Back from War

Published in the Spring 2008 issue of SSA Magazine

An array of views on the returning vets who have been affected by their experiences— and how well we're helping them

By Sasha Abramsky

They are starting to come home, the more than 1.1 million active American military personnel and another 400,000 National Guard and Reserve personnel who have served in Afghanistan and Iraq since 2001. Even as debate about whether to stay or leave Iraq continues, hundreds of thousands of veterans are returning to civilian life. Like the vets from past wars, most are fine—happy to be home, ready to return to normal life. But many have been hurt, physically or mentally, and are facing a difficult transition out of military service.

Nearly one in five veterans from the Iraq conflict experienced serious psychological distress within the past year, according to a report released by the National Survey on Drug Use and Health from the U.S. Department of Health and Human Services last November. While it appears that new drug epidemics aren't being formed overseas, as happened in Vietnam, more than 7 percent of today's vets were abusing drugs, and younger, poorer, veterans were disproportionately at risk: one in four veterans in the 18-24 age group had a substance-use disorder.

Press coverage of the needs of returning vets and how well we are—and aren't—serving those needs has become a steady drumbeat. The Washington Post has published an award-winning series on shameful conditions at the Walter Reed Army Medical Center last year, and an article in January highlighted the rising suicide rate in the military: In 2006, nearly 2,100 soldiers injured themselves or attempted suicide, compared with about 350 four years ago, according to the U.S. Army Medical Command Suicide Prevention Action Plan.

"Over the past year, four high-level commissions have recommended reforms and Congress has given the military hundreds of millions of dollars to improve its mental health care, but critics charge that significant progress has not been made," Post writer Dana Priest reported.

In an article last November, the New York Times found that 72,000 vets are paying more than half their incomes for rent, leaving them vulnerable to homelessness. That same month, Stars and Stripes, the country's military newspaper, reported that the number of young veterans receiving treatment for posttraumatic stress disorder (PTSD) from the U.S. Department of Veterans Affairs (V.A.) increased 87 percent from September 2005 to June 2006, rising from about 20,000 patients to more than 38,000. The Chicago Tribune Magazine dedicated a cover in February to the story of Eugene Cherry, an Army medic whose difficult transition from Iraq has uncovered a severe PTSD.

How vets who need help are faring is far from clear, however. Federal programs to fight homelessness include components to assist vets, for example, and the rise in soldiers receiving PTSD treatment may be due in part to new outreach programs to destigmatize the disorder and identify who needs counseling.

Further complicating the picture is that these wars are unlike any we've fought in the past, from the type of warfare to the personnel who serve. Today's all-volunteer military has a higher- than-average education level and comes from neighborhoods that are disproportionately rural. A higher number of National Guard and Reserve personnel serving means that returning vets are more likely to be married and have children. And about 11 percent of the military force that have been stationed in Iraq and Afghanistan are women, a figure that dwarfs figures from past conflicts. Compared to their male counterparts, a higher percentage of women are reporting signs of mental health issues when they return home, according to the V.A.

SSA Magazine has interviewed more than a dozen experts—counselors, researchers, advocates, veterans, and program administrators—for their thoughts on the issues facing returning vets. There is no definitive answer here, but their insight helps build a case for why social services need to be prepared for a new generation of returning vets and how we can begin to help.

"When they return to the U.S. from Iraq or Afghanistan, every individual in the military has to fill in a Post-Deployment Health Assessment questionnaire, and 90 days later they have to complete a follow-up. Anyone identified as suffering from mental health problems is brought in for counseling and further evaluation, paid for by the military. Some army bases, such as Fort Lewis, have gone one step further, mandating all returning personnel see a counselor upon their arrival Stateside. Nationally, 30 percent of National Guard and reserve personnel who have been to Iraq or Afghanistan have sought mental health services upon their return.

