Wednesday, May 22, 2013

The Few. The Proud. The Pained: Confronting Mental Health Issues Among Returning War Veterans by Vijay E.

Marcy Rivera was pissed. She was with her friends, a group that she desperately wanted to be a part of. Even though she was aware of her phobia of crowded places, she knew she had to get outside of her comfort zone. Friends, after all, for an ex-Marine Corps member who had been deployed on tours of duty three times, were hard to come by. But from the instant she set foot inside that club, she knew she was uncomfortable. “I was anxious the entire night. I was on guard the entire night. It was very scary,” she reflected. It had been four long and confusing years for the veteran of the wars in Iraq and Afghanistan. And now she had finally reached a breaking point. When someone pushed her friend, she tried to calmly confront that person. But when that individual got in her face, she snapped. Even though it was only a brief verbal altercation, Ms. Rivera viewed this incident as the defining moment of years of frustration. “As part of the Marine Corps, you are always told to hold your bearing. I lost mine. I could have ripped her head off. I was so enraged and ready to hurt someone over something stupid.” A simple and fun night out at a club with some friends had turned into a near catastrophe, escalating from a trivial situation. Ms. Rivera was at a crossroads. Either she could continue down the same path as before or she could try and seek help that would, hopefully, put a stop to her intense anger. She chose to do the latter.
Ms. Rivera is among the rising number of returning war veterans who are receiving treatment for post-traumatic stress disorder (PTSD) or other chronic physical or mental injuries that have hampered their reintegration back into society. Nonetheless, nearly two-thirds of veterans who suffer from PTSD are not being treated for their symptoms, a number that is quite alarming (Reno). With the United States reeling from two wars abroad and future conflicts brewing in other hotspots, the need for appropriate and substantial mental health care for returning war veterans has reached a peak.
According to the Department of Veterans Affairs (VA), a government entity that supports veterans and their families, PTSD “is a psychiatric disorder that can occur following the experience or witnessing of life-threatening events such as military combat, natural disasters, terrorist incidents, serious accidents, or physical or sexual assault in adult or childhood” (“Post Traumatic Stress Disorder”). The disorder causes stress reactions that can worsen over time, which is why it is imperative to diagnose the disorder as soon as possible. These reactions often stem from reliving the traumatic experience through flashbacks and nightmares, which can lead to a lack of sleep, detachment, and a general pejorative effect on the individual’s life. In order to diagnose PTSD, individuals are categorized based on three types of symptoms: re-creation of the traumatic experience to the point where it influences the person’s decision-making process in the present, withdrawal and detachment from normal activities – which can often be mistaken for clinical depression, and fluctuating behavior patterns, as well as shorter attention spans and a quicker trigger towards violence and rage. Even though PTSD has some distinctive features, it is largely clouded by other disorders, including substance abuse, memory loss, and depression. As a result, a diagnosis of PTSD may go undetected and instead be mistaken as a general character trait. The main treatments for PTSD are psychotherapy, also known as “talk therapy”, and antidepressant medication (“Post Traumatic Stress Disorder”).
Marcy Rivera, an earnest young woman, always knew she wanted to join the military ever since she was a young girl. She was particularly drawn to the Air Force, where she could fulfill her dream of flying fighter jets. She changed her mind after finding out she did not have 20/20 vision – a requirement for a fighter jet pilot. Then came the September 11th attacks. “I felt it was my duty or calling,” she said of wanting to enlist. After helping her friend out with his exams for the Marine Corps, she too decided to join. However, as a minority (a woman) in the smallest branch of the armed forces (the Marine Corps), she described herself “as the ultimate woman minority.” Initially, in order to gain the respect of her male compatriots, she often tried to stand out, doing her various jobs completely and quickly and volunteering to do any extra work. Subsequently, she found that in the Marine Corps some of the stereotypes of being a woman were broken down. “In the Marine Corps, they don’t care who you are. Man or woman, you need to be able to do your job. Because of this, we together created a bonded brotherhood through a team mentality.” She keeps in regular contact with her team members who are “closer than [her] blood family.” Ms. Rivera feels this way about a lot of veterans. Anytime she meets a veteran, she is able to bond with that person through shared experiences. Over her three deployments, in Afghanistan, a ship near Kuwait, and Iraq, respectively, she has good and bad memories. Given that Marines have to work twelve to sixteen hour workdays, all the team members do get close and form strong bonds. Some of the best times were had just sitting around or playing cards. But there were also some scary times. One of her first scares occurred before she was even deployed overseas. “Right before you leave you need to write a will, settle your life insurance, etc. I think that’s when I, for the first time, really thought of dying.” Ms. Rivera recalled one particular attack on her base in Afghanistan: “right when you are getting attacked, the reality sets in that you may die, which makes you think of mortality and life.” But her brothers (her team), helped immensely. “Knowing that members of my team were willing to kill and die for me definitely made me feel more comfortable,” she says. Despite some concerns about why the United States was at war during those frightening situations, she never questioned anything because Marines “do what they are told.”  Eventually, Ms. Rivera chose not to re-enlist. She felt that after a certain amount of time, everyone goes his or her separate ways. Even though she felt guilty about leaving her comrades and not being able to support them, she decided it was time for her to leave.
