Increase of PTSD in the Military
Psychology
Increase of PTSD in the Military
Introduction
In the post cold war era, there was widespread hope for the end of armed conflict. However, such hopes were belied. Instead of long-drawn standoffs between the major powers of the world, the nature of conflict became more variegated and localized. Added to the larger number of smaller scale conflicts was the new phenomenon of a ‘clash between civilizations.’ Islamic movements challenged the supremacy of the United States, which had emerged as the sole superpower on the global stage. The new realities have forced the United States to continue to deploy military personnel in conflict zones across the world. US forces have deployed for long tenures in Afghanistan and Iraq. Continued requirements for troops in these hotspots has resulted in troops getting deployed on multiple tours of duty.
Multiple deployments of American forces have given rise to a new scourge – posttraumatic stress disorder (PTSD). PTSD affects large swaths of the US defense forces. The Department of Defense (DoD) and the US Department of Veteran Affairs (VA) are taking steps to mitigate the dangers posed by PTSD on American society. While considerable progress has been made, there is a need for greater synergy and collaboration. Continued research into PTSD generates new light into the various nuances of the disease. While the percentage of service personnel afflicted from PTSD is huge, care must be taken to separate those claiming disabilities purely from the economical viewpoint.
Thesis Statement
Posttraumatic Stress Disorder (PTSD) needs to be tackled with greater synergy and collaboration between the DoD and the VA by removing the stigma associated with it, improved screening mechanisms, timely responses, and readily available treatment resources.
Literature Review
Background
A paper prepared for the Library of Parliament of Canada provides a suitable background to the subject of posttraumatic stress disorder. It has taken a century for the world to acknowledge posttraumatic stress disorder as an ailment. During the First World War, soldiers who suffered from brain damage after being exposed to artillery barrages were said to be suffering from ‘shell shock’. A large number of civilians were screened out of the draft for the Second World War by psychiatric evaluation. PTSD entered the lexicon of common usage only after increased incidence of stress-related disorders during the Vietnam War (Library of Parliament, Canada, 2013).
PTSD can get triggered with exposure to actual or threatened death and serious injury. It may cause recurrent and distressing memories and dreams. Efforts to avoid such dreams can accentuate PTSD. Victims suffer from loss of memory, distorted cognition, diminished social interaction and inability to experience positive emotions. As a result, they can be irritable, violent, reckless and self-destructive. In scientific terms, PTSD is a ‘delayed or protracted response’ to a stressful event or situation of such catastrophic proportions that it is likely to cause distress in most people (Library of Parliament, Canada, 2013).
An analysis of PTSD across the service personnel of Canada, US and Australia reveals that the service personnel of the USA suffer the most from PTSD, probably because members of the US Armed Forces have been deployed for longer rotations and in closer proximity to the enemy (Library of Parliament, Canada, 2013). This correlation of the higher incidence of PTSD with deployed troops dovetails with the research of Sundin, Fear, Iverson, Rona, & Wessely (2009), who studied peer reviewed articles and published reports covering the incidence of PTSD amongst troops in Iraq and Afghanistan. To ensure that they had a fair representation of the population, they excluded all studies with samples of less than 300 participants. They found the prevalence of PTSD to be between 1.4% and 31%. The researchers found that the reported cases of PTSD were higher amongst American forces as compared to British forces. Attempting to find the reason for this discrepancy, the researchers found that the research methodology varied between the two countries. They also found a greater prevalence of PTSD post deployment as compared to the pre-deployment phase. PTSD rates were lesser across generic samples of them military population as compared to the infantry. The researchers did not find a change in incidences of PTSD between enlisted men and officers. The highest incidence of PTSD was reported from infantry units (Sundin, Fear, Iverson, Rona, & Wessely, 2009).
Thus, deployment on the ground is a big factor in the development of PTSD, and the infantry is therefore the most affected. This finding could serve to be a pivot in the treatment of the subject, yielding solutions about how to treat soldiers on repatriation to the country (Sundin, Fear, Iverson, Rona, & Wessely, 2009).
Context and Impact
The US Government constituted a Task Force under the aegis of the American Psychological Association to examine potential risks to the psychological wellbeing of service members and their families, to determine the context and impact of the deployment cycle and to recommend changes at the policy, program and practice levels. The Task Force discussed the programs in place within the Department of Defense (DoD) and Veteran Affairs (VA), and offered recommendations to improve the system of providing psychological care to veterans. The Task Force found that there was no comprehensive and coordinated program in place to provide psychological care to affected soldiers and their families. The quality of care varied across different programs. Once soldiers made a transition to veteran status, they experienced a drop in the quality of psychological care. The Task Force identified the lack of availability of skilled caregivers, the prevalent stigma surrounding psychological help and the lack of accessibility to psychological care due to geographical and administrative reasons as the chief barriers to psychological care (American Psychological Association, 2007).
