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Over the past twenty years there have been multiple operational
deployments involving combat, security, and humanitarian missions to
Panama, Somalia, Haiti, Bosnia, Kosovo, and other locations. Veterans of
the Iraq and Afghanistan wars (Operation Iraqi Freedom-OIF and Operation Enduring Freedom-OEF), the post-9/11 generation, have experienced the lack of a clear front line, other than the concertina wire at the perimeter of the FOB ("Forward Operating Base"), and missions involving
simultaneous and overlapping duties-combat, security, humanitarian,
training of local nationals-going on in the same sectors of the battlefield. They have also faced multiple deployments, in-theater extensions in
deployment length, recalls to active duty, stop-loss (the "hidden draft"),
single parents deploying, and dual military families (with deployments of
both partners), along with many other challenges.

However, the day-to-day experience of war, from the perspective
of the average line infantry "grunt" and anyone supporting them
"outside the wire" or far forward (in convoys, logistics, supply, medical, intelligence, aviation, etc.), has huge similarities from one war to
the next-namely, working 24/7 in a hostile operational environment
where people are trying to kill you using tactics and weapons that in
many ways haven't changed through the years (ambushes, sniper fire,
mortars, roadside bombs, grenades, rockets, etc.); where you may well
find yourself helpless to respond because the enemy looks like noncombatants; and where you're hampered by whatever rules of engagement exist at the moment (and they change frequently), or whatever
other nonsensical orders may be raining down from higher up during
moments of chaos.

Unique Challenges for Modern Warriors

In recent years the military has considered the "resetting" of a warrior's
health after combat in much the same way that it considers the resetting or
refitting of equipment and vehicles. The protracted duration of the Iraq
and Afghanistan wars and the reality of multiple deployments have led to
the unrealistic expectation that warriors (and their family members) can
"reset" physically and mentally for another combat tour in less than twelve
months. Numerous Active Component Infantry Brigade and Regimental
Combat teams have deployed multiple times since the start of these wars,
with "dwell" times between deployments of not much more than the time
spent in-theater. Service members in some Reserve or National Guard
units have experienced more than one mobilization, each lasting up to
twenty months including training prior to deployment. Warriors have put life plans-such as college education, family, and civilian careers-on
hold for extended periods.

Modern warriors have faced the cumulative emotional toll of not being
available to raise their children, missing numerous milestones in their
children's lives, missing funerals of close relatives or friends, or not being
able to assist in the care of an aging parent. Women have for the first time
been involved in direct-combat operations in substantial numbers. Single
parents have faced the challenge of having to arrange extended child care,
and there is evidence that parental absence as a result of deployment has
been associated with increased conduct and academic problems in military children, and in some cases child abuse. Dual military couples have
faced many of the same stresses.

Warriors and their family members are often surprised at how difficult
the transition period is after coming back from a combat deployment.
Many expect that they'll just need a little time for things to go back to
"normal," but find that "normal" is elusive and time is relative.

The government is awesome at getting men ready for war, but they
can't quite get them back to civilian life and a humble heart.

-JUNIOR ENLISTED MARINE, POST-IRAQ

After we came back, many of us were only back in body. Our souls
stayed over there.

-ARMY COMBAT ENGINEER, POST-IRAQ

Transition can mean the big picture of how a warrior has to try
to adjust back into society, but the short term is very critical, from
when a warrior leaves the battlefield to when they hit the streets
at home. If there's one thing I learned from my experiences, it was
that there was no transition at all.

-VIETNAM VETERAN

I want to express my gratitude for the many soldiers, marines, sailors, airmen, and family members I've encountered during my years of
research and clinical work, and whose quotes and stories from their Iraq
and Afghanistan deployment experiences I drew from to bring this book
to life. (Names have been changed, and some of the stories have been
modified to protect the individuals involved.)

I also want to thank my collaborator and friend, First Sergeant
Michael Schindler (Retired), who helped to bring alive the experience of
transitioning home by sharing his story, stemming from two tours in Vietnam (1970 and 1971) and a twenty-eight-year career in the Army Infantry
(Ranger-qualified, two combat infantryman badges), in both the Active
and Reserve Components. First Sergeant Schindler's transition and the
process of wrestling his demons of war didn't begin until 2002, after he
had retired from the Army, and more than thirty years after his combat
experiences. No matter how much time had passed, his transition was no
less direct and immediate than if he had begun the process the day he'd
returned from the war zone. His words add to the many quotes and stories
from Iraq and Afghanistan warriors and highlight the opportunity these
warriors have to address transition issues much earlier than warriors from
prior conflicts.

Enjoy the reading, and please feel free to send me any feedback at
onceawarrior.com.

Charles W. Hoge, MD

Colonel, U.S. Army (Retired)

Chapter 1 will get into what PTSD is all about, including a discussion of
the physiology of stress, and when normal responses and normal "transition" issues become PTSD. The chapter explains the PTSD paradox-the
fact that what medical professionals label symptoms are also combat survival
skills-and how this paradox can create misery after coming home. The
chapter will help you understand that PTSD is not an "emotional" or "psychological" problem, but a physiological condition that includes physical,
emotional, psychological, and behavioral reactions; this is of vital importance in understanding how to address it. "PTSD" is a catchall term used to
describe many reactions to combat that go beyond the medical diagnosis;
PTSD is also strongly linked to a wide range of physical health effects (e.g.,
endocrine, adrenaline, cardiovascular, and immunity).

