It is important that VA, vet center and other mental health practitioners recognize that the skills and experience they’ve developed in working with veterans with chronic PTSD will serve them well with those returning from the war. Their experience in talking about trauma, educating clients and families about traumatic stress reactions, teaching skills of anxiety and anger management, facilitating mutual support among groups of veterans, and working with trauma-related guilt, will all be useful and applicable. The challenges described below, discuss ways in which treatment of these veterans may differ from the usual contexts of care, and pay specific attention to particular methods and materials that may be relevant to the care of the veteran recently traumatized in war.*
The helping context: active duty vs. veterans seeking health care
There are a variety of differences between the contexts of care for active duty military personnel and veterans normally being served in the VA. These differences may affect the way practitioners go about their business. First, many veterans will not be seeking mental health treatment. Some will have been evacuated for mental health or medical reasons and brought to VA, perhaps reluctant to acknowledge their emotional distress and almost certainly reluctant to consider themselves as having a mental health disorder (e.g., PTSD).
Second, the emphasis on diagnosis as an organizing principle of mental health care is common in VA. Patients are given DSM-IV diagnoses, and diagnoses drive treatment. This approach may be contrasted with that of frontline psychiatry, in which pathologization of combat stress reactions is strenuously avoided. The strong assumption is that most soldiers will recover and that their responses represent a severe reaction to the traumatic stress of war rather than a mental illness or disorder. According to this thinking, the “labeling” process may be counterproductive in the context of early care for war veterans. As Koshes (1996) noted, “labeling a person with an illness can reinforce the “sick” role and delay or prevent the soldier’s return to the unit or to a useful role in military or civilian life” (p. 401).
Veterans may have a number of incentives to minimize their distress:
- To hasten discharge.
- To accelerate a return to the family.
- To avoid compromising their military career or retirement.
Fears about a possible impact on career prospects are based in reality; indeed, some will be judged medically unfit to return to duty. Veterans may be concerned that a diagnosis of PTSD, or even acute stress disorder, in their medical record may harm their chances of future promotion, lead to a decision to not be retained, or affect the type of discharge received. Some may think that the information obtained if they receive mental health treatment will be shared with their unit commanders, as is sometimes the case in the military.
To avoid legitimate concerns about possible pathologization of common traumatic stress reactions, clinicians may wish to consider avoiding, where possible, the assignment of diagnostic labels such as ASD or PTSD, and instead, focus on assessing and documenting symptoms and behaviors. Diagnoses of acute or adjustment disorders may apply if symptoms warrant labeling.
Concerns about confidentiality must be acknowledged and steps taken to create the conditions in which veterans will feel able to talk openly about their experiences, which may include difficulties with commanders, misgivings about military operations or policies, or possible moral concerns about having participated in the war. It will be helpful for clinicians to know who will be privy to information obtained in an assessment. The role of the assessment and who will have access to what information should be discussed with concerned patients
Active duty service members may have the option to remain on active duty or to return to the war zone. Some evidence suggests that returning to work with one’s cohort group during wartime can facilitate the improvement of symptoms. Although their wishes may or may not be granted, service members often have strong feelings about wanting or not wanting to return to war. For recently activated National Guard and Reservists, issues may be somewhat different (Dunning, 1996). Many in this population never planned to go to war and so may be faced with obstacles to picking up the life they “left.” Whether active duty, National Guard, or Reserve, listening to and acknowledging their concerns will help empower them and inform treatment planning.
War veterans entering residential mental health care will have come to the VA through a process different from that experienced by “traditional” patients/clients. If they have been evacuated from the war zone, they will have been rapidly moved through several levels of medical triage and treatment, and treated by a variety of healthcare providers (Scurfield & Tice, 1991). Many will have received some mental health care in the war zone (e.g., stress debriefing) that will have been judged unsuccessful. Some veterans will perceive their need for continuing care as a sign of personal failure. Understanding their path to the VA will help the building of a relationship and the design of care.
More generally, the returning soldier is in a state of transition from war zone to home, and clinicians must seek to understand the expectations and consequences of returning home for the veteran.
For example, is the veteran returning:
- To an established place in society?
- To an economically deprived community?
- To a supportive spouse or cohesive military unit?
- To a large, impersonal city?
- To unemployment?
- To financial stress?
- To an American public thankful for his or her sacrifice?
Whatever the circumstances, things are unlikely to be as they were. The deployment of a family member creates a painful void within the family system that is eventually filled (or denied) so that life can go on. The family assumes that their experiences at home and the soldier’s activities on the battlefield will be easily assimilated by each other at the time of reunion and that the pre-war roles will be resumed. The fact that new roles and responsibilities may not be given up quickly upon homecoming is not anticipated (Yerkes & Holloway, 1996, p. 31).
(This section was written by: Josef I. Ruzek, Ph.D., Erika Curran, M.S.W., Matthew J. Friedman, M.D., Ph.D., Fred D. Gusman, M.S.W., Steven M. Southwick, M.D., Pamela Swales, Ph.D., Robyn D. Walser, Ph.D., Patrician J. Watson, Ph.D., and Julia Whealin, Ph.D. Edited by: Kathryn Brohl, M.A., L.M.F.T.)