Stephanie L. Spray
Abstract
Returning from a deployment to Iraq or Afghanistan changes lives for all veterans who served time there. The more obvious life-change involves learning how to accommodate any physical injuries they sustained; but not all veterans wear their injuries on the outside. Others must learn to cope with mental disorders because of their service. The focus of this paper is specifically on the issue of Posttraumatic Stress Disorder (PTSD) and the effects it has on war veterans who deployed to Iraq and Afghanistan. Symptoms of PTSD range from interference with sleep patterns, to experiencing unwanted flashbacks, and even thoughts of suicide. The US Department of Veteran Affairs (VA) assists veterans suffering from this disorder by providing services such as counseling services and compensation. Despite these services, an issue of stigma attached to military personnel with PTSD prevents some from seeking treatment. This paper will describe what PTSD is, what assistance is available to veterans, and possible solutions to reduce the stigma associated with this disorder.
Effects of PTSD in Military Personnel After Deployment to Iraq
Being part of the US military involves more than just fighting for your country and your freedom. Many civilians neglect to acknowledge the aftereffects deployment may have on military personnel. Returning from the War Zone, a guide provided to military personnel by the US Department of Veterans Affairs upon returning from deployment, attributes numerous symptoms to common stress reactions. These symptoms are normal for veterans to experience when making the transition from a military mindset back to a civilian one. Some of the symptoms include having trouble sleeping, feeling overly tired, having nightmares, experiencing frequent flashbacks of unwanted memories, being angry, feeling nervous or helpless, having an upset stomach or trouble eating, headaches, sweating when thinking of war, a racing heart, shock, numbness, and/or an inability to feel happiness. Most service members are able to readjust quickly. However, others may experience great distress and an interference with how they are able to function. Their reactions are consistently more intense and bothersome and appear to show no sign of decreasing over the course of a few months. Three other possible red flags service members should watch out for accompany the aforementioned common reactions. The first is experiencing relationship problems brought on by constant and intense conflicts, lack of good communication, and/or an inability to meet their normal responsibilities. Second, experiencing poor performance in work/school/other community functioning due to an inability to concentrate, failure to meet deadlines, and/or having a higher number of absences. The third, and final red flag, is having any thoughts of harming oneself and/or another individual. The VA advises service members to seek assistance if they experience any of the red flag symptoms because they may indicate the veteran is suffering from a more serious problem such as Posttraumatic Stress Disorder (United States Department of Veteran Affairs, 2010). Veterans suspected of having PTSD will begin treatment after a formal diagnosis of the disorder.
To make a formal diagnosis, all clinicians must follow a standard developed by the American Psychiatric Association. The Diagnostic and Statistical Manual of Mental Disorders Fifth Edition (DSM-5) is the most recent edition of the manual used by clinicians to diagnose persons for possible mental disorders. The essential features of PTSD are described as being the development of characteristics such as intrusive memories, avoidance stimuli, negative alterations in cognition and mood, exaggerated negative beliefs or expectations of oneself, and alterations in arousal and reactivity following the exposure to one or more traumatic events. The symptoms must last longer than one month and cannot be attributed to the physiological effects of a substance or any another medical condition. Those who have experienced trauma and lived through events such as rape, military combat and captivity constitute the highest rates of persons suffering from PTSD (American Psychiatric Association, 2013).
PTSD itself has been a common diagnosis among Iraq and Afghanistan war veterans. In their article in Psychological Medicine, Sundin et al. (2010) discuss the difference between military personnel deployed to Iraq from both the United States and the United Kingdom. They were able to conclude that the United States demonstrates a higher number of soldiers returning home with PTSD but were unable to conclude whether or not the location of combat has any impact on whether or not a soldier will suffer from PTSD. Sundin et al. (2010) noted, “Post-traumatic stress disorder (PTSD) has been called one of the signature injuries of the Iraq War” (p. 367). By naming PTSD the signature injury of the Iraq War, Sundin et al. were emphasizing the level of severity existing in military personnel returning from deployment to Iraq.