For Marcy Rivera, the symptoms of PTSD came to a head during that eventful night out at the club. According to her, the VA right now is overwhelmed. “It’s not right. These are the people who defend the country and sometimes there is a six-month waiting period and you have to wait two months for an appointment. They don’t have enough money.” Ms. Rivera said she mainly suffered due to being separated from her unit, which she likened to her social support system. Though she kept in touch with her immediate family through e-mail, if a computer was available, they did not know what she went through and therefore could not be very helpful. However, she did find the exercise of talking about her issues with her husband to be therapeutic, an approach not commonly utilized by veterans. Still, she realized that this tactic does not work for everyone.  “I don’t want to push a friend who has survivor’s guilt, because I know what it feels like to have your back against a wall. Because we didn’t sign up for this, it isn’t our fault. I didn’t go to war looking for PTSD or mental disorders.”
PTSD’s impact on veterans cannot be overstated. From crime to homelessness to simply exacerbating a current condition, PTSD has shown time and time again that if it is not treated, it can have devastating impacts. In a 2008 report by The New York Times, there were 121 cases of homicide committed by a veteran of the military, most of which were due to the psychological lapses that are associated with PTSD (Sontag and Alvarez). These psychological lapses can be due to a variety of reasons, from a certain smell or sound that recalls a specific moment during the traumatic event to relapsing into the habits of a soldier. However, there are several issues facing veterans other than just crimes. The first is that unemployment among veterans is nearly twice as high as that of the civilian population. There are a number of reasons for this. The first is that veterans leaving for the military, right after or before graduating from high school, are often not able to compete in the competitive job market after their return. The skill sets required of a soldier and those required of a regular civilian are also largely different. This leads to a high homeless rate, with a third of the American homeless population being veterans (Meshad). Another growing and troubling trend over the past decade has been an increase in suicides among veterans. Unlike losing a limb, damage to the brain can cause repeated suffering for the rest of the victim’s life and cannot be easily overcome. Whether resulting from PTSD or just the trauma of a war, there is no doubt that servicemen and women are committing suicide at greater rates than ever before. In a recent New York Times column, Nicholas Kristof states that America is losing more service members to suicide than to the actual wars, as for every one soldier killed in battle this year, twenty five took their own lives (Kristof SR1). However, with America still easing its way out of an economic recession, there is quite simply not enough money to spend on veteran clinics and programs says the VA. The situation is currently, at best, dire. In the latest survey conducted by AMVETS, a veterans service organization in Chicago that sponsors several programs for servicemen and women and their families, eighty percent of veterans believed that the government could do more to ensure that veterans have a smooth transition into the workforce. Even more staggering is the sixty-four percent of veterans who said they did not receive any instruction on how to find a job until they had almost left the military. Additionally, two-thirds of the veterans have extreme difficulty in accessing their disability benefits (“AMVETS”).
All over the United States, there are various efforts being undertaken to ensure veteran safety and prosperity. One, based right here in Oregon, is the Returning Veterans Project, a nonprofit organization that includes healthcare practitioners who offer services to veterans and their families for free. The organization is largely active in Oregon and Southwest Washington. It provides counseling as well as any type of medical assistance that may be needed. The organization was founded with five primary principles: to provide free counseling and therapy, education (mobilizing the community by raising awareness), clinical workshops that train volunteers, an information source, and network/collaboration with other military families (“Returning Veterans Project”). Carol Levine started the Returning Veterans Project in 2002. Ms. Levine, utilizing her knowledge as a therapist, decided to create an organization that would help these returning veterans suffering from a variety of issues. While growing up in New York City, Ms. Levine never thought in a million years that she would be working on anything related to war. However, when she saw the veterans returning from the war in Vietnam being treated poorly, she was intrigued. Then, after seeing the dawn of the wars in Iraq and Afghanistan, she saw an opportunity. “I was tired of feeling hopeless, as nothing seemed to be going well,” she reflected.  “These men and women suffered from traumatic brain injuries through explosives going off, jarring the brain, the side of a skull and causing memory issues. I was struck by the fact that veterans can come home and not have services.” Presently, the organization is made up of over one hundred and fifty therapists mostly in the Portland Area, but also in Bend, Salem, Eugene and all across the state. These therapists, including doctors, surgeons and chiropractors, help with any type of physical problems that veterans suffer from. The organization encountered many bumps along the way to fulfilling its mission. In order to get the word out, Ms. Levine had to find support, which eventually came from the VA Center. Due to a long wait list and a lack of funding, the VA, today, points individuals to the organization and sends more referrals than anyone else. According to Ms. Levine, in an ideal world, the VA would be able to cover all veterans with little to no wait time for appointments. If this were ever the case, the Returning Veterans Project would disband and reconvene only if the problem presented itself again. Providers commit to seeing one veteran for free, and treat them in the same manner as their own patients. The doctors affiliated with the organization are trained by staff to aid in their mental health counseling, and to know and understand the trauma fully. Ms. Levine recalls the first patient she saw. “It was a woman who was in the National Guard, a career