POST-TRAUMATIC STRESS DISORDER AND NEUROANTHROPOLOGY: STOPPING PTSD BEFORE IT BEGINS

Abstract

Post-traumatic stress disorder (PTSD) is a problem that affects many combatants in war, including a high percentage of military personnel serving in Iraq and Afghanistan. The high rates of PTSD among veterans has pushed research and intervention to address the serious mental and behavioral health problems associated with wartime trauma. However, these efforts have largely proceeded using biomedical and psychological approaches, without recognizing the institutional and social contexts of trauma, adaptation, and recovery. Moreover, biomedical and psychological approaches have serious shortcomings in recognizing how individual–environment interactions, meaningful interpretations, and sense of identity play a key role in the impact of trauma and development (or not) of PTSD. A neuroanthropological approach can use ideas of neural plasticity and the encultured brain to link culture, interpretation and identity, and the impact of trauma. This synthetic approach then permits a critique of present efforts in the U.S. military to increase resilience and prevent PTSD, and propose alternative strategies and research approaches to more effectively understand and address PTSD.

NEUROANTHROPOLOGY, TRAUMA, AND COMBAT

Neuroanthropology combines cultural formations, biocultural responses, and neuroscience, which together serve to formulate a “big picture” of stress and trauma. This unique formulation of perspectives offers the proactive ability to recognize certain cultural formations that can increase the impact of trauma, hasten the development of post-traumatic stress disorder (PTSD), and worsen outcomes. People in combat zones, as well as people who engage in hazardous and life-threatening service such as first-line responders in emergency zones, experience higher rates of PTSD (Perkinogg et al. 2001; Sundin et al. 2010), and there is a critical need to understand how the interpretation of stress and adversity play into the development and alleviation of trauma. We argue that providing the tools to recognize and manage cultural constructions of stress and to draw on sources of personal identity and resilience offers the key to helping soldiers deal with trauma during and after military service. Alleviating the destruction and suffering caused by PTSD is the humanitarian goal that inspires this research.

PTSD

The wars in both Iraq and Afghanistan have been catalysts for staggering levels of PTSD among U.S. troops. Currently, it is estimated that over 31 percent of U.S. military personnel are returning from deployment with the disorder (Sundin et al. 2010). Typically, most soldiers that face trauma on the battlefield are resilient and only suffer minor setbacks of mental distress before being able to “bounce back” into a functional role within the military or while reassimilating into civilian life (Bonanno et al. 2011). Yet, some develop PTSD and are diagnosed through criteria that include increased hypervigilance, uncontrollable outbursts of anger, inability to concentrate, recurrent visions or dreams about events experienced, sporadic sleeping patterns, and disabilities in acculturating with other members of society (Turnbull 1998).

Since the onset of both “Operation Iraqi Freedom” (OIF) and “Operation Enduring Freedom” (OEF), psychiatrists, psychologists, and other medical personnel have been searching for ways to respond to the increased prevalence of PTSD. The remedies developed have been largely reactive, seeking to diminish the lasting effects of PTSD postdeployment. Much less attention has been paid to developing a proactive, predeployment approach that examines how different service members negotiate adversity, stress, and trauma. In maintaining this institutional approach that addresses trauma after the fact, the military has neglected how to prepare its members for the adversity they will almost inevitably face during deployment.

This neglect is not because of a lack of recognition. PTSD has been given many names throughout history, including soldier's heart, cardiac weakness, traumatic shock, traumatic neurosis, nervous shock, shell shock, neurocirculatory asthenia, war psychoneurosis, battle fatigue, combat exhaustion, and, most recently, PTSD (Turnbull 1998; Young 1995).

In the face of a “stressor,” individuals who subsequently develop PTSD often feel intense fear, helplessness, or horror, as indicated in the Diagnostic and Statistical Manual (DSM-IV-TR; American Psychiatric Association 2000). But this “event plus emotion” model is not adequate. First, the reaction to stress is framed largely in individual terms—people who become afraid or shocked by what they experienced. This approach leaves out the institutional forces that place individuals in harm's way. Second, an event-focused approach leaves out much of what we know about stress from both neuroscience and anthropology. Stressors that are uncontrollable and unpredictable—that individuals can do little to change and that can happen at any time—are worse than stressors that come at regular intervals and that can be moderated by an organism's behavior. Moreover, horror and fear are not just reactions to immediate physical threats, but also meaningful reactions—losing a unit member or seeing a child killed in combat is not the same as seeing an enemy combatant killed. We use systems of meaning to try to make sense of these terrible events, to say sacrifices were worth it or death is part of war. But oftentimes these justifications are not adequate. This disjuncture, where the senselessness and helplessness of an event are magnified, has a direct impact on individuals’ ability to cope with trauma.

