Returning veterans
The Returning Veteran of the Iraq War: Background Issues and Assessment Guidelines
A National Center for PTSD Fact Sheet
Brett Litz, Ph.D. and Susan M. Orsillo, Ph.D.
It is safe to assume that all soldiers are impacted by their experiences in
war. For many, surviving the challenges of war can be rewarding, maturing,
and growth-promoting (e.g., greater self-efficacy, enhanced identity and sense
of purposefulness, pride, camaraderie, etc.). The demands, stressors, and conflicts
of participation in war can also be traumatizing, spiritually and morally devastating,
and transformative in potentially damaging ways, the impact of which can be
manifest across the lifespan.
This section of the Iraq War Clinician Guide provides information that is
useful for addressing the following questions:
- What are the features of the Iraq War that may significantly impact the
quality of life, well-being, and mental health of returning veterans?
- What are important areas of functioning to evaluate in returning veterans?
- What might be beneficial for veterans of the Iraq War who present clinically
needrequest clinical services?
The material below provides an initial schematic so that clinicians in the
Department of Veterans Affairs can begin to appreciate the experience of soldiers
returning
from the Iraq War. It is offered as a starting place rather than a definitive
roadmap. Needless to say, each veteran will have a highly individualized and
personal account of what happened, to them and what he or she experienced
or witnessed, in the Iraq War. Each veteran will also reveal a unique
set of social, psychological, and psychiatric issues and problems. At the end
of the day, the most important initial needs of returning veterans are to be
heard, understood, validated, and comforted in a way that matches their personal
style. Every war is unique in ways that can not be anticipated. There is much
to be learned by listening carefully and intently.
The Form and Course of Adaptation to War-Zone Stressors.
The psychological, social, and psychiatric toll of war can be immediate,
acute, and chronic. These time intervals reflect periods of adaptation to severe
war-zone stressors that are framed by different individual, contextual, and
cultural
features (and unique additional demands), which are important to appreciate
whenever a veteran of war presents clinically.
The immediate interval refers to psychological reactions and functional impairment
that occur in the war-zone during battle or while exposed to other severe
stressors during the war. The immediate response to severe stressors in the
war-zone
has had many different labels over many centuries (e.g., combat fatigue);
the label combat stress reaction is used most often currently. However, this
is
somewhat a misnomer. As we discuss below, direct combat exposure is not the
only source of severe stress in a war-zone such as Iraq. The term war-zone
stress reaction carries more meaning and is less stigmatizing to soldiers
who have difficulties as a result of experiences other than direct life-threat
from combat. Generally, we also want to underscore to clinicians that being
fired upon is only one of the many different severe stressors of the war-zone.
In the war-zone, soldiers are taxed physically and emotionally in ways that
are unprecedented for them. Although soldiers are trained and prepared through
physical conditioning, practice, and various methods of building crucial
unit
cohesion and buddy-based support, inevitably, war-zone experiences create
demands and tax soldiers and unit morale in shocking ways. In addition, the
pure physical demands of war-zone activities should not be underestimated,
especially
the behavioral and emotional effects of circulating norepinephrine, epinephrine
and cortisol (stress hormones), which sustain the body's
alarm reaction (jitteriness, hypervigilance, sleep disruption, appetite suppression,
etc.). In battle, soldiers are taxed purposely so that they can retain their
fighting edge. In addition, alertness, hypervigilance, narrowed attention
span, and so forth, are features that have obvious survival value. Enlisted
soldiers, non-commissioned
officers, and officers are trained to identify the signs of normal “battle
fatigue” as well as the signs of severe war-zone stress reactions that
may incapacitate military personnel. However, the boundary line between
“normal” and “pathological” response
to the extreme demands of battle is fuzzy at best.
Officers routinely use post-battle “debriefing” to allow soldiers
to vent and share their emotional reactions. The theory is that this will enhance
morale
and cohesion and reduce “battle fatigue”. Even if soldiers manifest
clear and unequivocal signs of severe war-zone stress reactions that affect
their
capacity to carry out their responsibilities, attempts are made to restore
the soldier to duty as quickly as possible by providing rest, nourishment,
and opportunities to share their experiences, as close to their units as possible.
