Clinical Issues and Treatment Considerations for New Veterans: Soldiers of the Wars in Iraq and Afghanistan
Primary Psychiatry. 2006;13(3):66-71
Dr. Hutchinson is assistant professor of psychiatry and pediatrics at Howard University Hospital in Washington, DC. Ms. Banks-Williams is a board certified clinical nurse specialist and runs a weekly group to address family reintegration issues in the Psychiatric Continuity Service at Walter Reed Army Medical Center in Washington, DC.
Disclosure: The authors report no affiliation with or financial interest in any organization that may pose a conflict of interest.
Disclaimer: The views expressed in this article are those of the authors and do not reflect the official policy of the Department of the Army, the Department of Defense, or the United States Government.
Please direct all correspondence to: Lisa Banks-Williams, APRN, BC, Psychiatric Continuity Services, Walter Reed Army Medical Center, 6900 Georgia Ave, N.W., Washington, DC 20302; Tel: 202-782-3358; Fax: 202-782-2306; E-mail: Lisa.Banks-Williams@na.amedd.army.mil.
• The stress of war follows the soldier from the war zone to home, where the response of family, friends, and the community can re-traumatize the returning soldier.
• Expectations of returning soldiers and their family and friends may be mutually confusing.
• The stigma of mental illness impairs the ability of soldiers and their families to seek psychiatric and mental health support.
• Psychiatrists and mental health professionals must be prepared to provide diagnostic and treatment interventions to soldiers and their families individually and concurrently.
War can be traumatizing for some armed forces personnel and their families. It is widely accepted that soldiers exposed to combat may develop mental disorders, such as posttraumatic stress disorder, depression, and other emotional problems. Families of service personnel are also stressed and changed by the absence of their loved ones and fear for their loved one’s safety. This results in traumatically changed soldiers returning home to dramatically changed families. Psychiatrists and other mental health professionals are challenged to treat mentally distressed returning war veterans who are also responding to adaptations, adjustments, and alterations of mentally stressed families. The pathology of post-war soldiers may be much more complex than clinicians are prepared to acknowledge. This article examines the impact of family changes on the psyche of already stressed soldiers, and makes recommendations for individual and collaborative treatment of veterans and their families.
A patient presents to the emergency room (ER) with reports of flashbacks, poor appetite, depressed mood, and fleeting homicidal thoughts. Upon further interview, the patient reveals that he is hypervigilant, easily startled, and overly concerned about the safety and security of his family and friends. He has recently been discharged from the military and served in Iraq as a part of Operation Iraqi Freedom. He was treated at a military treatment facility prior to discharge from the service for major depressive disorder and posttraumatic stress disorder (PTSD). Upon return home, his children seemed more out of control than usual and his wife was managing the budget, children, homework, and household chores. The family members asked if the patient had killed anyone. Everyone seemed overly cautious in their approach to the returning soldier, in an effort to avoid conflict. Veterans Administration (VA) psychiatric services were either unavailable or required the patient to be put on a waiting list. People without military experience were unable to understand what the patient was going through.
It is important to examine the major focus points in treating new post-war veterans as well as to prepare civilian providers for the challenge. The said patient is representative of a growing population of new war veterans who have returned to civilian life and will be in need of long-term care. A recent study by the Army Center for Health Promotion and Preventive Medicine1 revealed that approximately 1,700 service members returning from the war in 2005 proclaimed harbored thoughts of hurting themselves, or that they would be better off dead. More than 250 returnees reported that such thoughts were quite frequent. Nearly 20,000 reported nightmares or unwanted war recollection, and >3,700 said they had concerns of hurting others or losing control around others. The American public should review and reflect on this information as it may affect their soldier loved ones. It is imperative that privately practicing clinicians consider such statistics when working with post-war veterans.
Many soldiers will be seeking psychiatric treatment outside of the military and/or VA systems, and the civilian psychiatric community must prepare to treat them. It has been reported that at least 17% of post-combat veterans have depression, anxiety, or PTSD.2 Many believe that the numbers are under-representative and that many will not be diagnosable until 6–12 months postcombat. Non-white, post-Vietnam soldiers reported a substantially higher incidence of PTSD.3 African-American and Hispanic veterans experienced more life adjustment problems after the Vietnam War than did white veterans. Minority soldiers are also less likely to accept and/or receive treatment. These families report a higher incidence of overall unhappiness, marital difficulties, and parenting problems. The stigma associated with seeking mental health services may appear great once the soldier has been discharged from the military. One soldier stated that asking for mental health services was like saying “I just could not cut it.”4
The opinion of the authors of this article is that soldiers’ responses to how their families and communities receive them may be as injurious as any battle wound and may have long-lasting effects. The purpose of this article is to educate psychiatric clinicians with little or no wartime experiences to the needs of the veterans returning from wars in Iraq and Afghanistan. This article examines the impact that a veteran’s family and community has on recovery, and identifies the critical areas of concern and focus for the psychodynamic treatment of the new post-war veteran.
