Resilience and Restoration Center as consolidated by COL Lorree K Sutton, Carl R. Darnall Hospital Commander. 

A number of Fort Hood units were deployed to Afghanistan in support of Operation Enduring Freedom and to Iraq for Operation Iraqi Freedom during the GWOT. In December 2003, the 4th Infantry Division captured Saddam Hussein. In the spring of 2004, the 1st Cavalry Division followed the 4th Infantry Division deploying to Iraq. These divisions then generally rotated through the deployment cycle, with the Restoration and Resilience Center supporting deploying troops and aiding the returning troops with their mental health needs and re-adjustment to garrison in rotation. In 2009, Fort Carson, Colorado‘s First Army Division West re-stationed to Fort Hood in order to consolidate its mission to conduct Reserve Component mobilization training and validation for deployment, switching places with 4th Infantry Division, which then relocated to Fort Carson.

It was into this situation that the senior author reported to CRDAMC in June of 2006 and assumed the position of Officer-in Charge (OIC) of the Restoration and Resilience Center. The second author served as a Psychology Intern and the third author as Chief of Behavioral Health during this time period respectively. Half of the CRDAMC psychiatrists and psychologists were deployed during this interval, primarily with the 4th Infantry (Ivy) Division, leaving only one active-duty psychiatrist and one civilian psychiatric employee to serve all of CRDAMC, in addition to only four psychologists to cover a health care cohort of easily over 50,000. 

The senior author had volunteered to return to active duty, as he was one of the only senior clinical psychologists in the United States who was both a Clinical Neuropsychologist and who also had substantial prior military experience. He was also the only Army Medical Neuropsychologist with a pharmacology degree who could manage patient medications, for which he was awarded the Bronze Star Medal after his service in Iraq. He was specifically returned to active duty as he had previously established the Traumatic Brain Injury Clinic (TBI) at Landstuhl Army Regional Hospital and was the de facto Army expert on brain injury and concussions.2 He had also been the Chief of Neuropsychological Services at Brooke Army Medical Center from 1981 through 1983 before being assigned to the Individual Ready Reserve (IRR). For these reasons, he was chosen on his return to active duty by the Vice Chief of the Joint Chiefs of Staff and the Psychology Consultant to the Army to be assigned to CRDAMC and ultimately to deploy in support of Operation Iraqi Freedom. 

Upon assuming duties at CRDAMC, the Hospital Commander, COL Loree K. Sutton, requested that the senior author design and implement surveys designed to determine the mental health care needs of the garrison Soldiers and to document the need for increased mental health services. This was particularly needed in terms of the marked increase in diagnoses of post-traumatic stress disorder (PTSD) and traumatic brain injuries (TBI). As part of that request, returning Soldiers needing services were referred to the Restoration and Resilience Center for mental health treatment, most of them from the returning 4th Infantry Division. These Soldiers were thereafter systematically screened, not only for general mental health needs, but also specifically for traumatic brain injuries which were then occurring with increasing frequency in the wartime theaters as a result of improvised explosive device (IED) blast injuries. 

 LTC Michael Adams, COL Wilma Larsen, and COL Lorree K. Sutton presenting the senior author with an award in recognition for TBI and PTSD screening procedures. 

 As part of the education of CRDAMC and Restoration and Resilience Center staff at the time in regard to blast injuries / concussion or mild traumatic brain injuries / (mTBI), some of the following guidance from the Centers for Disease Control (CDC)3 were followed: 

Blast Injuries: Essential Facts / Key Concepts: 

• Bombs and explosions can cause unique patterns of injury seldom seen outside combat. 
• Expect half of all initial casualties to seek medical care over a one-hour period. 
• Most severely injured arrive after the less injured, who bypass EMS triage and go directly to the closest hospitals. 

• Predominant injuries involve multiple penetrating injuries and blunt trauma. 
• Explosions in confined spaces (buildings, large vehicles, mines) and/or structural collapse are associated with greater morbidity and mortality. 
• Primary blast injuries in survivors are predominantly seen in confined space explosions. 
• Repeatedly examine and assess patients exposed to a blast. 
• All bomb events have the potential for chemical and/or radiological contamination. 
• Triage and lifesaving procedures should never be delayed because of the possibility of radioactive contamination of the victim; the risk of exposure to caregivers is small. 
• Universal precautions effectively protect against radiological secondary contamination of first responders and first receivers. 
• For those with injuries resulting in nonintact skin or mucous membrane exposure, hepatitis B immunization should be administered (within 7 days) and age-appropriate tetanus toxoid vaccine (if not current). 

Blast Injuries 

• Primary: Injury from over-pressurization force (blast wave) impacting the body surface — Tympanic membrane rupture, pulmonary damage and air embolization, hollow viscous injury. (a sudden and pronounced rise in intra-abdominal pressure can rupture a hollow viscus). 
• Secondary: Injury from projectiles (bomb fragments, flying debris) — Penetrating trauma, fragmentation injuries, blunt trauma. 
• Tertiary: Injuries from displacement of victim by the blast wind — Blunt/penetrating trauma, fractures, and traumatic amputations. 
• Quaternary: All other injuries from the blast — Crush injuries, burns, asphyxia, toxic exposures, exacerbations of chronic illness. 

Primary Blast Injury  

Lung Injury 

• Signs usually present at time of initial evaluation but may be delayed up to 48 hours. 
• Reported to be more common in patients with skull fractures, >10% BSA burns, and penetrating injury to the head or torso. 
• Varies from scattered petechiae to confluent hemorrhages. 
• Suspect in anyone with dyspnea, cough, hemoptysis, or chest pain following blast. 
• CXR: “butterfly” pattern. 

• High flow O2 sufficient to prevent hypoxemia via NRB mask, CPAP, or ET tube.3 

 Typical IED Blast in Iraq 2008. One of the Senior Author’s Patients Treated by the 785th Combat Stress Company, Camp Liberty, Iraq. 

The Global War on Terrorism (GWOT) brought to the forefront the issue of the relation between mild traumatic brain injury (mTBI) and combat-induced post-traumatic stress disorder (PTSD). The two are related because of the similarities in how soldiers incur mTBI and/or PTSD. Soldiers are frequently exposed to concussive blasts related to improvised explosive devices. In and of itself, being exposed to an IED blast meets the Diagnostic and Statistical Manual of Mental Disorders-Fourth and Fifth Edition-Text Revised (DSM-IV- V – TR) Criterion A1 for PTSD and can potentially cause mTBI due to concussive blast. It should be noted that the DSM-IV-TR was the version of the DSM at the time of the major part of GWOT and this research. Additionally, the empirically-based published literature at the time of the screening will only be used to give the reader an understand of the state of scientific thought during the GWOT. 

As a resident from 1975 – 1976, the senior author had also been the very first student and Senior Resident of Harvey Levin, PhD, who co-directed the formal traumatic brain injury (TBI) program in the Division of Neurosurgery at the University of Texas Medical Branch, Galveston (UTMB).  Based upon this early work with TBI models, Levin et al. suggested that post-concussional symptoms occur along three dimensions; somatic, cognitive, and affective. Somatic symptoms include headache, dizziness, vision difficulty, and deficits in balance and motor functioning, as well as a number of additional symptoms.4 Neurocognitive sequelae consist of deficits in attention/concentration, memory, cognitive processing speed, fatigue, and impairment in both simple as well as complex reaction time.5, 6 Typical affective symptoms can include anxiety, depression, irritability and mood swings. The documentation of such symptoms by Harvey Levin and Hopewell at the UTMB – the official Traumatic Brain Injury program at the time for the State of Texas,7 led to the eventual development of the Neurobehavioral Symptom Inventory as a brief screening effort to record most of the typical symptoms associated with concussions.8 

Most civilian TBI injuries are acceleration / deceleration impact inertial related such as occur in motor vehicle accidents. However, blast injuries appear to be better described as a fluid percussion model. In this regard, a fluid percussion model of brain injury is similar to an IED related concussive blast and has also been studied in animals and used to hypothesize changes in people with mTBI. “Human blast injury studies in organs other than the brain have shown that at least two atmosphere percussion waves in the fluid media of the brain can produce mTBI findings similar to findings in animal studies.”9 Over-pressure waves have been associated with producing diffuse axonal injury (DAI) via rapid acceleration and deceleration (coup-countercoup). DAI is associated with the shearing or damaging of axons that project from the brain stem. If the coup-countercoup action is severe enough it can cause a loss of consciousness (LOC). When LOC is experienced, a Soldier can further harm the brain by making significant contact with a physical object such as a weapon, vehicle structure, or the ground as he or she falls. 

PTSD is amongst the most controversial diagnoses included in the DSM-IV-TR.10, 11, 12 The controversy with PTSD revolves around the boundaries of the disorder, diagnostic criteria, central assumptions, clinical utility, and prevalence in various populations.10- 12 Spitzer et al., Gold et al., and Boals and Schuettler arrived at conflicting results when looking at the importance of Criteria A1 and A2 in defining PTSD. Gold et al. reported that higher levels of PTSD symptoms were associated with non-traumatic events than traumatic events when scoring results were based on classification by coders.11 On the other hand, Boals and Schuettler  found that PTSD symptoms were more associated with traumatic events than non-traumatic events when scoring results were based on participants’ ratings.12 Further Boals and Schuettler  reported that Criterion A1 had a minimal relation to PTSD symptoms when A2 was considered.12 These two conflicting studies bring in to question the validity of Criteria A1 and A2 in diagnosing PTSD.