The guiding principal is known as Proximity - Immediacy - Expectancy - Simplicity
(“PIES”). Early intervention is provided close to a soldier's unit,
as soon as possible. Soldiers are told that their experience is normal and
they
can
expect to return to their unit shortly. They are also provided simple interventions
to counteract “fatigue” (e.g., “three hots and a cot”).
The point here is that soldiers who experience severe war-zone stress reactions
will have likely received some sort of special care and treated humanely.
On the other hand, it is without question stigmatizing for soldiers to openly
share fear and doubt and to reveal signs of reduced
capacity.
This is especially true in the modern, all volunteer, military with many
soldiers looking to advance their careers. Thus, it is entirely possible that
some veterans
who present at Department of Veterans Affairs Medical Centers will have suffered
silently and may still feel a great need not to not show vulnerability because
of shame.
It should be noted that a very small percentage of soldiers actually become
what are known as combat fatigue casualties. Research on Israeli soldiers has
revealed
that severe war-zone stress reactions are characterized by variability between
soldiers and lability of presentation within soldiers. The formal features
of severe incapacitating war-zone stress reactions are restlessness, psychomotor
deficiencies, withdrawal, increased sympathetic nervous system activity,
stuttering,
confusion, nausea, vomiting, and severe suspiciousness and distrust. However,
because soldiers will vary considerably in the form and course of their decompensation
as a result of exposure to extreme stress, military personnel are prone to
use a functional definition of combat fatigue casualty. For commanders, the
defining
feature is that the soldier ceases to function militarily as a combatant,
and acts in a manner that endangers himself or herself and his or her fellow
soldiers.
If this kind of severe response occurs, soldiers may be evacuated from the
battle area. Finally, clinicians should keep in mind that most combatants are
young
and that it is during the late teens and early twenties is a time when vulnerable
individuals with family histories of psychopathology (or other diatheses)
are at greatest risk for psychological decompensation prompted caused by the
stress
of war. As a result, a very small number of veterans of the Iraq War may
present with stress-induced severe mental illness.
For soldiers who may be in a war-zone for protracted periods of time, with
ongoing risks and hazards, the acute adaptation interval spans the period
from
the point at which the soldier is objectively safe and free from exposure
to severe stressors to approximately one month after return to the U.S., which
corresponds
to the interval defined for Acute Stress Disorder (ASD) in the DSM-IV. This
distinction is made so that a period of adaptation can be identified that allows
clinicians
to discern how a soldier is doing psychologically when they he or she gets
a chance to recover naturally and receive rest and respite from severe stressors.
Otherwise, diagnostic labels used to identify transient distress or impairment
may be unnecessarily pathologizing and stigmatizing and inappropriate because
they are confounded by ongoing exposure to war-zone demands and ongoing immediate
stress reactions. Typically, in the acute phase, soldiers is are in their
garrison
(in the US or overseas) or serving a security or infrastructure-building
role after hostilities have ceased.
One month after trauma exposure is the interval during which Acute Stress
Disorder (ASD) may be diagnosed, according to the DSM-IV. The symptoms of ASD
include
three dissociative symptoms (Cluster B), one reexperiencing symptom (Cluster
C), marked avoidance (Cluster D), marked anxiety or increased arousal (Cluster
E), and evidence of significant distress or impairment (Cluster F). The diagnosis
of ASD requires that the individual has experienced at least three of the
following: (a) a subjective sense of numbing or detachment, (b) reduced awareness
of one’s
surroundings, (c) derealization, (d) depersonalization, or (e) dissociative amnesia.
The disturbance must last for a minimum of two days and a maximum of four weeks
(Cluster G), after which time a diagnosis of posttraumatic stress disorder (PTSD)
should be considered (see below).
Research has shown that that there is little
empirical justification for the requirement of three dissociation symptoms.
Accordingly, experts in the field advocate for consistency between the diagnostic
criteria
for ASD and PTSD because many individuals fail to meet diagnostic criteria
for ASD but ultimately meet criteria for PTSD despite the fact that their symptoms
remain unchanged.
