During the years and decades ahead, it will be imperative for the United States to provide for the wide array of complex and intensive mental health care needs of the nation?s returning military veterans. This article will attempt a brief summary of the scope and variety of mental health issues presently impacting combat veterans of the United States military, An effort will be made to assess the psychological and psychosocial challenges confronting our veterans after they return from combat theaters. After a brief discussion of the programs most commonly providing mental health care and therapeutic services to veterans and their families, two promising, recently established advocacy organizations working to improve mental health services for veterans will be examined. Attention will be paid to the roles that social workers ¨C as clinicians, organizers and advocates ¨C can play in addressing the urgent and often unmet needs of the nation?s veterans.
¡°. . . let us strive on to finish the work we are in, to bind up the Nation?s wounds, to care for him who shall have borne the battle and for his widow and his orphan . . . .¡±
©\©\ Abraham Lincoln, Second Inaugural Address, Saturday, March 4, 1865.
¡°A man who is good enough to shed his blood for his country is good enough to be given a square deal afterwards. More than that no man is entitled to, and less than that no man shall have.¡±
©\©\ Teddy Roosevelt, 1903
At the time of this writing, approximately 120,000 and 45,000 active duty soldiers are deployed to the theaters of war in Iraq and Afghanistan, respectively. Despite affirmations made by President Obama during his presidential campaign, there is no valid basis for believing that all combat troops will be redeployed from Iraq in the near future. The President has already begun delivering on his campaign promise to increase troop levels in Afghanistan, and the Department of Defense has committed 20,000 additional troops to that conflict in coming months in an attempt at an Afghan ¡°surge.¡±
The number of veterans who have already completed their tours of duty in both conflicts is large and rising: Since 2002, more than 1.7 million members of the U.S. armed forces have served in an active duty capacity in the Iraq and Afghanistan wars. It will be imperative during the years and decades ahead for the United States to maintain a public mental health infrastructure sufficiently and capably equipped to deal with the ongoing, multiple, complex and intensive mental health care services our veterans will certainly require.
This paper will attempt a brief summary of the scope and variety of mental health issues presently impacting combat veterans of the United States military, with a particular focus on Post Traumatic Stress Disorder (PTSD). An effort will be made to assess the psychological and psychosocial challenges confronting our veterans both as they depart for, and after they return from, combat theaters. A limited analysis will then be ventured of the efficacy, and potential areas of improvement, of the programs most commonly providing mental health care and therapeutic services to veterans and their families. Finally, the work of two promising, recently established advocacy organizations striving to improve mental health services for veterans will be examined in some detail.
As war is inherently horrifying and shocking, soldiers involved in war inevitably experience trauma of some variety. While human beings ¨C especially men ¨C appear to be ¡°designed¡± for combat and possibly possess an innate taste for extreme violence and killing, the actual experience of warfare is profoundly psychologically damaging to the many who have been exposed to, or who have engaged in, it. A small minority of soldiers and combat veterans may deeply enjoy mortal combat on the battlefield, and be gratified by the infliction of harm or even death on other human beings. Those veterans are not the focus of this paper, and it would likely prove difficult to empirically support such a speculative, provocative claim.
The battlefield offers endless opportunities for soldiers to sustain psychological and emotional shocks and wounds. Yet perhaps the most damaging element of warfare is its capacity to undermine a person¡¯s general sense of security and safety at any given moment. This overall, everyday sense of safety and security ¨C that it is safe to walk down the street to a subway station, or that a fellow subway passenger does not, in fact, have a bomb vest hidden beneath his sweater, or that the destination the subway is transporting you to is not laden with mines and explosives and/or populated by fanatical adversaries willing to commit suicide in order to end your life as well, etc. ¨C is a kind of ¡°prerequisite¡± for normal and adaptive psychological functioning and participation in the social order. In the absence of this overall sense of security, an individual can live in a nightmarish state of acute, constant fear of looming physical danger and threats, a state in which an apprehension of imminent risk or even death never relents and can never be alleviated. This shifting of the normal, daily experience of an individual from a secure to an insecure, vulnerable state is the most widely observable consequence of participation in warfare by soldiers and veterans. PTSD is rooted in this loss of a fundamental sense of security and safety, and in the consequent shifting of daily experience from a secure to an insecure state.
