Ulrich Schnyder and Marylène Cloitre (eds.)Evidence Based Treatments for Trauma-Related Psychological Disorders10.1007/978-3-319-07109-1_22

22. Considerations in the Treatment of Veterans with Posttraumatic Stress Disorder

Shannon E. McCaslin¹, Jessica A. Turchik^{2, 3} and Jennifer J. Hatzfeld⁴

(1)

Dissemination and Training Division, National Center for PTSD, VA Palo Alto Health Care System, 795 Willow Road, Menlo Park, CA 94025, USA

(2)

Center for Innovation and Implementation, VA Palo Alto Health Care System, 795 Willow Road, Menlo Park, CA 94025, USA

(3)

National Center for PTSD, VA Palo Alto Health Care System, 795 Willow Road, Menlo Park, CA 94025, USA

(4)

Defense Medical Research and Development Program, Combat Casualty Care Research (JPC-6), MCMR-RTC, 504 Scott St, Building 722, Fort Detrick, MD 21702, USA

Shannon E. McCaslin (Corresponding author)

Email: Shannon.McCaslin@va.gov

Jessica A. Turchik

Email: Jessica.Turchik@va.gov

Jennifer J. Hatzfeld

Email: jennifer.j.hatzfeld.mil@mail.mil

22.1 Introduction

The soldier is the Army. No army is better than its soldiers. The soldier is also a citizen. In fact, the highest obligation and privilege of citizenship is that of bearing arms for one’s country. – George S. Patton Jr.

Military service requires a commitment of service to one’s country, motivated by very different passions which can range from the most patriotic to the most pragmatic. However, regardless of the reason a service member decides to enter military service, this commitment also demands a willingness to place oneself in situations that can mean exposure to unique stressors and traumas. As such, service members, particularly those who serve in combat, are at higher risk to experience potentially traumatic events. Traumatic events experienced while serving in the military may include not only exposure to combat and other life-threatening situations but also incidents that occur during rigorous training and interpersonal violence (e.g., military sexual harassment or assault). In turn, greater trauma exposure can place service members at increased risk for the subsequent development of stress-related mental health difficulties such as posttraumatic stress disorder (PTSD), depression, and alcohol misuse. The majority of studies examining the prevalence of PTSD among veterans have sampled those exposed to combat. Estimates of current PTSD prevalence in national samples have included 15.2 % of males and 8.1 % of females among veterans who served in the Vietnam War (Kulka et al. 1990), 10.1 % among those serving in the Gulf War (Kang et al. 2003), and 13.8 % among veterans of Operations Iraqi Freedom (OIF) and Enduring Freedom (OEF; Tanielian and Jaycox 2008). Veterans with PTSD have reported greater interpersonal disturbances (e.g., Koenen et al. 2008), lower occupational functioning (e.g., Zatzick et al. 1997), and reduced quality of life (e.g., Schnurr et al. 2006).

Delivering high-quality treatment to veterans with PTSD and other trauma-related conditions requires awareness not only of evidence-based treatment practices but also of military-related stressors and the underlying military cultural context in which they occur. In this chapter, we aim to provide the clinician with a greater understanding of military-related stressors and increased insight into the military cultural context. Important aspects of the military experience are introduced, and additional resources are provided so that the clinician can learn more about each topic. Please note that the majority of our review and recommendations are grounded largely in the experience of US military service and veteran care.

22.2 Military Culture and Context

It can be argued that the military is a distinct culture, made up of a unique set of values, beliefs, and cultural rules. For example, service to community and country, courage, integrity, and loyalty are among core values. There is also a shared sense of purpose, and a fostering of strong bonds among service members. Service members begin the process of learning about this culture in basic training and become acculturated to various degrees. The degree to which a veteran continues to identify with military culture following separation from the military can influence how mental health symptoms are experienced and reported to the clinician. Hoge (2011) recognized this meeting of cultures by stating that the clinician should meet veterans where they are, literally and figuratively, in terms of culture. Separation from the military and transition back into the civilian setting can be challenging, even apart from stressful or traumatic experiences that may have been experienced while serving.

Recognizing sources of transitional stress in veterans can be an important part of an initial assessment. For example, factors such as whether individuals worked in the civilian sector prior to or after the military, if they are separating, retiring, or remaining connected in a reserve status, whether the separation from the military was planned or involuntary, and how well the job that the veteran had in the military translates to civilian work can all influence the ease of transition from the military context to civilian context. Additionally, military service-related achievements, experience, and recognition—easily seen on a uniform in medals and ribbons—become “invisible” in the civilian context. Rank and organizational hierarchy, clearly identified and articulated in the military setting, are less evident to the military member and may be difficult to navigate without understanding the unique cues and social norms in a civilian context. Another potential source of transitional stress involves the loss of social support from other service members. Social bonds with other service members can be extremely deep, and the loss of camaraderie and proximity of these relationships can be understandably difficult.

