Resources and support for veterans transitioning with PTSD

Veterans Diagnosed With Post Traumatic Stress Disorder

"Resources for Veterans diagnosed with Post Traumatic Stress Disorder (PTSD) after transitioning back into a civilian lifestyle

Veterans with Post Traumatic Stress Disorders transition to civilian lifestyle

PTSD is an "injury to the mind" in which a traumatic event causes lasting anxiety (McFarlane, Williamson, & Barton, 2009). PTSD may be difficult to treat, since stigma may prevent service members from seeking help (McFarlane et al., 2009). Study published in the American Medical Association Journal by (Shalev et al., 2001), show over a third of troops coming back from Iraq have been assessed to be at risk of PTSD and other mental health situations on their Post Deployment Health Assessment (PDHA).

The Military Health Service (MHS) recorded 39,365 patients who have been diagnosed with PTSD (Cook, Riggs, Thompson, Coyne, & Sheikh, 2004). The scope of the problem is considered to be greater given the likelihood of undiagnosed, unreported PTSD. Stigma and the fact that negative behaviors associated with PTSD can lead military service members to be dishonorably discharged are some of the reasons why PTSD may be undiagnosed and unreported. Dishonorably discharged service members are not eligible for VA benefits increasing the likelihood that if they have PTSD it will go undiagnosed.

The conditions of the Iraq and Afghanistan wars place war fighters at an increased risk for PTSD. They are open to extremely hostile circumstances, in constant 360-degree danger of coming under mortar attack, drawing fire, and falling prey to IEDs. The recurrent exposure to trauma and the fact that just being in Iraq/Afghanistan is itself a traumatic stressor results in numerous numbers of veterans undergoing mental health problems, from difficult transition to full blown PTSD the require crisis intervention. In addition to the traumatic experience of combat exposure, other traumatic events that may trigger PTSD include sexual trauma/MST, unexpected death of a friend or family member, natural disasters, or serious accidents (McFarlane et al., 2009).

Those at higher risk for PTSD include individuals who have experienced traumatic events as a child, those with existing mental health issues, and/or substance abuse issues and females (McFarlane et al., 2009). The duration and severity of PTSD can vary, depending on factors such as the intensity of the trauma, perceived control of the traumatic event and the amount of social support received (McFarlane et al., 2009). PTSD can have lasting effects on one's life. PTSD is associated with impaired physical, social and mental health (Gabriel & Neal, 2002; Shalev et al., 2001). Thus, those with PTSD use health services more often (Campbell et al., 2009; Kennedy, Leal, Lewis, Cullen, & Amador, 2010)

According to (Cozza, 2005), PSTD is complicated by it occurrence accompanied by related difficulties or problems such as substance abuse, depression, memory loss problems among other mental and physical health difficulties. PSTD is associated with physical and social impairment upon an individual. Individuals suffering PTSD will be incapacitated to undertake to social and family roles, occupational and marital obligations. This inability will in some instances lead to family conflict, divorce, occupational instability and subsequent loss of job and difficulties in parenting (Cozza, 2005).

Re-establishment in civilian life after military service goes well for many, but challenges others in ways that can persist over the life course (Taft, Street, Marshall, & Dowdall, 2007; Van de Pitte, 2007). Military to civilian transition is an extremely meaningful but poorly researched event in the life courses of military Veterans (Van de Pitte, 2007). While there is no standard framework for defining and measuring successful reestablishment, Gottman, Gottman, and Atkins (2011) propose that physical, mental and social health, disability, access to determinants of health, and life course perspective are core concepts (Gottman et al., 2011).

The very nature of military training instills the idea that military-trained personnel are very different from civilians (Van de Pitte, 2007). While this view serves an important purpose in the military world, upon discharge, military personnel are likely to experience a strong "culture-shock" characterized by feelings of isolation and aloneness (Clark, Scholten, Walker, & Gironda, 2009). Friends and family members are often unaware of the stark contrast between civilian and military culture, thus unwittingly contributing to the veteran's difficulty in reintegrating.

This incomprehension is further compounded by the fact that often, military personnel in their transition are not offered adequate support by society (Westwood, Black, & McLean, 2005). Additionally, the recognition and glory that can come with the status of a veteran is usually quickly forgotten by the community, leaving former soldiers alone in their transition (Gawande, 2004). Former military members thus return to a life that not only they do not recognize, but that does not recognize them.