However, clinicians have transformed PTSD into a psychiatric disorder that is largely medicalized (Young 1995). In other words, reactions to trauma are defined almost exclusively in psychobiological terms—arousal, avoidance, and repetition. However, individuals who face trauma, particularly combat, develop altered understandings of themselves and their lives (Finley 2011; Hinton and Lewis-Fernandez 2010; Kienzler 2008; Polusny et al. 2011). Issues of reacculturation, familial integration, social awareness, substance abuse, depression, violent tendencies with loved ones, and the inability to express their traumatic experiences have lasting consequences, which not only affect the health of the soldier but also the family and friends of the soldier.

In anthropological terms, PTSD has a cascade of effects that create behavioral and social dynamics, which can increase, or decrease, the impact of trauma, hypervigilance, and arousal over time (Finley 2012). How these effects play out for the individual soldier and his or her spouse are important to take into consideration, especially when children are within the household and bear witness to it. For example, Sayers and colleagues (2009) showed that soldiers returning from either Afghanistan or Iraq showed a 60 percent increase in domestic abuse since returning from deployment, and 53.7 percent of the study population experienced some sort of shouting, pushing, or shoving with their partner after returning from a combative theater. Exposure to such events has the possibility of fostering “Second Hand PTSD” in which children are exposed to traumatic environments (Arzi et al. 2000). Furthermore, an alarming number of soldiers are becoming addicted to alcohol, drugs, and prescription medications after developing PTSD (Bray et al. 2010). The use of antianxiety and antidepressant medications (i.e., Paxil or Zoloft), often given by the Veterans Administration, is common among soldiers who have been diagnosed with PTSD (Bray et al. 2010). Such medications serve largely as a temporary band aid and have fostered an “assembly line” approach in treating PTSD symptoms and perpetuate addiction behaviors.

UNDERSTANDING PTSD: DISORDERED MACHINE OR ENCULTURED BRAIN?

The “encultured brain” is a core concept in neuroanthropology, referencing how our brains develop within a cultural milieu, shaping neural structure and function over the lifespan. This approach provides a framing for understanding how cultural experience can get under the skin, and increase vulnerability to stress and trauma. This view contrasts with a common paradigm in both cognitive science and clinical practice that approaches human neural function as essentially having the same processes as modern technology such as computers. For example, clinicians often apply a universal approach to understanding mental health issues in combat and trauma (Kienzler 2008); this approach further emphasizes an “assembly line” style of medical treatment. This type of functional view emphasizes cause-effect models of trauma, hardware–software dichotomies about the brain and mind, and treatment approaches emphasizing pharmaceuticals and standardized clinical care. In the mind-as-technology view, human experience and function can be broken down into component parts that can be isolated and fixed, with little attention paid to ethnographic inquiry and the complexities of the human condition.

Neuroanthropology, in contrast, emphasizes the importance of actually understanding how trauma, stress, and adversity are experienced and interpreted before, during, and after combat, because this interpretation matters at the neural level. In this approach, cognition is not a content-free process, simply running on whatever neural processor is installed and with whatever environmental input is provided. The idea that human beings “process” information and have the ability to “download” ideas is not an accurate model that serves our unique ability to interpret our environment. The importance of culture, meaning making, and institutional identities reflect the ways in which interpretation is played out and ultimately the effect that it has on the perspective set forth by each individual when faced with adversity.

FACING ADVERSITY: THE COMPREHENSIVE SOLDIER FITNESS APPROACH

Recently, the U.S. military has created a thrust toward a more “resilient” army. This concept of resilience and the ability to maintain a positive outlook throughout adverse conditions has gained a lot of recognition within clinical psychology and is being adopted as official military practice within the U.S. Army. The army has implemented a program entitled “Comprehensive Soldier Fitness” (CSF), designed principally by Dr. Martin Seligman from the University of Pennsylvania's Positive Psychology Center. The program seeks to lower PTSD, increase resilience, and augment the number of military personnel “who grow” after experiencing some sort of adversity on the battlefield (Seligman and Fowler 2011). The program looks at emotional, social, family, spiritual, and physical domains of influence on a soldier's resiliency; resiliency is defined as the ability for a soldier to adapt swiftly to adversity, stress, and combative trauma (Ballenger-Browning and Johnson 2010). The program, instituted across the U.S. Army, is still in its infancy. The long-term results are not yet known, although preliminary results show a decrease in the severity of anxiety related disorders and a somewhat better assimilation process stateside in a small percentage of participants (Gottman et al. 2011).