Overlapping symptoms between mTBI and PTSD can complicate the differential diagnosis process and lead clinicians to wonder whether they should ascribe a person’s clinical presentation to a diagnosis versus dually-diagnosing. The lack of agreement in the research community regarding which specific PTSD and mTBI symptoms overlap further complicates diagnosis.13,14 Defense Veterans’ Brain Injury Center (DVBIC) considers depression, anxiety, and attention difficulties as overlapping symptoms. Depression, anxiety, and sleep are non-neuropsychological overlapping symptoms of post-concussional syndrome (PCS) and PTSD that the ICD-10 and DSM-IV-TR agree upon. The Veterans Administration considers concentration difficulty, sleep difficulty, irritability, and social withdrawal as overlapping symptoms. Further complicating the differential diagnosis process is the overlapping symptoms between anxiety and major depression, which are common behavioral symptoms of mTBI and PTSD. These overlapping symptoms consist of problems with sleep, concentration, and fatigue as well as psychomotor/arousal symptoms.15 Other research suggests that irritability, attentional dysfunction, difficulty concentrating, amnesia, decreased cognitive processing, and sleep disturbances are overlapping.9,16  

There are issues with accurately measuring both PTSD and mTBI primarily because symptoms are subjective, can be exaggerated, and can demonstrate considerable overlap. When a client endorses a symptom on a self-report measure it is up to the clinician to determine the etiology of the symptom. For example, if a person endorses experiencing headache, the clinician needs to determine whether the headache is tension-based (i.e., psychiatric-etiology) or is a posttraumatic headache. Just because a person has a headache does not mean it is a headache that is characteristic of a TBI and therefore, can lead to a misdiagnosis of post-concussive syndrome (PCS). In terms of PTSD symptomatology, there is little consensus regarding the best diagnostic cut scores for self-report measure and no research has been conducted to determine optimum cut scores for active-duty service members. A cut score should shed light on to the diagnostic efficiency (i.e., sensitivity and specificity, negative predictive power, and positive predictive power) of an instrument and therefore, aid the clinician in rendering a diagnosis. 

Reported symptoms can also be exaggerated due to secondary gain or somatization. It is not uncommon for a soldier to report on an inventory that a symptom is severe, but further investigation reveals that it does not impact their activities of daily living. Most researchers do not conduct item analyses to determine which symptoms discriminate best between those who do and do not have a clinical diagnosis.17, 18 This is important in research when there are diagnoses that share multiple symptoms like PTSD and PCS. 

At the self-report psychological instrument level, overlapping symptom between the PTSD Checklist (PCL)19 and Neurobehavioral Symptom Inventory (NSI)20, 21 includes difficulty concentrating, sleep difficulty, irritability, and forgetfulness/trouble remembering. Across cultures, all 16 items on the Rivermead (European version of the NSI) are on the NSI. Loss of balance, poor coordination, hearing difficulty, numbness/tingling, change in taste/smell, change in appetite are items that are not on the Rivermead. There is no universal agreement in the behavioral health community on the specific etiology of post-concussion symptoms in individuals with mTBI. Persistent post-concussion symptoms could be neurological, psychological, or both. The neurological side of the debate documents that post-concussion symptoms are attributed to neurological damage often associated with axonal stretching or injury. The persistence of symptoms is assumed to be due to metabolic and physiologic changes in the brain that have not returned to homeostasis.22 The psychological camp suggests that symptoms are attributed to transient physiological disturbance and are maintained by psychological distress.23, 24 Bazarian et al. showed that post-concussive symptoms are reported more by mTBI patients without positive neurological or radiological findings than patients with moderate or severe TBI.25 Research suggests that a significant risk factor for the development of PCS is three or more prior concussions, which a service member can receive via multiple combat tours.22, 26 This also means that the person has likely been exposed to more psychological trauma with increasing numbers of both combat tours and blast exposures. 

Some of the variance in the literature related to post-traumatic stress and neurobehavioral symptoms is also likely due to a combination of conceptualization problems and measurement issues. As previously mentioned, there are no universally accepted diagnostic criteria for assigning a diagnosis associated with mTBI and there is no “gold standard” for post-concussive symptoms. With regards to PTSD, there is some question about whether a person needs to be conscious to develop PTSD and there is no universally accepted structure of PTSD. Some of the variance involved in the different structures may also be due to researchers using different instruments to measure PTSD (i.e. PCL and CAPS). 

The VA/DoD Clinical Practice Guideline for the Management of Post-Traumatic Stress states that: 

“Post-traumatic stress disorder (PTSD) is the most prevalent mental disorder arising from combat. It also strikes military men and women deployed in peacekeeping or humanitarian missions, responding to acts of terrorism, caught up in training accidents, or victimized by sexual trauma. Its burden may be transient or last a lifetime. The response to psychological trauma is probably as old as human nature but the diagnosis of a traumatic stress disorder is among the newest in the diagnostic catalogue. Twenty years ago, most people, including most clinicians, did not know that PTSD existed. Even among those who acknowledged PTSD, their view tended to be retrospective: PTSD planning and practice in the Departments of Defense (DoD) and Veterans Affairs (VA) centered on work with survivors of past conflicts such as Vietnam, Korea, or World War II. As DoD and VA face the challenge of a new generation of combatants and veterans, our perspective must become prospective: building on the lessons of the past and serving those in present need but also aiming at the future in order to maximize preparedness and, if possible, prevention” (2004, pg. i).27 

A thorough review of the etiology, nature, effects upon the nervous system, the comorbidity of TBI, and the treatment of PTSD especially after combat is additionally provided in Moore, Hopewell, and Grossman’s book Violence and the Warrior, Living and Surviving in Harm’s Way: A Psychological Treatment Handbook for Pre- and Post-Deployment.28 

A screening instrument checking for these symptoms along with the Center for Epidemiological Studies-Depression (CES-D) depression checklist29 and the Traumatic Event Sequelae Inventory (TESI)30 was used to screen Soldiers, mostly from the 4th Infantry Division, for concussion and PTSD, although a few Soldiers who were Veterans of Operation Enduring Freedom in Afghanistan were also screened. The CES-D, originally published by Radloff, is a 20-item measure that pulls for ratings as to how often over the past week symptoms associated with depression have been experienced such as restless sleep, poor appetite, and feeling lonely.29 Response options range from 0 to 3 for each item (0 = Rarely or None of the Time, 1 = Some or Little of the Time, 2 = Moderately or Much of the time, 3 = Most or Almost All the Time). Scores range from 0 to 60, with high scores indicating greater depressive symptoms. 

The CES-D also provides cutoff scores (e.g., 16 or greater) that aid in identifying individuals at risk for clinical depression, with good sensitivity and specificity and high internal consistency.31 The CES-D has been used successfully across wide age ranges, is sensitive to differences between caregivers and non-caregivers, and is sensitive to changes in caregiver depressive symptoms after intervention.31, 32 Although the CES-D has somewhat different factor structures across racial and ethnic groups, it can be used appropriately with diverse caregivers.33 

The Traumatic Event Sequelae Inventory (TESI) is a special psychometric instrument design to diagnose and quantify a very specific emotional and behavioral symptom spectrum most frequently reported by individuals who has been exposed to traumatic events.30 TESI was developed in 1995 as a focal component of a comprehensive multidimensional psychometric battery for assessment and quantification of emotional injury and psychiatric disability. Originally intended for the commercial market (personal injury/workers’ compensation) the first announcement of TESI appeared in the California CLAIMS Journal, Winter 1996.34 TESI has since become one of the most widely used instruments in the USA for the assessment of posttraumatic emotional and behavioral sequelae, with the military cohort screened resulting in a normative population of over 86,000 subjects. The original TESI items were selected from the actual medical records of patients diagnosed with and treated for trauma-based anxiety disorders from 37 psychiatric inpatient, residential, and outpatient health care facilities in New York, New Jersey, Pennsylvania, California, and Florida. TESI utilizes a dual scoring system, yielding diagnostic accuracy greater than 95 percent. The first system utilizes standardized t-scores developed during the initial standardization of TESI in 1996.30 

The second scoring system, with Gradient Frequency Scores (GFS,) or TESI Score Levels, was empirically developed during the second standardization of TESI in 2002, based on the clinical population of 36,340 individuals who have experienced single or multiple traumas and were in treatment for related posttraumatic disorders in a variety of clinical settings. Comprehensive assessments, clinical diagnostic summaries, and psychometric data from follow up assessments were utilized in the development of the Gradient Frequency Scores. Each GFS represents a particular level of TESI raw scores at which significantly different diagnostic classifications are present at the confidence interval of .95, rendering specific interpretive clinical considerations and therapeutic interventions.

The first four GFS levels (1–4) are likely to be indicative of subsyndromal disturbances which may or may not be related to a traumatic event(s). Based on the data available from our normative samples, it was our conclusion that the diagnostic certainty at these levels is not sufficient enough to satisfy the DSM-V or ICD-10 diagnostic criteria for a posttraumatic stress disorder. 

The fifth GFS level (5) may indicate a subthreshold form of PTSD, but with insufficient degree of diagnostic certainty to diagnose a full, syndromal level of the disorder. The “rule out” diagnoses at this level should be supported with the GFS scores from other TESI components used in evaluation. Diagnosis of subthreshold post-traumatic disturbances and dysfunctionality is also only possible by using combined battery scores. 

The sixth GFS level ( 6) represents the average number of symptoms found among our normative sample, with a range of 1 SD of mean for clinical group and more than 3 standard deviations above mean for non-clinical group. Diagnostic formulation of posttraumatic disorders at this level must be supplemented with the results (GFS scores) from other TESI components. 

The seventh and the eighth GFS levels (7 – 8) of TESI’s raw scores represent ranges of symptomatology, characteristic of our normative sample which is sufficiently wide in spectrum to suspect that scores at these levels may involve a more complex clinical picture rather than PTSD as a single, or a focal disorder, or at least a severe level of PTSD. At these levels, either significant psychopathology with etiology other than the trauma may be present. These may be concussions complicated by other medical factors. This may occur when a single concussive episode produces cognitive and affective symptoms which persist and which are influenced or exacerbated by concomitant medical factors such as serious other medical complications, such as chronic pain associated with severe orthopedic injuries, as often happens in a combat Veteran population. These complications are often also further complicated by exacerbating emotional disorders which act as moderating variables. At this level, many concussion survivors demonstrate multifactorial difficulties. In some cases, the presence of self-deception, intentional symptom exaggeration, factitious disorders, malingering, or conscious engagement in cost benefit analysis of injury and its sequelae may be present and must be distinguished from actual injury levels. 

Primary Disturbances (PD): 

Initial post-traumatic disturbances reported in primary care: Somatic Disturbances, Affective Disturbances, Cognitive Disturbances, Behavioral Disturbances, Marital Disturbances, Occupational Disturbances, Disturbances of General Functionality, Psychomotor Acceleration, Psychomotor retardation, Fear, Dissociative Experiences and Hypervigilance. 

Systemic Disturbances (SD): 

Systemic Disturbances are disorders diagnosed by various clinical and laboratory methods such as: Cardiological Disturbances, Musculoskeletal Disturbances, Hematological Disturbances, Metabolic Disturbances, Endocrine Disturbances, Gastrointestinal Disturbances, Neurological Disturbances. 