Unfortunately, there have been insufficient longitudinal studies of adaptation
to severe war-zone stressors. On the other hand, there is a wealth of research
on the temporal course of post-traumatic reactions in a variety of other
traumatic contexts (e.g., sexual assault, motor vehicle accidents). These studies
have
revealed that the normative response to trauma is to experience a range of
ASD symptoms initially with the majority of these reactions remitting in the
following
months. Generalizing from this literature, it is safe to assume that although
acute stress reactions are very common after exposure to severe trauma in
war, the majority of soldiers who initially display distress will naturally
adapt
and recover normal functioning during in the following months.
Thus, it is particularly important not to not be unduly pathologizing about
initial
distress or even the presence of ASD.
The chronic phase of adjustment to war is well known to clinicians in the
Department of Veterans Affairs; it is the burden of war manifested across the
life-span.
It is important to note that psychosocial adaptation to war, over time, is
not linear and continuous. For example, most soldiers are not debilitated in
the
immediate impact phase, but they are nevertheless at risk for chronic mental
health problems implicated by experiences during battle. Also, although ASD
is an excellent predictor of chronic PTSD, it is not a necessary precondition
for
chronic impairment - there is sufficient evidence to support the notion of
delayed PTSD. Furthermore, the majority of people who develop PTSD did not
meet the full
diagnostic criteria for ASD beforehand. It is also important to appreciate
that psychosocial and psychiatric disturbance implicated by war-zone exposure
waxes
and wanes across the life -span (e.g., relative to life-demands, exposure
to critical reminders of war experiences, etc.).
Posttraumatic stress disorder is one of many different ways a veteran can
manifest chronic post-war adjustment difficulties. Veterans are also at risk
for depression,
substance abuse, aggressive behavior problems, and the spectrum of severe
mental illnesses precipitated by the stress of war. Generally, the psychological
risks
from exposure to trauma are proportional to the magnitude or severity of
exposure and the degree of life-threat and perceived life-threat. The latter
is particularly
pertinent to the war in Iraq, where the possibility of exposure to chemical
or biological threats is a genuine concern. Exposure to chemical or biological
toxins can be obscure,
yet severely
alarming
before,
during, and after
battle.
A number of individual vulnerabilities have been shown to moderate risk for
PTSD.
For example, history of psychiatric problems (in particular, depression),
poor coping resources or capacities, and past history of trauma and mistreatment
increases
risk for posttraumatic pathology. Individuals who show particularly intense
and frequent symptoms of ASD (particularly, severe hyperarousal) in the weeks
following
trauma are particularly at risk for chronic PTSD. In addition, the quality
and breadth of supports in both the military and civilian recovery contexts
(in the
military and outside the military) and beyond (e.g., in the home) can impact
risk for PTSD. People who need intervention most are the ones that are isolated
and cannot get the respite from work, family, and social demands that they
may need (or who have additional family or financial stressors and burdens),
have few secure and reliable outlets for unburdening their experiences, and
receive little or no validation, in the weeks, months, and years following
exposure to war trauma.
Most clinicians in the Department of Veterans Affairs will interact with veterans
of the new Iraq War during the chronic phase of adjustment. Nevertheless,
early assessment of PTSD and other comorbid conditions implicated from exposure
to the Iraq War is crucial and providing effective treatment as soon as possible
is critical. Although technically chronic with respect to time since hostilities
ceased, soldiers' mental health status will be relatively new with respect
to their extra-war roles and social context. For example, a soldier might
be newly reunited with family and friends, which may tax coping resources
and produce shame and lead to withdrawal. In this context,
interventions provided as early as possible will still provide secondary
prevention of very chronic maladaptive behavior and adaptation.
On the other hand, it is important to appreciate that many things may have
happened to a veteran with steady difficulties through the immediate and acute
phases
that color the person's
clinical presentation. For example, a soldier may have been provided multiple
interventions in the war-zone and in the acute phase, such as critical incident
stress debriefing (CISD), or pastoral counseling, or formal psychiatric care.
It is important to assess and appreciate the course of care provided and
not to not assume that the veteran is first now presenting with problems.
It could
be that some veterans experienced their attempts to get help and guidance
or respite as personal failure and they may have been stigmatized, ostracized,
or
subtly punished for doing so.
What Kinds of War-Zone Stressors Did Soldiers in the Iraq War Confront?