Chapter 2 will cover the topic of combat mTBI (mild traumatic brain
injury, i.e., concussion) and it's relationship to PTSD and various physical,
cognitive, and behavioral symptoms experienced after coming home from
deployment. There is a lot of confusion about mTBI, even among medical
professionals, which this chapter will address.

Chapters 3-11 will cover specific skills to help with the transition process, including one chapter for spouses, partners, and family members of
warriors. When I was thinking about the content of these self-help chapters, I found myself struggling to find the best term(s) to describe what
I wanted to write about. My wife suggested the term navigating instead
of words like coping, overcoming, healing, recovering, surviving, understanding,
transcending, improving, or self-helping, a term that is active and engaged,
with you firmly in the driver's seat, and with no suggestion that something
about you is broken. There might be something that needs adjusting or
dialing up or down, but there's not something personally wrong with you.

The subjects of PTSD and transitioning from combat are not about
illness, per se. They are also not about growth-although there is a whole
body of literature on "post-traumatic growth." Yes, we grow from all of our life experiences, but we don't ask for the "growth" experiences that get
thrown our way. We have little or no control on the nature of any divine
plan, luck, fate, or random disturbance life may send our way.

The word navigating is very much the spirit of this book-finding your
own way to a healthy, meaningful warrior existence, with help along the
way, but understanding that no one has the answers for you or a magic
pill. As warriors, land navigation (LANDNAV) is an essential skill that you
hone, to ensure that you know where you are at all times, where you need
to be, and what coordinates you want rounds dropped on. There are many
ways to get off track, lost, or call in rounds on the wrong target if your
LANDNAV skills falter. A small mistake can cascade into mission failure.
But if you stay focused on this skill, it will help get you through. "Navigating" (LANDNAV) became the framework that this book is built upon.

In addition to covering individual LANDNAV skills, this book includes
in chapter 8 information on how to navigate the mental health care system, should you want or need to seek professional help. It addresses several hard facts regarding treatment of PTSD, mTBI, and other war-related
reactions. This can help you to advocate for yourself or your loved one and
find the formula that best suits you.

The first hard fact is that many mental health professionals are hampered by the existing structure of medical practice and/or don't have sufficient training or experience in providing treatment to combat veterans.
They are likely to be knowledgeable about the diagnosis of PTSD and
other mental health problems, but don't necessarily have the vocabulary
for the unique military experiences, or an understanding of the range of
what's normal. Most combat veterans need to feel that the person listening
to their story understands, appreciates, and relates to it. This doesn't mean
that every therapist needs to have deployed to a combat zone, but it does
mean that every therapist needs to know their own limitations concerning
the extent of their knowledge of military culture. The health professional's
knowledge or experience may not be sufficient to discern what is normal
or abnormal for a particular combat veteran, but if they remain open and
honest regarding their own limitations, it can go a long way toward making
the veteran or family member feel like it's worth talking with them.

The second hard fact is that even the best treatments for PTSD fall
far short of being 100 percent effective; they are closer to 50 percent. The
confusion that the medical community has regarding the treatment of
mTBI-related symptoms adds to problems with treatment effectiveness.
There are many factors that play into this, including the nature of health
care, as well as the current state of science and practice for the various
treatment approaches. Some initiatives intended to help service members
and veterans actually may have the opposite effect.

This doesn't mean that you should throw in the towel and not try to
get help. It just means that it's important to take the time to learn about
the broad range of treatment and "self-help" options available, so you'll
know how to tailor them in a way that works best for you; be able to combine them to increase their effectiveness; and prepare yourself to take
charge of your health and become a better advocate for yourself or your
loved one. This isn't necessarily something that mental health professionals are able to spend their time explaining.

In summary, this book is about navigating the perils, pitfalls, and
"growth" opportunities in the unique terrain of the home front after you,
your spouse, family member, or friend has returned from a military deployment. LANDNAV means understanding the warrior spirit, keeping track
of where you are at all times, planning where you want to move next, and
what coordinates you need to focus on. This ability to navigate in a treacherous environment is exactly the skill needed to get you through any situation. The military acronym "LANDNAV" was co-opted and turned into a
mnemonic for the purposes of helping you learn to "cope"/"navigate" in a
unique home-front environment during the ill-defined "transition" period,
whether this period has lasted only a few months or has gone on for years.

Who This Book is for and the Terminology Used

For this book, the terms warrior and veteran are meant to be interchangeable, with warrior being most often used. "Once a warrior-always a warrior." The term warrior refers to anyone who has ever put their life in
harm's way as a result of duty in a war zone: soldiers, marines, airmen,
sailors, government workers, and contractors from the United States and other countries. This includes service members in both the Active and
Reserve Components (Reserves and National Guard), and those who
served in line operational units as well as support roles. Although masculine sounding, the term warrior is used for both men and women. Veteran
also refers to anyone who has ever deployed to a war zone, whether or not
they are still in military service or eligible for VA government benefits. The
term post-combat is not meant to imply that this book is only for those who
have experienced direct combat. The terms post-combat, postwar, and postdeployment are synonymous, recognizing that significant war-zone experiences encompass combat as well as noncombat roles. This book is just as
much for government employees and contractors, and acknowledges the
enormous contribution that they've brought to war efforts.