Clinical Impairments (CI): 

Clinical impairments include subsyndromal, subthreshold, or syndromal short, intermediate, and long-term posttraumatic manifestations of physiological, cognitive, psychological, and environmental disturbances present during the entire duration of trauma integration, synthesis, and diffusion. Some domains of impairments may persist in form of residuals of the integration process, subsequent constitutional vulnerabilities to re-traumatization, or factors rising various disturbances to levels of permanent and stationary disabilities.  

TESI Varimax Factors (F): 

Individual TESI items (1-39) were factor analyzed to determine which items clustered together in a discernible structure. Given that, by definition, the structure of typical PTSD symptoms is not meaningful for those who do not have the disorder, but only the clinical sample was used in this analysis. Principal components analysis using varimax rotation yielded eight factors with eigenvalues of 1.0 or higher. Factor 1 (eigenvalue=9.19) accounted for 23 percent of the variance. Factor 2 (eigenvalue = 1.99) explained 5 percent of the variance. The remaining factors yielded figures as follows: Factor 3 (eigenvalue =1.44) 3.7 percent; Factor 4 (eigenvalue 1.27) 3.3 percent; Factor 5 (eigenvalue = 1.2) 3 percent; Factor 6 (eigenvalue = 1.1) 2.9 percent; Factor 7 (eigenvalue= 1.1) 2.7 percent; and Factor 8 (eigenvalue 1.0) 2.6 percent. The entire analysis thus accounted for 46.8 percent of the variance. Underlying concepts for these factors might be described as follows: 

Factor 1 might best be described as detachment & loss of control; 

Factor 2 relates to impaired cognitive abilities; 

Factor 3 can be termed physical complaints, primarily related to digestive processes;  

Factor 4 captures physical complaints primarily related to anxiety & stress;  

Factor 5 taps into ruminations and related dysfunction; 

Factor 6 taps into anger and frustration;  

Factor 7 relates to psychomotor agitation;  

Factor 8 can be labeled “marital problems.” 

 

Overall, the factor structure supports TESI as an instrument which incorporates dimensions relevant to the diagnosis of PTSD. Given the differences in TESI item responses between gender and ethnic groups within the clinical sample, principal component analysis was also repeated separately for each ethnic and gender group. Results indicate that that TESI’s factor structure differs somewhat among these sub-samples. For each group, 9 factors with eigenvalues above 1.0 were derived. Principal component analysis with African Americans accounted for 50.34 percent of the variance. For Latinos, the analysis, accounting for 50.06 percent of the variance. When the analysis included only non-Latino Whites, it accounted for 53.75 percent of the variance. For women, the analysis accounting for 56 percent of the variance. Finally, principal component analysis including only men accounted for 57.6 percent of the variance. 

One thousand two hundred and fifteen (1,215) combat Veteran Soldiers were screened with TESI and the CES-D at Carl R. Darnall Army Medical Center, Ft. Hood, Texas, upon their return from a combat deployment to Iraq in support of Operation Iraqi Freedom.35 Most returning Soldiers were from a returning combat infantry unit that was engaged in some of the heaviest fighting in Iraq prior to the successful Surge, although a few were returning Operation Enduring Freedom Veterans. The screenings were done after initial Post-Deployment Health screenings mandated referral to the Resilience and Restoration Center at Darnall Army Medical Center, the outpatient clinic of the Department of Psychiatry and Behavioral Health. The screenings were accomplished in 2007, a time when the Department of Psychiatry and Behavioral Health at Darnall Army Medical Center operated essentially the largest outpatient psychiatry clinic in the world. 

The screenings included 966 males and 249 females ranging in age from 18 to 59 years of age.35  104 of the Soldiers were documented to have blast related concussions in addition to a range of psychiatric co-morbid disorders, to include post-traumatic stress disorder (PTSD). Ninety-seven (97) concussed Soldiers were male and seven were female. Verimax factor analyses documented psychiatric factors demonstrated by the Soldiers, with an analysis of combined PTSD and concussion symptoms, comparing Soldiers with and without concussion.  Degrees of primary disturbances generally ranged from a low of 33 percent to a high of 68 percent for the sample. The severity of PTSD and concussion injuries, clinical considerations, and varimax factors are discussed.  Some of the major findings in terms of demographic composition, TESI scores, and GFS levels are presented below. 

Population groups included Anglo/Caucasian, African Americans, Latinos, and Asians, both male and female. Ages ranged from 19 to 59 years of age with mean ages from 24 to 28 years of age, partly as older Reservists had returned to active duty for GWOT. The modal educational level was 12 years. Mean GFS levels ranged from 5.7 for non-injured, non-concussed Soldiers to 6.4 for combat Veterans with injuries and concussions. Caucasians accounted for 64.42 percent of those screened, African Americans for 13.46 percent, Latinos for 11.54 percent, Asians for 1.92 percent, and “Others” for 6.73 percent. Only three of the concussed group had no combat exposure, presumably being injured during non-combat duties. Individuals with concussion scored an average GFS level of 6.4, while Soldiers without concussion scored an average GFS level of only 5.8. The presence of concussion therefore raised the GFS by one level, obviously complicating the underlying PTSD symptoms. This means that in addition to probable PTSD, concussion will substantially increase the comorbidity of damage to the individual injured Soldier. Females also scored higher at a GFS of 6.1, while males scored at the lower GFS level of 5.8, this being consistent with literature indicating that females often experience PTSD at higher or more severe levels than do males. 

While primary disturbances ranged from affective to somatic disturbances, those which appeared to affect both the injured as well as the concussed cohorts were those of psychomotor retardation, with fear and affective disturbances interestingly being less problematic. Systemic disturbances for the injured as well as the concussed cohorts were those of musculoskeletal and endocrinological and neurological, respectively, with this being consistent with the conceptualization and likely sequelae of these injuries. Degrees of impairment for the injured as well as the concussed cohorts included communication problems for the former and concentration deficits for the latter, again being consistent with the conceptualization and likely sequelae of these injuries. 

As previously noted, the fifth GFS level indicates significant psychiatric disturbance, and may indicate a subthreshold form of PTSD, but with insufficient degree of diagnostic certainty to diagnose a full, syndromal level of the disorder. The “rule out” diagnoses at this level should be supported with the GFS scores from other TESI components used in evaluation and from possibly other evaluations. In an extremely busy military practice with over 400 patient consults a day, Soldiers scoring at this GFS level on TESI could be “triaged” for further PTSD examination. Therefore, the cut off level of the fifth GFS level proved to be very important, as Soldiers scoring less than this could be put more on a regular treatment schedule, while Soldiers scoring 5 or more could be expedited for further and more thorough evaluation. 

Soldiers with concussion scoring at the sixth GFS level, could also be expedited for assessment, with additional focus on the TBI aspects of their injury, aspects which, for example, could involve substantially different medication treatment such as for headache, the single most frequent symptoms seen after concussion. Identifying such patients meant that they could be routed much more quickly to Advance Practice Nurses and Physicians’ Assistants to initiate such treatment quickly. Recognizing the intersection and overlap of PTSD and TBI symptoms, as well as which symptoms remain unique to each disorder also proved critical in the appropriate treatment responses to these injuries.  Results were also consolidated into briefings for the combat units pending further deployments, such as the following briefings given by the senior author to the 4th Infantry Division. 

Upon completion of this project, the senior author was designated both OIC of the newly formed CRDAMC Traumatic Brain Injury Clinic and was also named liaison Officer between CRDAMC and the Defense Veterans’ Brain Injury Center (DVBIC). DVBIC serves active-duty military, their beneficiaries, and veterans with traumatic brain injury through state-of-the-science clinical care, innovative clinical research initiatives and educational programs, and support for force health protection services. DVBIC was the TBI operational component of the Defense Centers of Excellence (DCoE) for Psychological Health and Traumatic Brain Injury and has since been rebranded as the TBI Center of Excellence. The third author was assigned to duties at the newly formed Triage Center for the R&R Clinic, where he oversaw the screening and triage of hundreds of injured Soldiers. Over the next six years, all authors assisted in the management of the CRDAMC Traumatic Brain Injury Clinic and the R&R as well as the ongoing collection of further research data related to TBI. These findings were eventually incorporated into treatment protocols for injured Soldiers, and contributed to the eventual writing of the VA/DoD Clinical Practice Guideline For Management Of Concussion/ Mild Traumatic Brain Injury,27 the official guidelines for the diagnosis and management of TBI for the military,36 and motor vehicle operations guidelines after TBI injury for the military.37 The Clinic founded by the authors eventually developed into the National Intrepid Center of Excellence located at Carl R. Darnall Army Medical Center, a far cry from screening re-deploying Soldiers in the waiting room of the “old Restoration and Resilience building!” 

The National Intrepid Center of Excellence Satellite Center at Fort Hood opened its doors to patients for the first time Jan. 11, 2016, moving from the senior author’s modular buildings and ushering in a new era of care on Post. The 25,000-square-foot facility includes state-of-the-art technology, a fully functioning gym, a yoga and meditation area, group session rooms, and an outdoor patio. The staff of health care and mental health professionals was reinvigorated after the Hasan attacks by the senior author. The Center continues to offer the same multidisciplinary, holistic approach to treating TBI, PTSD and other conditions as when it was initially founded by the senior author, these indications of excellence not having changed. 

The National Intrepid Center of Excellence Satellite Center at Fort Hood is now the fifth of its kind on military installations across the country, all part of a joint effort by the government and the private sector. 

