06 January 2011

PTSD and Canadian snipers

Up front: If you have not read Jim Gourley on what PTSD is stop reading this and go there now. This will be here when you get back.

What Gourley nails that is often missed is the import uncertainty plays in inducing PTSD (both as a chronic condition and acute attacks). Another way to think about this uncertainty is to couch it in terms of control. Soldiers have profoundly little control on their environment and this is a fact made nakedly apparent to them every single day they are down range (and many they are not). Here are two passages from Sebastian Junger's War that evince this:
The Navy study compared stress levels of the pilots [who have to land on tiny aircraft carrier landing strips] to that of their radar intercept officers, who sat immediately behind them but had no control over the two-​man aircraft. The experiment involved taking [cortisol] samples of both men on no-​mission days as well as immediately after carrier landings... Radar intercept officers lived day-​to-​day with higher levels of stress -- possibly due to the fact that their fate was in someone else's hands -- but on mission days the pilots' stress levels were far higher. The huge responsibility borne by the pilots gave them an ease of mind on their days off that they paid for when actually landing the plane.

The study was duplicated in 1966 with a twelve-​man Special Forces team in an isolated camp near the Cambodian border in South Vietnam... There was a serious possibility that the base would be overrun, in which case it was generally accepted that it would be "every man for himself." The two officers saw their cortisol levels climb steadily until the day of the expected attack and then diminish as it failed to materialize. Among the enlisted men, however, the stress levels were exactly the opposite: their cortisol levels dropped as the attack drew near, and then started to rise when it became clear that they weren't going to get hit... "The members of this Special Forces team demonstrated an overwhelming emphasis on self-​reliance, often to the point of omnipotence," they wrote. "These subjects were action-​oriented individuals who characteristically spent little time in introspection. Their response to any environmental threat was to engage in a furor of activity which rapidly dissipated the developing tension."

Specifically, the men strung C-​wire and laid additional mines around the perimeter of the base. It was something they knew how to do and were good at, and the very act of doing it calmed their nerves. In a way that few civilians could understand, they were more at ease facing a known threat than languishing in the tropical heat facing an unknown one.
Not only does activity, for its own sake, seem to have a stress relieving effect; some research has found that repetitive visuospatial tasks (by which I mean "playing Tetris") have a similar effect.

The second quote makes clear the equality between uncertainty and (lack of) control:
One of the most puzzling things about fear is that it is only loosely related to the level of danger. During World War II, several airborne units that experienced some of the fiercest fighting of the war also reported some of the lowest psychiatric casualty rates in the U.S. military. Combat units typically suffer one psychiatric casualty for every physical one, and during Israel's Yom Kippur War of 1973, frontline casualty rates were roughly consistent with that ratio. But Israeli logistics units, which were subject to far less danger, suffered three psychiatric cases for every physical one. And even frontline troops showed enormous variation in their rate of psychological breakdown. Because many Israeli officers literally led from the front, they were four times more likely to be killed or wounded than their men were -- and yet they suffered one-​fifth the rate of psychological collapse. The primary factor determining breakdown in combat does not appear to be the objective level of danger so much as the feeling -- even the illusion -- of control. Highly trained men in extraordinarily dangerous circumstances are less likely to break down than untrained men in little danger.

The division between those who feel in control of their fate and those who don't can occur even within the same close-​knit group. During World War II, British and American bomber crews experienced casualty rates as high as 70 percent over the course of their tour; they effectively flew missions until they were killed. On those planes, pilots reported experiencing less fear than their turret gunners, who were crucial to operations but had no direct control over the aircraft. Fighter pilots, who suffered casualty rates almost as high as bomber crews, nevertheless reported extremely low levels of fear. They were both highly trained and entirely in control of their own fate, and that allowed them to ignore the statistical reality that they had only a fifty-​fifty chance of surviving their tour.
Similar research (gated) from the aftermath of the USS Cole found similar results. Two brief excerpts from the Cole study because they are sort of relevent later.
Rank may [have been] a surrogate for certain psychological characteristics such as self-efficacy, or what has been described as an internal locus of control. Internal-external locus of control has been described as the degree to which an individual senses the events around them as dependent on his or her own behavior versus the result of powers beyond his or her own control and understanding.
[L]eaders' internal locus of control may be bolstered by having the authority to respond to aggression during combat, in contrast to lower ranking service members who more often must wait for orders to react, reinforcing the belief that events are beyond his or her control.
Now what does all this have to do with Canadian snipers? This: An Exploratory Study on Sniper Well Being (Scribd).

