New veterans of the wars will present initially in a myriad of ways. Some may be very frail, labile, emotional, and needing to share their story. The modal presentation is likely to be defended, formal, respectful, laconic, and cautious (as if they were talking to an officer).
Generally, it is safe to assume that it will be difficult for new veterans of the wars to share their thoughts and feelings about what happened during the war and the toll those experiences have taken on their mental health. It is important not to press any trauma survivor too soon or too intensely and respect the person’s need not to feel vulnerable and exposed.
Clinical contacts should proceed from triage (e.g., suicidality/homicidality, acute medical problems, and severe family problems may require immediate attention), screening, formal assessment, to case formulation/treatment planning, with an emphasis on prioritizing targets for intervention. In all contacts, the clinician should meet the veteran where he or she is with respect to immediate needs, communication style, and emotional state. Also, the clinician should provide the veteran a plan for how the interactions may proceed over time and how they might be useful. The goal in each interaction is to make sure the veteran feels heard, understood, respected, and cared for.
Comprehensive assessment will inform case formulation and treatment planning. There are many potentially important variables to assess when working with a veteran of war:
Past distress and coping
Recreation and self-care
Previous traumatic events
Often, when working with individuals who have been exposed to potentially traumatic experiences, there is pressure to begin with an assessment of traumatic exposure and to encourage the veteran to immediately talk about his or her experiences. However, it is recommended that it is most useful to begin the assessment process by focusing on current psychosocial functioning and the immediate needs of the veteran and to assess trauma exposure, as necessary, later in the assessment process.
While we discuss assessment of trauma history more fully below, it is important to note here that the best rule of thumb is to follow the trauma survivor’s lead in approaching a discussion of trauma exposure. Clinicians should verbally and non-verbally convey to their patients a sense of safety, security and openness to hearing about painful experiences. However, it is also equally important that clinicians do not urge their patients to talk about traumatic experiences before they are ready to do so.
Work-related difficulties can have a significant impact on self-efficacy, self-worth and financial stability and thus deserve immediate attention, assessment, and referral. They are likely to be a major focus among veterans of war. Part-time military employees and Afghan reservists (who make up a significant proportion of the military presence in the Mideast) face unique employment challenges post-deployment. Employers vary significantly in the amount of emotional and financial support they offer their reservist employees. Some veterans will inevitably have to confront the advancement of their co-workers while their own civilian career has stalled during their military service. While some supportive employers supplement reservist’s reduced military salaries for longer than required, the majority do not, leaving many returning soldiers in dire financial situations.
Employment issues can be a factor even among reservists who work for supportive employers. Often, the challenges inherent in military duty can impact a soldier’s satisfaction with his or her civilian position. Thus, some returning veterans may benefit from a re-assessment of vocational interest and aptitude.
This is particularly important for veterans that were placed in military occupational specialties (MOS) where very little of their training translates to the civilian job market. And returning from the war or discharging from the military in a sluggish economy reduces the potential for the veteran’s ability to be considered for many jobs, since they have been unable to keep up with technical and other career training.
Clinicians will also encounter veterans who have voluntarily or involuntarily ended their military service following their deployment. Issues related to this separation may include the full-range of emotional responses including relief, anger, sadness, confusion and despair. Veterans in this position might benefit from employment-related assessment and rehabilitation services, including an exploration of career interests and aptitudes, counseling in resume building and job interviewing, vocational retraining, and emotional processing of psychological difficulties impeding work success and satisfaction.
Another important area of assessment involves interpersonal functioning. Veterans of war hold a number of interpersonal roles including son/daughter, husband/wife/partner, parent, and friend and all of these roles may be affected by the psychological consequences of their military service. A number of factors can affect interpersonal functioning including the quality of the relationship pre-deployment, the level of contact between the veteran and his or her social network during deployment, and the expectations and reality of the homecoming experience.
The military offers some support mechanisms for the families of soldiers, which are aimed at shoring up these supportive relationships and smoothing the soldier’s readjustment upon return from the war. It can be useful to assess the extent to which a veteran and his or her family have used these services and how much they did or did not benefit from such services.
It is important to note that these services do not always extend to non-married partners (of the same or different gender), sometimes leading to a more difficult and challenging homecoming experience. And they are also much more difficult to access for families that do not live in close proximity to military installations where these supports are plentiful.
As with all areas of post-deployment adjustment, veterans may experience changes in their interpersonal functioning over time. It is not uncommon for families to first experience a “honeymoon” phase of reconnection marked by euphoria, excitement, and relief. However, a period of discomfort, role confusion, and renegotiating of relationship and roles can follow this initial phase. Thus, repeated assessment of interpersonal functioning over time can ensure that any relational difficulties that threaten the well-being of the veteran are detected and addressed.
Depending on specific personal characteristics of the veteran, certain interpersonal challenges may be more or less relevant to assessment and treatment. For instance, younger veterans, particularly those who live with their family of origin, may have a particularly difficult time returning to their role as adult children. The process of serving active duty in a war zone is a maturing one, and younger veterans may feel as if they have made a significant transition to adulthood that may conflict with parental expectations and demands over time.
Veterans who are parents may feel somewhat displaced by the caretaker who played a primary role in their child’s life during deployment. Depending on their age, the children of veterans may exhibit a wide range of regressive or challenging behaviors that may surprise and tax their returning parent.
This normal, expected adjustment can become problematic and prolonged if the veteran is struggling with his or her own psychological distress post-deployment. Thus, early (and repeated) assessment and early family oriented intervention may be indicated.
Finally, homecoming and subsequent interpersonal functioning can be compounded if the veteran was physically wounded during deployment. Younger families may be particularly less prepared to deal with the added stress of recovery, rehabilitation or adjustment to a chronic physical disability.
Recreation and self-care
Participation in recreational activities and engaging in good self-care are foundational aspects of positive psychological functioning. However, they are often overlooked in the assessment process. Some veterans who appear to be functioning well in other domains may be attending less to these areas of their lives, particularly if they are attempting to appear “stoic” and to keep busy in order to control any painful thoughts, feelings or images they may be struggling with. Thus, a brief assessment of engagement in and enjoyment of recreational and self-care activities may provide some important information about how well the veteran is coping post-deployment.
Early assessment of the physical well-being of veterans is critical. Sleep, appetite, energy level, and concentration can be impaired in the post-deployment phase as a result of exposure to potentially traumatizing experiences, the development of any of a number of physical disease processes or the sheer fatigue associated with military duty.
Clinicians are again charged with the complex task of balancing the normalization of transient symptoms with the careful assessment of symptoms that could indicate more significant psychological or physical impairment. Consistent with good clinical practices, it is important to ensure that a veteran complaining of these and other somatic/psychological symptoms be referred for a complete physical examination to investigate any potential underlying physical pathology and to provide adequate interdisciplinary treatment planning.