References 

1. Ragland, J. (6 December 2009).“Tested by tragedy, Fort Hood family of civilians and soldiers deserve Texan of the Year honor”.The Dallas Morning News. Retrieved 4 May 2013. 
2. Hopewell, C. A. (1982). Neuropsychology in the U.S. Army Europe. European Medical Bulletin, 39, October, (10), 9-15. 
3. Blast Injuries: Essential Facts. National Center for Injury Prevention and control; Division or Injury Response. U.S. Department of Health and Human Services. Centers for Disease Control and Prevention. CS218119-A). 
4. Levin, H.S., Mattis, S., Ruff, R.M., Eisenberg, H.M., Marshall, L.F., Tabaddor, K., High Jr,W. M., Frankowski R.F., (1987). Neurobehavioral outcome following minor head injury: a three-center study. Journal of Neurosurgery, Feb; 66 (2): 234-43. 
5. Bleiberg, J., Cernich, A., & Reeves, D. (2006). Sports Concussion Applications of the Automated Neuropsychological Assessment Metrics Sports Medicine Battery. In R. J. Echemendía (Ed.), Sports neuropsychology: Assessment and management of traumatic brain injury (pp. 263–283). The Guilford Press. 
6. Arciniegas, D. B., Anderson, C. A., Topkoff, J., & McAllister, T. W. (2005). Mild traumatic brain injury: A neuropsychiatric approach to diagnosis, evaluation, and treatment. Neuropsychiatric Disease and Treatment, 1(4), 311–327. 
7. Levin, H. S., Eisenberg, H. M., and Benton, A. L, (Eds.) (1989). Mild Head Injury. Oxford University Press, New York/ Oxford. 
8. Klein, R., Hopewell, C.A., & Kennedy, J. (2012). Empirical Assessment of the Neurobehavioral Symptom Inventory to Determine Construct Validity of Postconcussion Syndrome. Poster presentation at the meeting of the American Academy of Clinical Neuropsychology: Seattle, WA. 
9. Trudeau, D., Anderson, J., Hansen, L., Shagalov, D. N., Schmoller, J., Nugent, S., and Barton, S., (1998). Findings of Mild Traumatic Brain Injury in Combat Veterans With PTSD and a History of Blast Concussion. Journal of Neuropsychiatry. Volume 10, Issue 3, August, 308-313. 
10. Spitzer, R., L., First, M., B., and Wakefield, J., C. (2007). Saving PTSD from itself in DSM-V. Journal of Anxiety Disorders, Volume 21, Issue 2, 233-241. 
11. Gold, S., D, Marx, B., P, Soler-Baillo, J., M., and Sloan, D., M. (2005). Is life stress more traumatic than traumatic stress? Journal of Anxiety Disorders. 19 (6): 687-98. 
12. Boals, A. and Schuettler, D. (2009). PTSD symptoms in response to traumatic and non-traumatic events: the role of respondent perception and A2 criterion. Journal of Anxiety Disorders. May;23(4):458-62. 
13. Kennedy, J. E., Jaffee, M.S., Leskin, G. A., Stokes, J. W., Leal, F. O., and Fitzpatrick, P., J. (2007). Posttraumatic stress disorder and posttraumatic stress disorder-like symptoms and mild traumatic brain injury. Journal of Rehabilitation Research and Development. Vol 44, N: 7, 895 – 920. 
14. Stein, M, B. and  McAllister, T. W.  (2009). Exploring the convergence of posttraumatic stress disorder and mild traumatic brain injury. American Journal of Psychiatry. Jul;166 (7): 768-76. 
15. Stahl, S. (2008). Stahl’s Essential Psychopharmacology: Neuroscientific Basis and Practical Applications, Third Edition.  Cambridge University Press:  New York. 
16. Glaesser, J., Neuner, F., Lütgehetmann, R., and Elbert, T. (2004). Posttraumatic stress disorder in patients with traumatic brain injury.  BMC Psychiatry, 4 Article No 5, March 9. 
17. Benge, J. F., Pastorek, N., J., and Thornton, G. M.  (2009).  Postconcussive symptoms in OEF-OIF veterans: factor structure and impact of posttraumatic stress.  Rehabilitation Psychology.  Aug; 54 (3): 270-8. 
18. Blanchard,  E., B.,  Jones-Alexander, J., Buckley, T., C., and  Forneris, C. A.  (1996). 
19. Bovin, M. J., Marx, B., P.  et al. (2016).  Psychometric Properties of the PTSD Checklist for Diagnostic and Statistical Manual of Mental Disorders–Fifth Edition (PCL-5) in Veterans.  Psychological Assessment In the public domain, Vol. 28, No. 11, 1379 –1391. 
20. Klein, R., Hopewell, C.A., & Kennedy, J. (2012). Empirical Assessment of the Neurobehavioral Symptom Inventory to Determine Construct Validity of Postconcussion Syndrome. Poster presentation at the meeting of the American Academy of Clinical Neuropsychology: Seattle, WA. 
21. Vanderploeg, R. D., Cooper, D., B.,  Belanger, H., G., Donnell, A. J., Kennedy, J. E., Hopewell, C., A., and Scott S. G.  (2014).  Screening for postdeployment conditions: development and cross-validation of an embedded validity scale in the neurobehavioral symptom inventory.  The Journal of head trauma rehabilitation 29 (1), 1-10. 
22. Iverson, G., Gaetz, M., Lovell, M., & Collins, M. (2004). Cumulative effects of concussion in amateur athletes. Brain Injury, 18(5), 433-443. 
23. Levin, H., Amparo, E., Eisenberg, H., Williams, P., High, W., McArdle, C. & Weiner, R. (1987). Magnetic resonance imaging and computerized tomography in relation to the neurobehavioural sequalae of mild and moderate head injury. Journal of Neurosurgery, 66, 706-713. 
24. Lishman, W. (1988). Physiogenesis and psychogenesis in the post-concussional syndrome. British Journal of Psychiatry, 153, 460-469. 
25. Bazarian, J., Wong, T., Harris, M., Leahey, N., Mooherjee, S., and Dombovy, M. (1999). Epidemiology and predictors of post-concussion syndrome after minor head injury in an emergency population. Brain Injury, 13, 173–189.  
26. Iverson, G., Brooks, B., Lovell, M., & Collins, M. (2006). No cumulative effects for one or two previous concussions. British Journal of Sports Medicine, 40(1), 72-75. 
27. VA/DoD CLINICAL PRACTICE GUIDELINE FOR MANAGEMENT OF CONCUSSION/ MILD TRAUMATIC BRAIN INJURY. Department of Veterans Affairs/ Department of Defense.  Prepared by: The Management of Concussion/mTBI Working Group With support from: The Office of Quality and Performance, VA, Washington, DC & Quality Management Directorate, United States Army MEDCOM Version 1.0 – 2009. 
28. Moore, B., A., Hopewell, C., A., and Grossman, D. (2009).  Violence and the warrior, In Living and Surviving In Harm’s Way: A Psychological Treatment Handbook for Pre- and Post-Deployment. S. M. Freeman B. A. Moore, and A. Freeman, (Eds.) Routledge: New York. 
29. Radloff, L. S. (1977). The CES-D Scale: A self-report depression scale for research in the general population. Applied Psychological Measurement, 1(3), 385–401. 
30. Christopher, R., Reiman, J., and Hopewell C. A., (1997). Traumatic Event Sequelae Inventory. Military trauma assessment TESI-mt. 
31. Lewinsohn, P. M., Seeley, J. R., Roberts, R. E., & Allen, N. B. (1997). Center for Epidemiologic Studies Depression Scale (CES-D) as a screening instrument for depression among community-residing older adults. Psychology and Aging, 12(2), 277–287. 
32. Pinquart, M., & Sörensen, S. (2003). Differences between caregivers and noncaregivers in psychological health and physical health: A meta-analysis. Psychology and Aging, 18(2), 250–267. 
33. Roth, D.L., Ackerman, M. L., Okonkwo, O. C., & Burgio, L. D. (2008). The four-factor model of depressive symptoms in dementia caregivers: A structural equation model of ethnic differences. Psychology and Aging, 23, 567–576. 
34. California CLAIMS Journal, Winter 1996. 
35. Christopher, R. and Hopewell, C. A. (2007). Psychiatric correlates of combat trauma in military personnel: PTDS and TBI TESI statistical analysis. Operation Iraqi Freedom and Operation Enduring Freedom.  ISBN 158028-16-4. Reno, Nevada: Psychological, Clinical, and Forensic Assessment. 
36. McCrea, M., Pliskin, N., Barth, J., Cox, D., Fink, J., French, L., Hammeke, T., Hess, D., Hopewell, C. A., Orme, D., Powell, M., Ruff, R., Schrock, B., Terryberry-Spohr, L., Vanderploeg, R., Yoash-Gantz, R. (Jan 2008). Official position of the military TBI task force on the role of neuropsychology and rehabilitation psychology in the evaluation, management, and research of military Veterans with traumatic brain injury. The Clinical Neuropsychologist, 22 (1) 10 – 26. 
37. Driving Following Traumatic Brain Injury: Clinical Recommendations (This is the actual Clinical Practice Guideline for Driving for the Unites States Army, signed off on by BG Lorree Sutton). Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury. Driving Evaluations after Traumatic Brain Injury Conference. 28 July 2009, Washington, DC. 

By Richard S. Biehl, Police Chief (RET), Dayton Police Department 

With contributions by: 

Maris Herold, Police Chief, Boulder, CO Police Department 

Thomas Wells, Police Chief, Springdale, OH Police Department 

*This is an article from the Winter 2022/2023 issue of Combat Stress

“Be prepared to grieve!” This was my response at the October 2019 Major Cities Chiefs Association conference session, “Mass Shootings: Lessons Learned,” when I was asked by an attendee how I personally managed the experience of the mass shooting in Dayton (OH) that had occurred nearly three months prior. 

It was shortly after 2 A.M. on August 4th, 2019, when I received a call from Assistant Police Chief Matt Carper stating, “Chief, we’ve had an officer-involved shooting.” I had received these calls numerous times over the prior two decades as a former Cincinnati Assistant Police Chief and subsequently as the Police Chief of Dayton, so this was not unfamiliar terrain. Then he added, “It’s a mass shooting, there are ten persons dead including the shooter.” I ended the conversation quickly, telling him that I would be back to Dayton as soon as possible. 

My return flight to Dayton landed nine hours after the mass shooting occurred. Late that afternoon, I conducted the first of four major press conferences held over the following two weeks. During that time span, I met with elected officials, homicide investigators, federal law enforcement officials, surviving family members of some of those killed, the six officers that confronted and stopped the assailant within 32 seconds of the first shot, and the Montgomery County Coroner, all while also attending to the endless other demands that stem from such incidents. This also included a Presidential visit. 

For weeks, I went home every evening after long, exhausting days. Most nights, while alone in the quiet, I wept. 

Little did I know that traumatic loss would visit again quite soon… 

Traumatic Loss and Grief in Law Enforcement: Often Unacknowledged, Unspoken, and Unexpressed 

It is not that the experience of traumatic loss and grief, stemming both from professional and personal losses, is foreign to those within the law enforcement profession. Rather, it is that it so rarely discussed organizationally or professionally outside of a line-of-duty death (LODD), which is a rare experience for most police organizations. Further, it is mostly ignored in professional articles on policing. 