The VA directs veterans diagnosed with PTSD to seek treatment. According to a study published in Health & Medicine Week, approximately 20 percent of veterans returning home from their deployments in Iraq and Afghanistan report symptoms of PTSD with only a little over half seeking treatment for it. The majority of the veterans will avoid seeking treatment due to the fear that it will harm their careers. However, the veterans who do seek treatment claim to feel it is inadequate for their needs (“Study,” 2008). Their article in Psychological Services (2009), Treatment Presentation and Adherence of Iraq/Afghanistan, Erbes, Curry, and Leskela discuss the need for treatment of PTSD in Iraq War veterans. Erbes et al. reported, “The need for mental health services for returning veterans from the wars in Iraq (Operation Iraqi Freedom or OIF) and Afghanistan (Operations Enduring Freedom or OEF) is substantial” (p. 175). Erbes et al. are expressing their belief that PTSD is a prominent issue for Iraq war veterans and treatment is necessary for the individuals suffering from it.
The number of Iraq war veterans diagnosed with PTSD exceeds the number of Afghanistan war veterans. The New England Journal of Medicine (2004) published the article “Combat Duty in Iraq and Afghanistan, Mental Health Problems, and Barriers to Care” by Hoge et al. This article discusses combat duty in both Iraq and Afghanistan, any potential mental health concerns for the soldiers, and issues soldiers may face when seeking treatment for such mental health concerns. Specifically, they discuss the difference in numbers of war veterans suffering from PTSD deployed in Iraq versus Afghanistan. Hoge et al. (2004) concluded:
Exposure to combat was significantly greater among those who were deployed to Iraq than among those deployed to Afghanistan. The percentage of study subjects whose responses met the screening criteria for major depression, generalized anxiety, or PTSD was significantly higher after duty in Iraq (15.6% to 17.1%) than after duty in Afghanistan (11.2%) or before deployment to Iraq (9.3%); the largest difference was in the rate of PTSD. Of those whose responses were positive for a mental disorder, only 23 to 40% sought mental health care (p. 13).
Hoge et al. provide statistical evidence of the substantial toll PTSD has on the lives of soldiers returning home from deployment; especially from Iraq. PTSD is conclusively a major issue for veterans returning from the Iraq War.
Impact on the Life of the Veteran and their Family
The impact PTSD has on the lives of veterans is apparent. Returning from the War Zone explains four symptoms of living with the disorder in depth. First, veterans may endure unpredictable bad memories of the traumatic event with the ability to bring back the very terror felt when the traumatic event occurred. Second, they may isolate themselves in attempt to avoid triggers (sound, sight, or smell causing you to relive the event). Third, they will emotionally shut down in order to protect themselves from having to feel the pain and fear. Fourth, the veterans are operating at all times on a high-alert mode causing them to be startled easily and often have very short fuses. The soldier suffering from PTSD is not the only one affected by the change it has on their behavior. The behavioral changes immensely impact the lives of their families as well. While the soldier is on deployment, their families were dealing with their own challenges such as feeling lonely, concerned, and worried. The separation may have caused insecurity, misunderstanding, and distance within the family. Resolving these concerns quickly results when the soldier and their family talk through their issues. This allows them to gain a better understanding and appreciation for all members involved, bringing the family closer together. When a soldier returns from war and is suffering from PTSD, their families will still have similar concerns needing to be resolved, only this task is often more difficult to achieve due to the behavioral changes of the returning veteran. In addition to the aforementioned symptoms, trauma and PTSD may decrease the satisfaction the veteran has with their family relationship and increase the likeliness of them being violent towards their partner and children (United States Department of Veteran Affairs, 2010, p. 6, 11). The effects of PTSD go beyond the veteran diagnosed.
Christopher Pupek is an Iraq War Veteran suffering from PTSD who provided a firsthand account of how this disorder has affected his life. He claimed that living with PTSD was troubling to him. His sleep patterns were irregular and his nightmares haunted him on a regular basis. Oftentimes they would cause him to wake up and not want to fall back asleep. He no longer enjoys camping in a tent because being out in the wilderness triggers flashbacks of the war zone. Garbage bags and trash on the sides of the road are triggers as well because they were a common hiding place for roadside bombs. His PTSD has negatively affected the relationship with his current wife and his three children, though he did not care to discuss that in more detail. He added that the degree to which people suffer from PTSD varies greatly (C. Pupek, personal communication, April 1, 2014). His testimony of his experience of life with PTSD after the Iraq War gives a better understanding of the extent to which this disorder impacts a veteran’s daily life and indicates there is a negative influence on the lives of their families as well.
