Returning Veterans and Readjustment

While most individuals successfully transition from military to civilian life, a certain number do not – often leading to confrontations with clinicians, law enforcement and the criminal justice system.  Understanding these individuals goes a long way towards preventing encounters from escalating into life changing events that lead to prison terms or worse.  While a version of this article was directed at the law enforcement community, those of us in the treatment and recovery world can also benefit from a discussion of common Veteran readjustment issues and ways to resolve them.

There are roughly 2.6 million Post-9/11 Veterans in the United States, most of them having served in Iraq, Afghanistan, or both.  The nature of these conflicts are different from previous wars, as are the soldiers who fought in them.  In both conflicts there were few “safe” areas and the prevalence of Improvised Explosive Devices (IEDs) and ambushes exposed everyone – not just the infantry – to combat conditions.  These are also the first protracted conflicts fought with a Volunteer military – unlike the Vietnam conflict when draftees served two years and a single combat tour, these professional soldiers are in for a longer term and many have been deployed to combat theaters multiple times.

We spend a great deal of time, money and effort in turning young high school graduates into highly trained soldiers.  Most often we spend less than two days turning that soldier back into a civilian when discharged from the service.  Many of the habits that kept them alive in a combat theater are not acceptable behavior in the civilian world. Nearly every new Veteran requires some amount of time to readjust their habits from the combat environment. That combat environment includes constant stress and uncertainty, exposure to injury and death, separation from friends and family, and stress at home.  Nobody comes home from that world unchanged.

In general the combat environment can create a constant state of 360 degree situational awareness – there are no safe areas and they are constantly on alert. There is a mistrust of any civilian authority – trusting only your battle buddies.  The soldiers on your left and right are looking out for you – everyone else doesn’t matter.  There are also grief, guilt, blame, and shame.  Grief from loss of friends, survivor guilt when others around you are injured or killed, blaming superiors for bad outcomes that occur during a mission, or feeling shame over personal actions or lack of actions that got people killed.

The most commonly diagnosed Mental Health condition for this group is depression; the most commonly diagnosed physical conditions are orthopedic injuries – mainly knees and backs from violent physical activity while wearing over 60 pounds of gear. Add in those with TBI and PTS and there exists fertile ground for self-medication – through alcohol, substance, or prescription drug abuse.

The military has a tradition of “binge” drinking, despite command efforts to reduce the occurrence.  Alcohol is cheap, legal, and easy to obtain – even in combat theaters where the open sale is forbidden.  Many of these Veterans become addicted to prescription pain medication from injuries – it’s easier for a soldier to be returned to duty with painkillers than taking time to heal properly.  With prescription drugs more difficult to find in the civilian world many turn to other substances such as heroin – which is often cheaper and easier to obtain. Finally, many Veterans use drugs and alcohol as a coping mechanism for undiagnosed and untreated stress.

Post-Traumatic Stress is described as a normal response to abnormal events – and some people adjust better than others.  Symptoms exhibited include hypervigilance and hyper arousal – an exaggerated startle response or constant surveillance of surroundings.  It also presents as aggressive, irritable behavior – overly violent response to minor situations. PTS is frequently accompanied by insomnia – individuals sleeping less than two or three hours a day. Another manifestation is emotional numbness – a lack of engagement with family and friends that is described in the military as the “thousand yard stare.”

Traumatic Brain Injury is any injury to the head – it can be either open or closed.  TBI is a cumulative injury – additional blast (or other) exposures exacerbate the condition and even a slight blow to the head can turn a mild TBI into a severe one.  Most TBIs are mild and affect about 15% of returning Veterans.  Many of the symptoms mimic those of PTS (they can also co-occur), but the most common symptoms are memory and attention deficits – which can be quite startling for family and friends and quite frustrating for employers and co-workers.

This group is also prone to some very reckless behaviors – a propensity for activities involving motorcycles, hang gliding, and skydiving to replicate the adrenaline rush of combat. In a similar vein, impaired or aggressive driving is the leading cause of death among recently returned Veterans. High speeds, sudden lane changes, and driving off the road are all common combat driving techniques that lead to accidents in the civilian world.  Road rage and impaired driving can result from lack of sleep or drug/alcohol abuse caused by PTS, TBI, or other stress related conditions.

Experience with recent Veterans from a variety of clinical and law enforcement settings indicate that they can be more impulsive and more willing to fight than their predecessors as well as displaying less respect for police or any other type of authority.

A significant group of Veterans are either married or in a permanent relationship.  There is a risk of domestic violence if there is significant stress on the family unit as a result of service.  Long, frequent deployments can cause significant changes in relationships – if the husband is deployed the wife assumes all the household roles like paying the bills, cutting the grass, etc.  Returning home the Veteran finds their role changed and can be unsure how to get back to “normal”.  Likewise for National Guard and Reserve soldiers who are deployed they may return home to jobs that don’t pay enough or seem important as those they had in the military – putting stress on everyday living.  All of this can be exaggerated if accompanied by PTS or other mental health conditions.

Another potential issue can be firearms.  Nearly every Veteran is well trained in their use and they are more likely than the rest of the population to have them.  Most have them as a defense and are not likely to pose a threat, but the mere presence of a weapon can escalate a situation.

There are ways for clinicians to cope with many of these issues – the overarching goal being to keep everybody safe and obtain peaceful resolutions when situations arise.  These are strategies for low risk events where we are able to work towards treatment and nonviolent resolution.  High risk situations require immediate action by qualified individuals regardless of any other conditions.

The first step is to open a dialog – and determine their Veteran status.  Visual cues such as vehicle stickers, clothing, or general appearance can help, but the easiest way is to ask “Were you in the military?”  Thanking them for their service is a good way to open a conversation.

The objective in this type of dialog is to keep it calm.  Maintain a physical space – don’t crowd into the conversation.  Keep a neutral tone and posture – not raising your voice or making any kind of gesture that could be construed as threatening.  Ask questions that orient the conversation – “What’s going on?” and use restatements to clarify any ambiguities “I understand that you …” Be absolutely transparent with any actions taken – communicate clearly what your are going to do and provide a rationale for why you are doing it.

There are communication aids that you should always try to incorporate into the conversation: conveying a non-judgmental attitude, giving undivided attention to the conversation, listening carefully to what is being said, and allowing for periods of silence for reflection.

There are also some communication cautions that you should always avoid in the conversation:  overreacting to provocative statements, entering into a power struggle with the individual, making promises you can’t keep, and threatening the individual in any way.

The U. S. Department of Veterans Affairs has a host of specialists and programs to assist non-VA providers in treating Veterans, from VA Medical Centers, Community Based Outpatient Clinics, and Vet Centers.  Individual programs for PTS, TBI, Depression, and Alcohol/Substance Abuse are all available.  Many larger facilities have walk-in clinics and 24 hour Emergency Departments. Additional resources can be found with State or County Veteran Service Officers and Veteran Service Organizations.

Working together we can provide safe, prompt, and effective treatment for readjustment issues facing returning Veterans – and better serve those who have served their country.

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