Soldiers rarely admit to suffering from stress, even though it can affect health, performance, attitude and even one's ability to survive in places that are thick with it.
In 2012, the 349 military suicides were a record number that exceeded the 310 combat deaths. Up to 24 percent of veterans of wars in the past half century suffered post-traumatic stress disorder, once known as combat fatigue, shell shock or war neurosis.
The Journal of Traumatic Stress in 2007 found that 44 percent of soldiers who volunteered to participate in the study reported clinically significant levels of depressive symptoms, post-traumatic stress symptoms or both.
Such overpowering results "suggest a potentially high rate of mental health concerns in soldiers immediately after returning from a combat zone," the study said.
That's where Thomas Stokes has been fighting the war within the war. His military role is to reduce the impact of stress on soldiers' bodies but especially their minds.
Col. Stokes, 54, of Shaler, commands the U.S. Army Reserves 328th Medical Detachment's Combat and Operational Stress Control Unit in Coraopolis. He spent about a year in Afghanistan, beginning in April 2011, on a mission to help soldiers cope with battlefield stress.
He uses methods that Bruce S. Rabin, the University of Pittsburgh immunologist and stress expert, recommends in his stress-management program, "Coping With Stress for Health and Wellness." For the Afghanistan mission, Dr. Rabin supplied the colonel with a case of compact discs featuring deep breathing and guided imagery presented through a soothing voice and music to encourage a person to close eyes, think happy thoughts and focus on being in a happy place.
For soldiers, isolation and persistent anxieties of living in remote, rustic camps in strange locations, all against a backdrop of war, and with little contact with friends or family, represents the perfect recipe for damaging stress.
"The mission is to keep military members in the fight," Col. Stokes said.
The U.S. Army Reserves has 13 COST units, with the Army, Air Force and Navy also deploying such units, said Lt. Col. Matthew W. Lawrence, the Army Reserves media relations officer at Fort Bragg, N.C. They've been helping soldiers since the beginning of the war in Afghanistan.
COST units meet with individual soldiers and groups, with some units using stress dogs to calm soldiers and convince them to discuss their problems. Suicides and homicides represent the most extreme manifestations of stress. But it also can cause a soldier to shut down, withdraw, misbehave or get into serious and even criminal trouble.
"These are things we want to avoid," Lt. Col. Lawrence said. "Everybody has a little bit of stress. But there's an acceptable level that everyone works with. You don't want stress to overcome normal operations for a person."
In Afghanistan, Col. Stokes assisted 800 soldiers in their battle against stress in the Paktya Province, which borders Pakistan in southeastern Afghanistan.
"There were no suicides or its ugly cousin, homicides," he said, now back home. "We didn't lose one military person in that theater" due to suicide and homicide, although there were combat deaths.
His unit's mission sets up stress-management programs in battlefield outposts. Each stress unit has a psychiatrist, psychologist, master's degree-level social worker (which is the role Col. Stokes serves), a psychiatric nurse practitioner and enlisted personnel trained as support staff.
The problem is, soldiers "are very reluctant to ask for help." By the time they do, "they are so far down the road in terms of pathology that they really are in trouble," he said
Stress is a normal reaction to what Col. Stokes describes as "a very abnormal set of circumstances" during war in a foreign land.
"They aren't just experiencing exposure to rockets, mortars and getting shot at. It's the operational tempo that military members face when deployed," he said. "They are working long, long hours, 6 1/2 days a week, over and over again, separated from family and under the threat of potential danger in austere conditions that they find themselves in."
In Paktya, he used a creative method to attract soldiers and offer them help in dealing with the pressures they face. He set up a clinic inside a plywood shed that he called "The Bee Hut," that he also described as a Free X -- a play on the military store known as a PX. There soldiers could get donated candy bars, soap and stuffed animals, which could serve as makeshift pets, along with other free supplies. The privacy of the Bee Hut gave him a chance to gain a soldier's trust before offering guidance.
He schooled soldiers in deep breathing and meditation while passing out Dr. Rabin's CDs. He advised them to get more exercise, reduce caffeine consumption and use mindfulness exercises to stop the flow of stress hormones.
Soldiers returning home can experience anxiety about exchanging the daily military routine for a less structured lifestyle, with relationships back home often not as tight as those galvanized in combat.
"We try to make them understand it's a process, readjusting to coming back home," Col. Stokes said. "They have to expect to feel losses and feel a little bit lonely and anonymous because back here no one can understand that. Who is there to talk to? There also is guilt if a fellow soldier was killed, along with second-guessing."
Col. Stokes is working with local filmmaker JulieHera DeStefano, who is producing a documentary, "Journey to Normal," that focuses on female military veterans, their experiences in combat and how they readjust to home life. It's another tale of war and stress.
"You have to make people aware of it. That's the first step in being able to deal with it," Col. Stokes said. "There's no magic."
David Templeton: firstname.lastname@example.org or 412-263-1578.