Support Offered by US Government to Iraq War Veterans with PTSD
The US Department of Veteran Affairs developed a guide for military personnel, Returning from the War Zone (2009), to ease the transition from the battlefield to their everyday home life. It begins with a thank you and an explanation of how their deployment benefited their country and themselves. It discusses common reactions the soldier should expect following the trauma of war, the experiences they are likely to encounter at home, positive ways to cope with the transition, signs to watch for to know if they need outside assistance, and locations to obtain the services. It covers the likelihood of a veteran developing PTSD and covers the red flags indicating they may be suffering from the disorder, and what they should do if they are experiencing those symptoms. There is also a short and simple PTSD Screening Test included in the guide that assists veterans with determining whether PTSD is a potential concern for them. It also shares personal stories of other military personnel who suffer from PTSD and addresses the stigma associated with having mental health issues. The guide makes it clear that having a mental health problem does not mean they have a weakness (United States Department of Veteran Affairs, 2009, p. 1, 9, 10, 11). This guide is an attempt by the VA to reach out to the veterans at risk for PTSD.
In some cases, the VA offers compensation to veterans suffering from PTSD. In their article in the PTSD Research Quarterly, (2011), Marx and Holowka discuss how the VA offers disability compensation. They go in depth to discuss the issue of compensation seekers which is a common stereotype in returning Iraq war veterans who are suffering from Posttraumatic Stress Disorder (PTSD). In one section, they discuss the exaggeration of PTSD symptoms by returning war veterans but the compensation has no impact on whether or not they will seek treatment for it. Marx and Holowka explain:
Even among other decidedly subjective mental disorders, PTSD is a condition that is especially likely to be exaggerated. Importantly, though, service-connected PTSD was no more common among Veterans who exaggerated symptoms than it was among Veterans who did not exaggerate. This finding is inconsistent with the hypothesized negative impact of VA psychiatric disability policies (p.3)
In other words, Marx and Holowka are trying to point out that even if a veteran is exaggerating their symptoms, it does not mean that they will not receive treatment for PTSD even if they do not meet the standard for compensation for the disability.
The VA and the Department of Defense developed The Iraq War Clinician Guide as an aid for clinicians specifically treating veterans returning from the war in Iraq and Afghanistan. In Chapter 4 of The Iraq War Clinician Guide (2004), Treatment of the Returning Iraq War Veteran, Brewin et al. discuss the various approaches that have been developed for treating veterans returning from Iraq that are diagnosed with PTSD. The methods of care according to this chapter are education about post-traumatic stress reactions, training in coping skills, exposure therapy, cognitive restructuring, family counseling, early interventions for Acute Stress Disorder (ASD) or PTSD, toxic exposure, physical health concerns, and mental health, family involvement care, outpatient treatment, residential rehabilitation treatment, and pharmacologic treatment. Brewin et al. emphasize:
There are a variety of differences between the contexts of care for active duty military personnel and veterans normally being served in VA that may affect the way practitioners go about their business. First, many Iraq War veterans patients will not be seeking mental health treatment. Some will have been evacuated for mental health or medical reasons and brought to VA, perhaps reluctant to acknowledge their emotional distress and almost certainly reluctant to consider themselves as having a mental health disorder (e.g., PTSD) (p.33).
This shows that the US government is taking care to ensure their active duty military and veterans are receiving mental health treatment. It also demonstrates that a stigma does exist in the military regarding veterans diagnosed with PTSD and especially for receiving treatment for it.
The outline of the treatment provided by the VA specifically for PTSD, located in Chapter 7 of the Iraq War Clinician Guide (2004), PTSD in Iraq War Veterans: Implications for Primary Care, provides clinicians with a standard procedure when working with these clients. Prins, Kimerling, and Leskin discuss the importance of informed clinicians regarding what PTSD is and how it affects the clients they will be treating. It also touches on the importance of using assessments when treating their clients. The chapter suggests primary care practitioners should know two things. They should know their patients want primary care providers to acknowledge their traumatic experiences and responses. Also, they should know how to detect and effectively manage PTSD in primary care settings. A primary care provider should determine the patient’s status in relationship to the war, acknowledge the patient’s struggles, and assess for PTSD symptoms, be aware of how trauma may impact on medical care. There is also a procedure to follow in case a patient demonstrates symptoms of PTSD in the middle of a medical examination (p.58-60). Kimerling et al. noted, “Because far fewer people experiencing traumatic stress reactions seek mental health services, primary care providers are the health professionals with whom individuals with PTSD are most likely to come into contact” (p.58). Kimerling et al. are emphasizing that there is treatment available for Iraq War veterans but fewer soldiers are taking advantage of it.