As William Tecumseh Sherman memorably phrased it, ¡°war is hell.¡± The Roman poet Virgil captured the impenetrability of that private hell to those who have personally and directly endured the horrors of warfare ¨C an impenetrability of which caregivers aspiring to treat the ¡°invisibly wounded¡± would be well advised to be cognizant and respectful ¨C when he said that ¡°each of us bears his own hell.¡± According to a major recent study conducted by the RAND Institute, some 20% of combat veterans who have returned from Iraq and Afghanistan are already bearing their own hell, as evidenced by their suspected suffering from PTSD, depression, and general anxiety disorder (Tanelian & Jaycox, 2008, p. 96). Based on the above©\cited 1.7 million total number of soldiers who have rotated through Iraq and Afghanistan since 2002, roughly 340,000 cases of PTSD and related conditions have either been diagnosed already among, or are presumed to be warranted for, returning combat veterans.
Even more disturbing is the RAND report¡¯s conclusion that half of those troops and veterans affected are not receiving proper mental health care. Furthermore, physiological conditions such as concussions and Traumatic Brain Injury, conditions that are highly comorbid with PTSD and depression, are likewise not being properly diagnosed and treated. The present reality is that tens of thousands of new veterans returning home every year are suffering from mutually reinforcing psychological and brain injuries, which are diagnosed and treated only half of the time. In addition to PTSD, a high number of returning veterans are suffering from undiagnosed and untreated major depression, anxiety disorders, increased substance abuse, a heightened vulnerability to physical ailments, and are generally unable to reintegrate into the social order. This is a moral outrage and constitutes a social policy failure of great magnitude.
There are a number of reasons for this massive failure of public mental health care systems. First and most obvious, longstanding, deeply ingrained stigmas associated with seeking mental health care and being treated for mental health conditions persist, especially in the culture of the military. The RAND study found that many of the interviewed service members actively and intentionally avoided subjecting themselves to clinical assessments and care that they believed would have resulted in a mental health disorder diagnosis. A substantial body of research bears out the commonsense claim that ¡°stigma impedes people from seeking and fully participating in mental health care services. In particular, the threat of social disapproval and diminished self©\esteem that accompanies the label accounts for underused services¡± (Corrigan, 2004). There is every reason to suspect that military©\cultural factors render soldiers and veterans even more susceptible than members of the general public to the adverse and inhibiting effects of stigma.
A major study was published in the New England Journal of Medicine in 2004 which, to date, represents the most comprehensive examination of the barriers to proper mental health care faced by both active duty and returning combat veterans. Study participants who met screening criteria for a major mental health disorder were asked what they believed to be the most significant barriers to their receiving mental healthcare. The fear of being perceived as ¡°weak¡± and a fear of losing the trust and confidence of their colleagues were the leading reported barriers (Hoge et. al, 2004, p.17).
Nearly as commonly, respondents felt that integrating a mental healthcare treatment regimen into their lives and schedules would be a significant challenge. A majority of respondents believed that accessing appropriate treatment would hinder their ability to execute their duties and responsibilities, and there is no good reason to believe that their concerns were groundless. This implies that the military¡¯s own systems of mental health care are not adequately integrated into their total provision of healthcare for service members. The military is simply not well prepared for the virtually certain contingency that a large share of combat soldiers will sustain mental health injuries. The healthcare service delivery mechanisms maintained both by the service branches and by the Veterans Administration simply have not integrated mental healthcare preparedness as well as they ought to. Whether this is a greater barrier to care than an excess of caution in receiving potential treatment born of careerist caution remains to be seen.