CSF utilizes the Global Assessment Tool (GAT) to track and monitor the resilience of soldiers while both stateside and deployed. The GAT contains 105 computer-based questions that evaluate what the army considers to be the five pillars of fitness: family fitness, spiritual fitness, emotional fitness, social fitness, and physical fitness (U.S. Army Comprehensive Soldier Fitness 2011). It is taken once every 90 days and is thought to expose areas where improvement can be made to one's resilience through enhanced training techniques in areas of character that are thought to be “malleable” (U.S. Army Comprehensive Soldier Fitness 2011). Overall, the GAT presents generalized assessments derived from concepts used within psychology, often with an individual and internal focus and without a specific assessment of the demands and strengths related to military life and deployment. Furthermore, as Peterson and colleagues (2011:16) acknowledge, the GAT only assesses “at ease psychosocial fitness. The real challenge of fitness is during challenge and crisis and would require … measuring a soldier's assets in actual use.”

Deployment, from combat trauma to the everyday grind of service in an active war, to dislocation from family at home and local communities, changes the ways in which soldiers view themselves as well as their relationship with the world (Brewin et al. 2010; Finley 2011). CSF only takes a “snapshot” of soldiers’ mental health. Subjective self-assessment in front of a computer does not represent an accurate means to assess inevitable changes during soldiers’ service, particularly when in an active war zone. Moreover, the CSF program does not examine who these men and women were before they entered the armed forces and what social, cultural, emotional, and religious (if any) influences persuaded them to want to serve in the military, and how that might affect their ability to adapt to present circumstances and potential trauma.

PTSD AND WORKING WITH SOLDIERS

Using neuroanthropology to address the current challenge of high PTSD rates in the military could bear a significant amount of fruit. Utilizing ethnographic methods from anthropology, recognizing the need for enhanced qualitative and quantitative assessments, and introducing the importance of biocultural consequences owing to varying personnel background offer new opportunities to address the prevention of PTSD. However, it is important to recognize that applied work takes on ethical considerations beyond those involved in the typical protection of human subjects. Doing research with the military has the potential for complicity and cooptation of research to unintended ends (Gusterson 2007). Critical perspectives can work to question how the military engages with anthropologists and other social scientists, and the ways in which they use research for political and institutional ends, which might not align with soldiers’ interests and certainly not with the interests of the many different parties involved in a war zone (Gusterson 2007; Rylko-Bauer and Singer 2011). For example, the military might establish “acceptable risks” for personnel with regard to exposure to trauma and who is vulnerable to PTSD, in ways that contrast with research findings or the views of the soldiers actually facing those risks. Research within an institution like the U.S. military requires this sort of critical positioning of the researcher, and a clear sense of the ethical goals at the center of the research (Rylko-Bauer and Singer 2011). For us, our main motivation in doing this research is the social and personal suffering of veterans returning from war, and the belief that a preventive approach can reduce that suffering by helping lower the rates of PTSD among veterans and improve the quality of their lives as well as the lives of their family and friends.

THE NEUROANTHROPOLOGY OF PTSD

Culture and PTSD

Culture matters in PTSD, from resources that foster social and emotional support to interpretations of symptoms and how to make sense of trauma. Sources of emotional and social support have been linked to positive adjustment following disasters and other traumatic events (Bonanno et al. 2011). Similarly, organizational and economic resources make a difference in how stressful events are interpreted, as something controllable or as something threatening and disruptive (Hobfoll 2002; Miller and Rasmussen 2010). These sources of support and subjective interpretations emerge from cultural and social dynamics (Finley 2012; Panter-Brick and Eggerman 2011). Institutional constructions of “right” and “wrong” as well as the ability to make sense of different cultures and “acceptable” interpretations of combat all play a role in soldiers’ interpretations of what happens to them, their comrades, and enemy combatants (Burnell et al. 2011). As Brewin (2011) shows, the memory disturbances associated with PTSD are shaped by negative appraisals of self and negative interpretations of memory symptoms; in turn, emotions like shame and interpretive frameworks work through sociocultural dynamics (Budden 2009; Finley 2012; Hinton and Lewis-Fernandez 2010).

These types of internalized cultural structures, and their relationship to military policy, are important factors in soldiers’ take on adversity. The military can both help and hinder acquiring the support and understanding that prove a necessary buffer to adversities faced while deployed. Panter-Brick and Eggerman (2011) highlight how deep rooted cultural understandings of stress are always “in play,” and in the context of deployed soldiers, will generally be more important for understanding combat functionality than the military training that service members go through predeployment. The training experienced within boot camp and soldier's subsequent MOS training (their job or occupation within the Army or Marines) often do not have the same influence as the constructed cultural views of trauma, stress, and adversity that military personnel have acquired while growing up.

