THE WAR ZONE
Created by experts at the National Center for PTSD, 2006
A Guide for Families of
The days and weeks after a homecoming from war can be filled with excitement, relief, and
many other feelings. This guide is for military family members, like you. This guide is also
helpful for friends and returning veterans themselves. Following the veterans return from
overseas duty, the entire family will go through a transition. This guide will help each of you
understand readjustment during homecoming.
Reintegration following homecoming involves taking time for the veteran, family and friends to
become reacquainted. Talk and listen to one another to restore trust, support and closeness.
There may be times when you and your returning veteran feel stress, uncertainty, concern, and
distance from one another. It may feel as if the service member is still fighting a war, rather than
truly being home. All of these emotions are a normal part of readjustment following deployment
to a war zone. At first, these reactions may be difficult to deal with. Some service members have
real difficulties and struggle during their transitions back home. Because many service members
face redeployment back to overseas duty, it is especially important to address these difficulties
during this time back home. Learning more can help your family cope. In this guide you will
How expectations about homecoming may not be the same for service members and
Ways to talk and listen to one another in order to re-establish trust, closeness and
Information about possible problems to watch out for
How to offer and find assistance for your loved ones
What help is available and what it involves
A common expectation is that the family will be exactly the same as it was before the
deployment. However, during deployment families naturally change. Children have grown and
spouses have taken on new responsibilities. New friendships may have formed. War zone
exposure is a life changing experience for those deployed. Understanding what you might
expect will help with the transition back to civilian life. In this guide you will learn ways to
cope better, and if problems arise, ways to find assistance.
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THIS GUIDE CONTAINS:
• WHAT IS A COMBAT STRESS REACTION?
• EXPERIENCES IN THE WAR ZONE
• EXPECTATIONS ABOUT HOMECOMING
• EFFECTS ON FAMILY LIFE
• WHAT ARE THE SYMPTOMS OF PTSD?
• HOW OFTEN IS PTSD DIAGNOSED IN VETERANS?
• WHAT CAUSES COMBAT STRESS REACTIONS OR PTSD?
• OTHER COMMON STRESS REACTIONS
• ROLE OF THE FAMILY IN PROBLEM SOLVING
• ENCOURAGING A VETERAN TO SEEK HELP
• HOW TREATMENT WORKS
• COMMON THERAPIES USED TO TREAT PTSD
• WHERE TO GO FOR HELP
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WHAT IS A COMBAT STRESS REACTION?
Understand that service members respond to experiences in a war zone in different ways.
Some service members report feeling upset or “keyed up” even after they return home. Some
may continue to think about events that occurred in combat, sometimes even acting as if back in
a combat situation. These are common “combat stress reactions” (also called acute stress
reactions) that can last for days or weeks and are a normal reaction to combat experiences.
Below is a list of common reactions:
Trouble sleeping, overly tired
Feeling nervous, helpless, or
Jumpy & easily startled
Stomach upset, trouble eating
Sad, guilty, rejected or
Being on guard, always alert
Headaches and sweating
Edginess, easily upset or
when thinking of the war
Bad dreams or flashbacks
Lack of exercise, poor diet or
Experiencing shock, being
numb, unable to feel happy
Avoiding people or places
Rapid heartbeat or breathing
Feeling hopeless about the
related to the trauma
Work or school problems
Too much drinking, smoking,
Irritable or angry
or drug use
Loss of intimacy or feeling
Other health problems
Not trusting others, being over
withdrawn, detached and
controlling, having lots of
Most service members, who experience combat stress reactions like those listed above, will
recover naturally over time.
Others continue to struggle with memories of their combat experiences and their reactions.
Research still does not tell us why some people struggle while others do not. BUT it is NOT
because of any type of weakness. Combat stress reactions may create problems in
relationships with partners, other family members, or friends; troubles at work; or troubles
handling money. If the service member continues to experience these reactions and if it begins
to cause problems for them or their family, it may become post-traumatic stress disorder or
PTSD. Other operational stress injuries can also develop and are discussed later in this guide.
EXPERIENCES IN THE WAR ZONE
During deployment, service members may have taken part in missions and operations that
exposed them to very stressful or often life threatening experiences. It is important for families to
understand what they have been through. Service members may have been shot at, seen the
death or injury of American personnel or of civilian and enemy combatants, or even witnessed
the death or injury of people they knew. IEDs (improvised explosive devices) are common;
many convoys deal with piles of garbage blowing up just as they pass by. Many troops are on
alert 24/7. Service members may have been injured as a result of bombings, blasts, weapons or
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accidents, maybe even surviving with very serious injuries. All of these experiences and others
occurred in a hot, dry desert environment without the normal comforts of home.
Frequent Combat Experiences Reported by Members of the U.S. Army, 2003
The military teaches service members skills that help them to survive and succeed in war.
These same skills can cause problems at home. For example, secretiveness and control are
very important in the war zone; however, communication and sharing the decision-making are
necessary for good family relations.
EXPECTATIONS ABOUT HOMECOMING
Families often want to hold barbecues and big welcome home parties for their loved one when
they return. The service member often has mixed feelings about returning home because they
now face a completely different day-to-day life than they have grown used to. Relaxing may be
what they want, not a big party. Reworking “who does what”, who handles the money now, who
takes the kids to school, who mows the lawn; these issues will need to be dealt with. Make sure
that all family members talk to each other about what they want and expect, even before
EFFECTS ON FAMILY LIFE
One challenge everyone faces is adjusting to changes in the family; both the person
returning from war and the family left behind have changed. War experiences have changed the
person who was deployed. Children have grown and developed new skills in school. Spouses or
other family members may have taken on more responsibilities and control in the family.
Everyone needs to work and get used to a new family pattern that works for all involved. Be
aware that problems in relationships that were already there before deployment may return.
Returning service members need to relearn
how to feel safe, comfortable and trusting
Remember that family members also need
again with family members. This involves
your understanding. While you were
getting reacquainted and communicating with
deployed they might have had to take on
spouses, children, parents, friends, coworkers
extra responsibilities, had to deal with
problems without your help, or felt lonely. It
also takes time for them to readjust.
The service member should not feel forced
to talk about his or her combat experiences. They should be given opportunities to talk about
the war and their reactions and feelings with people who will not be judgmental or negative. You
should join in these discussions if you are invited to do so. Service members may be more
comfortable talking with their buddies about their time at war. It may be helpful for the service
member to speak with a counselor about his or her experiences, or about any concerns about
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sharing the details of war experiences with family members. Family and friends need to
remember not to take signs of withdrawal personally and to remember to be patient. Recovery
Sometimes the everyday stress of family life can feel overwhelming for the service member.
He or she may become more irritated or react more strongly to common family issues. Anger
and aggression are common combat stress reactions but these reactions may scare spouses
and children, and even the service member. Continued angry outbursts or over-reacting to
everyday situations might mean that you should get help.
NOTE FOR VETERANS:
Men and women may have different
Getting into arguments and fights with family ways of integrating back into the family.
members and others, often for minor reasons, can
To cope with stress, men may isolate
happen because of the angry or aggressive more and leave the home to be with
feelings that are common after a trauma. In friends or buddies. Women may need to
addition to having more family conflict, those who
talk about more of their experiences with
return home from a war zone often feel their partners. Some male partners
disconnected or detached from others. Sometimes
experience resentment or
this has to do with not feeling able to tell other
misunderstanding towards their
family members about what happened, not returning woman veteran, and are
wanting to intrude on them by speaking about the
reluctant to sympathize both with her
war, or just thinking that no one will be able to
accomplishments and difficulties during
understand. Sometimes this is related to having
war. In a war zone, both women and
difficulty in feeling or showing positive feelings. men often have camaraderie with their
Sometimes wanting to be alone or avoiding family
buddies that may be difficult to recreate
gatherings creates isolation from family and
in civilian life.
friends. Yet the support of these people is
needed for a healthy recovery. Even though you
might feel like you want to withdraw, try to Men and women both may face
reconnect with family and friends.
challenges coming home to their
children and kids can need time to
Because the symptoms of PTSD change how you
reconnect. Children may feel
feel and act, traumatic experiences that happened
resentment, abandonment, sorrow or
to you can affect everyone else in the family. anger when a parent leaves. During
Family members react to the fact that their loved
deployment, a child may have learned to
one has gone through a trauma. At the same
rely more on the parent who remained
time, trauma symptoms can make you difficult
at home. Homecoming may bring back
to get along with or cause withdrawal. It can be
the child’s normal fears of separation.
very hurtful and confusing for everyone in the It’s important for the veteran not to take
family when these changes occur.
these reactions personally, but instead
to reassure the child. Communication
within the family, or in counseling, is very important in helping the family as a whole.
Parents are also very important in the readjustment process yet they are often overlooked. Most
of the information in this guide also applies to you. Even if your child is deployed from another
state, every US state has Family Assistance Centers that assist ALL military family members in
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EFFECTS ON WORK FUNCTIONING
For some veterans, going back to work is hard because changes have happened at their job
during deployment. He or she also might be getting their first civilian job and may have difficulty
finding a job or a career to get started in. Following the excitement of deployment, he or she
may find their old job boring. Combat stress reactions, such as feeling irritable or “on edge”,
having trouble sleeping, or problems relating to people, make going back to work very difficult or
even seem like an impossible undertaking. The veteran may also worry that an employer (or
future employer) might not want to work with somebody who is dealing with symptoms of PTSD
or other combat stress reactions.
EFFECTS ON OTHER FUNCTIONING
Some other areas where problems can occur: Money issues can add to stress at work or home,
and finances are often complicated by deployment; Veteran’s sleep is often disrupted and
getting a full night of sleep is important to maintaining a healthy and happy life; Aggressive
driving is common, and although adaptive in the war zone, causes problems at home. A
veteran experiencing combat stress may also have trouble concentrating, which can affect
many regular activities.
Effects of PTSD on Relationships
• Vietnam veterans with PTSD are three to six times as likely to divorce than Vietnam
veterans without PTSD.
• Veterans diagnosed with PTSD, compared to those without PTSD, are more likely to be
violent with partners and children, with rates as high as 63% for some type of physical
violence in the past year.
• Partners of Vietnam veterans with PTSD reported markedly reduced satisfaction in their
lives and greater demoralization compared to partners of Vietnam veterans not
diagnosed with PTSD.
Problems with family relationships, relationships with other people or day-to-day life should not
be overlooked. These difficulties can turn into marital separation and divorce, family violence,
and caregiver burden. Communication is key to working through these problems. You may want
to consider talking to a counselor for support and assistance.
WHAT ARE THE SYMPTOMS OF PTSD?
You may have heard of PTSD, in relation to combat experiences or other intense or traumatic
situations, but have questions about what it really means. Basically, the symptoms of PTSD
include common reactions that immediately follow a traumatic event such as combat. If these
reactions continue long after the combat or traumatic event has finished, it can become
PTSD. PTSD varies widely in how severe it can be, from mild and short lasting to severe and
chronic. These reactions can cause problems in getting along with family and friends,
functioning on the job or at school, or adjusting to the transition back to civilian life.
Remember, immediately following a traumatic experience, most people commonly experience
symptoms. If these symptoms persist months after the event, they may indicate the veteran has
PTSD. Three types of reactions or “symptoms” make up PTSD.
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1. RE-EXPERIENCING. Sometimes after a service member has returned from combat, they may
continue to think about things that happened in the war-zone. They may have nightmares about
events they have witnessed or actual combat situations. At times, they may feel as though they
are actually back in the war-zone. Others report that upsetting images of the war-zone can
flash into their mind making it difficult to think or concentrate. Sometimes, these images are
SYMPTOMS OF COMBAT STRESS REACTIONS AND PTSD
Continuing to think about combat or feeling as if one is still in combat
2. AVOIDANCE AND NUMBING OF EMOTION
Not wanting to discuss the traumatic event, feeling detached from others, feeling
shut down emotionally
Having a hard time relaxing or feeling “on guard,” feeling jumpy, unable to sleep,
unable to concentrate, excessive concerns about security, getting angry easily
“triggered” by reminders, such as sights or sounds or smells that remind them of their combat
2. AVOIDING REMINDERS AND NUMBING OF EMOTIONS. It seems normal to not want to think about
distressing thoughts and to avoid upsetting reminders. However, individuals with combat stress
reactions or PTSD often go to great lengths to prevent recalling memories or discussing their
past experiences. They may also avoid reminders of their experience. They may appear to
withdraw emotionally or physically from family and friends and be numb and detached. They
may resist or even become angry when asked to talk about their feelings or behaviors. They
may use alcohol, drugs, or prescription medications to avoid thinking or feeling. This avoidance
is a reaction to their combat experience and is not a sign that they are no longer committed to
their family and relationships.
3. AROUSAL. The service member may have difficulty letting their “guard down.” Sometimes
service members describe feeling jumpy or easily startled. They may drive aggressively. They
might closely examine people or places to look for signs of danger or attack. They may be
overly protective of children and fear for the child’s safety. Feeling keyed up can also make it
harder for them to sleep and concentrate and can cause irritability.
Even if the person does not have PTSD, these symptoms can cause problems. Acting early can
prevent symptoms from becoming worse and negatively influencing relationships, careers and
the family’s well-being.
HOW OFTEN IS PTSD DIAGNOSED IN VETERANS?
Among American Vietnam theater veterans, 31% of the men and 27% of the women have had
PTSD in their lifetime. Preliminary findings suggest that PTSD will be present in at least 18% of
those serving in Iraq and 11% of those serving in Afghanistan. PTSD has been observed in all
veteran populations that have been studied, including World War II, Korean conflict, Vietnam,
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Persian Gulf, Operation Enduring Freedom and Operation Iraqi Freedom veterans. It also has
been found in United Nations peacekeeping forces deployed to other war zones around the
world. PTSD is not only a problem for
veterans, however. It occurs both in
Although most veterans do not develop PTSD, a
adults and children who have been
sizeable minority will have PTSD for some exposed to extremely stressful situations
period of their life. Preliminary findings suggest
(such as assault, rape, disasters or
rates of PTSD will be at least 18% for Iraq serious accidents), men and women,
veterans and 11% for Afghanistan veterans Western and non-Western cultural groups,
and at all socioeconomic levels. A
national study of American civilians
conducted in 2005 estimated that 7% of people have had PTSD in their lifetime.
WHAT CAUSES COMBAT STRESS REACTIONS OR PTSD?
Mental health professionals do not know why some people have PTSD reactions to traumatic
situations and other people don’t. We do know that it does NOT say anything about the strength
or character of the person suffering. Again, there is no relationship between how strong a
person is and these symptoms; many people who are brave or strong end up with PTSD
symptoms after going through a traumatic experience.
PTSD is not a result of something the person wants or has chosen. In fact, we know that most
people would not choose to have PTSD. Life factors that are related to PTSD include: greater
exposure to life threatening situations, prior trauma, and poor social support. Remember, these
are reactions that people sometimes experience after life-threatening situations that can often
be dealt with given help.
OTHER COMMON REACTIONS
DEPRESSION. Depression can vary from person to person, but generally, depression involves
feeling down or sad more days than not, and losing interest in hobbies or activities that used to
be enjoyable or fun. The service member may feel low in energy and be overly tired. Depression
also involves a feeling of hopelessness or despair, or the feeling that things are never going to
get better. Depression may be especially likely when a person has had personal losses
connected with their deployment such as the death of close friends. This sometimes leads a
depressed person to think about hurting or killing him or herself. Because of this, it is important
for your family member to get help for depression. If you notice that your loved one seems to be
feeling down most of the time or less interested in things they used to enjoy.
SUICIDAL THOUGHTS. War experiences and combat stress reactions, especially personal loss,
can lead a depressed person to think about hurting or killing themselves. If you think your family
member may be feeling suicidal, you should directly ask them. You will NOT be putting the idea
in their head. If anyone you know has a plan to hurt themselves and the means to do it (e.g., I
have a gun and will shoot myself), and cannot make a contract with you to stay safe, you should
call 911 immediately. For more information, contact the National Suicide Prevention Lifeline at
1-800-273-TALK (8255) or www.suicidepreventionlifeline.org/
ANGER OR AGGRESSIVE BEHAVIOR. Anger and irritability are symptoms of PTSD and often
associated with fear or loss of control; someone who is physically tense tends to be angry as
well. A typical example is over-reacting with anger to a slight provocation. Frustration over the
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inability to control PTSD symptoms (feeling that PTSD symptoms "run their life") can make a
person angry. Thinking about things that happened at the time of trauma (the unfairness of the
situation) can also lead to anger.
Although anger is a natural and healthy emotion, it can be expressed in healthy or unhealthy
ways. Intense feelings of anger and aggressive behavior can cause marital, relationship, and
family problems, job problems, and loss of friendships. Because angry feelings keep people
away, they also stop a person from having positive connections and getting help. Some service
members may be especially over-protective of kids, or have angry reactions to normal child
behaviors. These types of reactions may actually be the service member’s own fears about
possible dangers the children could be exposed to.
If anger or aggressive behavior is related to threatened or actual violence against members of
the family or others, it is especially important to seek care from the police, or professional
counselors (chaplains, behavioral health, primary care, nursing, family assistance program) to
address the anger and combat stress reactions.
ALCOHOL AND/OR DRUG ABUSE. “Self-medicating” by drinking or abusing drugs is a common
way many cope with upsetting traumatic stress reactions. Usually this is related to other
readjustment concerns, as a person tries to deal with the difficult thoughts, feelings, and
memories related to their war zone experiences by using drugs or alcohol to numb themselves.
When a person wants to avoid the memories or feelings related to combat, alcohol or drugs may
seem to offer a quick solution, but they actually lead to more problems. If you or your family
member begin to lose control of drinking or drug use, it is important to get appropriate care.
SELF-BLAME, GUILT, AND SHAME. Sometimes service members, in trying to make sense of their
war experiences, take too much responsibility for bad things that happened, for what they did or
did not do or for surviving when others didn’t (sometimes referred to as survivor guilt). Guilt and
self-blame are common for those who have been through difficult combat situations, as the
individual tries to make meaning of what happened. Understand that the individual may even
feel as if they have committed a moral or religious wrongdoing, even if they were following
ROLE OF THE FAMILY IN PROBLEM SOLVING
Adult family members can help the returning veteran by learning and understanding some of the
stressors and emotions a veteran may experience after being away from home for a period of
time, especially when he or she has served in a war zone. Family members’ most important role
is to be genuine, loving, and supportive. You should be forward about expressing your own
needs and expectations, rather than hiding them in an effort to protect the veteran.
At the same time, adult family members need to be supportive and respectful of the veteran’s
need for time to adjust. Spouses or partners need to be prepared for change, and be ready
to get used to to sharing control of the family and important tasks and goals. It is important that
partners and spouses show their trust in the service member’s role as parent and support joint
Family members should be ready to learn and accept new skills or tools for coping used by the
service member. For example, talking about likely “triggers” will allow both partners to
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understand what might cause an upsetting reaction. A positive attitude towards treatment
and readjustment can go a long way to making homecoming an easier transition.
It is also important to remember that all individuals in the family count. The spouse or partner
at home should be prepared to seek counseling for themselves and children if needed.
Oftentimes couples counseling can help make the needs of individual family members clearer.
Parents and extended family also need to be taken into consideration.
ENCOURAGING A VETERAN TO SEEK HELP
Family members are often the first to notice problems in a veteran’s readjustment. You also
need to watch for any negative impact on children and teens. While a veteran needs some
practical time to readjust, problems that continue over months may be on the way to becoming
negative habits and family patterns. If the veteran is using harmful strategies to cope with
stress, such as drinking, drugs, withdrawal and isolation, or showing strong emotions that seem
wrong in front of the family, consider encouraging the veteran to seek assistance. Try to
communicate your concerns to the veteran with understanding and not blame.
Getting your loved one to seek help is not always as easy as you may hope. A study of soldiers
returning from Iraq found that only 40% of those that were having mental health problems said
they were interested in receiving help. Many returnees hesitate to receive mental health
treatment for fear that it will hurt their image or even ruin their military careers. Family members’
most important job may be to encourage the veteran to seek counseling and treatment, for
everyone’s’ benefit. Effective treatments exist and early treatment can prevent worse problems
from happening. Encouraging the veteran to seek help is a benefit for all concerned.
HOW TREATMENT WORKS
Combat stress reactions usually go away over time. But, if they don’t, a person might develop
PTSD. The good news is that there are effective treatments for PTSD and the other problems
mentioned above. Counseling for combat stress reactions or PTSD is really very practical and
involves common sense steps.
The person in treatment has regular conversations with a trained professional.
They are helped to think about their current situation and how they want to change it.
They learn more about PTSD and how it is affecting them and those around them.
In addition they may speak with other service members who served in combat operations, to
give and receive support.
Many veterans receive treatment for PTSD in Veterans Affairs (VA) PTSD treatment programs
and Readjustment Counseling Service Vet Centers. In the usual type of outpatient treatment the
veteran comes into a clinic for individual appointments and maybe group sessions. For the
most severe cases of PTSD, residential treatment, where the veteran lives in the treatment
program for several weeks, is often recommended.
Treatment usually focuses on the following activities:
• Assessment. Treatment typically begins with a discussion with a counselor about
problems the service member has faced since returning.
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