The Returning Veteran of the Iraq War: Background Issues and Assessment Guidelines
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 from 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 oneâs 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 personâs 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:
Work functioning
Interpersonal functioning
Recreation and self-care
Physical functioning
Psychological symptoms
Past distress and coping
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
patientâs 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 reservistâs 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 soldierâs 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 ãstoicä
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 veteranâs 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
veteranâs 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 assessin
