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Saving Our Vets Once They're Home

The right kind of mental health treatment is vital.

June 13, 2005|Sally Satel | Sally Satel is a scholar at the American Enterprise Institute and coauthor of "One Nation Under Therapy" (St. Martin's Press, 2005).

"The mental toll that this war has had on our newest generation of veterans ... could well be my generation's Agent Orange syndrome." That's the head of the nation's largest advocacy group for Iraq war veterans, Operation Truth, speaking.

He's not alone in his concerns. Rep. Lane Evans (D-Ill) has sponsored legislation to increase federal spending on mental health treatment for our troops, because, he says, returning soldiers could suffer post-traumatic stress disorder at rates "roughly comparable" to Vietnam War veterans.

Of course, it's true that some soldiers will return from Iraq and Afghanistan with severe psychological problems, and we must do everything to help them. But our Vietnam experience doesn't just tell us that some vets will be afflicted with mental illness, it also tells us that if we aren't careful we can make the problem worse.

The issue is chronicity. As Evans says, "Quick intervention and ready access to services are keys to ensuring that an acute stress reaction does not become a chronic one."

I worked as a psychiatrist at a Veterans Affairs hospital in Connecticut for five years in the late '80s and early '90s. Unsettling as this sounds, I believe a sizable number of the roughly 224,000 veterans that the VA counts today as being disabled by post-traumatic stress disorder could have been rehabilitated.

Despite good intentions, the agency itself almost certainly played a role in many veterans becoming lasting psychiatric casualties of war.

This resulted from a confluence of unfortunate practices. First, VA mental health workers commonly believed -- and many still do -- that participation in war results, de facto, in post-traumatic stress disorder. In communicating this mistaken notion to veterans, they set up expectations of illness. Second, treatments themselves inadvertently contributed to problems. Third, generous VA disability payments may act as a disincentive to recovery.

How can the VA avoid creating a "new generation" of chronically ill vets? It can start by carefully interpreting psychological states. Many soldiers returning from war will feel confused, sad. They may have trouble sleeping, be easily distracted, and some will be bitter, even hostile. Whether this is psychopathology depends on how impaired they are and the persistence of the problem. It is vital to remember, however, that people in a fragile state can be susceptible to the suggestion that they are ill, and latch on to that idea.

Conversely, when otherwise healthy men and women are told they are experiencing natural and time-limited reentry difficulties, they will generally adopt that outlook.

The VA must also emphasize "reintegration."

Smoothly adjusting to family and community life depends largely on a veteran's economic security, family stability and physical health. Rehabilitation and social services are key. Such support can also help veterans regard their service as a worthy sacrifice or put their regret or guilt into perspective. They will suffer less than those who remain isolated and demoralized.

Another lesson is to keep treatment practical. Standard care for Vietnam War vets entailed months-long inpatient stays in special units. That increased identification with invalidism and made readjustment to civilian life harder. Therapy often consisted of repeatedly telling war stories to release anger and sadness. For many this exacerbated their problems. As the VA now recognizes, hospitalization should be reserved for those who can't function in another environment.

Unfortunately, experience shows that the VA must be skeptical about claims of combat-related distress. In a report this month in the British Journal of Psychiatry, researchers at a South Carolina VA facility checked the backgrounds of 100 Vietnam War vets being treated for combat-related post-traumatic stress disorder. They could not confirm combat exposure for 59% of them.

Finally, the VA must beware of the disability trap: Veterans should not be urged to obtain long-term disability payments for at least two years after their return from overseas. In most circumstances, psychiatric conditions will be temporary. Moreover, generous disability payments provide an economic incentive to remain ill. In fact, work is often good therapy, providing structure, a sense of purpose and social opportunities.

The VA and mental health workers will do returning war veterans a disservice if their care isn't handled correctly. As my colleague, British psychiatrist Simon Wessely, says: "Generals are justly criticized for fighting the last war, not the present one. Psychiatrists should be aware of the same mistake."

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