Beyond Symptom Management: Existential/Humanistic Treatment for Combat Veterans

One observation of military veterans who served in Beirut, Afghanistan, and Iraq is their presentation and experience of persistent hypervigilance, avoidance, emotional constriction, and transitional forms of disillusionment. These symptoms may be part of a larger trauma response and mask unresolved affective states that should be addressed as a regular component of treatment.

The recommended treatment guidelines for veterans are predominately skill-based and symptom-focused in the form of cognitive-behavioral, cognitive processing, prolonged exposure, and eye movement desensitization and reprocessing therapies (Schnurr et al., 2024). Existential and Humanistic approaches (Guigno et al., 2017; Krippner & Pitchford, 2018; Vachon et al., 2016) have commented on the importance of collaborating with veterans to sort out the meaning of their experiences and develop acceptance of how these experiences have shattered many fundamental assumptions of their existence. Using deidentified and altered case examples, this article hopes to enlighten clinicians to the complexities and benefits that can arise when working beyond symptom management into the emotional and existential concerns that drive symptomatic behavior.

A Case of Persistent Hypervigilance

J served two duties in Afghanistan. He recalled not being sure of what he was getting into at the time and described a lack of organization upon deployment with missions seeming to be conducted on the fly and with little preparation. His missions were primarily related to transportation. On two occasions, he was ambushed and attacked, then was significantly injured.  Several of his troop members were mortally wounded.

Upon returning home, J was unable to feel a sense of ease in his daily life. He was distant from others at work, who nicknamed him “Mr. Serious.” At home, his need for safety and order led to obsessive routines which created tensions with his partner. He often felt she distorted his sense of reality and overreacted to her words and facial expressions.  He started a bar fight after he thought a man was staring at and talking about him, which resulted in a battery arrest.

For J, the initial goal of treatment was to validate the experience of his service; unpredictable, mismanaged, and confusing. The focus became one of connecting his war trauma with active, real-world events. He slowly began to engage in grounding exercises and became more aware of his arousal levels by tuning into his body. Cognitive restructuring was used to challenge and correct the assumptions he was making about others, such as co-workers and his girlfriend.

What eventually surfaced was unresolved anger toward his military branch and the public. J reported feeling misled, taken advantage of, and misunderstood He ultimately connected these feelings to an upbringing with an abusive, reality distorting parent. This childhood dynamic mirrored his experience in the service, which was exacerbated when he came home to civilians who did not understand what we went through. Civilians mirrored his classmates and family members, who also never understood what he went through at home. His foundational sense of self, he discovered, rested on feeling misunderstood. This became a driving force in his recovery.

A Case of Avoidance

B served in the second Iraq war. Like J, his service was confusing, the missions were not well-defined, and they were often wrought with danger and risk. In B’s case, he was propelled to open fire and struggled with the knowledge of taking lives. Upon returning home, he found himself questioning his service and the hero status that was bestowed upon him. He did not want to talk to anyone about it, including his partner. Slowly, his life became one of going to work and doing basic home tasks before retreating to the basement for hours on end. He was reclusive at parties and sat far away from others at his child’s sports games.

For B, his avoidance allowed him to manage his anxiety and the immense guilt he felt for his actions in service. In his mind, what he did was unforgiveable and needed to make himself invisible. He felt like a fraud when people called him a hero. He unfairly compared himself to his father and grandfather who served in “real wars,” which only perpetuated feelings of shame and inferiority that colored his childhood and foundational sense of self.

Sessions were focused on reframing his thinking about comparisons of war service and his struggle to accept the absence of purpose of his war service. With some relief and trust established, B began to process the events and feelings associated with his service roles and redefine his lived-emotional-meaning. He began to set limits on isolating, and he started coaching his child’s little league team. Spontaneity with his family was encouraged and he came to the realization that he did not owe any explanation for his service or his actions.

A Case of Emotional Constriction

M served in Beirut during a terrorist attack in the early 1980s. Upon returning home from service, M began exhibiting emotional constriction. Family members and co-workers described him as flat and unfriendly, which was significantly different from the warm and friendly person he had always been. For M, the flatness reflected a mistrust of others’ intentions and served to keep him from getting angry in public, as he did not trust his ability to control it.

The author posited that M’s emotional constriction served to psychologically shrink him and his feelings out of existence; the goal of which was to keep him from feeling vulnerable and keep feelings such as anger from becoming a problem. M’s emotional constriction was consistent with a history of early childhood trauma by a violent and physically abusive parent. He learned to hide himself and constrict his emotions as a young boy. Similarities were noted between his childhood and military trauma responses which validated him and gave him clarity.  Spatial referencing and bodily awareness exercises were implemented to facilitate a grounding and awareness of himself and his feelings which he began processing more frequently in session.  He slowly worked on making himself more noticeable and expressive in safe places around safe people.

Transitional Disillusionment

As mentioned earlier, transitional disillusionment refers to an existential self-examination and questioning of others based on the subjective meaning veterans attach to their military service, how military service is portrayed by the media, and how they are received by the public upon returning home.  Guigno et al. (2017) commented on the confusion and self-questioning that veterans experience when returning to civilian life.  Quite often, there is a disconnect between what the veteran experienced, what has been portrayed by the media, and reactions from the public.

Take for example, the conflict in Beirut that occurred in the early 1980s. Beirut is an example of a military engagement that has been relatively ignored by the media and become less commonly known to the public. Beirut veterans, such a M, have reported feeling invisible upon their return from service and question whether it was equal to others who served in more formally recognized wars.

The same can be said for those who served in Bosnia, an extremely dangerous conflict of which many people remain unaware. Veterans who served in the second Iraq War, which revealed no weapons of mass destruction, have also questioned their service. Some have felt deceived into taking part in a war that as J once expressed, “meant nothing”. These mixed messages can make for complex feelings and existential questions about one’s service. This is exacerbated when the public responds with a simultaneous congratulatory, demeaning, or dismissive comments.

Managing transitional disillusionment requires opening a space to explore and reframe the most vulnerable thoughts and feelings that veterans resist sharing. Validation and normalization of these emotions, thoughts, and experiences can release some of the existential burden they carry.

A key to unlocking this material is paying close attention to more subtle entries into existential discussion; whether it is talking about being called a hero, people wanting to shake their hand at a party, or strangers wanting to thank them for their service. Engagement in these topics opens therapeutic windows. Though seemingly benign, they may have flooded the overly vigilant or emotionally constrictive veteran with a variety of unwanted thoughts and feelings. These examples provide opportunities to validate, explore, and begin the process of reorganizing and consolidating aspects of transitional disillusionment. Keep in mind that validation, a genuine curiosity, and appropriately timed humor go a long way when treating veterans providing the atmosphere needed to begin moving into more sensitive material.

Conclusion

Beyond nightmares and flashbacks, veterans return home with varying symptom presentations that include persistent hypervigilance, avoidance, emotional constriction, and struggles with transitional disillusionment. While symptom management has proven quite effective, it is important to consider the underlying emotional and existential concerns that drive symptomatic behavior. As evidenced in the cases described, pre-service psychological disruptions often play a role in the processing and manifestation of service-related trauma. For those returning home, the experiences can be complex and varying, that is, depending on the veterans’ missions and how they are portrayed by the media and received by the public. Paying close attention to what may seem a benign story may go a long way toward validating the veterans’ experiences and open the door to process more vulnerable unresolved vulnerable affective states that perpetuate symptomatic behavior and restore the veteran into a person-as-a-whole.