soldier in her forties, and someone told her about our program. She was extremely suspicious, and during the first hour, I got a million questions about why I was doing this. By the end of the hour, she was giving me advice on how to improve.” Yet, there are consequences to seeking therapy. Due to military rules, attending therapy goes on the permanent record of the veteran if provided by the VA center. According to Ms. Levine, “going to therapy can lead to not receiving a promotion and that’s why the [Returning Veterans Project] values confidentiality. Once they get past any of the preconceived notions, it works really well.” In order to spread the word, the organization attends job fairs, and offers papers and other information to prospective families. Word of mouth also helps. “Because they have to be the ones to make the phone call, they often times need to trust us.” She recounted the story of a former Marine who trained people on weekends and promoted the work of the project. Since he too suffered from the same issues (from PTSD) as the other veterans, he was just like one of them.
A major issue hindering any type of assistance is the immense burden these veterans have to maintain a tough and invincible image. In his autobiography, Shadow of the Sword: A Marine’s Journey of War, Heroism, and Redemption, former marine, Jeremiah Workman, reveals that “[the marines] are proud men and women who don’t like to admit we’re hurting. To do so is a sign of weakness that in our warrior profession we normally revile. Your pain is my pain. We share that as a bond” (Workman and Bruning 247). Whether it is not wanting to disappoint a unit, being loyal until death in service of country, emotional restraint, dedication to finishing a mission or just following orders, soldiers are taught to be fearless and battle non-stop. Taking this mentality home with them, soldiers often do not understand the need to seek treatment, perceiving it to be a weakness. Research over the past few years has shown that service members have a general tendency to underreport injuries. This is a result largely due to the fear that by using mental health services, they are succumbing to the pain. Other reasons include potential career harm, loss of privileges, abandonment, being discharged and consequences in the army itself.  In fact, the VA has set aside a portion of their time and budget to understanding the psychology of veterans and understanding military culture. By learning about the “warrior mentality,” a more effective and precise approach can be taken to solve the problem. For example, how do the values held by the military community relate to injuries or traumatic experiences? (Weiss, Coll, and Metal). This is the exact type of research and work that the Returning Veterans Project and others like it are looking into and hoping to solve. “Most people function in the beginning, but it gets harder and harder,” Ms. Levine stated. She recalled speaking to a man who cried on the telephone, because he thought he had his life under control but ended up beating his child after getting drunk. Lately, according to Ms. Rivera, there has been a slight shift in this general military culture. With additional research as well as more opportunities to seek help confidentially (such as the Returning Veterans Project), veterans are going to health clinics and other organizations at higher rates than before. Even with this change in mindset, Ms. Rivera still believes that it will take a couple of generations before a large shift is seen, with “more people looking for PTSD rather than just thinking it is shellshock from coming back from a war.”
Ms. Levine feels that while veterans are being shown more attention than in past decades, there is still a long way to go before the problem can be resolved. “People who have shown symptoms of PTSD are often times encouraged to be redeployed consistently, going seven, eight times. That’s not good care.” And with the funding cuts at the VA, and the economy still struggling, the situation is grim at best. But the most harm comes from the occupation itself. Ms. Levine asserts: “these people think they know who they are. But they have to go against everything that they were taught. They have to kill innocent people. That’s why PTSD is more complex than thought. It really is a disorder of the soul.”
On a typical rainy Portland morning, The Lines for Life Military Helpline room was tense. Three veterans were on the other end of the phone line requesting help in their most desperate hour. As some volunteers glanced anxiously at the big overhead screen displaying the parked (waiting), queued (about to be answered) and live (presently occurring) calls, David Dedrickson pulls out confidentiality agreements for the visitors to sign. He too is edgy, glancing swiftly but frequently at the overhead screen. Mr. Dedrickson is not a volunteer. He is the Helpline supervisor overseeing one of the five major subordinate crises prevention lines affiliated with the primary Veterans Crisis Line (the national hotline). Ever since he was a student at Portland Community College studying to be a drug and alcohol counselor, Mr. Dedrickson, a former veteran serving from 1973 to 1976, always wanted to help in the veteran area. Having been in recovery for drug and alcohol abuse himself, Mr. Dedrickson was first contacted to volunteer at a local helpline and jumped at the opportunity. However, when he first joined Lines for Life Military Helpline, the organization faced many issues. While there is a National Guard in Oregon, there are no official military bases, meaning that Oregon veterans do not get any active duty benefits which are provided by the federal government. Because of this, contends Mr. Dedrickson, the situation “can get quite precarious for veterans”, most of whom need help and need help fast. “Our job is to help veterans navigate the system,” he added, stating that the helpline was like a middleman. Often times, this results in their job solely being to listen and deescalate the situation. According to Mr. Dedrickson, the helpline is able to deescalate the situation 98% of the time, but occasionally, a veteran can call during a PTSD attack or when they have suicidal thoughts. That is why Mr. Dedrickson says, “we get so nervous because every call is a different adventure. Once you pick up the phone, you don’t know what it is going to be.” He says that the helpline tries “to meet them in reality” using ASIST (Applied Suicide Intervention Skills Training) to help them with their struggles. The ASIST training normally requires the volunteer to find out what happened (as sometimes veterans may have never spoken about their troubles), and try and make them live in the present moment. Mr. Dedrickson has heard a lot of stories. “I’ve heard everything from veterans needing direction through the resources that are available to them to a guy suffering because he was remembering scraping body parts off of his uniform after returning from battle and a guy, who after fighting in hand to hand combat, had to watch the life come out of his opponent’s eyes as he was dying. The point is to meet them where they are at, because their balloon is full of air. They are overwhelmed with too much trauma. We need to let them get it out.”