Cultural models and interpretations acquired in childhood and adolescence frame the ways that individual soldiers interpret combat and adversity and serve as a cipher of how and why some individuals can cope with trauma and combat and some cannot (Hinton and Lewis-Fernandez 2010; Panter-Brick and Eggerman 2011). This point establishes the importance of looking at multiple cultural spheres as influential forces in the development and functionality of soldiers on the battlefield, including recognizing them as people outside the military and embracing the idea that they are not just ``GIs.'' Being thought of as only a soldier with a specific function in combat may serve the military mission at a critical moment, but the aftereffects of trauma can last a lifetime unless the soldier can make some sense of his or her combative actions and losses endured.

This cultural view needs to be augmented by a consideration of the socioeconomic diversity of people coming into the armed forces. A large majority of U.S. recruits come from a low socioeconomic status (Kleykamp 2006). These recruits do not have any other means of going to college and have typically dealt with ranging levels of adversity because of the economic disadvantages that have surrounded them (Kleykamp 2006). This type of economic adversity leaves the military as a last resort option in which young men and women seek to receive education funding via the Montgomery GI Bill. The decision to enlist as a last resort alternative because of economic hardship creates a sense of forced military service in which deep-rooted motives such as patriotism, honor, sense of duty, and an overall true excitement about volunteering for service in a time of war can be artificially present. Such words to describe military service are often seen advertised in low socioeconomic environments as a means of recruitment and enticement for young men and women. Yet, the motives for joining are often fueled by the desire for military benefits; a sense of personal pride and recognition; as well as the constructed and often romanticized view of being a war hero.

Finley (2011), in her ethnography of veterans struggling with PTSD on their return from Iraq and Afghanistan, highlights the adaptive qualities that humans possess that enable them to function in differing environments. These qualities include possessing a sense of service to others as well as increasing social capital postdeployment, and yet go awry in veterans who seek to isolate themselves from others and lack the ability to speak about the overall impact that combative trauma has had on their personal lives. The contrast between civilian life expectations and living a life of war is immense. Recognizing the need for GIs to be with individuals who care and are willing to listen to them reaffirms the positive outcomes that are associated with smooth transitioning between the two identities. The separation and differing expectations between civil society and military combative culture leaves room for confusion that is not navigated easily and almost always calls for strong support systems as a means of reaffirmation of servitude, duty, and justification for trauma suffered.

Dislocation is a central analytical construct in Finley's research (2011, 2012). PTSD is marked by the physical and psychological sense of dislocation; for combat veterans, both the camaraderie with other soldiers and the sense of the person they once were before war are gone. Together, these jarring changes feed into a sense of dislocation in which they feel they are different from others and cannot connect interpersonally. For Finley, forms of treatment, rituals of memory, webs of relationships and social support, and understandings of what trauma means shape veterans’ attempts at making sense of trauma and coping with PTSD.

This ethnographic research highlights the social component of camaraderie and why it is that service members are known to suffer PTSD from enduring the loss of a fellow soldier, although they may have only known their comrade for a short amount of time. It is the strength of social interactions and what soldiers mean to one another, which buttress the ways that soldiers interpret what is going on within the battlefield. These intense relationships and forms of interpreting adversity carry over into civilian life once returning from deployment, and can create difficult situations when trying to adjust back to social norms. No longer are these service members faced with imminent danger; there are no improvised explosive devices (IEDs) lurking underneath a piece of pavement, Taliban snipers waiting to take a fatal shot, or the sound of incoming mortar fire. Rather, soldiers are surrounded with domestic issues (paying the bills, becoming employed, communicating emotions with loved ones), and are expected to deal with such issues with ease and confidence, as if they were never deployed to a combat zone for well over a year.

Identity

Identity matters in PTSD. As Berntsen and Rubin (2007) show, the degree to which traumatic memory forms a part of one's personal identity is directly correlated with the severity of PTSD symptoms, even when controlling for mental health problems like depression and anxiety. Furthermore, Jobson and O’Kearney (2008) shows cultural differences in identity that are linked to PTSD through interpretive frames, for example, how self is defined in relation to others and to culturally important goals. Anthropological research has established that for some combat personnel, fostering an identity as “indestructible” or as “Rambo” (as taught in boot camp) can create an identity crisis when faced with trauma and interpreting combat and loss (Finley 2011). This crisis can provoke or worsen mental health issues such as depression, substance abuse, PTSD, domestic violence, and suicide. What needs to be focused on within future resiliency training paradigms is the balance of cultural identities within the service member population. This issue of identity formation requires a closer look into the cultural constructs that are responsible for what stress and trauma mean to each individual soldier.

