Few psychologists would challenge the notion that the ongoing Middle East conflicts are producing record numbers of behavioral health problems in military personnel. According to the National Survey on Drug Use and Health, an estimated 9.3 percent of veterans age 21-39 experienced at least one major depressive episode in the past year; slightly more than half reported severe impairment in at least one of four role domains: home, work, relationships or social life, and 59.6 percent received treatment for depression. This increase in deployment stress-related disorders is prompting closer examination within the psychological community.
The best way to understand what returning veterans experience is to serve alongside them. That’s exactly what Cliff Trott, Ph.D., who works at the Veterans Administration (VA) Community-Based Outpatient Clinic at Fort Ethan Allen in Colchester, Vermont, did. Trott worked with a mental health unit in his first deployment, covering five bases in southern Iraq; during his second deployment, he dealt with day-to-day emotional reactions as a mental health officer for a unit of 3,500. He says, “Nothing in my clinical training remotely prepared me for these deployment experiences. During clinical training, we learn to have objectivity to promote analysis and nudge clients toward insight. In [a combat] situation, it’s very difficult to maintain your objectivity.”
Knowing firsthand how difficult transitioning can be has prepared Trott well to work with veterans. “I can relate to these veterans, since, with some, we were deployed together,” he says. “But you lose objectivity. I do think though that I can weave this into treatment as a benefit rather than a potential detriment. There is a perception with the veteran community that it takes another vet to understand a vet.”
Trott points out, too, that in the United States he works with colleagues to whom he can turn for support, an advantage not available while he was deployed.
Jennifer J. Vasterling, Ph.D., chief of psychology at the VA Boston Healthcare System, clinical investigator with the Behavioral Sciences Division of the VA National Center for PTSD and professor of psychiatry at Boston University School of Medicine, shared editorial responsibilities for the American Psychological Association publication “Caring for Veterans With Deployment-Related Stress Disorders: Iraq, Afghanistan, and Beyond.” The book addresses the range of stress reactions to deployment, including both those that constitute diagnostic disorders, such as posttraumatic stress disorder and those responses that do not reach the level of a clinical diagnosis.
Determining whether a diagnosable disorder exists begins by asking the veteran questions regarding daily functioning and evaluating the duration and severity of any symptoms, Vasterling points out. She notes that veterans are trained to survive in dangerous situations, but that the “survival response” sometimes does not dissipate immediately after service members return from the war zone. “When survival responses become perpetuated, they can cause problems for people,” she says. “It’s common to have immediate reactions. But, they can become problematic if they continue for too long.”
Vasterling emphasizes that it’s never too late to seek help. “Intervention works even if it’s delayed, although emotional problems can build if left untreated. For example, you can get into a bad cycle that may affect the way you relate to others, just when their support may be the very thing that you need. As compared to stress reactions experienced soon after return from deployment, there may be a different set of challenges when stress symptoms go unchecked for too long,” she says.
Paula P. Schnurr, Ph.D., deputy executive director for the VA National Center for PTSD, research professor of psychiatry at Dartmouth Medical School and editor-in-chief of the Journal of Traumatic Stress and CTU (Clinician’s Trauma Update)-Online, also served as editor for “Caring for Veterans With Deployment-Related Stress Disorders.” She explains that veterans often present with PTSD, but that other diagnoses, such as anxiety and depression are “serious, prevalent and persistent.” Although screening is provided before deployment, readjustment difficulties are common, she adds.
Schnurr promotes a holistic approach to help veterans handle day-to-day stressors. “Cognitive behavioral therapy is the single most effective approach for depression, PTSD, panic syndrome and substance abuse,” she says. “CBT shows good evidence across a range of diagnoses.” Schnurr adds that ACT (acceptance and commitment therapy), stress inoculation, EMDR (eye movement desensitization and reprocessing) and mindfulness have also been used with some success.
Having worked in a residential PTSD clinic in Cleveland that incorporated yoga with acceptance and commitment therapy, Trott prefers mindfulness techniques when working with veterans, although he notes that some “just want to come in and chat.” He says, “the veteran’s willingness to receive care is more of an issue.”
Studies indicate that families suffer physical and mental effects when spouses are deployed, according to Schnurr. She says, “We looked at the medical records of spouses of deployed husbands. [Wives] were using more health care, both physical and mental. The more deployments, the more health care they sought.” Schnurr reports that in some cases, the family may not get services they need while the spouse is deployed.
Schnurr adds that those who serve in the Guard or Reserves face unique challenges. “[These service members] are not coming back to a base. They are going to family that may be isolated from support,” she says.
Clinicians like Nicole L. Sawyer, Psy.D., who has a private practice in Exeter, N.H., often include family in their treatment plans. “This is not standard practice at the VA and the DOD (Department of Defense),” she says. “As a private clinician, I involve family in the treatment. That validation is far more valuable than anything I can provide.”
Sawyer, who serves on N.H.’s legislative commission to study the effects of PTSD and traumatic brain injuries (TBI), emphasizes the importance of asking veterans about exposure to explosions and moments of unconsciousness. “We are coming to find that a mild TBI can play a tremendous role in symptom presentation,” she says. “Depending on the symptoms and severity, a TBI may remit on its own, but a psychologist should be mindful of how long the symptoms linger.”
In spite of awareness efforts and education, stigma remains a barrier to treatment. Fear of retribution, diminished future career prospects, misunderstanding and shame prevent veterans from seeking help, notes Schnurr. “Part of our efforts has been to promote greater understanding, to help veterans recognize the need for help and that treatment does help. PTSD is not a lifetime diagnosis. We’ve been trying to get the word out, to help people recognize the signs and know that treatment interventions are effective,” she says.
By Phyllis Hanlon