At Lines for Life and other helplines, the goal for treating veterans is to provide peer support and to develop a safety or action plan, which allows for a break from a certain behavior or to distract the veteran from their past memories. Therefore, having the veterans avoid isolation is a primary goal. Volunteers are taught to talk about what the veteran likes to do (for example, if the veteran likes fishing, the volunteer would ask when they last went fishing, if they liked it, etc.). By helping them engage back with the world, the helpline provides a safe place to call and talk about life, as these veterans are often times overwhelmed with daily life and worried. Occasionally, the helpline tries to intervene. As a result, they sometimes make follow up calls to see how the veterans are doing. Sometimes, according to Mr. Dedrickson, veterans want to speak to someone who “gets it.” Consequently, some of the volunteers are police officers, other veterans or friends, family and spouses of veterans, so they can relate to the veterans experience. This is absolutely crucial, because often there is not one sole reason why veterans may have problems. Any problem a veteran suffers from is heightened by another problem. Mr. Dedrickson outlined the four major issues facing veterans right now: drug and alcohol abuse, financial troubles, difficulty with or a lack of personal relationships, and a mental diagnosis (which often times magnifies the situation). Another issue along with PTSD that has really affected veterans has been traumatic brain injury (TBI), which can often mask PTSD. TBI can be a result of anything from a concussion to hitting the head after an explosion. Over the past decade, there have been over 250,000 diagnoses of TBI as per Mr. Dedrickson.
Mr. Dedrickson believes, like Ms. Levine, that the main obstacle facing veterans largely lies with themselves rather than outside support systems. “When a veteran understands that it’s okay for help, they will improve. I can see when a veteran has a broken leg or a broken arm. I can’t however see when a veteran has a broken mind. I can only be aware of the signs and symptoms that may lead to a broken mind. There is a stigma attached to being a veteran. That’s why it takes the courage of a warrior to make the call.” But with the increasing number of veterans, the system has become overwhelmed. In order to alleviate this problem, the VA and the federal government have jointly tried to create awareness of the type of symptoms common to certain disorders for family members to identify. Additionally, they have also created outreach programs to help certain veterans with specific problems. For example, in response to the increasing crime rate, the VA created a justice outreach program, so that if a veteran were to commit a crime, which has become increasingly common, they can easily navigate through the system and find people such as lawyers to help them. The programs are, according to Mr. Dedrickson, “not about condoning action, but understanding the situation.”
 Mr. Dedrickson also states that the after effects of a war are almost as devastating as the actual war. Veterans do get some privileges, but nothing is guaranteed. So when a service is long and protracted, a situation arises where there are no jobs upon returning home and the veterans do not always have the necessary skills to be contributors to the work force. This causes soldiers to reenlist numerous times, which is exactly what is happening currently. While there are some benefits and funds to allow veterans to go to college, for example, the programs and benefits are largely underfunded or have limited funding. Despite this lack of resources, there have been many more opportunities for jobs and scholarships for veterans than in past conflicts such as the wars in Vietnam and Korea. Other than helplines or organizations, there are also stand-downs, which help veterans who need medical or mental health attention, hygiene, clothing or just the need to be recognized.
Having known several people with PTSD, Ms. Rivera did not initially believe that she had it. “It’s hard, it’s like a feeling of numbness. You’re separated from the people who you were deployed with. Being in the military, you’re so used to making decisions that are life or death. Everything starts becoming life or death, from the honking of cars to getting down the stairs fast. And when it starts to affect regular life, it can result in bad.” After seeing a flyer for the Returning Veterans Project, Ms. Rivera decided to give it a try. Initially, it was difficult for Ms. Rivera, who needed holistic medicine and chiropractic help, as she had to pay out of pocket, which was nearly $150 per month. While it helped greatly for back pains and migraines, she took a giant risk by having to pay for something that may or may not work. Ms. Rivera also believes that being deployed multiple times takes a toll physically and mentally, as PTSD will be a lifelong battle for her and many other veterans. Additionally, since there is no cure for PTSD, she believes the government should not just send people away and not deal with the consequences. Nevertheless, in the interim, organizations such as the Returning Veterans Project and the Lines for Life Military Helpline can fill the void. Despite these organizations, though, public support can still be elusive. “I’ve spoken to some Vietnam veterans who have had multiple divorces, have suffered alcohol abuse and have been suffering from PTSD for forty years,” Ms. Rivera poignantly concludes, “before, I used to think, “What the hell is wrong with everyone else? That now scares me, because when you lose yourself in the moment, other people don’t get it. While it’s not others’ fault that veterans are suffering, they just need to understand.”
Works Cited