The cultural influences that young men and women have before going into the military help shape multiple facets to their identity. From the time a young man or young woman approaches a recruiter of the armed forces, they have a culturally constructed meaning of what serving in the military signifies. Through mass marketing campaigns and consistent exposure to governmental influences of how “glorious” military service is, many of these individuals develop a fantasy of military culture and the rewards that combat can bring. These influences are cultural constructs that are not only practiced on a daily basis but also are emphasized by recruiters, politicians, and segments of the U.S. population. They are wooed by the college incentive programs of enlisting, the benefits of a steady paycheck, and the opportunity of international travel. They are exposed to video games and movies that glorify the battlefield as a place of action and excitement, and imagine the characters of such entertainment as themselves operating as a hero as well as a person to be admired. Finally, they are encouraged to be an “Army of One,”“Army Strong,”“All That You Can Be,”“A Global Force For Good,” or “The Few. The Proud,” all service mottos that have cultural interpretations of pride, honor, and servitude.

This cultural construction clashes with the realities of war once these young recruits enter into a theater of operation. Video games and mottos do not accurately depict the true nature of the combative military experience. Resources that might be drawn on to make sense of these experiences are often limited. From the military point of view, there is little room for the clashing of identities or the confusion of what one's place is on the battlefield. Nevertheless, this sort of clash and confusion inevitably happens.

When soldiers are initially trained to do things the “Army way” in boot camp, they are not allowed to build on their own identity as a person outside the military. This neglect can help foster disassociation (Seligman and Kirmayer 2008) and dislocation (Finley 2012), given that the identity and interpretations of an individual cannot be erased in a ten week period. There are tentacles of associations between their identity as a soldier and their identity as a son, daughter, mother, father, brother, sister, friend, and so forth. These associations attach meaning, and become essential when dealing with the vivid presence of death, violence, and dislocation. These expectations about combat and being a soldier, as well as how and even if to maintain a civilian identity, shape how service members interpret the loss, trauma, and adversity they meet once hitting the battlefield.

The contrast between what one thought the battlefield would be like and what it actually is can help produce disjunctures of identity and meaning making and foster soldier dysfunction. This dysfunction in turn can lead to increased levels of adversity for the individual, his or her comrades, and thus increase potential problems for entire units. Soldiers need to know that their loss and adversity mean something (Burnell et al. 2011). They need to feel and be defined by the fact that getting shot, blown up by an IED, or suffering the loss of their best friend in combat has meaning to it. Their ability to define meaning is correlated to their cultural understanding of honor, pride, and sacrifice. This sense of honor and sacrifice exist in contrast to horror and fear, two key components of initial reactions to trauma that can drive the development of PTSD (Finley 2012). We propose that as soldiers’ ability to relate these positive meanings to traumatic experiences on the battlefield suffers a disjuncture, the possibility for PTSD can increase. This neuroanthropological view builds on research that shows that the feeling of loss and not having control of their environment causes a sense of distrust in their surroundings and is known to further increase symptoms of the disorder (Johnson et al. 2011).

The ability to “make sense” of adversity, trauma, sufferance, and loss in combat makes a large difference in how a soldier is going to deal with the inevitable flashbacks and memories after returning from deployment. This interpretive strength allows for a “big picture” to be formed and can help prevent the soldier from being defined by the trauma lived in combat. In making cultural connections with their unit members, Afghani and Iraqi citizens (combatants and noncombatants), family members, friends, as well as their surrounding environments, they will be able to maintain an image of why it is they are doing what they are doing and faced with such adversity on the battlefield.

Culturally specific understandings of trauma, idioms of distress, and the interpretation of trauma-caused symptoms all play a role in reactions to trauma (Hinton and Lewis-Fernandez 2010, 2011; Zur 1996). During deployment, interpretations of war will differ from one soldier to another. For example, if two soldiers are involved in a firefight and are side by side throughout the duration of the engagement, the story of significance that one soldier gives will not be the same exact story of significance that the other soldier gives. Because of differing cultural backgrounds and interpretations of death, killing, previous violence experienced (both within the military as well as a civilian), and motivational factors for voluntary military service, the events lived within that firefight will resonate with different meanings. The idea that an enemy force is actually trying to kill them and their need to respond with such violence of action will have an altering affect in how each soldier describes what took place post engagement. If one soldier had multiple deployments under his belt and had been involved with multiple past firefights over a nine year span, and the other soldier was a first year service member and had never been in a firefight but had been exposed to gang violence and shootings as a civilian, the ways in which they negotiate and describe the transpired events will differ.