This is bewildering, considering the “death-saturated” environment of policing as referenced by Papazoglou, Blumberg, Collins, Schlosser, and Bonanno,1 who note that while the experience of death and loss in policing is discussed in “some” articles, “researchers have yet to study of how officers experience and cope with death, loss, and grief.” This is likely truer for those in leadership positions. The following narrative is an effort to provide anecdotal perspective to this end. 

But first, additional clarification regarding some of the permutations of grief in the sphere of experience, as well as some of its unique characteristics within law enforcement, is needed. 

Traumatic Loss and Grief by Various Names  

Various names and descriptions have been used to capture the nuances of unusual bereavement and grief such as “traumatic grief” (defined by its “two underlying dimensions…trauma and separation distress”),2 subsequently renamed as “Complicated Grief Disorder” (as this term captured better “the broader clinical syndrome”),3 and “Persistent Complex Bereavement Disorder” (“a bereavement-specific syndrome characterized by prolonged and impairing grief”),4 just to name a few. Efforts have been made over more than two decades to provide context and definition for a pathological grief disorder due to the experience of some bereaved persons of grief of prolonged duration and with severely disabling symptoms.5 There also has been a recognition of significant differences in bereavement from traumatic versus non-traumatic loss, both with the potential for “complicated grief reactions” described as “an umbrella term covering symptoms of prolonged grief disorder…and other post-loss complications, including symptoms of depression, anxiety, posttraumatic stress.”6,7 

Recently, a text revision (DSM-5-TR) to the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, has been issued, wherein the criteria for “Prolonged Grief Disorder” (PGD) has been added. Although confirmation of multiple criteria is required for a for a positive diagnosis related to a “death, at least 12 months ago, of a person who was close to the bereaved,” three of the following eight-symptom criteria must be “present most days to a clinically significant degree;” “identity disruption, disbelief about the death, avoidance of reminders that the person is dead, intense emotional pain related to the death, difficulty with reintegration into life after the death, emotional numbness as a result of the death, feeling that life is meaningless as a result of the death, and intense loneliness as a result of the death.”8 

Yet, it is arguable whether these evolved definitions and classifications of bereavement and grief actually capture the complexity of death, loss, and grief in police work. Do surviving police officers have to be “close” to a colleague killed in the line-of-duty or to have responded to the scene of such tragedy to experience a LODD as traumatic or to experience prolonged grief? Police officers generally do not know anyone “personally,” much less have personal ties to most who are killed in mass casualty incidents. Does this mean that their very human reactions to such horrific events are not to be recognized as a response to traumatic loss and potentially subject to prolonged grief? What about their more frequent experiences responding to traumatic death due to intentional violence, traffic fatalities, suicides, and unexpected health conditions as well as other factors involved that can lead to posttraumatic stress and extended grief? Or the cumulative effects of experiencing tragic events over the entirety of a police career? How is the professional and personal havoc of unknown frequency from such experiences captured in the evolved therapeutic lenses of bereavement and grief? 

The breadth and depth of traumatic loss and grief in law enforcement, which can be considerable, deserves far greater attention of law enforcement leaders and social science researchers to better probe and answer these troubling questions and provide effective means to mitigate the inherent grief too often experienced by law enforcement personnel without adequate support and help. 

Traumatic Loss Knows No Bounds: Cumulative, Unexpected, and Compounded Loss 

Cumulative Loss 

In late October 2019, on the final day of the International Association of Chiefs of Police conference, Assistant Chief Matt Carper, unprompted by prior conversation, said to me, “Chief, you know there is one thing we haven’t had…” He did not finish his comment or explain further, I knew exactly to what he was referring. 

Less than one week later, on the evening of November 4th, I was notified that Dayton Police Detective and Drug Enforcement Administration (DEA) Task Force Officer Jorge Del Rio had been shot during the execution of a DEA drug search warrant in West Dayton. I asked, “How bad is it?” The response was, “It’s bad!” I knew everyone touched by this tragedy was facing a very difficult night and well beyond.9 

Detective Del Rio was kept on life support for three days, he succumbed to his injuries on November 7th. Even in his death, Detective Del Rio continued to serve others by giving them hope and potentially life as an organ donor. This day marked the beginning of another painful grieving period for so many law enforcement personnel throughout the Dayton region, but not nearly as excruciating as that for his wife, Kathy, and his four daughters. A tortuous path of grief lay ahead for many, particularly those police personnel who were still recovering from the tragedy of the Oregon District mass shooting, which had occurred three months to the date of the mortal wounding of Detective Del Rio.   

Unexpected Loss 

Police Chief Tom Wells, Springdale (OH) Police Department, had reached the pinnacle of his 30-year police career when he was appointed as police chief in the very agency in which he had come through the ranks. It is a rare achievement within law enforcement and one to truly celebrate. On the evening of March 21, 2020, joy turned to tragedy in his thirty-third day as police chief when he was notified of a pursuit that entered his jurisdiction resulting in a traffic crash and an “officer down.” 

Having served as an Assistant Police Chief for ten years prior and having been notified of and responded to many serious incidents, he calmly told his spouse what had occurred and immediately changed into appropriate attire, leaving home to respond to the scene. While enroute, Chief Wells was informed that it was Springdale Police Officer Kaia Grant, an officer that he had helped hire in 2012, who was the officer down. Chief Wells saw Officer Grant at the scene, lying on the opposite side of the roadway from where she was struck by an armed aggravated burglary suspect. The suspect had swerved intentionally toward on-scene officers, including Officer Grant, who was standing at the median wall behind her car, prepared to deploy Stop Sticks. She was transported to University of Cincinnati Hospital by Air Care.10 

After leaving the scene, Chief Wells went to notify Officer Grant’s family of her critical injury, news that would produce shock and grief far greater than his own. He then went to University Hospital, escorting Officer Grant’s mother, aunt, and uncle, where Officer Grant was pronounced deceased.11 The Springdale Police Department had never had a police officer killed in the line-of-duty until then. 

He next had to face local media, at times struggling with intense emotion, to inform them of the tragic event of the evening resulting in the death of Officer Grant. Afterwards, he faced his fellow law enforcement members who were not at the scene to deliver the devastating news and where he witnessed in their subsequent facial expressions what could not adequately be described as “grief and despair.” It was this memory and its replication whenever he had to speak to a public audience thereafter that resulted in tears for months. He eventually realized that these tears were “beyond grief.”12 

Compounded Loss 

In March 2021, Police Chief Maris Herold, a prior police chief at the University of Cincinnati Police Department and 26-year veteran of the Cincinnati Police Department, was just about to complete her first year as the Police Chief of Boulder (CO) Police Department. On March 22nd at approximately 2:30 P.M., a heavily armed, lone gunman began to walk across the road to the parking lot of King Soopers grocery store in South Boulder, methodically shooting individuals as he did.13 

Chief Herold was doing paperwork at her desk when initially notified via text message of an “active shooter” at King Soopers, a grocery store in the neighborhood where she lived. Due to a recent series of false text alerts, she called Deputy Chief Carey Weinheimer to verify the information. When her call was answered, she could hear gunfire over the phone. She immediately began responding to the scene and was filled with dread when she initially tried unsuccessfully to reach her spouse, who frequented the store. Upon her arrival, she assisted with critical incident management of what was a chaotic scene that included motorists trapped in their vehicles.14 

The armed suspect was barricaded in the store and after nearly an hour, the incident ended when the suspect was wounded and taken into custody.15 With the scene stabilized, Chief Herold entered the scene and saw Officer Eric Talley, who was shot in the head by the assailant during an initial entry into the store shortly after the mass shooting began. Officer Talley was removed from where he was located to the front of the store by SWAT personnel and later transported from the scene.16 Officer Talley was one of ten persons killed in the assault. 

As the scene stabilized, Chief Herold, along with Deputy Chief Weinheimer and a close friend of Officer Talley, responded to the Talley residence to notify Officer Talley’s wife, Leah, and their seven children of Officer Talley’s death, providing compassionate presence and emotional support, with the assistance from a chaplain. 

After leaving the Talley residence, Chief Herold met with District Attorney Michael Dougherty and FBI officials to conduct an initial press conference, her voice and facial expression evident of the emotional burden she was bearing. Afterwards, she proceeded to the CU Event Center, where families of the deceased were gathered. She stayed the night with them in their “unbelievably horrible” anguish, which she also shared.17 

Leading While Grieving: What Helped Getting Through It All 

Each of the traumatic and tragic events described above resulted in varied losses, with great complexity within police responses. Consistent themes emerged from the police leaders that shouldered substantial weight in responding to them, while under media and public limelight. The following is what substantially helped them professionally and personally to be able to do so. 

Organizational and Leadership Support 

Substantial resources are often required in critical events, and this was certainly true in the aforementioned tragedies. Chief Wells received support from the Ohio Bureau of Investigations in the criminal investigation of the death of Officer Grant and the assistance of the Ohio State Highway Patrol in the fatal crash investigation. Mutual aid from neighboring police agencies was also instrumental in providing patrol coverage for 10 days, which allowed most of the Springdale PD officers to be granted administrative leave for their personal health and to attend funeral services for Officer Grant. 

Chief Herold acknowledged personal and professional support from Boulder County agencies that responded to the scene and offered continuing assistance thereafter, support from Special Agent in Charge (SAC) Michael Schneider, the Federal Bureau of Investigation (FBI) as well as agency personnel that processed the crime scene, and District Attorney Michael Dougherty, who participated in press briefings and paid meticulous attention to the development of evidence that would allow prosecution of the offender and justice for all the victims of the mass shooting.18 

Similar support was provided to the Dayton Police Department in response to the Oregon District mass shooting by multiple local police agencies helping to stabilize the scene, provide aid to and transport victims to local hospitals, and assisting with crime scene processing. Substantial follow-up investigation was provided by the FBI to include forensic lab analysis of digital evidence and investigative support by the Behavioral Analysis Unit, as well as local agents. The staff of the US Attorney for Southwest Ohio provided substantial legal assistance in the expedited review of federal search warrants related to the case.  