Trauma and Relationships
According to the Pentagon’s Defense Manpower Data Center, a total of 3,325 army officers’ marriages ended in divorce in 2004.4 This represents 6% of all marriages among officers (including enlisted personnel). This also represents a 78% increase from 2003, when approximately 1,866 marriages of officers ended in divorce. The United States air force, navy, and marines saw increases in the divorce rate but to a lesser extent.5
Research has indicated that the divorce rate for veterans is 62% greater than for civilians. Combat-exposed veterans also had a higher rate of divorce after the Korean, Vietnam, and Gulf wars.5 The implications are the same for each branch of service. Repeated deployments, especially to combat zones such as Iraq and Afghanistan, may have a impact on military families.
Soldiers suffering from PTSD have difficulty in their ability to manage and sustain relationships.2,3 Little research has been conducted on PTSD and other psychiatric symptoms expressed in the families of returning soldiers. PTSD symptoms in veterans may include flashbacks, a sense of self and family isolation, emotional distance from family and friends, depression and worthlessness, anger and rage, substance abuse, and extreme anxiety or nervousness. PTSD among loved ones may be expressed as constant anxiety, alienation from friends, low self-esteem, depression and hopelessness, resentment and bitterness, over-responsibility and enabling behaviors, and feelings of being overwhelmed and stressed. In many instances, a traumatized soldier is greeting a traumatized family, and neither is “recognizing” the other. Many soldiers are finding that neither they nor their spouses are able to cope with the changes in their relationships. Such changes result from both physical and psychologic battle-related injuries.
Besides severe marital adjustment issues leading to divorce, war veterans with PTSD engage in more physical and verbal aggression.6 The army is attempting to respond to these relationship issues through a multi-pronged approach. Chaplains have been encouraged to hold retreats and provide counseling to troubled couples. The Prevention and Relationship Enhancement Program utilizes a workshop approach on communication and conflict resolution. A 24-hour hotline is available for soldiers and their families who are not adapting or adjusting to post-war life. The army is recognizing the role of early prevention and intervention in addressing relationship post-war maladies, thereby aborting more traumatic outcomes of divorce and/or domestic violence.
An in-depth look at some typical, yet difficult, issues to evaluate and address will put these soldier’s and their needs into perspective. The post-war veteran faces potential disappointment on many levels. First, there is a multi-layer, and sometimes profound, sense of disappointment. Reasons for disappointment include loss of military career, difficulty obtaining substantial employment, major changes in roles and responsibilities as parents and spouses, sequelae of physical and/or psychiatric injuries, and social isolation due to ambivalence regarding the mission. In some cases, veterans encounter a hostile climate about the war. Additionally, some veterans perceive that the military is not doing enough to help, despite all of the post-deployment initiatives to reduce the negative impact of the war.
The Return Home
Another major source of disappointment is the reception that some service members receive upon returning from deployment. The veteran is most likely to displace some of these feelings upon family and loved ones. This begins a vicious cycle that moves from disappointment to resentment, to distance and isolation, and then to depression. The post-war veteran faces potential disappointment, beginning with high expectation regarding reunion with families and reception from peers. One soldier indicated that he expected the country to rally around the troops and support the mission. He expected the “World War II spirit.” Instead, the response was the “Vietnam rejection.” There is a huge difference between the two sentiments in terms of self-esteem issues. One implies validation, praise, and support for their sacrifices and effort. The other implies criticism, dissatisfaction, and a lack of appreciation.
Many soldiers who receive psychiatric injuries return to the US in the back of an army transport plane seated with other soldiers that have obvious physical injuries and deformities, making multiple stops. A bus then takes them to a large military hospital facility, hundreds of miles away from their families, where military medical personnel covered in gowns, gloves, and masks wait to triage them to the appropriate psychiatric units before clearing them to go home. A soldier expecting a ticker-tape parade and warm reception from family and friends might instead experience the sterility of the hospital as well as well-intended efforts to make the service members feel welcome.