Treatment engagement and rapport with veteran clients can be improved by taking the time to learn about military culture. Unlike many other countries, the USA currently has an all-volunteer military, and those who serve make up a small minority of the population. Thus, civilian providers may not have had exposure to the military and may not have a deep understanding of military culture or context. In countries that require most civilians to serve within some component of the military for a period of time, there may be a deeper sense of connection with the veteran’s military experience. Further, veterans vary broadly in their perceptions of their military service. For example, some will perceive their military service positively, whereas others may report more negative experiences and little to no continued positive identification with military culture. Thus, it is important to thoughtfully engage the veteran in conversation about their unique military experience and perceptions of their service. Respect for each individual’s experience can be conveyed through sensitively inquiring about the veteran’s military experiences such as their role and job, and whether they served in combat or not. Time in session should be dedicated to understanding their overall experience. At the end of this chapter, we provide links to resources that can help the treating clinician become more familiar with key values and beliefs of military culture and logistical and organization aspects of the military.

22.3 Combat Service

We few, we happy few, we band of brothers. For he to-day that sheds his blood with me, Shall be my brother; be ne’er so vile, This day shall gentle his condition; And gentlemen in England now a-bed, Shall think themselves accurs’d they were not here, And hold their manhoods cheap whiles any speaks, That fought with us upon Saint Crispin’s day. – William Shakespeare (Henry V, Act IV, III)

As mentioned previously, there are various types of stressors that a service member may experience, including intense training and deployment experiences. Deployments are not limited to the direct support of combat operations and may include supportive roles well outside of the combat zone as well as humanitarian missions and actions. However, we focus on combat exposure in the next section because of the intense and often profound psychological impact of combat service. Combat stressors may include life-threatening situations, physical injury, witnessing death and dying, experiencing injuries and losses of comrades, and participating in actions that result in the injury or death of another. Additional factors that can compound these combat stressors include periods of intense action and long work hours interspersed with inactivity and downtime, separation from usual coping mechanisms or support systems, and a loss of control over the situation or environment.

Combat exposure has been associated with higher rates of PTSD, depression, and alcohol misuse (Hoge et al. 2004; Kulka et al. 1990; Kang et al. 2003). Post-deployment PTSD rates were found to vary between 11 and 22 % among veterans of OEF and OIF (Hoge et al. 2004; Seal et al. 2009). Length of deployment and higher level of combat exposure have been found to increase risk for PTSD (Schell and Marshall 2008). Among the many stressors that can be experienced in the combat environment, the consequences of losing comrades and of facing situations which conflict with one’s deeply held beliefs and values are profound but often less addressed in traditional treatments for combat-related PTSD.

22.3.1 Grief and Loss

Many veterans who served in combat have experienced the sudden loss of comrades and continue to experience powerful symptoms of grief years later. Studies of US Army soldiers and marines who had deployed to Iraq and Afghanistan found that between 63 and 80 % of those surveyed knew someone who had been seriously injured or killed and 20–25 % experienced having a buddy shot or hit nearby (Thomas et al. 2010; Hoge et al. 2004; Toblin et al. 2012).

Strong bonds formed during training and combat and a sense of responsibility for the well-being of one’s comrades can result in losses that deeply impact veterans who have survived combat (Papa et al. 2008). Among one sample of soldiers who had experienced the loss of a comrade, approximately 20 % reported difficulty coping with symptoms of grief (Toblin et al. 2012). In another study of 114 veterans who had served in combat during the Vietnam War, those who reported losses of comrades while serving reported a high level of grief symptoms (Pivar and Field 2004). Strikingly, the authors observed that the level of grief symptoms reported by the veterans was comparable to that endorsed by individuals who had experienced the death of a spouse within the past 3–6 months. Moreover, it was clear that grief symptoms could be distinguished from PTSD and depression symptoms and were most predicted by the losses themselves. Difficulty coping with such losses has also been associated with poorer physical health, occupational functioning, sleep disturbance, fatigue, and pain—including musculoskeletal and back pain and headaches (Toblin et al. 2012). Grief for the loss itself can be complicated by feelings of guilt about surviving when comrades did not or feelings of self-blame related to the belief that the service member or veteran could have prevented the death (Currier and Holland 2012).

