There are well-established guidelines for the treatment of PTSD , developed by the American Psychiatric Association (APA) and the Department of Defense (DoD) and the Veterans Health Administration (VHA). These are often referred to as evidence-based treatments. These will be summarized later in this chapter and referred to in other chapters. However, there are many patients who are either unwilling or unable or do not respond to the evidence-based treatments.

While these patients may be called “treatment-resistant ” or “refractory,” it is the treatments themselves that are often not palatable to service members. That may be because of: (1) unacceptable side effects from medication; (2) difficulties with making frequent appointments, especially for the cognitive behavioral treatments; (3) the distaste of many service members to relive their trauma and/or talk about it; or (4) the stigma of seeking treatment from a mental health-care provider.

Thus this volume will focus on the more “refractory” patients, treated with newer and less conventional therapies, with a focus on how to engage reluctant veterans in treatment.

Service members need to be physically and mentally fit for duty, according to various regulations [4] . They need to be able to deploy to war zones and other austere environments. They may carry firearms, drive tanks, fly helicopters, and pilot ships.

Thus, if a service member has a severe mental illness, they usually will receive a medical evaluation board (MEB) to see if they are fit for duty. Severe mental illnesses include psychotic disorders, and may include mood disorders and PTSD. If found not fit for duty, they may be medically discharged. A medical discharge usually has some disability benefits attached.

They may also be “medically retired,” depending on the severity of their condition. Retirement carries significant health-care and disability benefits (often at 50 % of their base pay). A medical retirement is generally a lifelong benefit. The medical/physical evaluation board, now called the integrated disability evaluation system, is a complex process [5]. Many chapters within this volume refer to the MEB process, which is why it is discussed here .

PTSD does not necessarily lead to a medical discharge. If a service member responds to treatment, he or she may be found fit for duty. Alternatively, with actual practice varying according to the service, they may be administratively discharged, which comes without benefits. The financial discrepancy between a medical and administrative discharge is substantial.

Many of the complex cases described in this book have been referred by their physician to the MEB process. Service members may or may not want a medical discharge, which offers both benefits and potential shame.

There are in general two major drivers of not seeking or seeking treatment, in my experience. Service members who want to stay in the military do not want to go near a mental health provider , as they fear for their jobs. For example, Marines refer to a psychiatrist or psychologist as the “Wizard,” as he or she makes Marines “disappear.” This often leads to a medical or administrative discharge.

However, those who are nearing the end of their enlistment, or are planning to retire, have many pressures to endorse PTSD symptoms. The pressures include the financial benefits of medical retirement as well as priority for VA care .

A theme throughout the book is of cultural competency . Especially if you are a civilian provider, how do you understand the military culture?

As a start, one of the easy ways is to ask the patient about their military occupational specialty (MOS). Ask about basic and advanced training, and where they have been stationed. Ask when and where they have been deployed. Do not assume that the official DD 214 (official discharge paperwork) will list all their battle assignments.

Learn what their military rank is or was, and ask how they want to be addressed. Some will prefer to be addressed by rank, others by their first name. Patients who have been in the Special Forces, served at Guantanamo Bay, or have served in classified operations, may not be able to talk about the specifics of their experiences.

An important piece of cultural competency advice for providers: Today’s combat veterans do not want to be seen as victims. Treat them as “battle-hardened” or maybe “battle-scarred.” Respect their service [6].

The Military Health System (MHS) is separate and distinct from the VA health-care system, usually referred to as the VHA. The MHS mainly consists both of the direct health-care system, offered by hospitals and clinics on military posts , and also the purchased care system, commonly known as TRICARE. Technically, the direct health-care system and the purchased care system are all one in the MHS, but differences exist in eligibility. For example, retirees and dependents can go to the direct care system, but only if there is space available. Often they are referred to the purchased care system under TRICARE. (For more details on these health-care systems, see Ref. [7].)

“Service” refers to the branch of service, Army, Navy, Air Force, or Marines (although the Marines are actually part of the Department of the Navy). Correspondingly, the uniformed personnel are soldiers, sailors, airmen, or Marines. The term “service members” refers to all of the military personnel.

The term “veteran” has several uses. It usually means service members who are no longer on active duty. The term “combat veteran” is used for both service members and those no longer on active duty who have served in conflict zones.

Active duty service members wear the military uniform full time and receive care through the MHS. Reservists include many categories of reserve service members, as well as the National Guard. Reservists usually serve a weekend a month and 2 weeks a year, although there are many variations. Reservists may transition between active duty and veteran status. The National Guard belongs to their state, and may be mobilized in the event of state emergencies, or be called up to action for war.

All reserve components have seen deployments unprecedented since World War II. Their care is often complicated. They receive health care through the military health-care system while active, but are generally not eligible for care when on inactive status. However, they may be eligible for care within the VA system if they have served in combat, or met other eligibility criteria. Often reservists transition between the military health-care system, the VA, and civilian health-care organizations.

The cases discussed here are mainly of service members who have served in Iraq or Afghanistan. The Iraq War is usually called “OIF” for Operation Iraqi Freedom. Later, another term was Operation New Dawn. The conflict in Afghanistan was “OEF” for Operation Enduring Freedom.

But there have been many other conflicts in the last 20 years, including the first Gulf War (Desert Storm), Haiti, Somalia, and Bosnia. The latter three conflicts are often referred to as Operations Other than War (OOTW).