In 1971 I was assigned to the 98th Medical Detachment, KO Team, one of two specialized, 28 man units made up of psychiatrists, a social work officer, nurses, and para-professional enlisted specialists in social work and neuropsychiatric procedures to assess and treat psychiatric casualties and drug and alcohol abuse in the combat theater that comprised the then Republic of South Viet Nam.
Our mission was to “Conserve the Fighting Strength.” This meant we were not only to treat psychiatric and chemical dependence problems but to sort out those trying desperately to get out of their combat unit, from individuals who were truly psychotic and could not function safely in a combat situation. The diagnosis of Post-Traumatic Stress Disorder (PTSD) did not exist at that time. Rather, the official military diagnosis was “combat stress,” the latest name for what had been known in World War II and Korea as “combat fatigue” and in World War I as “shell shock.”
The course of treatment for combat stress included rest, supportive counseling, visitations from members of the soldier’s unit, and return to duty within 30 days. To do otherwise, we were told, was to risk the soldier’s emotional well-being by allowing an “easy” way out of an unpleasant and often terrifying situation, and possibly result in serious regrets, such as survivor’s guilt if his buddies were later killed or wounded. In truth, as we now know, stress reaction to emotional trauma is cumulative if not resolved before being re-traumatized by later events. We were undoubtedly returning soldiers to their units who were still suffering symptoms of emotional trauma.
Subsequent research involving Viet Nam vets led to recognition by the APA of the formal diagnosis of Post-Traumatic Stress Disorder in the Diagnostic and Statistical Manual. The Veterans Administration went on to develop or adopt treatment modalities and techniques that now include desensitization, flooding, cognitive behavioral therapy, and EMDR, to name a few. Military psychiatry also evolved as evidence-based practices are continually introduced and research conducted involving military behavioral health professionals and paraprofessionals in implementing what is now termed Combat Operational Stress Control (COSC) measures.
Emphasis is also placed on preventive measures in what is termed “Battlemind” readiness. Battlemind is a descriptive term used to prepare soldiers, in training, on what emotional stressors they can expect to experience and how to prepare themselves for coping with it. It also addresses the need to develop a certain mental toughness and adaptive behaviors to functioning safely in a combat zone. Officers and non-commissioned officers are trained to recognize and minimize the impact of stress on their subordinates. Nevertheless, in this era of an all-volunteer military, with a smaller number of men and women in arms, repeat deployments has accelerated the consequences of additional traumatic experiences on our military. And its impact extends beyond the individual soldier to his family and other natural support networks who must live with traumatized soldiers as they struggle to readjust to civilian life.
Battlemind behaviors are often difficult to put aside when returning from war. They become maladaptive behaviors outside a combat zone. If compounded by untreated combat stress, these behaviors can become destructive to the soldier and to those close to him or her.
Military psychiatry still struggles with the same issues as civilian psychiatry, including stigma and inadequate levels of service availability. Soldiers, returning from a combat tour are eager to get home and will not fully disclose signs and symptoms of traumatic stress. This can be exacerbated in an all-volunteer military since many soldiers are reluctant to disclose their emotional struggles for fear of jeopardizing their careers or experiencing derision at the hands of their fellow soldiers in a culture that prides itself on toughness. They are also more likely to shun treatment made available both by the active duty military and the Veterans Administration, for fear of disclosure. Additionally, these systems must contend with increasing numbers of veterans as the current conflicts drag on, while still caring for veterans of previous wars. Their resources have become overburdened. Moreover, many National Guardsmen and Reservists do not live near military posts and VA centers to be able to easily access care even if they did overcome their reluctance to seek help.
The civilian mental health system, then, is quickly becoming the last best treatment alternative for veterans and their families. Mental health agencies are beginning to recognize this as they prepare their clinicians for what will be an increasing number of veterans and families of veterans in need of treatment. On Long Island, which has the second largest concentration of veterans in the county, the Mental Health Association of Nassau County and State Office of Mental Health’s Long Island Regional Office have led an effort to form the Veterans Health Alliance of Long Island, which Catholic Charities and a number of other non-profit agencies have joined. The purpose of the Alliance is to increase awareness of our community services among veterans and their families and provide training for civilian clinicians on how to effectively assess and treat combat related post-traumatic stress and its impact on family members. The Alliance is also engaged in advocacy efforts to secure legislation that will provide a more comprehensive approach to mobilizing resources across New York State to assure veterans, and their families, access to needed services and supports.
The psychological impact of war on our soldiers and their families is not very visible to the public but is nonetheless shocking when examined. The advocacy organization, Iraq and Afghanistan Veterans of America, has compiled data from various legitimate private and government sources that begs attention. For example, at least 30 to 40% of Iraq veterans, or about half a million people nationally, will face a serious psychological wound, including depression, anxiety, or PTSD. Multiple tours and inadequate time at home between deployments increase rates of combat stress by 50%. Twenty percent of married troops in Iraq say they are planning a divorce. At least 40,000 Iraq and Afghanistan veterans have been treated at a VA hospital for substance abuse. And these represent only those who actually seek help. The current Army suicide rate is the highest it has been in 26 years. Since the start of the wars, there have been a total of 147 military suicides in Iraq and Afghanistan (Mental Health Injuries: The Invisible Wounds of War,” January 2008). These statistics are not dissimilar to those experienced by Viet Nam veterans, a conflict in which more than three million Americans served over the course of that 10-year war. And psychiatric casualties among surviving World War II and Korean War veterans do indeed exist but have received far less attention.
As a society, we must recognize that when we commit our nation to war, there will be consequences that reach far beyond the eventual peace treaties. And we must be prepared not only to honor our veterans who place themselves in harm’s way, but to provide them the care and resources necessary to put their lives back together after exiting the gates of hell that is war.