In 2008, the RAND Corporation commissioned a monograph in 2008 to fill gaps in knowledge about the mental health of US servicemen returning from deployments in Iraq and Afghanistan. The RAND monograph mirrors the findings of the American Psychological Association. The RAND study focused on PTSD, Traumatic Brain Injury and reactions to trauma. The study inquired about the prevalence of these conditions amongst soldiers, the attendant costs and the institutionalized care system in place. The study found that at least one third of soldiers displayed one of the three mental health conditions, with 5% soldiers suffering from a combination of ailments. Only half of those afflicted had sought medical help. Quality care was restricted to a few patients. Unless treated, those afflicted would be impaired from leading healthy lives over their lifetime. The study assessed the cost of treatment to amount to approximately $ 900 million and attributed more costs to loss of productivity. The study identified gaps in treatment and care, and recommended an increase in the cadre of caregivers. The study pointed out policy changes required to encourage veterans to seek care and advocated the institutionalization of evidence-based treatment and care. The RAND study is comprehensive and can provide a major bulwark of any study on PTSD (RAND, 2008).
The Iraq and Afghanistan Veterans of America (IAVA) commissioned a report to analyze the incidence of PTSD afflicting service personnel. While acknowledging the RAND report, the IAVA report went into greater detail about the contributory factors of PTSD. The report highlights that long tours and multiple deployments exacerbate the incidence of PTSD. The report highlights the added strain on female troops. The report describes the effect of PTSD manifested in divorces, substance abuse, homelessness and suicide. A critique of the DoD efforts to combat PTSD is a unique aspect of this report, as it highlights staffing shortages, insufficient training and poor evaluation of combat troops as contributory factors to the incidence of PTSD. The report is unique in its critique of the DoD and the details of the impact of PTSD on the armed forces (IAVA, 2009).
One assessment measure for PTSD is the 17-item PTSD Checklist-Military (PCL-M) is a widely used assessment for both military and veteran healthcare settings. Fissette, Snyder, Balderrama-Durbin, Balsis, Cigrang, Talcott, & Smith studied196 active duty service members from the U.S. Air Force Security Forces that underwent a year-long high risk deployment to Iraq between 2009 and 2010. After the Airmen returned from deployment, they were asked to return to Lackland Air Force Base in San Antonio, Texas to complete the follow-up testing. The study noted feelings were more prevalent than those that were stereotypically identified as symptoms of PTSD. The report provided the measurement scale and concluded with a discussion on the results, effectively calling for a review of the longstanding PCL-M scale (Fissette, Snyder, Balderrama-Durbin, Balsis, Cigrang, Talcott, & Smith, 2014).
Financial Reasons for Rise in PTSD Cases
McNally and Freuh (2013) take a contrarian approach to the rising prevalence of PTSD amongst soldiers and veterans returning from deployments in Afghanistan and Iraq. They hypothesize that the rising incidences of PTSD may be attributed to malingering, delayed onset of PTSD and the economic benefits that accrue from medical disability allowances. They determine that questionnaires seeking to identify the onset of PTSD tend to overestimate its existence; however, the reported cases of PTSD are far in excess of all estimates. The authors quote extensive studies to assess the incidence of delayed PTSD, and conclude that delayed PTSD occurs in only 4-5% of the cases. They focus on the issue of malingering, and found that a majority of patients seeking medical help for PTSD did not take follow up psychological sessions; they were more interested in the financial benefits of medical disability claims rather than curing themselves. Veterans who were unable to find jobs tended to resort to reporting of PTSD more often. With this as a background, the authors question the medical basis of declaring disabilities and recommend that disabilities should be awarded if a person is unable to perform a role in society. The paper serves as a useful counterpoint to any study on the prevalence of PTSD and acts as a useful warning signal, indicating that the problem may not be as acute as reported (McNally & Frueh, 2013).
Counterpoint: The Soldiers’ Perspective
While institutional analysis on the scourge of PTSD and ways to mitigate its social impact looks at the subject dispassionately, a view from the ground provides a suitable perspective on the subject from the human angle. Veterans afflicted with PTSD have been active in the social media, recounting their experiences in blogs and websites. Burns (2014) provides one such human angle to the problem. Burns highlights the case of Cecil Ranne, a veteran of two overseas deployments in the US military. