Introduction

Statement of Purpose

He purpose of this research was to explore the intrapsychic and interpersonal experiences that contribute to the combat soldier's self-perception as "broken." His researcher first heard the term while working in an Adult Behavioral Health Clinic at Fort Campbell, Kentucky. Returning combat soldiers created and used the term "broken" to characterize their psychological condition as a result of combat experiences. It is necessary for clinicians to discover the vast psychological meanings within this term in order to appropriately serve this population.

Significance of the Study for Clinical Social Work

He researcher first heard the descriptor of being "broken" when it was used by a patient treated in her clinical practice. With this patient, therapeutic work focused on the meaning of feeling "broken" and was essential to understanding the constructs that comprised this term. He patient presented underlying thoughts of suicide, which led to the patient's hospitalization for approximately six weeks. As a result of this work, a class project was conducted to further investigate the therapeutic experience with soldiers who reported being "broken." He results of the class project, which consisted of interviewing three therapists working with soldiers who identified as "broken," indicated that the therapists were familiar with the term and proceeded to delineate a wide range of emotional phenomena as well as social, familial, and command interactions that were associated with the term. It is possible that the term "broken" has been in colloquial use in military circles for many years. Remarque (1928) used the term to describe the experience of soldiers in World War I: "We will be weary, broken, burned out, ruthless and without hope. We will not be able to find our way anymore ..." (p. 254).

According to a Department of Defense (DOD) report from August 2012, there were 131 potential suicides of active duty soldiers. Eighty of these have been confirmed as suicides and 51 still remain under investigation (DOD, 2012). In 2011, the DOD also reported that 165 suicides had been confirmed, with none under investigation. Suicide has helped focus public concern for the mental health needs of returning soldiers. The researcher has observed a wide range of distress among this group. Some soldiers report feeling broken along with suicidal ideation while others do not; however, these individuals can be suffering from significant psychological symptoms.

A systematic study of the experiences of soldiers who report feeling broken provided an in-depth exploration of war-related distress and how it is experienced intrapsychically, interpersonally, and in the context of Army life. It also offered a phenomenological context for the relationship between suicidal ideation and war-related trauma or distress.

Statement of the Problem to Be Studied and Specific Objectives to Be Achieved

This researcher's interest in the topic centers around the population she worked with at the Army post on Fort Campbell, Kentucky. Many soldiers there have been through multiple deployments since joining the Army and since the war began in Afghanistan, moving into Iraq and continuing in Afghanistan. Some of them have deployed as many as eight times since the onset of the war. Many of these soldiers have endured injuries during these deployments, which present as physical, psychological, or coexisting in nature.

According to the RAND Study (Williamson & Mulhal, 2009), 68% of 33,000 soldiers experienced blast-related injuries (p. 1). Fourteen percent of the soldiers return from combat with symptoms of Posttraumatic Stress Disorder (PTSD), Traumatic Brain Injury (TBI), or Major Depressive Disorder (p. 5). It was reported that 30% of soldiers that return screen positive for PTSD and TBI symptoms (p. 6). The report was broken down to define the ranges of the three most prevalent psychological conditions: 14% PTSD, 14% Depression, and 19% TBI of the 30% returning with mental health symptoms (p. 6). Since September 11, 2011, more than 638,000 soldiers have deployed more than once (p. 6). According to the Army Mental Health Advisory Team, soldiers that deploy longer than six months or more than once are more likely to be diagnosed with a psychological injury (p. 6). It was stated that multiple deployments increase combat stress by 30% or more (p. 7). Overall, 17.2% of 80,000 soldiers screened positive for mental health immediately after returning from combat (p. 9).

This researcher's experience indicates that soldiers returning with either a physical condition or mental health condition use the term "broken" to describe their presenting issues and psychological state in general. This term is one that the soldiers have created and is commonly used among the soldiers at Fort Campbell, Kentucky. Although this term is used frequently, there is no consistent understanding of what meanings lay beneath the term. This research is aimed at an in-depth understanding of the descriptor "broken" as a summary statement regarding a grossly altered sense of self.

Emotional consequences of combat and life in a time of war are well documented in the literature (Fairbairn, 1952; Freud, 1920; Kardiner, 1941; Ornstein, 1994; Stolorow, 2002, 2007; Wolf, 1995). Combat often includes losses of fellow soldiers and commanders. It is important to note that psychological distress is experienced in the context of the soldier's unit, command structure, and family relationships. In addition to individual distress, the responses of command, fellow soldiers, and often family members to perceived emotional difficulties are all potentially linked to feeling "broken" (Mezei, 2012).