Mental Injury Versus Physical Injury
The journey home may evoke uncomfortable, dystonic feelings. Some soldiers may experience guilt in returning from combat physically unscathed. Their psychiatric injuries may seem inapparent, even to themselves. Psychiatric injuries are regarded as less significant when compared to injuries that are physical. Tangible injuries are perceived as valid, while invisible injuries are not. Physical damage suggests strength, fearlessness, sacrifice, and honor. Mental damage may suggest weakness and dishonor. The stigma that characterizes attitudes toward mental illness also extends to military zones. Soldiers know they may be considered unfit for service if they acknowledge mental problems. Many will deny their emotional distress when specifically questioned. It has been determined that at least 60% of veterans are unlikely to seek help secondary to the fear of stigma or loss of career advancement opportunities.2 These soldiers must contend with navigating through the maze of clinics and appointments in order to be cleared to return home. In the meantime, their families typically wait until they are released, or some come to visit the service member at the military hospital. The initial reaction to the reunion is often one of exuberance, but many soldiers have reported that the reunion is bittersweet and that the excitement is short-lived. The fact that they returned home and some of their fellow soldiers did not, the reality of being thrust back into the role of spouse and/or parent, and receiving treatments for their injuries is often more than many soldiers can manage. Therefore, they withdraw from their families. They experience significant guilt and they suffer in silence with the symptoms of their injuries (ie, anxiety, depression, nightmares, fear, withdrawal, isolation, and/or hyper aggression). These unrevealed and unrecognized feelings may lead to alcohol and drug abuse/dependency; suicidal and homicidal behaviors; and depressive, dissociative, anxiety, and psychotic disorders.
The transition from military to non-military status can be emotionally disturbing. Even for a soldier who is leaving military service by choice, the move to civilian life can be laden with anxiety and uncertainty. However, for the most part, these post-war veterans are released from the military under three sets of conditions. They are medically retired via a medical evaluation board, they are administratively separated through an employment personnel procedure that is managed by the soldier’s command, or they come to the end of their tour of duty. Despite the existence of transition services, depending upon the circumstances surrounding departure from the military, soldiers can have a profound sense of disappointment. This can be related to soldiers not completing tours of duty and therefore not upholding their contracts, feeling disenfranchised from the service due to administrative action, or not being able to complete missions or commitments to serve their country. Others may feel like the military lifestyle and structure have been taken away from them, and they find that becoming a civilian is a very difficult and unwelcome transition.
Another area of concern is how post-war veterans address feelings about experienced images of war or the duties that they were expected to perform as a part of combat. Many soldiers find it difficult, if not impossible, to share their experiences with non-combat family, friends, and other civilians. They typically choose not to share details of their combat experiences with loved ones, thus causing further isolation due to the inability of loved ones to put such experiences into context. Even if a soldier does share some details of the war, there is no likely frame of reference for those who have not seen combat in the same proximity and/or intensity as the soldier. Therefore, it is often difficult to justify a soldier’s wartime actions. In a war veterans group, one female soldier told the group that she was haunted by one particular firefight. She stated that it was impossible to explain to her children how or why she had to cut an Iraqi insurgent in half with her M-16. While she indicated that she could barely explain it to herself, she said that in the end it was a matter of life or death, and she chose life. That the id, ego, and superego converged is a difficult concept to explain in this context to family members. Thus, communication was restricted for fear of negative judgment by her loved ones. It was difficult for the soldier to accept what she had done, let alone imagine that her family could accept her actions, justified as they may have been. This soldier was careful to protect her integrity as wife and mother. These were primary identities that she did not wish to be destroyed by negative perceptions of her as mother-turned-monster.
Some soldiers struggle with how their actions will be viewed by their family members and friends. A common complaint was that when soldiers return from leave, family and friends alike want to know if they had killed or seen someone killed. On some level, the media sensationalizes the war experience without reporting the day-to-day experiences and concerns that soldiers may have. Being part of human destruction as either warrior or witness is a devastating, emotionally compromising experience. The soldier may experience an inquiry like this as a re-traumatizing event. It can disrupt mental defenses of sublimation and/or denial of emotions related to horrifying events or actions. This type of reaction is common, but clinicians that work with these returning veterans must compassionately wait until a soldier is ready to tell his or her story. Through the development of a therapeutic alliance, the clinician gives the veteran permission to share war stories by creating a safe atmosphere by not forcing the soldier to open up. Insistence that the soldiers relive their combat experiences before they are emotionally ready can result in still further traumatization, thereby destroying any opportunity to establish a therapeutic alliance.