In summary, symptoms of grief can remain unresolved, endure for decades (Pivar and Field 2004), and uniquely impact functioning (Toblin et al. 2012). Losses of comrades should be assessed and attended to in the same manner as one would assess traumatic experiences involving the death of a family member or close friend of a nonveteran client. For more information on the assessment and treatment of traumatic or complex (prolonged) grief, please see Chap. 15.

22.3.2 Moral Injury

Moral injury is a construct that has been increasingly researched during the past decade. It refers to psychological injury resulting from participating in, witnessing, or learning about events during war that violate the service member or veteran’s deeply held values or moral beliefs about themselves and humanity (Currier et al. 2013; Litz et al. 2009). The types of experiences that may result in moral injury are broad and include betrayal by leadership or peers, betrayal of one’s own values, inability to prevent harm to others, injuring or killing enemy combatants or civilians, witnessing or experiencing atrocities (e.g., inhumane acts), and facing ethical dilemmas (Currier et al. 2013; Stein et al. 2012).

Recent surveys have attempted to quantify the numbers of service members that have been exposed to such situations while serving in Iraq and Afghanistan. Among US Army soldiers and marines who served in Iraq and Afghanistan, 23–32 % reported being responsible for the death of an enemy combatant, 48–60 % reported seeing ill or injured women or children whom they were unable to help, over 50 % reported shooting or directing fire at the enemy, and over 5–9.7 % endorsed being responsible for the death of a noncombatant (Thomas et al. 2010; Hoge et al. 2004). Perception of betrayals from military leaders and of their own personal values, overly harsh treatment of civilians, and guilt about surviving combat were found to be the most endorsed items on a moral injury self-report measure among a sample of veterans who had served in Iraq and/or Afghanistan (Currier et al. 2013).

Studies have found greater PTSD symptoms among veterans who have injured or killed others during their combat service, after accounting for other combat exposure and stressors (Currier et al. 2013; Maguen et al. 2010, 2013; Litz et al. 2009 for review). One study indicated that certain categories of events may be more associated with specific clusters of PTSD symptoms. In this study, morally injurious events committed by self were the best predictor of reexperiencing symptoms, whereas those related to acts of others (such as betrayal or enemy violence) predicted state anger (Stein et al. 2012). Other psychological consequences related to morally injurious experiences include emotional responses, such as guilt and shame, and spiritual or existential concerns (e.g., loss of meaning, struggles with one’s religious beliefs; Currier et al. 2013).

Psychological reactions related to morally injurious events such as guilt appear to be more likely to arise following an event versus during it, and it has been suggested that having time to reflect on and process the event may precede the development of some emotional reactions (Stein et al. 2012). The way in which the event is cognitively processed is the core component of the framework for understanding the cause and development of moral injury put forth by Litz et al. (2009). Key to this framework is the thesis that the individual is unable to contextualize or justify their own actions or those of others and that these experiences are not able to be successfully accommodated into preexisting moral schemas. This conflict then results in emotional responses, such as guilt or shame. Interestingly, a recent study reported that moral injury acts committed by self were related to the guilt-related constructs of hindsight–bias/responsibility and wrongdoing, but were not related to lack of justification (Stein et al. 2012). These findings suggest that service members may be able to understand the underlying rationale and context for their actions and simultaneously experience feelings of guilt.

Although the importance of addressing the impact of these types of experiences has been stressed (Currier et al. 2013), events with moral and ethical implications may not be given sufficient attention during a course of mental health treatment due to both clinician and veteran factors (Litz et al. 2009). Clinicians may not feel prepared to address what can be complex existential and spiritual questions, or they may be focused on other areas of the veteran’s experience (e.g., experiences related to life threat). Veterans may hesitate to discuss actions by self or others that are related to feelings of guilt or shame and may be concerned about the potential reaction by the clinician (e.g., rejection, being misunderstood; Litz et al. 2009). Furthermore, some veterans may have fears of legal ramifications for themselves or others. Currier et al. (2013) suggested that these fears may limit the information provided to the clinician in response to questions that are specifically directed at the violation of rules of engagement, participation in atrocities, or other similar types of experiences and thus recommend exploring these topics within the bounds of a broader assessment.

Routinely assessing for these experiences can increase the likelihood that they will come to light and enable them to be addressed during the course of treatment. Such assessment and discussion should be done sensitively and can be guided by recently developed assessment instruments such as the Moral Injury Events Scale (Nash et al. 2013) and the Moral Injury Questionnaire—Military Version (Currier et al. 2013). Whereas clinicians should always provide the space and encouragement for veterans to share traumatic experiences, veterans may wish to share only limited information initially. Clinicians should be sensitive to a veteran’s discomfort and allow him or her to determine the pace of any disclosures. Litz et al. (2009) proposed an eight-step treatment to address moral injury. This treatment touches on central components for processing such experiences, including components focused on strengthening the working alliance, providing education, important concerns such as self-forgiveness and social connection, and setting future goals. When appropriate, veterans struggling with spiritual or existential issues related to such experiences may benefit from referral to other services such as those of a chaplain or spiritual leader.