The objectives of this research were as follows: (a) to explore in depth the complex intrapsychic and interpersonal experiences that contribute to feeling "broken," (b) to generate a substantive theory about combat-related stress and its relationship to feeling "broken," (c) to compare and contrast the findings of this research with the trauma theories of Wolfe (1995) and Ornstein (1994), and (d) to provide a framework for clinicians working with war-related stress in active duty or veterans mental health facilities.

Trauma "Locations"

If it is assumed that "feeling broken" is an existential or a phenomenological expression of combat-related PTSD, or war-related distress, we must also be free to question our assumption about where trauma "resides." Does trauma only exist in the mind of the sufferer, or can it be found elsewhere? Contemporary trauma theorists have emphasized the relational, contextual, and mutual nature of trauma (Stolorow, 2007; Ulman & Brothers 1987). It can be said that trauma resides as a classification system in the Diagnostic and Statistical Manual of Mental Disorders (4th ed., text rev.; DSM-IV-TR; American Psychiatric Association [APA], 2000), or in a different classification system found in the Psychoanalytic Diagnostic Manual (PDM). It can also be said that trauma resides in the host of technical approaches that have evolved in response to the wars, and that it can be found in the contributions by Freud (1920), Fairbairn (1952), Kardiner (1941), Ornstein (1994), Wolf (1995), and Stolorow (2002, 2007).

The contextual and perhaps social nature of war-related trauma was observed at a war trauma conference held in Chicago (The Emotional Wounds of War, 2012). Several presenters made it clear that playing an active role in the conference was somehow helping them with dimensions of their war trauma. After the conference, several audience members expressed that they had experienced an activation and a reworking of some of their war trauma.

Data from a class project exploring clinicians understanding of soldiers who report "feeling broken" indicated that soldiers experienced a profound feeling of change in the way their command, fellow soldiers, and family interacted with them. Is this just an expression of a radically altered sense of self, or do individuals in the relational environment experience something about the identified war trauma "victim" and deal with him or her differently than they did in the past? Real life experience does not confine distress to the pages of a diagnostic manual, theoretical paper, or one person's isolated mind.

There has been an increase in soldiers starting the process of a Medical Evaluation Board (MEB) to aid in a medical discharge from the Army. This benefit allows the soldier to receive financial compensation for a physical or mental health diagnosis, potentially for life. The financial incentives that come with a diagnosis increase this potential for soldiers to go through MEB. However, the evaluation itself can be traumatic. Some soldiers are unable to endure the process as it often entails a detailed recounting of events. In addition, the MEB takes approximately one year from start to finish. However, the stigma remains that some soldiers who go through the MEB are malingering, in order to receive an Honorable Discharge, and are not truly impacted by the war trauma.

Posttraumatic Stress Disorder

Posttraumatic Stress Disorder (PTSD) is defined in the DSM-IV-TR (APA, 2000) as follows:

The development of characteristic symptoms following exposure to an extreme traumatic stressor involving direct personal experience of an event that involves actual or threatened death or serious injury, or other threat to one's physical integrity; or witnessing an event that involves death, injury, or a threat to the physical integrity of another person; or learning about unexpected or violent death, serious harm, or threat of death or injury experienced by a family member or other close associate (Criterion A1). The person's response to the event must involve intense fear, helplessness, or horror (or in children, the response must involve disorganized or agitated behavior; Criterion A2). The characteristic symptoms resulting from the exposure to the extreme trauma include persistent experiencing of the traumatic event (Criterion B), persistent avoidance of stimuli associated with the trauma and numbing of general responsiveness (Criterion C), and persistent symptoms of increased arousal (Criterion D). The full symptom picture must be present for more than one month (Criterion E), and the disturbance must cause clinically significant distress or impairment in social, occupational, or other important areas of functioning (Criterion F). (APA, 2000)

The DSM-IV-TR (APA, 2000) approaches diagnosis from the vantage point that symptoms reside only in the soldier's mind. This implies that no other part of that soldier's life is impacting the response to the traumatic incident. This presumption, however, does not explain why some soldiers have PTSD and others do not, despite being exposed to the same traumatic incident. The diagnosis of PTSD in the minds of clinicians and fellow soldiers has created an amplified public awareness of the plight of returning soldiers. However, as Williamson and Mulhal (2009) pointed out, only a small percentage of returning soldiers meet the diagnostic criteria for PTSD; therefore, many soldiers with psychological distress may be misdiagnosed by clinicians or unfairly identified by their fellow soldiers. Each of these thought locations, in part, have a unique meaning and contribution to the formation of PTSD. A diagnosis of war-related PTSD cannot be isolated from responses in the family, military, social, and political environments.