A remarkable advocacy organization called Iraq and Afghanistan Veterans of America (IAVA) was founded in 2004 by Paul Reickhoff, an Iraq War veteran. Its mission is stated simply: to improve the lives of Iraq and Afghanistan veterans and their families. While IAVA is only five years old, it has had significant success in impacting policy discussions and heightening awareness among policymakers and in the media of the multiple challenges facing new veterans as they return from the battlefield. IAVA places a particular emphasis on the need to publicize and destigmatize the discussion of mental health and Traumatic Brain Injury and the urgent need to increase mental health screening and support services among active duty soldiers as well as veterans.
IAVA maintains an extensive website which provides clear, easy©\to©\access information regarding how to attain mental and physical healthcare services and how to navigate the VA most effectively. The website also allows interested parties to easily contact local, state and federal political representatives on behalf of veterans, and the IAVA is building a rapidly growing lobbying presence in Washington D.C. The most ambitious element of IAVA¡¯s legislative agenda is a new GI Bill which would substantially increase educational benefits for service members, sufficient and reliable funding of veterans¡¯ health care, and mandatory, confidential mental health counseling for all troops returning from combat duty (IAVA 2008 Annual Report, p.6). This last element of the proposed new GI Bill reveals IAVA¡¯s explicit goal of placing mental health care for veterans at the heart of its mission and reflects its view that mental health care is inseparable from the overall welfare of returning veterans and their families, and needs to be consistently addressed in a public, open manner.
In recent years, suicide rates have increased markedly among active duty soldiers and veterans returning from Iraq and Afghanistan. IAVA has brought much©\needed media and legislative attention to this highly sensitive issue. In 2007, the organization succeeded in advancing the Joshua Omvig Suicide Prevention Act, which passed both houses of Congress unanimously. The Act was named after Joshua Omvig, an Army private who took his own life shortly after returning from Iraq in 2006. Although he was suffering from PTSD, his family¡¯s attempts to get him the mental health care he desperately needed were fatally stymied by difficulties with navigating the VA bureaucracy. The legislation mandates increased suicide preventions training for VA employees as well as a 24©\hour suicide prevention hotline for troops. IAVA also recently called attention to the alarming spike in suicides at the Fort Campbell Army base in Kentucky, where troops had been taking their own lives at more than three times the rate at which they were dying in combat. While the Army it©\ self claims to have proposed a ¡°stand©\down¡± at Fort Campbell prior to the popularization of the story in the news media, there is good reason to believe that IAVA¡¯s relentless raising of the story hastened the Army¡¯s attempt at corrective action.
IAVA appears to be a model of civic activism and community organization in the age of the internet and the hypermodern news media. By advocating for issues of unquestionable moral relevance in a highly public and publicized manner, IAVA has been extremely effective in moving political and governmental figures to action. IAVA has leveraged the by©\now clich¨¦d political commitment to ¡°support the troops¡± into concrete action and meaningful reform on behalf of veterans, reform which has normally failed to follow the public pronouncements of bureaucrats and politicians. Particularly striking is the group¡¯s willingness to address in such a public, relentless manner issues of veterans¡¯ mental health and the crucial need to eliminate the barriers of stigma and shame that so often block the recognition and appropriate treatment of mental health conditions among veterans.
Give an Hour is another advocacy organization that has been founded to provide mental health support services to returning veterans. Its mission is to ¡°provide free mental health services to U.S. military personnel and their families affected by the current conflicts in Iraq and Afghanistan.¡± Give an Hour operates under the assumption that current mental health care efforts undertaken by the service branches and the VA are quite extensive and are actually improving in response to increasing need. Its intention is to supplement existing services and fill in gaps where necessary, not to radically reform or restructure the provision of mental health care to veterans. Give an Hour is not a quasi©\political advocacy group with an active lobbying agenda or a stated interest in effecting macro©\level policy change. Rather, its purpose is to match the voluntarily provided services (usually the ¡°hour¡± of therapy suggested by the organization¡¯s name) of mental healthcare providers such as social workers, psychiatrists, and psychologists with veterans in need and their families.