Conclusion
Iraq War Veteran, Christopher Pupek, disclosed that he had an overall positive experience when dealing with the VA but he also has a few ideas about what the VA should do differently to help veterans suffering from PTSD. He noted it still suffers from bureaucratic woes of federal agencies such as having long waits for and between appointments and there is no urgent care clinic for veterans. He says living in Sault Ste. Marie, MI, driving 225 miles to Iron Mountain, MI is a pain in the neck. He also feels there should be more extensive counseling and psychiatric options for veterans and a better way to address the issues of stigma. He believes the VA should provide more awareness programs to friends and family. He used to be an Iraq War veteran who refused to accept he had PTSD due to the stigma associated with it. He stated that when he did finally accept it, he felt enlightened, like a weight lifted off his shoulders (C. Pupek, personal communication, April 1, 2014).
Other issues with the treatment provided by the US Government for veterans suffering from PTSD include compensation and a lack of assessment use. In their article in the Research Quarterly (2011), PTSD Disability Assessment, Marx and Holowka argued:
With so many evidenced-based assessment tools available, clinicians have no legitimate excuse for not using them in their practice. This is particularly the case in PTSD C&P examinations, where the use of reliable and valid instruments may mean the difference between whether or not a Veteran obtains compensation for his or her PTSD. Despite the wide availability of evidence-based assessment tools and what may be at stake in these examination, the available research suggests that many PTSD C&P examiners do not use such instruments (p. 1).
Marx and Holowka do well to point out the flaw with compensation and have discovered where the problem exists. By simply utilizing the tools already available, a better system for determining who receives compensation or not is born.
The most prevalent issues in dire need of attention are the stigma associated with both the diagnosis of PTSD and with receiving treatment. In their article in Psychological Services (2009), Treatment Presentation and Adherence of Iraq/Afghanistan Era Veterans in Outpatient Care for Posttraumatic Stress Disorder, Erbes et al. report, “There are high levels of perceived stigma among returning soldiers” (p.176). One study published in Health & Medicine Week noted, “The Rand report recommends the military create a system that would allow service members to receive mental health services confidentially in order to ease concerns about negative career repercussions” (“Study”, 2008). Another article published in the New England Journal of Medicine (2004), Combat Duty in Iraq and Afghanistan, Mental Health Problems, Barriers to Care by Hoge et al. suggests something similar:
Efforts to address the problem of stigma and other barriers to seeking mental health care in the military should take into consideration outreach, education, and changes in the models of health care delivery, such as increases in the allocation of mental health services in primary care clinics and in the provision of confidential counseling programs by means of employee-assistance programs (p.21).
An agreeable solution to reduce the pressure stigma places on veterans returning from the Iraq War who suffer from PTSD in need of receiving treatment would be to move the mental health services into a more confidential and discreet clinic while also educating the public.
In conclusion, PTSD is a major issue for veterans returning home from the Iraq War. It changes the lives of not only the veteran diagnosed with the disorder but also their families. The US Government is attempting to assist with treatment for those who are suffering from this disorder; however, there is room for improvement. The current stigma associated with veterans diagnosed with PTSD and who seek treatment for it is of great concern. A possible solution is to create a more confidential clinical setting for treatment and to raise awareness by educating the public on mental health disorders. As stated in Returning from the War Zone, “Mental health problems are not a sign of weakness. The reality is that injuries, including psychological injuries, affect the strong and the brave just like everyone else” (United States Department of Veteran Affairs, 2010, p.9). PTSD affects the way people live and treatment is a necessity. Reducing the stigma attached is essential to open the door for veterans suffering from PTSD to receive the treatment they need.
References
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