Reaction to a traumatic event in different people differs and individual reactions may differ with time depending on the environment and circumstance surrounding the individual. At the onset of the disorder, one finds difficulty concentrating on salient aspects with unusually high stress levels being observed. During this period, the individual is only able to think of the situation arousing their trauma. The acute trauma situation may decrease over time or last for days or weeks. In the unfortunate event that the traumas last for periods longer than psychologically expected and occur intensely and frequently, the situation is escalated to be Posttraumatic Stress Disorder PSTD (Clark et al., 2009)

Veterans can also be susceptible to war-related trauma (Westwood et al., 2005), adding extra difficulties to their re-adaptation to civilian life. Regardless of what position the individual served in the military, and regardless of the type of mission he or she was involved in, former military members can return home with unresolved issues and stress reactions related to their military experiences (Van de Pitte, 2007).

Although in recent years combat-related PTSD has gained widespread importance and acknowledgment, the military mindset has yet to move away from the notion that suffering from a psychological disorder does not imply one is weak, soft, or mentally unstable (Westwood et al., 2005). The "I should just be able to deal with it" mindset, coupled with the stigma associated with seeking treatment for psychological problems, decreases the likelihood of veterans effectively coping with their traumatic memories and associated difficulties. Despite the increased regard for combat veterans and increased recognition of combat trauma, the stigma of experiencing signs of combat trauma, such as depression, anxiety, fear, or post-traumatic stress, persist (Howard, 2007).

Male veterans may wish to identify with the masculine stereotype of the "real man" being one characterized by strength and emotional control; similarly, female veterans may feel they need to prove that they are equally as "tough" as their male comrades (Matsakis, 2007). Thus, both sexes can find it difficult to admit they may benefit from psychological assistance.

Veterans may also struggle with the language needed to openly talk about their experiences in a way that can be understood and accepted by those close to them (Westwood et al., 2008). They may even see themselves as toxic because they expect to harm others if they share their knowledge of the hideousness of war (Matsakis, 2007). The soldier is confronted with unimaginable human suffering, the consequences of war and destruction, death, physical injuries and psychological suffering, the brutalization of morality, cruelty, sadism, or apathy (Westwood et al., 2005), and mainly copes with it alone. Not succeeding (at least outwardly) poses a risk that they be viewed as morally or psychologically deficient (Matsakis, 2007). However, veterans who come home to families that embrace them and do not shame them for showing signs of combat trauma are much more likely to have an easier time readjusting to civilian life (Stecker, Fortney, Hamilton, & Ajzen, 2007).

Having been to war can also change the way veterans think. For example, the assumption that the world is a safe and loving place can be destroyed (Kennedy et al., 2010). Additionally, Matsakis maintains that the high stakes during combat and the warrior mindset that is developed create a perception that issues are either black or white, with someone either being "with you" or "against you," and no possibility of an in between stance. For example, "when thinking like a warrior, the vet will view another person based on what the person is doing at the moment or in the immediate past, rather than take into consideration other things he knows about that individual or all the other experiences he has had with him or her." Furthermore, due to the fact that, in war, mistakes are intolerable, veterans may come to develop a mid-set where no mistakes are allowed; instead, perfectionism is the only acceptable form of being. It may not be surprising, then, that these changes in cognitive processing can lead to extreme difficulties in the veterans' intimate relationships.

Veterans frequently indicate that upon returning home, they are expected to resume "life as usual" almost instantly. Often, it is not recognized that the readjustment to civilian life can take months, if not years (Matsakis, 2007)Former military members may face difficulties in social, emotional, and occupational adjustment upon discharge, resulting in a low quality of life that is often persistent over time (Taft et al., 2007).

Transition to civilian family from combat military life

The difficulties experienced by returning soldiers naturally impact all facets of their life (Gabriel & Neal, 2002); thus, intimate relationships are also bound to suffer. Within this area of study, researchers have focused primarily on veterans suffering from PTSD, The unique feature of PTSD is the re-experiencing of the traumatic experience, followed by attempts to numb memories of the trauma and the feelings associated with the trauma. This re-experiencing and numbing cycle is repeated over and over, causing significant problems for the sufferer and those around him or her. PTSD severely impacts functioning across major life domains; among sufferers, unemployment can be increased by approximately 30% and marital instability by approximately 60% (Taft et al., 2007).