It is important to appreciate the various types of demands, stressors, and
potentially traumatizing events that veterans of the Iraq War may have experienced.
This
will serve to facilitate communication between clinician and patient and
enhance understanding and empathy. Although there may be one or two specific
traumatic
events burned into the consciousness of returning soldiers that plague them
psychologically, traumatic events need to be seen in the context of the totality
of roles and
experiences in the war-zone. In addition, research has shown convincingly
that while exposure to trauma is a prerequisite for the development of significantly
impairing PTSD, it is necessary but not sufficient. For veterans, there are
a
host of causes of chronic PTSD. In terms of war-zone experiences, perceived
threat, low-magnitude stressors, exposure to suffering civilians suffering,
and exposure
to death and destruction, have each been found to contribute to risk for
chronic PTSD. It should also be emphasized that the trauma of war is colored
by a variety
of emotional experiences, not just horror, terror, and fear. Candidate emotions
are sadness about losses, or frustration about bearing witnessing to suffering,
guilt about personal actions or inactions, and anger or rage about any number
facets of the war (e.g., command decisions, the behavior of the enemy).
We describe below the types of stressful war-zone experiences that veterans
of the first Persian Gulf War reported as well as the psychological issues
and problems
that may arise as a result. We assume that many of these categories or themes
will apply to returnees from the War with Iraq.
Preparedness.
Some veterans may report anger about perceiving that they were not sufficiently
prepared or trained for what they experienced in the war. They may believe
that they did not have equipment and supplies they needed or that they
were insufficiently
trained to perform necessary procedures and tasks using equipment and supplies.
Some soldiers may feel that they were ill prepared for what to expect in
terms of their role in the deployment and what it would be like in the
region (e.g.,
the desert). Some veterans may have felt that they did not sufficiently
know what to do in case of a nuclear, biological, or chemical attack. Clinically,
veterans who report feeling angry about these issues may have felt relatively
more helplessness and unpredictability in the war-zone, factors which that
have been shown to increase risk for PTSD.
Combat exposure.
It appears that the new Iraq War entails more stereotypical exposure to warfare
experiences such as firing a weapon, being fired on (by enemy or potential
friendly fire), witnessing injury and death, and going on special missions
and patrols
that involve such experiences, than the ground war offensive of the Persian
Gulf War, which lasted three days. Clinicians who have extensive experience
treating
veterans of other wars, particularly Vietnam, Korea, and WW-II should
be aware of the bias this may bring to bear when evaluating the significance
or impact
of experiences in modern warfare. Namely, clinicians need to be careful
not
to minimize reports of light or minimal exposure to combat. They should
bear in
mind that in civilian life, for example, a person could suffer from chronic
PTSD as a result of a single, isolated life-threat experience (such as a
physical assault or motor vehicle accident).
Aftermath of battle.
Veterans of the new Iraq War will no doubt report exposure to the consequences
of combat, including observing or handling the remains of civilians,
enemy soldiers, U.S. and allied personnel, or animals, dealing with POWs, and
observing
other
consequences of combat such as devastated communities and homeless
refugees. Veterans may have been involved in removing dead bodies after battle.
They
may have seen homes or villages destroyed or they may have been exposed
to the sight,
sound, or smell of dying men and women. These experiences may be intensely
demoralizing for some. It also is likely that memories of the aftermath
of war (e.g., civilians
dead or suffering) are particularly disturbing and salient.
Perceived threat.
Veterans may report acute terror and panic and sustained anticipatory anxiety
about potential exposure to circumstances of combat, including nuclear
(e.g., via the use of depleted uranium in certain bombs), biological, or
chemical agents, missiles (e.g., SCUD attacks), and friendly fire incidents.
Research
has shown
that perceptions of life-threat are powerful predictors of post-war
mental health outcomes.
Difficult living and working environment.
These low-magnitude stressors are events or circumstances representing repeated
or day-to-day irritations and pressures related to life in the
war zone. These personal discomforts or deprivations may include the lack of
desirable
food,
lack of privacy, poor living arrangements, uncomfortable climate,
cultural difficulties, boredom, inadequate equipment, and long workdays.
These
conditions
are obviously
non-traumatizing but they tax available coping resources, which
may contribute to post-traumatic outcomes.