These cultural understandings of one's self and one's relationship to his or her environment can depend on age, experience, and maturity. Such maturity is reflected in how individuals handle adversity and combative stress. Many times, this is reflected by life experience, which normally equates to age. According to the National Center for PTSD, veterans from ages 18 to 24 years faced the greatest risk for receiving mental health or PTSD diagnoses in a study of 103,788 veterans returning from deployment in Iraq and Afghanistan (Litz and Schlenger 2009). Neuroanthropology explains such differentiation via the cultural awareness and environmental understanding that the 18–24-year-old age group has versus those who are older. Establishing a soldiers’ cognitive understanding of their surroundings and the institutional constructs that convinced them to go to war is of paramount importance in establishing greater resilience. Being grounded and culturally affluent with one's self outside adversity as well as predeployment is an important way for soldiers to not feel overwhelmed, and allows them to keep trauma and adversity on the battlefield “in check” with the big picture of their complete identity.

Neural Dynamics and PTSD

Previous research has established the close links between the meaning of specific acts and experiences and neural function, for example, in the salience of drug use or the impact of dissociative experience (Lende 2005; Seligman and Kirmayer 2008). Recent neuroanthropological work on memory and knowledge traditions highlights how different medical knowledge practices can drive differential use and organization of memory systems in the brain (Hay 2012). Neuroscience research also shows that established memories can become labile when they are retrieved or reactivated, with subsequent consolidation shaped by the present context and use of the memory (Inda et al. 2011; Schiller and Phelps 2011). Together, this research on memory highlights the strong possibility that memory-related aspects of identity rely both on cultural traditions and present uses, shaping the consolidation and activation of basic memory processes in the brain. This framework shows how soldiers’ lives during deployment will shape how they interpret trauma, from forming invasive memories to fitting experiences into a “big picture” of what trauma means.

Identity is not only related to memory but also to self. The neural correlates of self are found in the midline structures of the brain, including the anterior cingulate, insula, and prefrontal cortex (Medford and Critchley 2010; Modinos et al. 2009; Qin and Northoff 2011). In relation to our discussion of dissociation and dislocation above, the point by Qin and Northoff (2011:1221) on how self emerges in the relation between default-mode functioning and present engagement is particularly pertinent: “our data suggest that our sense of self may result from a specific kind of interaction between resting state activity and stimulus-induced activity.” Dislocations in self, in particular between more resting state and consolidated aspects of self and present challenges to self (such as caused by threats to life or to core aspects of personal meaning), can emerge through these interactions in ways that potentiate the impact of trauma on encultured individuals.

Finally, biocultural connections exist between the interpretation of trauma and how different individuals embody adversity (Kirmayer et al. 2007). Varying allostatic loads and epigenetic modifications can play a significant role in the dysregulation of the hypothalamus–pituitary–adrenal axis (HPA axis; see Yehuda and Bierer 2009), one of the primary systems mediating reactions to stress and trauma. This HPA dysregulation has been linked in part to the 5-HTT (serotonin transporter) gene, which promotes the development of the human stress response system (Gross and Hen 2004). Serotonin matters because the neurotransmitter works as a modulator of emotions and of stress-response hormones in the amygdala (Wang et al. 2011). Allele length variance of the 5-HTT gene is directly linked with an increase in amygdala activity when humans are put in moments of anxiety; this has been linked with greater susceptibility to the development of PTSD (Gross and Hen 2004). These differences can shape how people react to and interpret trauma; for example, experiencing greater or lesser amounts of anxiety will color what a particular event means to a person.

These aspects of neural function play a significant role in the impact of trauma and the overall development of PTSD. As Finley (2012) argues, there is a rewiring of responses to stress and fear in individuals who spend extended periods of time at war, with increases in vigilance and decreased reaction time and an emphasis on less cognitive processing in situations perceived as threatening. This response pattern demonstrates cultural priming, where previous learned experiences provide an instant interpretive frame for stress and trauma, both in the immediate aftermath and over the long term. Using this approach, Finley (2012) reinterprets the core diagnostic features of PTSD—hyperarousal, reexperiencing, and avoidance—through a model of neuroanthropological stress framed by the horror, dislocation, and grief that veterans experience through war.

In sum, the comprehensive lens that is offered through neuroanthropology allows us to connect the psychobiological components of reactions to trauma to individual experiences and interpretations that develop within specific cultural environments and are shaped by local institutional dynamics. This approach also paves the way for applied anthropological research to begin making recommendations for dealing with PTSD in a proactive manner.

HANDLING ADVERSITY AND APPLIED NEUROANTHROPOLOGY

Instead of adopting a uniform interpretation of stress and resiliency, the approach presented here argues that soldiers need to develop and utilize their own interpretations of the stresses of deployment, including combat. Soldiers need a balanced identity that can incorporate their previous cultural background, their present service, and the organizational values of the armed forces. Furthermore, these two elements—interpretation and identity—are not isolated themselves; individuals function within specific units, which can have varying assigned missions, access to resources, and cohesion. In creating an environment to handle adversity, greater resilience can be attained through shared world views and social reinforcement (Eggerman and Panter-Brick 2010). Fostering hope and the ability to push through adverse situations helps support the men and women in the unit, and are elements that can help the group deal with losses. In this way, having an ability to make sense of actions and events is not just an internalized resource; interpretation happens between people and depends on available social and cultural resources.