The Soldier, The Family, and PTSD
A young male strike team soldier in individual therapy for >8 months did not discuss his combat experiences until 6 months into treatment. The first 6 months were focused on getting him reintegrated into his family of origin and helping him to re-establish healthy intimate relationships. He experienced classic PTSD symptoms, including nightmares, flashbacks, hypervigilance, and anxiety attacks. He had close and loving parents who wanted their son back the way he had been prior to his deployment to Iraq. It is hard to comprehend the mental defenses and adaptation required to cope with danger and uncertainty on a daily, minute-to-minute basis. It causes extreme stress that often changes a person’s personality and character forever. The soldier’s challenge was to teach the family how he had matured, how he had been affected by his wartime experiences, and how to integrate those changes into their daily lives. Their challenge was to accept the physical and mental injuries that he sustained from the war.
Six months into therapy, the soldier shared a Web site that appeared benign on the surface, as he showed pictures of his battle buddies and members of his platoon posing at various campsites throughout Iraq. There were no gruesome pictures of mangled bodies or the expected carnage of war. With some apology, shame, and embarrassment, he stated that the hardest part for him was that he missed Iraq. He missed the action, the adrenaline rush, and the camaraderie of his fellow soldiers. Sharing the landscape of action with other soldiers was important for his emotional integrity. He experienced a feeling of safety that was elusive in the company of his family of origin. PTSD can cause changes in the chemistry and anatomy of the central nervous system that affect a person’s ability to feel safe in “normal” situations. Part of the isolation and withdrawal from the family emanated from the separation from fellow soldiers who understood the wartime experience. He and family members felt a mutual dissonance, but neither party understood why.
Having been separated from the military, a soldier seeking treatment will be hungry for a certain type of connection and camaraderie. Encouraging participation in veterans support groups can be helpful, as is encouraging the veteran to reconnect with wartime comrades to re-live, reflect, and re-think some of their wartime experiences in light of where they are at present. Reminiscing in this context is helpful to the soldier because he or she is encouraged to seek a personal frame of reference without insisting that a civilian therapist understand his or her plight. Cognitive-behavioral therapy has also been found useful in helping soldiers reframe their experiences and put them into context. It has become increasingly clear that the goal of treatment is not to ameliorate symptoms, but rather to teach veterans stress-management techniques and how to live with such symptoms.
Another thought for consideration is the family member’s response to the expected symptoms of PTSD. According to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text-Revision,7 a persistent avoidance of stimuli is associated with the trauma and numbing of general responsiveness. Frequently, the soldiers report that their families complain that they are distant, detached, and unwilling to talk about their experiences. One focus of treatment is to help the service member develop a script of what can be talked about and under what terms. This intervention may reduce the veteran’s anxiety and relieve the curiosity of family and friends. The service members should also learn to set reasonable boundaries on the intrusion and inquisitive nature of those who, though well intentioned, actually may re-traumatize the veteran by insisting on hearing about wartime experiences. The veteran’s fear of experiencing re-traumatization may be the underlying dynamic for why there is social avoidance and withdrawal from, or diminished interest in, significant family events. One soldier recounted how hard it was to miss his daughter’s 16th birthday due to his deployment. The guilt of his absence from her special event coupled with his growing ambivalence about his wartime experience served as a catalyst for his withdrawal from the same daughter’s birthday the next year. Consequently, there was further conflict, avoidance, and withdrawal by the veteran, and further rejection by the daughter, even though he was only acting to protect them both from himself.
Another source of concern is the restricted range of affect as exhibited by the returning soldier. Several soldiers have returned from a home visit and reported an inability to experience intimacy. One soldier even reported that he was unable to be touched by his son because the child’s touch seemed intrusive and unpredictable. Touching seemed scary and unsafe because touch, in the context of war, holds new meaning and memories. Training service members to be less sensitive to touch and more responsive to physical affection from their loved ones is also influenced by another common symptom—increased arousal. Hearing that the soldier is afraid to sleep in the same bed as his or her spouse upon return from combat is especially disconcerting, since having a patient return to a pre-combat level of intimacy would be a reasonable goal for treatment. However, due to repeated exposure to violence and perceived threat of danger, soldiers develop increased sense of arousal and hypervigilance. Therefore, close contact associated with sleeping with another person is shunned by service members because of the great potential for a violent response to inadvertent contact. The closeness and intimacy of the marital bed has thus been redefined emotionally as a fearful battleground. Hate and fear replace love and intimacy. The anxiety and fear of injuring loved ones outweighs the rejection soldiers communicate to their families while attempting to protect them from harm. An investigation of psychiatric symptomatology among wives of combat-stressed soldiers suggests there is diminished sexual interest.6 This may heighten tension and decrease the development of intimacy.