The findings of a class project (Mezei, 2010) indicated that there are multiple ways of "feeling broken." There were also indications that there are several influences that contribute to being "broken." More specifically, soldiers reported feeling "brokenness" internally, secondary to the responses from their command, their fellow soldiers, and their spouses.

The stance of this research was that "broken" is more than a psychological problem with an array of observable symptoms. It is an interpersonal, social, and economic issue. Each of these locations indicates that the multiple areas in the individual soldier's life have been impacted by the experience of being "broken," which broadens the meaning of the phenomena.

Despite the potential diagnosis based on presenting symptoms, the complex experience that needs to be explored in depth with soldiers in distress is not limited to diagnostic criteria. Clinicians participating in the class project interviews (Mezei, 2010) indicated that they each had a unique conceptualization of war trauma which influenced their understanding of soldiers' symptoms and distress. In addition to the individual theoretical conceptualizations of clinicians, the literature on vicarious trauma indicates that some patients evoke the clinicians' preexisting trauma while other patients can create a new traumatic experience (Rasmussan, 2012, p. 223).

In the researchers' work with war veterans, when soldiers are afforded the opportunity to tell their story and how the story is impacting their lives, the following diagnostic questioning has been used:

• Did you lose a fellow soldier in combat or an operational accident?

• How are you coping with the loss of your fellow soldier?

• What has been your experience of your unit and command?

• How is your family interacting with you and you with them?

These are all questions that encourage responses based on different locations that potentially contribute to the reported "brokenness." Thus, the open-ended style allows the person to explore the different locations that are impacting the symptoms, which are in the soldier's mind about the trauma, rather than the therapist completing a symptom checklist which does not promote contextual understanding.

This research on the soldier's experience of being "broken" holds the potential to bring forth a deeper understanding of the experience of war-related trauma. The hope is that it can allow for the understanding of the elements that play into symptoms and how intrapsychic, interpersonal, social, and potentially political dynamics are aiding in perseveration of symptoms. Ultimately, the goal of this study was to produce an in-depth exploration of the soldiers' experience that will assist clinicians in their day-to-day work with soldiers experiencing war trauma.

Literature Review

Statement of Relevant Knowledge

Psychoanalysis has made major contributions to war trauma. Beginning with World War I, psychoanalytic understanding of war-related trauma has continued to evolve and expand. A historical review of psychoanalytic contributions will be presented. Many of the earliest ideas continue to inform contemporary trauma theory. Given the complexity of the theories, a general summary of central features will be provided.

Freud (1920) referred to traumatic neurosis and "war neuroses" as "significant ailments that interrupt one's ability to satisfy psychological needs" (p. 11). Beyond the Pleasure Principle (Freud, 1920) is considered the classic paper on war-related trauma. Freud focused on trauma, repetition, resistance to remembering, and the mastery of traumatic events. He identified characteristics of traumatic neurosis and distinguished them from hysteria by presenting more subjective ailments and mitigating general mental capacities. Freud stated that in order to generate a traumatic neurosis, one must experience surprise through fright. He refuted the possibility of neurosis forming through the experience of anxiety alone; instead, he stated that the neurosis must develop from not being prepared for danger, hence fright (p. 15). Freud also explained that if a wound or injury is inflicted simultaneously with surprise or fright, then it is unlikely to develop into a traumatic neurosis (p. 15).

Freud (1920) felt that a sudden unanticipated shock or fright could rupture the stimulus barrier and create the traumatic experience. He believed that a person could become fixated on the moment of the breach. This is evident through dream analysis, in which the individual repeatedly reexperiences the trauma and thus awakens in fright, only to associate power and strength to the experience and inevitably reinforce the trauma. Freud further explored the repetition compulsion, similar to the repetitive pattern of dreams, and discovered that in a soldier, the recurring trauma plays out in nightmares and in daily thoughts. He explained that the events of the trauma are going through the soldier's mind at all times, while there is also considerable effort during waking hours devoted to not remembering. Within this continuous internal struggle with the trauma, a fear builds around the possibility that the memory could provoke survivor guilt in the soldier. Therefore, this repetition through dreams and unconscious thought creates the reluctance to open up and address the traumatic memory, inevitability increasing anxiety. However, Freud stated that he had doubts that a person who experiences traumatic neurosis is burdened with the memories in conscious thought; rather, he suggested that it may be more of a concern that one commits great effort to not thinking about the traumatic memory, which indirectly reinforces the neurosis. Freud's theory suggests that repressed memories could actually exonerate the person from blame or fault (Freud, 1920).