Utilizing neuroanthropology creates an applicable and flexible way to take on PTSD proactively. Identifying the role of earlier cultural domains on subsequent interpretations of deployment, the potential force of institutionally constructed meanings during military service, and the role of identity as a form of resilience in PTSD are all largely missing from the explicit methods and theories employed by the U.S. military and most clinicians. Complementing the snapshot that programs like CSF offers soldiers at a specific time within their service with a solid understanding of who they are prior to enlistment can buttress the way in which soldiers interpret the trauma and adversity they face. Showing soldiers how to identify their own reasons for experiencing stress based on their identity outside of their institutionalized role can create a more mature soldier that could have the tools to negotiate the traumas of war.

By establishing a greater synergy between different domains of identity, soldiers should be more resilient to the dislocations caused by trauma and have a greater ability to make sense of stress and adversity. The next question becomes, how? We believe that focusing on an applied strategy that addresses the conjunction of identity and vulnerability, and the need for interpretive reminders in the face of inevitable dislocations, offers a potential answer. One idea that arises from the conjunction of sense of identity and vulnerability to PTSD is to develop an identity card that reflects their overall cultural identity, rather than a more limited institutional identity.

This concept is a simple one—capture important social roles, formative experiences, and personally relevant symbols and represent them on an encultured identity map for the individual soldier. Service members would create a small poster (e.g., small enough to fit inside their body armor) that would have reminders of their civilian life back home and of important social experiences and cultural values for the soldier. This reminder of the many cultural influences that make them a person will allow the soldier to not lose sight of who they are and why it is they are facing the trauma and adversity that surrounds them in theater. Furthermore, these cards give moments of hope as to what is waiting for them once they leave combat and serve as reminders of their holistic identity and pillars of meaning that construct their interpretations of combat and embodied trauma.

Historically, the military has utilized the “battle buddy system” which pairs two soldiers together to watch out for one another (Lorge 2008). This system was modified in a response to rising suicide rates shortly after Operation Iraqi Freedom (OIF) as well as Operation Enduring Freedom (OEF) sparked off. Using a combination of anthropology, psychotherapy, and education, a program might be built to help instruct soldiers on ways to enhance their interpersonal communication, listening skills, and other forms of basic cultural analysis beyond their assigned “battle buddy.” This idea represents a longer-term project, with the basic premise that creating stronger communicative bonds between military personnel will help augment resilience. A consistent level of exposure to interpersonal communication and listening skills might allow for soldiers to become more culturally aware of all their fellow comrades, and consequently themselves. In sharing consistent interpretations of stress and adversity, tighter cultural bonds would hopefully be formed, resulting in a more cohesive unit that can execute their assigned tasks while also dealing with stress and adversity.

By implementing interventions that are rooted in meaningful interpretations (such as the two recommended here, among others), soldiers can potentially have the ability to foster a sense of heightened awareness to themselves and one another. Such ability could possibly be the beginnings of providing more consistent peer evaluation of each other's capacity to negotiate stress and handle consistent combative engagements that perpetuate PTSD.

RESEARCH METHODS OF NEUROANTHROPOLOGY

Research on PTSD in the military has highlighted the need for better understanding of what happens when soldiers are deployed (Peterson et al. 2011). Anthropology, with its emphasis on field-based research and the documenting of lived experience, offers a robust approach to examine how military personnel deal with war, including the wounds of war that come with trauma, overwhelming adversity, and a sense of dislocation. There is an urgent need for this type of research, and here we provide an overview of how such research can be carried out. An ideal approach would begin with participant-observation within military organizational culture, and includes studying and observing individuals preenlistment, while on duty, post trauma, and during the reintegration into society.

A mixed methods approach during deployment is especially important for examining stress, adversity, and resilience. Researchers can identify initial understandings that soldiers have of combat and monitor levels of stress and resilience through peer interactions, soldier self-description, and biological measures like cortisol. Such neuroanthropological research could provide the means to identify those cultural experiences and interpretations that lend themselves to the development of PTSD. Whether it is the cultural construction of false expectations of combat, the repeated exposure of traumatic events prior to enlistment, the lack of “malleable” socioemotional skills that make navigating stress more challenging, or the identification of biological predispositions that can attribute to the development of PTSD, a neuroanthropology framework offers the means to link these factors to what is happening to soldiers on the ground.