22.3.3 Considerations for Treatment

Civilian clinicians who have limited experience working with service members or veteran clients may question whether they will be able to connect with or be accepted by the veteran. On the contrary, when speaking with clinicians, they often report that they are not only able to build strong therapeutic connections but also find the opportunity to serve veterans through providing treatment to be extremely rewarding. There are steps that the clinician can take to strengthen rapport, trust, and engagement in treatment. Analogous to working with other individuals from a different culture, it is important to learn about the military and veteran population. Conveying an interest in and understanding of the aspects of military culture demonstrates respect, can strengthen the therapeutic relationship, and can improve treatment formulation. Whenever possible, treatment providers should seek out training and information to increase their knowledge of military culture.
In addition to gaining familiarity with military culture, it is essential to set aside stereotypes and assumptions about what it means to be veteran or to serve in combat. As noted earlier in the chapter, there is much variation among the veteran population including differences in reasons for joining the military, how veterans perceive or feel about their service, and their military assignments and experiences.
In preparing to work with service members and veterans, clinicians should consider conducting a personal assessment of their beliefs and potential limits. For example, will one be able to set aside one’s beliefs and judgments about war and politics, and how might one respond to or what is the extent to which one can tolerate themes that may arise in treating combat veterans such as gallows humor or situations involving moral ambiguity (e.g., inadvertently harming civilians in the context of combat)?
Due to the great variation in experiences among veterans, the importance of a sensitive and comprehensive assessment cannot be overstated. For veterans that have served in combat, factors such as combat operation and era of service as well as individual characteristics such as the veteran’s branch of service, job, and rank while serving may all influence the experiences and presentation of the veteran seeking treatment. Providing ample time for the veteran to share his or her personal experience can be critical to inform the direction of treatment. Sensitive experiences, such as those involving grief for fallen comrades and moral ambiguity, can be more difficult to share, accentuating the need to allow adequate time to develop a solid and trusting therapeutic relationship.
The need for multidisciplinary care should be recognized. Veterans should be screened not only for comorbid mental health conditions but also comorbid physical health conditions and referred appropriately. For example, the physical demands of military service (e.g., physical training, combat injuries) can lead to chronic pain. Among a sample of 1,800 veterans who served in Afghanistan and Iraq, 46.5 % reported some pain, with 59 % of those exceeding a clinical threshold of greater than or equal to 4 (0–10 scale; Gironda et al. 2006). Both PTSD and chronic pain tax the coping resources of veterans, which can exacerbate both conditions and can negatively impact functioning and quality of life (Clapp et al. 2010; Sharp and Harvey 2001). Other physical injuries, such as traumatic brain injury, can also profoundly impact recovery.
As stated above, combat veterans may present with a complex set of conditions including PTSD, pain, and sleep problems, which may feel overwhelming for the clinician to address. Awareness of one’s own limits of clinical expertise and knowledge of where one might seek additional resources and support (e.g., consultation, supervision, referral for additional services) can be important to both the clinician and the overall success of treatment.

Case Illustration: Luis, Male, Operation Enduring Freedom (OEF) Combat Veteran

Luis joined the military at 18 years of age after graduating from high school. He had looked forward to serving in the military as both his father and grandfather had enlisted in the military. He served two tours in Afghanistan during which he engaged in many firefights, both receiving fire and firing at enemy combatants. During his second tour in Afghanistan, he experienced a blast caused by an improvised explosive device (IED). This same blast resulted in the death of one of his comrades.

Upon separation from the military, Luis decided to use the educational benefits he had earned through serving in the military to go to college. He was unprepared for the feelings of anxiety that struck him when he stepped onto the campus. He found that certain class material and comments by teachers or other students about the war brought up vivid memories of his experiences in Afghanistan, and he would find himself unable to concentrate for the rest of the day. He felt unable to connect with civilian students, and he spent much of his time on campus in the Veterans Resource Center where he met and engaged with other veterans. Luis felt that he should have been able to deal with his feelings, “just suck it up,” as he had been able to do with many difficult experiences while serving, but no matter what he did, he found that the thoughts and images kept returning.

Only gold members can continue reading. Log In or Register to continue