As indicated, PTSD often exerts a strong and pervasive negative influence on those around the sufferers (Gottman et al., 2011); thus, especially relevant are the PTSD symptoms that interfere with social relations. Given these effects of PTSD, it is not surprising that combat veterans diagnosed with this disorder appear to be at higher risk for significant relationship problems. Specifically, these individuals tend to be less satisfied with their intimate connections, and their relationships are less expressive, less cohesive, more violent and with more conflict.

Intimacy is a central focus in romantic relationships. A lack of intimacy with one's partner is likely to result in decreases in marital satisfaction as experienced by both partners. Veterans with PTSD appear to experience increased anxiety and discomfort around intimacy, and their partners also exhibit a greater fear of intimacy, perhaps as a result of the problems exhibited by the veteran's distress (Matsakis, 2007; Stecker et al., 2007). Additionally, sexual dysfunction and sexual disinterest among PTSD veterans can be common (Gabriel & Neal, 2002; Gottman et al., 2011).

Researchers have remarked that "injured veterans often struggle with believing that they are still attractive to their partner and that they have the capacity to sustain their relationship" (Westwood et al., 2005) Veterans may conscientiously push away significant others for fear that they may reveal the atrocities they have committed in combat and subsequently lose the love and respect of those they most value (Matsakis, 2007). Thus, it is not surprising that military couples characterized by a PTSD-diagnosed spouse experience more problems in their relationship as a result of difficulties with intimacy (Taft et al., 2007). In contrast, those veterans without PTSD do not tend to experience intimacy issues to the same extent as their counterparts.

Communication factors such as avoidance and emotional numbing have also been linked to lowered levels of relationship satisfaction among veterans and their spouses when PTSD is present (Cook et al., 2004; Shalev et al., 2001). Open communication is vital for success in all close relationships and integral to overall couple satisfaction; if it is lacking, other problems are likely to ensue (Gabriel & Neal, 2002; Gottman et al., 2011). Although the effects of emotional numbing once returned to civilian life are severe, during combat soldiers need to put aside their emotions in order to survive.

Acknowledging feelings would be both personally confusing and life-threatening, as connecting with powerful emotions would lessen the ability of most soldiers to give and take directions (Matsakis, 2007). Thus, although detrimental once removed from combat, emotional numbing serves a life-preserving function while in the military. Of course, when the veteran responds to current (non-combat) non-life-threatening situations by going numb, interpersonal problems are likely to ensue.

Although the veteran may not intend to shut out his or her partner through numbing, the partner usually experiences these behaviours as personal rejection (Matsakis, 2007). In fact, it has been found that emotional withdrawal, more than any other symptom, has influenced wives of PTSD veterans to seek divorce or separation (Gottman et al., 2011). This may be due to the fact that emotional numbing can contribute to relationship distress by impairing emotional engagement between spouses, a factor crucial for maintaining intimacy and resolving marital conflict (Cook et al., 2004; Kennedy et al., 2010).

Combat trauma also greatly reduces verbal involvement (Gabriel & Neal, 2002) and self-disclosure, "the process through which one person expresses his/her feelings, perceptions, fear, and doubts to another, allowing relatively private and personal information to surface" (Taft et al., 2007). According to Taft et al. (2007), PTSD veterans may want to maintain emotional distance from their partners because they may fear they will not be understood (and may even be rejected) if close others become aware of their experiences and their needs. While attempting to reintegrate into civilian life, veterans may feel that their partners have no concept of the change they have undergone, or the difficulties they have endured (Gawande, 2004).

Taft et al. (2007), note that misunderstandings are further exacerbated by the lack of communication. Even nonverbal communication may be reduced, through the avoidance of eye contact, physical touch, and by keeping physical distance from close others. As a result of these negative communication patterns, the veteran's partner may feel rejected, and may resort to decreasing his or her positive interactions with the spouse. The marital communication system thus further becomes characterized by defensive rather than supportive behaviours (Taft et al., 2007).