Open-ended interviews would allow individual soldiers to present their ideas of who they are, where they stand in the “big picture” of combat, and understanding the methods they use to make sense of trauma and adversity will help show how they have been conditioned based on cultural influences. When conducted on a unit level, focus group interviews could identify specific cultural interpretations as well as underlying models that serve as pillars of representation in specific units. Biomarkers, such as cortisol and salivary alpha amylase, could provide physiological indicators of stress during deployment, and be linked to epidemiological and qualitative assessments of stress and resilience. Both cortisol measurements and salivary alpha amylase give independent indicators of stress, which provide insight into events that are interpreted as stressful or an altered state of homeostasis in which stress levels are consistently increased in “controlled” environments. Combining these methods can provide a necessary qualitative and quantitative intersection of understanding ways in which to negotiate trauma and foster resilience.

Identifying the sources of strengths and ways in which soldiers negotiate the trauma as well as adversity around them has yet to be addressed and calls for the perspective that neuroanthropology readily offers. Research on the concept of strengths, generally conceived in a psychological sense, has grown over the past decade. Bartone (1999) showed how “hardiness” can be understood as a set of personal characteristics that is linked to resilience in the face of combat exposure and trauma in troops in the first Gulf War. Bartone describes hardiness as commitment to life and work, a greater sense of control over life, an acceptance of stressful and painful experience as part of living, and more openness to change and challenges. Peterson and colleagues (Park et al. 2004; Peterson et al. 2008) examined a more comprehensive inventory of strengths that indicated that traits like hope, zest, curiosity, creativity, and bravery were linked to life satisfaction and coping with trauma. Three types of factors stood out: (1) learning and creativity, (2) persistence and hope, and (3) positive emotions like kindness and zest. Furthermore, trait resilience—“seeing the positive side of a bad situation”—recognizes that resilient individuals are often characterized by being committed to what they are doing, feeling in control of problems, and approaching difficult situations as an opportunity to master new challenges, rather than threats that must be endured (Ong et al. 2010).

This important research, however, has not examined specific strengths in military personnel, nor connected with the sort of on-the-ground qualitative insight anthropology can provide. Moreover, the implicit description of resilient versus nonresilient individuals ignores the natural heterogeneity in people, and does not ask the crucial question, how do these individuals actually accomplish being resilient? What strategies do they rely on? What resources do they draw on? How do they try to avoid negative outcomes? Qualitative research, as outlined above, can answer these questions in a broad sense. To specifically examine how these qualities might make a difference over deployment requires the development of quantitative assessments that can be track reactions to adversity and variations in interpretation and resilience. At present, there are both general measures of deployment risk and resilience (King et al. 2006) and psychological resilience (Connor and Davidson 2003; Johnson et al. 2011; Peterson et al. 2011). The development of novel scales offers the potential to complement these current resiliency measures by measuring the specific strengths of service members and other personnel serving in combat zones, as well as take into account sources of identity predeployment.

By combining qualitative and quantitative methods, neuroanthropological research can produce an overall picture of resiliency and strength. By working with military personnel before, during, and after deployment, such research could identify the strengths that soldiers have that heighten their ability to handle their duties and assignments while adapting effectively to life in a combat situation in a foreign theater. Alongside individual strengths, neuroanthropological research can examine the sources of strength that buttress service members’ ability to cope. Unit morale, positive experiences with other soldiers, effective communication with loved ones at home, and other factors can make a major difference in dealing with adversity and trauma. By developing a clear understanding of strengths and sources of strength, such research could provide keen insight into specific training modalities to foster a proactive approach in dealing with adversity and trauma.

CONCLUSION

Utilizing neuroanthropology to guide the ways in which soldiers interpret adversity, trauma, and stress is going to be of vital importance as young recruits begin new careers in the military and soldiers continue to return from deployment suffering from the wounds of war. The goal of using neuroanthropology is to prevent and understand PTSD. The approach developed here seeks to enhance the manner in which health professionals address the disorder as well as the ways in which recruits are trained to interpret their surroundings, their sense of identity, and their reactions to trauma. No longer are the days when fresh military recruits are taught to keep their emotions bottled up and to “take it like a man.” We have seen the product of such training and the long-term effects of creating a military trained in this manner. It is time that we tap into a new approach that takes seriously the connections between cultural interpretations, individual development and change, and neural function. The bridge that neuroanthropology provides between war and trauma and the social understanding of such events does not exist within any other academic discipline. Neuroanthropology aims to find which sociocultural factors shape the interpretations of stress and the biocultural consequences associated with military service. Yet, such an endeavor is going to require an interdisciplinary approach from all healthcare professionals and the ability to be open to one another's criticisms and critiques. This in itself requires researchers and professionals to have a sense of plasticity and cultural understanding of one another so that we can further our quest to improve the lives of our fellow human beings.