Concerns about life and family disruptions.
Soldiers may worry or ruminate about how their deployment might negatively
affect other important life-domains. For National Guard and Reserve
troops, this might include career-related concerns (e.g., losing a job or missing
out
on a promotion).
For all soldiers, there may be family-related concerns (e.g.,
damaging
relationships
with spouse or children or missing significant events such as
birthdays, weddings, and deaths). The replacement of the draft with an all-volunteer
military force
and the broadening inclusion of women in a wide variety of positions
(increasing their potential exposure to combat) significantly change
the
face of this
new generation of veterans. Single parent and dual-career couples
are increasingly common in the military, which highlights the importance
developing a strong
working
relationship between the clinician, the veteran and his or her
family. As is the case with difficult living and working conditions, concerns
about
life and
family disruptions can tax coping resources and affect performance
in the
war-zone.
Sexual or gender harassment.
Some soldiers may experience unwanted sexual touching or verbal conduct of
a sexual nature from other unit members, commanding officers,
or civilians in the war zone that creates a hostile working environment. Alternatively,
exposure
to harassment that is non-sexual may occur on the basis of
gender,
minority, or other social status. This kind of harassment may be used
to enforce
traditional
roles, or in response to the violation of these roles. Categories
of harassment include indirect resistance to authority, deliberate sabotage,
indirect
threats,
constant scrutiny, and gossip and rumors directed toward individuals.
In peacetime, these types of experiences are devastating for victims
and create helplessness,
powerlessness, rage, and great stress. In the war-zone, they
are no less
impactful.
Ethnocultural stressors.
Minority soldiers may in some cases be subject to various stressors related
to their ethnicity (e.g., racist remarks). Some service members
who may appear to be of Arab background may experience added racial prejudice/stigmatization,
such
as threatening comments or accusations directed to their
similarity in appearance
to the enemy. Also, some Americans actually of Arab descent
may experience conflict between their American identity and identity related
to their heritage. Such individuals may have encountered pejorative statements
about Arabs and
Islam as well as devaluation of the significance of loss
of life among the enemy.
Perceived radiologicalnuclear, biological, and chemical weapons exposure.
Some veterans of the Iraq War will report personal exposures to
an array of radiological, nuclear, biological, and chemical
agents that the veteran believes he/she encountered while serving in the war-zone.
Given the extensive
general knowledge of Persian Gulf War Illnesses among
soldiers (and the public), there is no doubt that veterans
of the new Iraq War will
experience concerns about potential unknown low-level exposure
that may affect their health chronically. For some, these
perceptions may produce a hypervigilant
internal focus of attention on subtle bodily reactions
and sensations, which may lead to a variety of somatic
complaints.
Assessment
New veterans of the war with Iraq will present initially in a myriad of different
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 Iraq
War 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 survivor of trauma 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 the Iraq War:
- Interpersonal functioning
- Previous traumatic events
- Deployment-related experiences
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, our recommendation is 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 patient’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 functioning.
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 the Iraq War.
Part-time military employees or reservists
(who make up a significant proportion of the military presence in Iraq) 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 does 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.
Clinicians will also encounter veterans who have voluntarily and/or involuntarily
ended their military service following
their deployment to Iraq. 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.
Interpersonal functioning.
Another important area of assessment involves interpersonal functioning.
Veterans of the Iraq 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 Iraq. It can be useful to assess the extent to
which a veteran and his or her family has 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.
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 and/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
and/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.
Physical functioning.
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 and/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.
Psychological symptoms.
Once the clinician gains an overall sense of the veteran's level of psychosocial
functioning, a broader assessment
of psychological symptoms, and responses to those symptoms that may be impairing
can be useful. However, this process can
also be difficult and confusing
since a wide range of emotional and cognitive responses to deployment and
post-deployment stressors including increased fear
and anxiety, sadness and grief,
anger or rage, guilt, shame and disgust, ruminations and intrusive thoughts
about past experiences, worries and fears about future
functioning may be expected.
Often a good clinical interview can elicit some information about the most
salient set of symptoms for a particular veteran,
which can be followed up and
supplemented with more structured assessment using diagnostic interviewing
and/or questionnaires.