Three months later, in response to the homicide of Detective Jorge Del Rio, regional and local Drug Enforcement Administration supervisors and agents engaged in relentless investigative efforts to pursue all investigative avenues, across the country and beyond, related to the drug trafficking organization responsible for supplying local dealers with 9 kilograms of cocaine and fentanyl. Alcohol Tobacco and Firearms (ATF) agents meticulously pursued the path of the crime guns recovered at the homicide scene and eventually filed criminal charges against the individuals responsible. Montgomery County Sheriff’s Office provided patrol coverage during funeral services for Detective Del Rio, so that Dayton Police personnel normally on patrol could attend the services. 

These actions collectively provided critical support at the scene of these tragedies, needed follow-up investigation to hold offenders accountable, and follow-up operational support for the primarily affected agencies so that their personnel could be provided respite and the ability for police officers to participate in the funeral of their fallen colleagues and other supportive activities. 

All three police chiefs were able to attend to community and operational needs while critical mental health support was provided to their agencies’ members who were immediately and significantly impacted by these tragedies. Dedicated and gifted police psychologists and community mental health counselors conducted post-incident defusings, critical incident debriefings, and in some cases, long-term psychological interventions to mitigate the immediate and potentially prolonged impacts of traumatic loss. Peer support personnel also performed a significant support role, both of which are vital topics which deserve much greater discussion beyond their mere mention in this writing.  

Expressions of Gratitude and Compassion 

All police chiefs who lead their agencies during these times of great loss noted the tremendous response from law enforcement agencies and their profound condolences for the loss of a fellow officer, which included letters and cards of sympathy and gifts of remembrance to honor their fallen colleagues. Financial support to the fallen officers’ families was also provided by law enforcement personnel and support organizations to offset financial hardship. 

Community organizations and individuals responded in kind, frequently providing food for some sustenance for the families of the fallen officers and mourning officers of the affected agencies during many long days during and after the immediate death. Many flowers were sent to the affected agencies. Substantial financial donations were made in addition to that provided by law enforcement agencies or government established benefits to provide for the financial support to the bereaved families. 

This outpouring of compassion from law enforcement agencies and personnel, as well as local communities and beyond, was a healing balm to the pain of such terrible losses. 

The Personal Journey Through Traumatic Loss 

Traumatic loss and the intense grief that springs from it is as much an individual, as well as a collective experience. That is certainly true for the police chiefs who experienced these events of traumatic loss. Each had unique experiences that aided them individually in regaining balance, while enduring inescapable grief. 

Chief Wells acknowledged that his “shock and grieving process had to be put on hold” as he focused on the care and well-being of his staff and their recovery. However, this understandable decision, a common one for those in leadership positions, came at a cost. Time spent “staring out the window, mindlessly watching TV” and distancing himself from family did not aid in his recovery from loss and grief. He initially sought support through Companions on a Journey, a grief support group. When months passed and the inevitable emergence of tears whenever addressing groups of individuals did not lessen, he decided to attend Help for Heroes after learning about their program for treatment of mental health conditions experienced by first responders.19 Chief Wells completed a five-week treatment program and this, in conjunction with a long overdue vacation, he substantially credits for recovery from PTSD stemming from the violent death of Officer Grant. He also found unexpected kindred support and a lasting friendship through the father of Officer Grant and Glen Schaffer, the father of Washington State Trooper Justin Schaffer, who died in the same manner as Officer Grant. These experiences, as well as prior training at the FBI National Academy, serving as a member of the regional honor guard for 15 years, and his many years of experience as a police officer, supervisor, and senior commander, helped him get through and get past the sometimes-incapacitating effects of grief and posttraumatic stress.20 

Beyond initial support from local law enforcement leaders, Chief Herold attributes some of her healing and recovery to attending most of the funerals of those killed in the mass shooting and being invited as a guest of honor to one of the funerals. She found this to be “very healing.” Also, substantial financial resources, provided through a private donor, helped to establish the Boulder Strong Resource Center that provided an array of treatment resources – acupuncture, therapy dogs, counseling, etc. – to first responders and the broader Boulder community. In addition, an art project featuring the photography of Ross Taylor,21 depicting the Boulder Police Department personnel, as well as other first responders and community members who responded to the mass shooting, in a way that they wanted to be remembered in that moment, was a powerful healing experience. The art was subsequently displayed publicly, bringing honor to the men and women of the Boulder Police Department and all that responded to the scene for their heroic and lifesaving response to a mass casualty scene.22 

The experience of the Oregon District Mass Shooting was the realization of my worst fear as police chief.  In immediate response to the collective grief of the Miami Valley community, a vigil was scheduled in the Oregon District at 8 P.M. on the evening of August 4th of 2019. Although being awake for eighteen hours and having less than three hours of sleep overnight, I attended the vigil. I wanted to be there with my community. But more accurately, I needed to be there. It was the beginning of what would be an extended healing process. 

What helped me function through the difficulty of the weeks and grief ahead was a focus on day-to-day demands of responding to this mass casualty incident, with the support of an incredible command staff and highly competent police staff. The eventual personal perception that I performed my duties well in addressing the needs of my community, my agency, and the officers of my agency, eased some of the burden and grief I felt. It was also helpful that many of the current and former Dayton Police Officers, police leaders from the region and members of the greater Dayton community recognized the leadership demonstrated by all members of the Dayton Police Department and surrounding agencies that responded to this horrific and violent scene, openly expressing it in so many ways. 

While still recovering from the physical and emotional toll of the Oregon District Mass Shooting, the homicide of Detective Del Rio renewed intense grief for so many police personnel, as well as for me. I struggled whether my words at his funeral provided the level of honor and recognition due such a dedicated and accomplished police officer, who gave his all in the service to his community and his noble profession. The day after the funeral services, Fire Chief Jeff Lykins presented to me a video (https://www.youtube.com/watch?v=r5mgu00ZAfY) made by Firefighter Marques Kincaid23 consisting of segments of the funeral of Detective Del Rio, with a voice over from my spoken tribute. This beautiful commemoration, with all the powerful images it captured, allowed police officers throughout our agency, the region, the DEA and beyond to witness the honoring of Detective Del Rio in such magnificent form. This became a vehicle for grief to have its expression for the many hundreds of police officers in attendance and for all who felt a soul-wrenching loss from his death. 

“We Don’t Heal from Grief; We Are Changed by It.”24 

Neither Chief Tom Wells, Chief Maris Herold nor I would claim that we or our agencies are fully healed from the trauma and grief endured through the tragic and traumatic loss of those with whom we have served or the terrible impact of the mass shootings that preceded or were concurrent with these losses. For better and to some degree less so, we and our colleagues have been forever changed by them. Yet, in the aftermath of profound tragedy, most of us have continued to serve our communities professionally and compassionately. In our collective emergence through trauma, loss, and grief, we have demonstrated our professional capacity and commitment to public service. We have not been impaired long-term by the tragedies that have befallen our agencies, our communities, and that so deeply affected us personally. We are forever indebted to Detective Jorge Del Rio, Officer Kaia Grant, and Officer Eric Talley for their legacy of devotion and ultimate sacrifice in helping and protecting their fellow officers and communities, “that cause for which they gave the last full measure of devotion.”25 

References 

1.  Papazoglou, K., Blumberg, D. M., Collins, P. I., Schlosser, M. Dd., and Bonanno, G. A. Inevitable loss and prolonged grief in police work: an unexplored topic. Frontiers in Psychology. 2020, 11(1178): doi: 10.3389/fpsyg.2020.01178  

1. Prigerson, H. G., Shear, M. K., Frank, E., Beery, L. C., Silberman, R., Prigerson, J., Reynolds C. F. 3rd. Traumatic grief: a case of loss-induced trauma [Abstract]. American Journal of Psychiatry. 1997, 154(7):1003-9. doi: 10.1176/ajp.154.7.1003. PMID: 9210753. 

1. Raphael, B., Martinek, N., & Wooding, S. Assessing traumatic bereavement. In J. P. Wilson & T. M. Keane (Eds.), Assessing psychological trauma and PTSD [Abstract]. 2004, (pp. 492–510). The Guilford Press. https://psycnet.apa.org/record/2004-21033-017  

1. Robinaugh, D. J., LeBlanc, N. J., Vuletich, H. A., & McNally, R. J. Network analysis of persistent complex bereavement disorder in conjugally bereaved adults. Journal of abnormal psychology [Abstract], 2014, 123(3), 510–522. https://doi.org/10.1037/abn0000002 

1. Lenferink, L. I. M., Van Den Munckhof, M. J. A., de Keijser, J., and Boelen, P. A. DSM-5-TR prolonged grief disorder and DSM-5 posttraumatic stress disorder are related, yet distinct: confirmatory factor analyses in traumatically bereaved people. European Journal of Psychotraumatology, 2021, 12(1): doi: 10.1080/20008198.2021.2000131 

1. Komischke-Konnerup, K.B., Zachariae, R., Johannsen, M., Nielsen, L.D. and O’Connor, M. Co-occurrence of prolonged grief symptoms and symptoms of depression, anxiety, and posttraumatic stress in bereaved adults: a systematic review and meta-analysis [Abstract]. Journal of Affective Disorders Reports, 2021, 4: 100140. 

1. Nakajima, S., Masaya, I., Akemi, S., and Takako, K. Complicated grief in those bereaved by violent death: the effects of post-traumatic stress disorder on complicated grief, Dialogues in Clinical Neuroscience. 2012, 14(2), 210-214, doi: 10.31887/ DCNS.2012.14.2/snakajima   

1. Prigerson, H. G., Kakarala, S., Gang, J. and Maciejewski, P. K. “History and status of prolonged grief disorder as a psychiatric diagnosis.” Annual Review of Clinical Psychology. 2021, 17(1): 109-126. 

1. Reed, M. Dayton police chief reflects on the death of Det. Jorge Del Rio a year later. 2020, November 6. WKEF/WRGT, Sinclair Broadcast Group, Inc. https://dayton247now.com/news/local/dayton-police-chief-reflects-on-the-death-of-det-jorge-del-rio-a-year-later  

1. Wells, T., Personal Communication. November 11, 2022. 

1. Rice, B. and Baum, S. One officer dead, another injured, after police chase ends on I-275 in Springdale. Cincinnati Enquirer. https://www.cincinnati.com/story/news/2020/03/21/crash-shuts-down-275-both-directions-state-route-4/2893654001/ 

1. Golick, K. B. Public tears, private struggles: an Ohio police chief’s PTSD. Cincinnati Enquirer. https://www.cincinnati.com/story/news/2021/01/10/public-tears-private-struggles-police-chiefs-ptsd/3920818001/  

1. Bradbury, S., Phillips, N., and Murray, J. 58 minutes of terror: how the Boulder King Soopers shooting unfolded. 2021, March 27|UPDATED: March 27, 2021. The Denver Post. https://www.denverpost.com/2021/03/27/boulder-shooting-king-soopers-58-minutes-how-unfolded/ 

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1. Herold, M. Personal Communication, November 12, 2022. 

