Courage After Fire: Coping Strategies for Troops Returning from Iraq and Afghanistan and Their Families

By Keith Armstrong, L.C.S.W., Suzanne Best Ph.D., and Paula Domenici, Ph.D., California: Ulysses Press, 2006, 239 pages

Reviewed by Rich Blake, B.A., Loyola College in Maryland

Courage after Fire: Coping Strategies for Troops Returning from Iraq and Afghanistan and Their Families is a readjustment guidebook for veterans returning from Operation Iraqi Freedom and Operation Enduring Freedom and those who care for them, as well as an insightful resource for clinicians. The authors share a collective wealth of research experience and clinical expertise specific to the treatment of veterans, and they have all been affiliated with the Posttraumatic Stress Disorder (PTSD) Program at the San Francisco Department of Veterans Affairs Medical Center. The book is well-organized, informative, concise, and written with a tone of empathy.

In an inviting foreword, former United States Senator Bob Dole writes of his own readjustment experiences following his service in World War II. He justifies the psychological difficulties faced by veterans and encourages them to attend to their well-being. In the introduction, the authors write directly to veterans and express gratitude for military service as well as outline the book's seven chapters.

The first chapter, Reactions to War, grabs the reader's attention immediately with an anecdote about a Marine returning from Iraq. Similar anecdotes are used throughout the book as a way of putting psychological phenomena in a context in to which combat veterans can easily relate. Often, multiple anecdotes are utilized for comparing and contrasting the many different ways veterans may respond to combat stress. Chapter 1 addresses symptoms of posttraumatic stress, panic attacks, anger, substance abuse and depression. Each chapter ends with Tips for Partners, Family Members, and Friends informing those close to veterans how to help manage the issues addressed in the chapter.

Chapters 2 and 3, titled Strengthening Your Mind and Body and Coping Strategies respectively, build upon the definitions from chapter 1 and provide detailed strategies for symptom alleviation.  These strategies include composing lists of how previous stressful events were dealt with, relaxation exercises, and taking breaks from watching the news which often depicts reminders of war.  The importance of healthy sleep, diet, and exercise habits is emphasized in specific plans to improve overall health.  Veterans are encouraged to use rating scales to keep track of their levels of avoidance, anger, substance use, and other symptoms and behaviors.

Chapter 4, Grief and Loss, briefly describes what to expect while dealing with death and loss.  This chapter is formatted into frequently asked questions. The chapter concludes with exercises that include creating a memory book, creating honoring rituals, and writing letters to the deceased and their families.

Chapters 5 and 6 deal with the transition to civilian life and how a veteran's changing views and beliefs about the world, influenced by war, affect that transition.  Chapter 5, Changed Views of Self, Others, and the World, tackles many world views affected by war including safety and trust, control and power, self-esteem, relationships, purpose in life, and spirituality. Also included are two special sections, Redeployment Anxiety and Traumatic Brain Injury. Chapter 6, Returning to Civilian Life, deals with practical issues such as education and employment decisions, as well as how to respond to questions from civilians that may be angering or upsetting.

Chapter 7, Restoring Family Roles and Relationships, addresses how to effectively reunite with family and friends, understand commonly experienced feelings, and open up and share experiences and emotions. A significant amount of the chapter is dedicated to reconnecting to children and helping young children adjust to a veteran's return home. After chapter 7 there is an extensive list of resources addressing issues ranging from posttraumatic stress, to parenting, to suicide prevention complete with phone numbers and web addresses.

Several aspects of this book could have value within and outside of psychotherapy. 

• The authors strictly avoid the use of jargon and keep things simple and to the point.
• The anecdotes allow veterans to identify with symptoms being discussed, which are presented in a manner that would not threaten a prideful military demeanor.
• The specificity of strategies and techniques put readers in a position to immediately implement them.
• A major advantage of the book is the Tips for Partners, Family Members, and Friends sections. These sections explain exactly how to confront situations that will likely arise with a returning veteran. It may be extremely beneficial to get this book into the hands of loved ones while veterans are still deployed.  In this case, loved ones would be prepared to guide the vet through the recovery process.

This book could be extremely valuable to clinicians, especially those unfamiliar with the military population. In bibliotherapy, the clinician would gain insight into the combat experience as the client gains insight into their new thoughts, feelings, and emotions. This mutual learning may facilitate rapport and help strengthen the therapeutic relationship.

Additionally, the book has built-in strategies and exercises in each chapter which are readily at the clinician's disposal to integrate into ongoing treatment with clients. For example, a clinician may use the authors' suggestions for dealing with sleep disturbances such having the client remove distractions from the bedroom and limiting bed usage to sleep and sex. For a veteran dealing the death of a comrade, a clinician may instruct the client to construct a scrapbook of memories which could be presented and discussed in treatment. Anxiety, phobia, and hypervigilance could be dealt with through the use of the many relaxation exercises provided in the book.

Courage After Fire has a few limitations:

• Although chapter 6 contains a short section addressing disability compensation, dedicating a chapter to obtaining veteran's benefits would make the book more comprehensive.
• Health care, compensation, and education play pivotal roles in recovery and information on what to expect from the process would be helpful.
• Chapter 4, Grief and Loss, is surprisingly short. Death and loss are often the centerpiece of traumatic stress and a more extensive explanation and additional strategies could improve the chapter.
• Despite the usefulness of the anecdotes for clinicians, a brief section written especially for clinicians may provide further insight into the individual differences of life in the military. The extent of combat preparation and exposure, as well as differences in the post-combat environment, is highly dependent upon the veteran's military occupational specialty (MOS) and duty status (active or reserve). This information can help a clinician conceptualize a case.

Courage After Fire, is an excellent book and likely an effective bibliotherapy tool. Veterans, those who care for veterans, and clinicians should seriously consider reading it.