Give an Hour¡¯s aim is to facilitate the provision of clinical, psychotherapeutic services to those who otherwise have been unable to secure them or who are in need of additional assistance. It is achieving this aim by ¡°developing national networks of volunteers capable of responding to both acute and chronic conditions¡± and its volunteer providers are able to treat conditions such as ¡°anxiety, depression, substance abuse, post©\traumatic stress disorder, traumatic brain injuries, sexual health and intimacy concerns, and loss and grieving.¡±
Give an Hour is similar to IAVA in that it operates primarily through its website. The Give an Hour website is the first point of contact for providers intending to volunteer their services, for potential recipients of care, and for donors and other interested parties wishing to assist the group in the carrying out its mission. Potential recipients can search for providers based on location or area of specialization, or both. Give an Hour also links to existing VA, service branch and public health sources of mental health care, and, like IAVA, it attempts to help veterans understand just what benefits they are entitled to, as well as how to access them. Give an Hour is quite distinct from IAVA, however, in that it does not appear to aspire to grow as an advocacy group lobbying for social change, and its agenda is clinical, not political, in nature. Its goal is to serve as a kind of ¡°meeting point¡± for volunteer providers and veterans in need of care; its mission is realized when caregiver and patient are connected and are no longer interacting in a way directly facilitated by the organization.
While IAVA and Give an Hour have very different goals and organizational approaches and ambitions, they have both arisen in response to growing mental healthcare needs of our nation¡¯s veterans and their families, needs which are not always being served or even addressed by the institutions designed to do so. Both advocacy groups effectively harness the power of the internet, and both originated outside of the realms of policymaking and official power. These facts give hope and even optimism to those who would aspire, in an increasingly internet©\driven world, to intervene meaningfully on behalf of veterans and their families.Veterans will continue to require outside assistance in order to attain the ¡°square deal¡± they are entitled to. In a more justly ordered society, perhaps they would not have to remind the rest of us either of their hard©\earned entitlements or of our own obligations, as President Obama said on Memorial Day 2009, ¡°to serve our nation¡¯s veterans as well as they have served us.¡±
Benedek, D. M., & Ursano, R. J. (2009). Posttraumatic stress disorder: From phenomenology to clinical practice. Focus 2009 7: 160©\175.
Benedek D. M. & Ursano, R. J. (2008). Exposure to war as a risk factor for mental disorders. Public Library of Science and Medicine 5(4): e82. doi:10.1371/journal.pmed.0050082
Corrigan, P. (2004, October). How stigma interferes with mental health care. American Psychologist, 59(7), 614©\625.
Hoge C. W., Castro C. A., Messer S. C., McGurk, D. Cotting, D. I. & Koffman, R. L. (2004). Combat duty in Iraq and Afghanistan, mental health problems, and barriers to care. New England Journal of Medicine, 351, 13©\22.
Tanielian, T. & Jaycoxx, L.H. (2008) Invisible wounds of war: Psychological and cognitive injuries, their consequences, and services to assist recovery. Santa Monica, CA: RAND Institute http:/www.rand.org/pubs/monographs/MG720/
Iraq and Afghanistan Veterans of America. (2009) IAVA 2008 annual report. Retrieved November 21, 2009, from http://iava.org/files/IAVAAnnualReport.pdf
Give an Hour.(2010). Give help. Give hope. Retrieved November 20, 2009 from http://www.giveanhour.org/skins/gah/home.aspx.
About the Author
David Shernoff is a graduate of Oberlin College, where he majored in English and Philosophy. During his first year at HCSSW he interned with a criminal justice nonprofit, advocating for alternatives to incarceration for nonviolent criminal offenders struggling with mental illness and substance abuse issues. During his second year field placement, he provided individual and family counseling to clients coping with terminal illnesses. His major method at HCSSW is Clinical Practice with Individuals and Families. Mr. Shernoff can be reached at email@example.com.