It is becoming apparent that returning soldiers have experienced a great deal of trauma. The severity and intensity of their presenting symptoms is indicative of that trauma. One psychiatrist describes this condition as “complex PTSD.”8 It is an injury to character in which the capacity for social trust is destroyed. Often inapparent is the degree of mistrust and hostility projected onto civilian providers just because they “were not there” to experience what the soldiers saw and felt. Therefore, to some degree, such clinicians are disqualified as credible agents of healing and change. Although the new post-war veterans are entering offices, clinics, and ERs with a wide variety of symptoms and complaints, the stated concerns are just the tip of the iceberg. These soldiers are coming back with more than the apparent war wound, and they are going to need clinicians and therapists who can hear their stories and decipher the sources of their pain. There is a growing number of soldiers that have sustained psychiatric injuries while deployed that have rendered them unfit for duty and therefore separated from the military either through medical retirement or administrative separation. Some of these soldiers, for a variety of reasons, may be released from the military without medical benefits and therefore are not entitled to care at their local VA hospitals. Others have been unable or unwilling to wait for the services to be made available to them through the VA. Some veterans choose not to engage in the military/VA system once they are released from service; these soldiers are most often resistant to treatment and are likely to be taxing to any primary care provider or healthcare facility.
Most Americans, whether civilian, non-civilian, medical, or non-medical, recognize the physical and emotional toll that war takes on the soldier. Physical and psychiatric injuries are common outcomes of war. However, many do not recognize or understand how war impacts the family and the subsequent interplay between returning soldier and waiting family. The loss of a loved one to war creates stress in relationships and changes in roles. Mutual readjustment difficulties occur, as both soldier and family have changed and each is experiencing the other from a different prism. To some extent, neither knows the other. One soldier commented that returning home was like walking around in a bubble. No one knew what to say to him or how to respond. He stated that the best thing for him was kindness, respect, patience, and some time to come out of the combat zone and return to safe and familiar surroundings. Effective treatment strategies must include both soldiers and their families. Therapy should be concurrently individual, family, couples, and group oriented.9 Returning soldiers and their families need to learn about the effects of trauma on individuals and families. It is extremenly important to help both the returning soldiers and their family members establish realistic expectations about recovery and healing. Family members need assistance in learning how to incorporate a soldier’s disability into their normal lives and daily routine.
All of these approaches can facilitate communication and develop coping interventions. Because of the separation that can occur between armed forces and soldiers, it has become important that VA personnel train and assist non-military clinicians in therapeutic management of post-war veterans. Effective management and treatment of these soldiers and families requires sensitive and empathic interventions, which may not be a military affiliation. There are many available resources for civilian clinicians to review in preparation for working with new post-war veterans. One informative collection of articles and treatment recommendations is the Iraq War Clinician Guide, Second Edition.10
Perhaps the most critical prevention and treatment is understanding the stigma of mental illness. Many cultures do not support psychiatric diagnoses and treatment. Soldiers and families misrepresent the nature and extent of their mental maladies post war, in an effort to sustain the expectations of self and family. Consequently, chronic emotional maladies, dysfunctional families, and sometimes divorce may be the outcome. PP
1. Zoroya G. 1 in 4 Iraq vets ailing on return. USA Today. October 18, 2005:4.
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3. Kulka RA, Schlenger WE, Fairbanks JA, et al. Trauma and the Vietnam War Generation: Report of Findings from the National Vietnam Veterans Readjustment Study (NVVRS). New York, NY: Brunner/Mazel; 1990.
4. Pentagon’s Defense Manpower Data Center (DMDC). Available at: http://www.dmdc.osd.mil/. Accessed January 27, 2006.
5. Byrne CA, Riggs DS. The cycle of trauma; relationship aggression in male Vietnam veterans with symptoms of posttraumatic stress disorder. Violence Vict. 1996;11(3):213-225.
6. Solomon Z, Waysman M, Avitzur E, Enoch D. Psychiatric symptomatology among wives of soldiers following combat stress reaction: The role of the social network and marital relations. Anxiety Res. 1991;4:213-223.
7. Diagnostic and Statistical Manual of Mental Disorders. 4th ed text rev. Washington, DC: American Psychiatric Association; 2000.
8. Shay J, Cleland M, McCain JS. Odysseus in America: Combat Trauma and the Trials of Homecoming. New York, NY: Scribner; 2002.
9. Nelson BS, Wright DW. Understanding and treating post-traumatic stress disorder symptoms in female partners of veterans with PTSD. J Marital Family Ther. 1996;22:455-467.
10. Schnurr PP, Cozza SJ, eds. The Iraq War Clinician Guide. 2nd ed. National Center for PTSD. Department of Veteran’s Affairs; 2004. Available at: http://www.ncptsd.va.gov/war/iraq_clinician_guide_v2/iraq_clinician_guide_v2.pdf. Accessed January 27, 2006.