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1. Wenzel, J. Emotional new art exhibition focuses on people directly affected by the King Soopers shooting. 2022, February 17. Denver Post.  https://www.denverpost.com/2022/02/17/boulder-king-soopers-shooting-anniversary-boulder-strong-museum-portrait-photo-ross-taylor/ 

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By Louise Gaston, PhD

*This is an article from the Spring 2022 issue of Combat Stress

As a psychotherapist, I had been stunned by how helplessness appeared to be one of the most painful feelings one can experience and thus, attempts to avoid at all costs.

Many years ago, I addressed the survivor guilt of a person presenting with Post-Traumatic Stress Disorder (PTSD) in psychotherapy. Thereafter, this person was able to move beyond such guilt feelings. Below, our conversation is presented from memory.

Such a psychotherapeutic encounter was possible due to a blend of diverse psychotherapeutic approaches I had learned, namely, psychodynamic, cognitive, and humanistic. Such an integrative approach was the fruit of over 15 years of training in various approaches, mostly psychodynamic, along with my appreciation of the clinical writings of many trauma experts.

Survivor guilt was brought up in the psychotherapeutic context by many of my patients struggling with PTSD. At first, I approached survivor guilt with empathy by recognizing their suffering, but nothing changed. Then, I tried a cognitive approach, attempting to demonstrate how their survivor guilt was not substantiated by reason or reality, but nothing changed. Finally, from a psychodynamic perspective, I decided to envision survivor guilt as a defense. I then endeavored to identify the pain hidden behind survivor guilt. In doing so, I remembered that, if PTSD ensues, helplessness was a core experience during the traumatic event. In addition, as a psychotherapist, I had been stunned by how helplessness appeared to be one of the most painful feelings one can experience and thus, attempts to avoid at all costs. Consequently, I saw how survivor guilt was a defense aimed at avoiding and assuaging a feeling of helplessness. When a solid therapeutic alliance was in place, I interpreted survivor guilt as a defense against helplessness, which allowed my patients to acknowledge their helplessness and to face it, which led to intense internal distress. However, these individuals ended up accepting helplessness as a fact of life and stopped fighting against it. Consequently, they moved on beyond survivor guilt, knowing that they could strive to be in control more often. This approach yielded a much higher success rate.

____________________

T: You tell me that you should have died like the others, that you have survivor’s guilt.

P: Yes. Why wasn’t I killed like the others? Why did I survive?

T: Do you have the impression that you should have died, that you should still die?

P: Why would I deserve to survive and not the others?

T: I hear you. Would you like to help me understand your experience by describing your inner experience at the very moment of the shooting?

P: Okay, if it helps.

T: So, when the firing started to occur, what did you do?

P: I threw myself on the ground.

T: To avoid the bullets?

P: Yes.

T: Okay, so you tried to stay alive.

P: I guess so. (pause) Yes!

T: Okay. Right after the firing finished and you realized that you were still alive while others were hit, what crossed your mind?

P: Well, I thought “Oh, no!’’ for those who were hit, but I also thought, “I’m glad I’m alive!’’

T: Okay, you were relieved to not be hit and to be alive. Right?

P: Yes.

T: You were also saddened those others were hit and appeared to be dead. Right?

P: Yes.

T: Okay, so let’s acknowledge this truth. In summary, you were both relieved to be alive and saddened those others were hit. Can you hold these thoughts clearly in your mind?

Now, another thought may have crossed your mind; something like “I’m glad it’s not me.’’

P: Yep!

T: Okay, however, did you think “I’m glad they are dead rather than me’’ or “I’m glad it’s not me’’?

P: “I am glad it’s not me,’’ of course!

T: Okay, so you were not glad that they were dead, right?

P: Right.

T: Are you sure?

P: Yep!

T: Okay. Do you hear and believe yourself?

P: (silence and then nod of the head)

T: Okay, now, could it be that the thought that “I am glad that they are dead rather than me’’ also crossed your mind? Could it be that you have been feeling really bad about having had such a thought?

P: I guess so.

T: Such a thought implies that you wished they were dead instead of you, that there was a choice during the shooting, that is, that you could have chosen who died or not. Right?

P: In a way, yes.

T: Did this spontaneous, survival-based thinking of ‘’better them than me’’ have any impact as to whom was killed on this day?

P: No, not at all. It was just a thought. I did not wish this.

T: So, in summary, you were relieved to be alive, really relieved to be alive, and you were glad that destiny did not hit you. You may have thought ‘’better them than me’’, but having such a thought crossing your mind does not imply that you wished them to be dead, right?

P: Right.

T: Okay, deep inside, you may have had the impression that the thought “better them than me’’ had influenced the outcome of the traumatic event, in an unrealistic way, if I may add. Yet, in reality, you had no choice whatsoever. (pause)

Thus, in reality, were helpless during this tragic event. You were completely unable to prevent the killing.

P: I hate helplessness.

T: I know. Everyone does; however, let’s go a bit further along this line of thought.

P: I am not sure that I enjoy this, but okay.

T: We can stop any time if you want. Just let me know.

Now, thinking afterward that you had a choice during the event may be soothing in a way, even though such thinking is not based on reality. I am sure that you can agree with me on this.

Let’s see. The thought “better them than me’’ is a bit delusional if it implies that you chose the outcome of the event. In addition, thinking ‘’them rather than me’’ induces survivor guilt. Nonetheless, such thinking is useful because it invokes a sense of control, which counters helplessness. Thus, by imagining some control over the outcome and thus feeling guilty, you avoid the obvious; that is, you avoid recognizing your sheer lack of control during the event. You are avoiding feeling helpless. So, you would rather feel guilty than helpless?

P: (thinking)

T: Let’s pause here. So far, you have preferred imagining that you did something wrong on this day, rather than acknowledging that there was nothing good to do, nothing you could have done. You were helpless.

P: I see your point.

T:  Working with people with PTSD, I have noticed that almost everyone would rather stew in guilt for years rather than recognize their helplessness and accept to be helpless at times. Helplessness appears to be the most painful feeling someone can experience; yet at times, there is nothing we can do…. absolutely nothing!

P: I hate it.

T: I know. We all do, but I can see how it is especially painful for you. In a paradoxical way, however, you have a choice now. At this very moment, you are not helpless. Indeed, you can choose, or not, to recognize that you were unable to protect others during the shooting.

Indeed, at this very moment, you can choose to acknowledge that you have been tragically helpless during the unfolding of this tragic event – helpless and vulnerable. Indeed, you do not have to make yourself feel excruciatingly guilty for the rest of your life. You can simply, although painfully, recognize that you were helpless.

Honestly, guilt is almost always a defense against helplessness. By imagining that we did something wrong, we can continue to entertain the idea that something good could have been done – thus, that we were not helpless. By imagining the possibility of control, we avoid feeling helpless.

P: (reflecting in silence)

T: This being said, I would like to throw you a curve ball. How’s that?

P: Okay (smiling a bit)!

T: I would like to suggest that you have done one thing right during the shooting.

P: What?

T: You threw yourself on the ground, which may well be the reason you survived.

P: I like that.

T: There is one thing I know for sure.

P: What?

T: You are here. I am glad you are both here and alive!

___________________________________________________________________________________

Survivor guilt can be very painful and can take over one’s life. Let’s look at three different ways that survivor guilt can damage one’s psyche:

First, to counter survivor guilt, a person could spend most of one’s vital energy trying to help others and to fix things incessantly. However, this strategy will never be truly appeasing because it is more often impossible to repair irreversible damages caused by traumatic events. Therefore, the efforts aimed at helping others need to be repeated, again and again. Such an unconscious psychological strategy is exhausting and pointless in the end, because it avoids acknowledging the root cause; namely, helplessness.

Secondly, a person could become actively destructive toward oneself to counter a feeling of survivor guilt. This unconscious psychological strategy aims at appeasing the trauma-based false conviction that one is a bad person. By punishing oneself, one tries to redeem themselves, but to no avail because there is nothing to redeem. Indeed, the person was helpless, but was not responsible for the damages incurred by the traumatic event.

Thirdly, a person could become psychologically paralyzed in life from survivor guilt. While survivor guilt can be experienced consciously, this person will be unconsciously overwhelmed by free-floating helplessness, which will attach itself to almost every aspect of the person’s life. Such psychological unconscious strategy will stalemate any of the person’s desires to achieve something which could be valuable for oneself or others.

In the above circumstances, survivor guilt is maintained to avoid helplessness. Therefore, helplessness needs to be recognized, acknowledged, and even embraced as part of the human condition, as part of one’s life, in order to move beyond survivor guilt and its damaging consequences.

By Vicki Topaz, Filmmaker, Photographer and Daughter of a WWII Veteran

*This is an article from the Winter 2021-2022 issue of Combat Stress

Perhaps more than any other art form, documentary film has the power to make the unseen seen. As filmmakers, this is what we set out to do in Dog Walk Home: offer a rare glimpse into the lives of three Veteran families as they share their stories from the privacy of their homes. Through their voices we learn about the causes and effects of post-traumatic stress disorder (PTSD) in all its myriad forms: injury, assault, survivor’s guilt; anger, self-isolation, and self-medication. Yet these are not the places where we linger. The heart of this film is elsewhere: in hope, family, recovery, and the service dogs that help make it possible.

Why would these Veterans and their families allow our filmmaking crew of five into their homes? Why would they bare their souls to us? It is not complicated. These people are a different breed of Americans — those few who have pledged their lives to protecting their country and their fellow Service Members. If this film saves even one Veteran’s life or inspires one Veteran to seek help, the discomfort of sharing their stories will have been worth it. And thanks to the love of their families and some very good dogs, these Veterans have regained the heart to complete this vital mission.