"A large institution like the military is always playing catch-up to some extent. The services are rising, but it's hard for them to rise fast enough. There aren't enough psychiatrists, residential treatment facilities, and counselors."
— Shelley MacDermid

"A recent report from the Department of Defense Task Force on Mental Health describes the inadequacy of services to meet the mental health needs of members of the military and their families. There's a need for additional funding and service providers, as well as additional attention to ensuring that evidence-based services are provided and that the effectiveness of services is evaluated. Because stigma is a significant barrier to seeking mental health services, a particularly important recommendation from the report is to make attention to mental health a routine part of military service.

"Between 55 percent and 90 percent of female veterans report experiencing sexual harassment in the military and nearly one in four report sexual assault. The effects often make the return to civilian life more difficult. For example, female veterans who experience military sexual assault are nine times more likely to experience PTSD than female veterans without a sexual assault history. Female veterans who experience sexual harassment or assault in the military also have higher risk of other mental health and substance use problems, as well as greater difficulty finding employment."
— Malitta Engstrom

"I've heard good things about the Illinois Warrior Assistance Program. It makes traumatic brain injury screenings mandatory for all returning members of the Illinois National Guard who served in Iraq and Afghanistan, as well as Vietnam vets experiencing PTSD through watching TV coverage of Iraq and Afghanistan.

"In my opinion, some sort of brief (one or two weeks or so) re-entry training should be mandatory for all military returning from a war zone. It should include simple things, like getting used to driving and being in a large shopping center, and be in the individual's home town or base. Mandatory retraining would provide some time for observation to detect symptoms that might have been missed; it would help people get used to being around civilian society, including their families; and it would remove the stigma because everyone would go through it, regardless of whether there were symptoms."
— Stan McCracken

"The social work knowledge base and orientation would say that the service systems should approach support and services in a holistic way, starting with a comprehensive assessment of the vet's needs around substance abuse, mental health, employment, transportation, health problems, and, particularly for women, childcare. If these comprehensive services are provided as a part of substance abuse treatment, the outcomes are improved.

"But our services, for vets and for nonvets, have been so balkanized. Services need to be integrated. These are whole people with a set of human needs—and addressing all of these needs will ultimately be the most effective approach. The V.A. is uniquely positioned to do this. They have a long tradition of social work services. But they are going to have to reach out into the community and work not only with vets but with vets' families in a community setting."
— Jeanne Marsh

"In our program, we have 59 participants. We start out with stabilizing the individual's situation. We try to get as many into independent living in long-term housing as possible. It takes three-to-four months. The other piece is getting the individual dealing with their substance abuse issues. Then we do individual and group treatment. One of the successful things here is that the retention of clients is really great. We're having individuals tracked once they've been discharged successfully from our treatment services, and we're seeing a higher rate of staying drug-free, alcohol-free."
— Daniel Ibarra-Fitzgerald

"I worked as an adjudicator for the V.A. from 1974 to '76, and worked as an intern for outpatient healthcare in '77. I talked to people who were having a rough time. They were using drugs because of being afraid of going to sleep. They'd close their eyes and have traumatic memories bouncing around inside their heads.

"Today, most of the contact I have with vets is with the people who are providing services. Here in the United States, they're using the same substances that are being used in the community. In Vietnam, there were guys getting addicted to heroin. I don't know if anything like that is going on in Iraq and Afghanistan. With substance abuse, the company commander's going to know about it. There's a potential for adverse ramifications on your military career, so people are very reluctant to seek services."
— Stan McCracken

"The Palo Alto V.A. Medical Center and the V.A. health care system in the San Francisco Bay Area still has a very good outreach to the homeless. The number of homeless veterans sharply increased after Vietnam, and they're seeing an increase now with the vets currently returning. The V.A. has a number of community day activity programs called Vets Centers where homeless veterans can come and get counseling, join support groups, and be hooked up with jobs if they're employable. The Vets Centers also try to coordinate their planning with community overnight shelters if needed. There are three or four of these programs in the Bay Area, and they're being emulated by other places on the West Coast."
— Allison Murdach

"What the people are going through in Iraq—where people shoot at you and there are no safe havens—then the mind takes a while to come back. When I would get deployed my body would come back before my mind would. If I was deployed to a place that wasn't a hot spot, I'd give myself two weeks for every month I was there for my mind to come back. If I was going to a place with combat, I'd give a month for every month. If I was shot at, three months for every month.