Again, clinicians must use their judgment in responding to transient normal
responses to potentially traumatizing events versus symptoms that may reflect
the development
and/or exacerbation of a psychological
disorder. Sometimes assessing both psychological responses and responses to
those responses can help determine whether or not
some form of treatment is indicated.
For instance, veterans may appropriately respond to the presence of painful
thoughts and feelings by crying, talking with
others about their experiences,
and engaging in other potentially valued activities such as spending time
with friends and family. However, others may attempts to
suppress, diminish or avoid their
internal experiences of pain by using alcohol and/or drugs, disordered eating,
self-injurious behaviors (such as cutting),
dissociation and behavioral avoidance
of external reminders or triggers of trauma-related stimuli.
Given that a full-range of psychological
responses may be seen, and given that multiple symptoms (and comorbid disorders)
may be present, one challenge to the
clinician during the assessment
process is to prioritize targets of potential treatment. A few general rules
of thumb can be helpful:
- First, one must immediately attend to symptoms that may require emergency
intervention such as significant
suicidal or homicidal ideation, hopelessness, self-injurious behavior
and/or acute psychotic symptoms.
- Second, it is useful to address symptoms that are most disruptive to
the veteran (which should be evidenced by a careful assessment of psychosocial
functioning).
- Finally, the best way to develop a treatment plan for a veteran with
diverse complaints is to develop a case formulation to functionally
explain the potential
relationship between
the symptoms in order to develop a comprehensive treatment plan. Substance
abuse, disordered
eating, and avoidance of trauma-related cues
may all represent attempts
to avoid thoughts, feelings and images of trauma-related experiences.
Thus, developing an intervention that focuses on avoidance behavior
per se, rather than on
specific and diverse symptoms of avoidance, may be a more effective treatment
strategy.
Past distress and coping.
In determining the extent of treatment needed for a particular presenting
problem, an assessment of the history
of the problem and the veteran's previous responses
to similar stressful experiences
is useful. A general sense of pre-deployment work and interpersonal functioning,
along with any significant psychological
history can place current distress
in context. A diathesis-stress model suggests that veterans with a history
of mental health difficulties can be at increased
risk for psychological problems
following a stressful event such as deployment to a war-zone, although this
relationship is not absolute.
Another area worth assessing, that can provide a wealth of pertinent information,
is the veteran's general orientation
toward coping with difficult
life events and its potential
relationship to current painful
thoughts, emotions and bodily
sensations. Many veterans will
enter into their military experience
with a flexible
and adaptive array of coping
skills that they can easily
bring to bear on their current
symptoms. In other cases, veterans
may have successfully used
coping
strategies in the past that
are no longer useful in the
face of the current magnitude
of their symptoms. Coping styles
can be assessed with one of
a number of self-report measures.
However, through a sensitive
clinical interview, one can
also get a general sense of
how often the veteran generally
uses common coping styles such
as stoicism,
social support, suppression
and avoidance, and active problem
solving.
Previous traumatic events.
While there is evidence in the literature for a relationship between repeated
lifetime exposure to traumatic
events and compromised post-event functioning, this relationship may be less
evident among veterans who are seen in the months
following their return from
Iraq. However, there may still be important clinical information to be gained
from assessing a veteran’s
lifetime experience with such traumatic events such as childhood and adult
sexual and physical abuse, domestic violence, involvement in motor vehicle or
industrial
accidents, and experience with natural disasters, as well as their immediate
and long-term adjustment following those experiences.
Deployment-related experiences.
Obviously, the assessment of potentially traumatizing events that occurred
during deployment will be
an important precursor to treatment for many veterans of the Iraq War, particularly
for those who struggle with symptoms of reexperiencing,
avoidance/ numbing,
dissociation, and/or increased arousal. VA clinicians are
highly skilled in many
of the clinical subtleties involved in this assessment such as the importance
of providing a safe and nonjudgmental environment,
allowing the veteran to
set the pace and tone of the assessment, and understanding the
myriad of issues that
involve the disclosure of traumatic experiences such as shame, guilt, confusion,
and the need by some soldiers to appear resilient
and
unaffected by their
experiences. However, unique deployment stressors accompany involvement in
each contemporary military action that may be important to
assess. Thus, clinicians
need to balance their use of current exposure assessment methods
with openness to hearing
and learning from each new veterans personal experience.