Dedrickson, David. Personal Interview. 1 November 2012.

Kristof, Nicholas. "War Wounds." New York Times [New York City] 12 August 2012, SR1. Web. 11 Nov. 2012. <>.

Levine, Carol. Personal Interview. 2 November 2012.

Meshad, Shad. "Care2." The Problems Facing America’s Veterans. N.p., n.d. Web. 24 Oct 2012. <>.

Reno, Jamie. "New Study: Two-Thirds of Veterans With PTSD Not Being Treated." The Military Life. Home Post, 31 2011. Web. 11 Nov 2012. <>.

"Returning Veterans Project." Homepage. N.p., n.d. Web. 24 Oct 2012. <>.

Rivera, Marcy. Personal Interview. 11 November 2012.

Sontag, Deborah, and Lizette Alvarez. "Across America, Deadly Echoes of Foreign Battles." The New York Times. The New York Times Company, 13 2008. Web. 24 Oct 2012. <>.

Weiss, Eugenia, Jose Coll, and Michael Metal. "The International Journal of Health, Wellness and Society." International Journal of Health, Wellness and Society. (2013): n. page. Web. 11 Nov. 2012. <>.

"What is PTSD?." Post Traumatic Stress Disorder. Nebraska Department of Veterans' Affairs, n.d. Web. 11 Nov 2012. <>.

Workman, Jeremiah and John Bruning. Shadow of the Sword: A Marine's Journey of War, Heroism, and Redemption. New York City: Ballantine Books, 2009. Print.

"80% of Veterans Say More Can Be Done to Help Them Find Work After Completing Their Military Service." AMVETS. PR Newswire, 18 2012. Web. 11 Nov 2012. <>.

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