"Sometimes traditional mental health arts don't work so well with returning combat vets, because talking with someone who hasn't been there will put you off. The Israelis, their mental health folk are basically with the unit. That was the model I used in the Air Force, unofficially. I'd fly with pilots and hang out with firemen. I would embed the mental health services not only with combat groups, but do programs and get to know the families of the troops."
— Robert Anderson

"I don't work in a program specifically designed for vets, but we certainly see our share. We have to deal with more sophisticated kinds of behavioral and mental health problems, like PTSD, which includes exactly the kinds of things that make a person more difficult to reach in terms of providing services. Hypersensitivity to stimuli. A lot of isolative behavior. Things that look like phobias. With many returning vets, we're seeing a lack of ability to trust individuals, institutions, and environment. These are not short-term wounds that will heal over time on their own. These are serious disturbances.

"There are what are called Vets' Centers, freestanding outpatient clinics affiliated with V.A. hospitals, but not in VA hospitals. Clients are referred upon discharge from V.A. hospitals, or in connection with outpatient services. They do individual counseling, case management. A lot of the knowledge base we have on treating PTSD has come out of group therapy sessions in these facilities."
— Peter Chapman

"We have an increasingly large body of evidence-based treatment, particularly for PTSD. There's been significant growth in knowledge about effective strategies. There's Stress Inoculation Training, for instance, designed to help manage stress proactively through muscle relaxation and breathing, and prolonged exposure therapy, which basically exposes individuals to traumatic effect in a gradual, controlled, repeated manner.

"Although we know, increasingly, what is beneficial and effective, increasing access is the core of the issue. The research has been done, but in terms of whether returning vets, especially those from rural areas, have access to the best available treatment, that's a question I don't know the answer to. I suspect they are to some extent, but not nearly enough to meet the need."
— Jeanne Marsh

"I started the Soldiers' Project after I heard about a similar project in Los Angeles. I'm doing the intake and initial screening and then placing the soldiers with clinicians. It's all free and there's no record. I wanted to keep it very person-to-person, not institutional. The soldiers really respond well to this approach. Many of them feel alienated by the government, the V.A., and the care they get. At the V.A., people are being diagnosed with personality disorders, for example, and then are being denied treatment because it's a pre-existing condition. It's a totally crazy situation.

"The soldiers we see have PTSD, anxiety disorders, or adjustment problems. Their symptoms include agitation, difficulty concentrating, moodiness, flashbacks, anger, nervousness. We offer them free counseling and help managing the health care system. I've gotten calls from people who want to start something similar in Indiana, Wisconsin, Seattle, North Carolina. There's going to be a lot of work for us to do over the next decade or more."
— Kate Schechter

"The topic of returning veterans is an area in which a lot of social workers are involved and a lot more will be involved in the years to come. Many vets are coming back with issues like serious mental health challenges, and our field needs to be prepared. We have people in their 20s, 30s, 40s, even their 50s with lives, families, and careers on hold while they're on prolonged tours of duty. That's a stressor on them and on their families. All these things are having effects, and we need to be talking about them."
— Joel L. Rubin

"A while ago I did a study looking at people who were homeless. One of the things that often came up was military service. We found that military service might be related to homelessness, but it was people who served in peacetime rather than wartime. And the effect was stronger for women than men. We found evidence that people were more likely to enter the military because they had so few social connections, and when they get out these folks have more trouble integrating. We didn't find evidence of any unique effects of serving during wartime.

"[But] we have a volunteer army today. So if the wartime/peacetime difference was about the draft versus volunteers, then today's veterans would be more susceptible to homelessness because of how they got into the military. Also, there may be stressors today that weren't there in the past."
— Michael Sosin