Section 1 of the Deployment Risk and Resiliency Inventory, developed Daniel
and Lynda King and colleagues
at the National Center for PTSD, can provide an excellent starting point for
the assessment of deployment related stressors and
buffers.
Items on this measure
were derived from focus groups with Persian Gulf veterans and they provide
useful information about some of the newer stressors associated
with contemporary deployments.
The inventory is provided
in the Appendix. Section 1 describes 9 domains of war-zone stressors that
Iraq veterans may have experienced: preparedness,
combat
exposure, aftermath
of battle, perceived threat, difficult living and working environment, concerns
about life and family disruptions, ethnocultural stressors,
perceived radiological,
biological and chemical weapons exposure. A careful assessment of each of
these domains can be useful both as a starting point for
assessing
any potential ASD and/or
PTSD and more generally to establish a sense of the potential risk and resiliency
factors that may bear on the veteran’s current
and future functioning.
Summary and Final Remarks
Individuals join the military for a variety of reasons, from noble to mundane.
Regardless, over time,
soldiers develop a belief system (schema) about themselves, their role in
the military, the military culture, etc. War can be traumatizing
not only because of specific
terrorizing or grotesque war-zone experiences but also due to dashed or painfully
shattered expectations and beliefs about perceived
coping capacities, military
identity, and so forth. As a result, soldiers who present for care in Department
of Veterans Affairs Medical Centers may be disillusioned
in one way or another.
The clinician's job is to gain an appreciation of the
veteran's
prior schema about
their role in the military
(and society) and the
trouble the person is
having assimilating (incorporating)
war-zone experiences
into that
existing belief system.
Typically, in traumatized
veterans, assimilation
is impossible
because of the contradictory
nature of painful war-zone
events. The resulting
conflict is unsettling
and disturbing. Any form
of early intervention
or treatment for chronic
PTSD entails providing
experiences and new knowledge
so
that accommodation
of a new set of ideas
about the self and the
future can occur.
A variety of factors including personal and cultural characteristics, orientation
toward coping with
stressors and painful emotions, pre-deployment training, military-related
experiences and post-deployment environment will shape responses
to the Iraq
War. Further, psychological
responses to deployment experiences can be expected to change over time. While
mental health professionals within the VA are
among the most experienced
and accomplished in assessing and treating chronic combat-related
PTSD, veterans
of the Iraq war can be expected to present unique clinical challenges.
The absence of immediate
symptoms following exposure to a traumatic event is not necessarily predictive
of a long-term positive adjustment. Depending
on a variety of factors,
veterans may appear to be functioning at a reasonable level
immediately upon
their return home particularly given their relief at having survived the
war-zone and returned to family and friends. However, as life
circumstances change,
symptoms of distress may increase to a level worthy of clinical intervention.
Even among those veterans who will need psychological services post-deployment,
ASD and PTSD
represent only two of a myriad of psychological presentations
that are likely.
Veterans of the Iraq war are likely to have been exposed to a wide
variety of
war-zone related stressors that can impact psychological functioning in a
number
of ways.
The psychological assessment of veterans returning from Iraq is likely to be
complicated and clinically challenging. We must enter into the assessment process
informed about the possible stressors and difficulties that may be associated
with service in Iraq and open to suspending any preconceived notions about how
any given individual might react to their personal experience during war. It
will be important for us to broadly assess functioning over a variety of domains,
to provide referrals for acute needs, and to provide some normalizing, psychoeducational
information to veterans and their families in an attempt to facilitate existing
support networks and naturally occurring healing processes. Repeated assessment
over time will best serve our veterans who may experience changing needs over
the months and years following their wartime exposure.
Related Fact Sheets
Common
reactions to trauma
An explanation of common reactions to trauma by Dr. Edna Foa
Coping
with PTSD
A fact sheet about specific coping strategies for traumatic stress and PTSD
symptoms
Homecoming reactions
Homecoming after deployment: Dealing with changes and expectations
Treatment and
assessment
Description of the phases of coping with traumatic stress and the typical symptoms
expressed following trauma
Treatment of veterans
General treatment considerations and care returning soldiers from the Iraq
War
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