How This Film Came About — and Why It Is Important to Me

All of my work with Veterans has been deeply personal — a truth which, over time, I realized was partially rooted in the formative experiences of my own childhood. My father was a U.S. Army Veteran who flew missions as a tail gunner in Europe during WWII. Like the Veterans in Dog Walk Home, he arrived home with PTSD, a condition that was unrecognized and untreated at the time. Now, all these years later, I know that he was grappling with PTSD which led to his anger and alcoholism. I also know that my childhood perspective has helped me foster deeper insights into the unique struggles of children and families living with trauma.

My desire to shed light on the Veteran experience began to take shape more than a decade ago, but it truly crystallized when I started interviewing and photographing Veterans living with PTSD for my multimedia project called HEAL! It was an honor and a revelation to listen to these Veterans relate their stories of military service, to learn about their subsequent battles with PTSD, and especially to witness how their service dogs helped put them on a path to restoring their independence.

Somewhere along the way, my thoughts circled back to my own childhood memories as I was gathering these intimate stories told in HEAL! I realized there was yet another facet of the Veteran experience that needed to be told: the role of the family. This insight ultimately led me to Dog Walk Home to show how PTSD impacts Veterans and also to reveal how secondary trauma impacts family members.

The Exceptional Families (and Dogs) in Dog Walk Home

The stories and perspectives of the three Military families in the film are unique, yet they all share a dual thread: their struggles with PTSD and secondary trauma and the discovery of dogs willing and able to meet them in their darkness and lead them into the light and love of family and friends.

We first meet Emilio Gallegos, a Mexican American U.S. Marine Corps Veteran, Purple Heart recipient, poet and single father. Speaking of his deployment in Iraq, Emilio describes how the Humvee he was driving on his base was blown apart by an improvised explosive device. Suffering with symptoms of PTSD and a traumatic brain injury, he returned home distant and angry, self-isolating from his own family and from the world. However, his isolation ends and reconciliation with his children begins when Emilio is partnered with his service dog, Samson.

Next, U.S. Army Veteran Kim Voss shares the heartbreaking account of how her PTSD first developed from early childhood abuse and was then compounded by a sexual assault in the military. Demoralized by “Don’t Ask, Don’t Tell,” she left the service to manage her symptoms as best as she could. Just as her marriage to wife Tamara is hanging on by a thread, Kim is partnered with her service dog, Artemis. She helps Kim remain in the present and gives both Kim and Tamara the strength and stability to stay together.

And finally, we meet Ramon Reyes, a Mexican American U.S. Army Veteran who deployed twice to Iraq. He is haunted by survivor’s guilt and stricken with severe PTSD. Ramon self-medicates with alcohol to such an extreme that he temporarily loses his wife and two children. When he is treated at the VA and then partnered with his service dog Huey, Ramon can finally start mending the rift with his family. Huey helps everyone in the family lessen their symptoms of PTSD and secondary trauma.

The Human-Animal Bond: How Does It Work, and How Does It Help?

“When you’re looking at the entire scope of the human-animal bond, dogs are the gold medal winners. The chemistry and wiring of their social brain network is most similar to ours. This is why, neurobiologically speaking, dogs are our best friends!” — Meg Daley Olmert, film advisor and author of Made for Each Other: The Biology of the Human-Animal Bond.¹

“Samson helps me decompress. I talk to him a lot too. When I’m at the store, buying cereal, I ask him, ‘What should we get today? What do you think? Maybe some Fruit Loops?’ People in the aisle are like, ‘Is that guy talkin’ to his dog?’ Having Samson gives me a chance to love someone every day. Sometimes I’ll step outside of the house, to run to my car quick, or go into the garage. When I come back in, he gets so excited, ‘Where did you go?’ I’m like, ‘Man I was just outside a couple of minutes.’ It’s easy to get lost in alone-ness but now, I’m not alone, I’m never alone, you know.”

—Emilio Gallegos, U.S. Marine Corps (1999–2010). Deployed to Iraq. Purple Heart recipient. Service dog and training provided by Operation Freedom Paws in 2016.

One of my first questions about service dogs was, how can they help reduce the symptoms of PTSD? The answer lies in their extraordinary ability to merge into our hearts and homes. They quickly become family and much more. Emilio Gallegos captured it when he said: “Having Samson gives me a chance to love someone every day.”

Like all good friends, they know us well — often better than we know ourselves. Their extraordinary sense of smell can alert them to the chemical changes that signal the onset of stress, anxiety and night terrors and pull their Veteran back from these emotional pitfalls and remind them they are safe and loved.

When Ramon Reyes first brought Huey home, there happened to be fireworks in the neighborhood. The explosions echoed Ramon’s wartime experiences, but Huey was able to detect his rising anxiety. By jumping on Ramon’s lap and licking his face, Huey created a distraction and prevented what would have surely been a triggering event.

As Meg Daley Olmert goes on to explain in the film, the social brain network is also the anti-stress network. So, when we pet, hug, snuggle and sleep with our dogs we are producing the brain chemicals that ease the symptoms of PTSD.

These are just a couple of examples that show us how service dogs anchor their Veterans in the present moment.

“There are times that I push people away, especially when it gets close to anniversary dates of certain events that happened in Iraq. Huey won’t let me. He senses it. He’ll come up and start nudging at me like, ‘Hey, pay attention to me. Pet me.’ He won’t stop until I actually pay attention to him. Every time I say, ‘Leave me alone.’ He comes back and he’s at it again. He helps with fireworks too. The first night some fireworks went off, I got real bad anxiety. Right away, he jumped on top of me and started licking my face. I was so amazed. And still to this day if there are fireworks going on, he comes up to me.”

—Ramon Reyes, U.S. Army (1995–2012). Two deployments to Iraq. Service dog and training provided by Operation Freedom Paws in 2017.

The Impact of COVID-19

COVID-19 has put Veterans at increased risk. Forced isolation, stress, fear of the unknown, and suicidal ideation are just a few of the factors they face. Not to mention the very real risk for Veterans whose immune systems were compromised in the military conflicts in which they served. For this group, fear of contracting the virus can trigger a vicious feedback loop and cause even higher levels of stress and anxiety. In a Zoom recording with Ramon Reyes, he shared this comment: “The past couple of days I haven’t been able to sleep right. The nightmares have started. There are times that it takes me back overseas, just fighting an enemy we cannot see.” We were also able to record Emilio Gallegos via Zoom, and he shared this with us: “I see how it can go one or two ways: having comfort in it, because I’ve been here before emotionally and mentally, or having extreme discomfort, because this reminds me of a bad place. And I don’t want to be there again. You know what I mean?”

The film revisits each family post shut-down to see how they’ve managed the challenges of COVID-19 and to catch sight of what their futures hold. To no one’s surprise, we learn that Samson, Artemis and Huey continued to play a profoundly stabilizing role for the whole family as the pandemic played out.

Helping Veterans Succeed: Why Dog Walk Home — and Why Now?

“When the peace treaty is signed, the war isn’t over for the Veterans, or the family. It’s just starting.”² —Karl Marlantes, author, Vietnam War Veteran, U.S. Marine Corps

How can we expect Veterans to smoothly reintegrate into civilian life when daily functioning is so difficult? Why do they wait so long before asking for help? And why do service dogs make such a positive difference?

The three Veteran families featured in Dog Walk Home are representative of the wider audience the film is made for. Namely, underserved Veterans and the communities that support them, including Latino, LGBTQ, and BIPOC groups as well as seniors, women, and disabled Veterans. An even wider audience of mental health workers, educators, and of course all dog lovers will draw their own meaning from the film.

Further, by holding up a mirror that reflects hope back to other Service Members and families who face similar challenges, we believe Dog Walk Home can offer a roadmap and urge them to seek help.

It Takes a Village (to Make This Film)

Telling such stories through the medium of film is, to say the least, a collaborative process. Years before Dog Walk Home began to take shape, I was introduced to Mary Cortani, herself a Veteran and Certified Army Master of Canine Education, and the founder of Operation Freedom Paws (OFP), a nonprofit that partners Veterans with service dogs. It is thanks to her that I had access to the Veteran community served by OFP. Being among them and hearing their stories opened my eyes and my mind to a world I had been seeking. I am so grateful for the many trusting relationships with Veterans and their families that I developed over time.

To help share these stories of trauma and healing, I joined forces with a like-minded filmmaker, Wynn Padula. Wynn collaborated with Iraq War Veteran Bobby Lane and other Veterans with disabilities when he codirected and shot Resurface, an award-winning Netflix original short documentary about the healing power of surfing for Veterans traumatized by PTSD.

The stories of Dog Walk Home are augmented with critical “how and why” insights from experts in the science of the human-animal bond, trauma specialists, and service dog training professionals. They help explain what we see and hear from our Veterans and their families about the healing power of their service dogs featured in our film. We will also get a better understanding of why the Veterans Administration has been reluctant to fund service dogs to those with the “invisible wounds” of war and the progress that is now being made.

To see the full lineup of our remarkable and dedicated crew and film advisors, please visit our website at Dog Walk Home. The film is currently in production with an anticipated release date in 2022. This project is made possible with support from California Humanities, a non-profit partner of the National Endowment for the Humanities.

 “Artemis has affected my entire life, both going out in public and being at work. She’s also helped my marriage quite a bit—I’m able to be present a lot more. I don’t stay locked in my head as much. Artemis helps all of us be aware of when I’m feeling particularly anxious or when I’m feeling angry. Having a service dog is an incredibly vulnerable thing because you can’t just hide your feelings and emotions because these darn dogs, they know, they can smell it, they can feel it. Artemis helps make me more aware and more accountable for who I am and how I show up in the world.”
—Kim Voss, U.S. Army (1989-1993). Military Intelligence. Service dog training provided by Operation Freedom Paws in 2019.

View a short 3-minute sample trailer for Dog Walk Home: https://vimeo.com/386530510

We are devoted to telling these stories of healing and transformation to prove to Veterans and non-Veterans alike that recovery is possible for those who seek help. If you are reading this right now, we are thankful to have reached you.

Contact: Vicki Topaz, San Francisco, CA, email: vicki@vickitopaz.com, text: 415-298-9465

 

 

 

 

 

 

References

1. Olmert, M.D. (2009). Made for Each Other: The Biology of the Human-Animal Bond. Boston, MA: Da Capo Press.
2. Marlantes, Karl (2011). What It Is Like To Go To War, New York, NY, Atlantic Monthly Press.