Caveats of the study up front: It is small (19 snipers were interviewed), it is preliminary, and comparison data is sorely lacking on key questions (pg 13 illustrates this well) and those are just the major ones. The study notes, but I'm going to repeat, that a study like this -- of a specialized combat skill group -- has one enormous problem:  selection effects.

Snipers are rigorously selected in the first place, the study mentions that the Canadians specifically look for those with a personality profile (they use the Big Five) which includes: a) low scores on "neuroticism" (or high scores on its opposite, "emotional stability"); b) strong scores on "conscientiousness" (more on this in a few paragraphs); and c) low scores in "tender mindedness."

A more minor selection issue is that those who meet the criteria to become snipers tend to be those who are more motivated in the first place and they thus end up being much more satisfied. While the snipers ranged in rank from private to sergeant, 14 of the 19 had been in the service 3-5 years and 5 had been in for 9 or 10 years. In other words, one can conclude that a substantial portion of this group have reenlisted at least once. People who are profoundly unhappy with their job do not tend to reenlist, so there may be a population of disaffected Canadian snipers who have left service and were not surveilled.

On to the results: snipers experienced more combat and combat stressors than non-sniper Canadian soldiers who served in Afghanistan (TFA). Interestingly, the study found that these snipers also experienced more trouble and/or concern over these events than the TFA soldiers did. However, when comparing levels of psychological stress (using the Kessler Psychological Distress Scale (K10) [pdf]) these same snipers showed lower levels of stress. To put this into plain English, the Canadian snipers reported more contact with the enemy, more concern with those events they had experienced, but were, paradoxically, less effected by those events.

Back to the three personalities traits the Canadians are looking for in snipers, one of them is conscientiousness. Without getting into a labryinthyine discussion of personality questionaires (maybe another post): in order to score highly on conscientiousness one must possess an emotional skill set that is preparatory for dealing with severe emotional and psychological stress. In essence, the Canadian Army is not teaching snipers to deal with the higher levels of combat or the higher levels of concern about that combat, the data strongly suggest that at least some of the effect stems from selection of those who are best able to deal with stress to be snipers.

Bolstering this claim is the data reporting the K10 scores of advanced search, evasion, rescue and escape (ASERE) school participants. They were tested prior to the course, immediately afterward, and then six-weeks later. Their average scores did not change in a statistically significant way across the test administrations. However, even more revealing is the breakdown of ASERE participants when compared to the general Canadian Army: 50% of the general Canadian Army score low risk on the K10, 39% moderate, and 11% high. Contrariwise, ASERE participants scored 85% low risk and 15% moderate, while Canadian snipers scored 70%, 20%, and 10% respectively. Among TFA soldiers the breakdown was much worse: 31% low risk, 57% moderate, and 12% high.

Given the relative scoring of these divergent groups the unavoidable conclusion is that the Canadian military seems to be doing a lackluster job of preparing its TFA troops to deal with the stresses attendant to their mission. What they are doing well is selecting those who are most capable of handling stress for tasks that require the heaviest burden. There seems to be a failure of preparation for those who come into the military without adaquate tools to deal with these stresses.

There are two alternative explanations for this data, neither of which I find convincing. The first is that sniping is a qualitatively different type of exercise than more routine infantry fighting, and that this difference is protective. I feel safe in rejecting this claim based on the reporting of the snipers themselves; they do not find different events to be troubling than the TFA soldiers; moreover, they find the same events to be more troubling. Notable among the data detailing this are the sniper's encounters with the same uncontrollable actions (IEDs, ambushes, artillery, knowing a WIA/KIA) as plague "regular" infantry in Afghanistan.

The second alternative explanation is that sniper training is imparting training that is facilitating the management of psychological stress considerably better than the training that infantry soldiers receive. This is not an all-or-nothing scenario, so I think it would be unwise to dismiss this possibility without first conducting a rigorous examination of the sniper curricula. I am skeptical that the answer lies here (mainly because if an answer to the PTSD epidemic were this near I cannot imagine it having remained undiscovered) but it is certainly an examination that should be carried out, if only because any fruit it might bear would be tremendously useful.

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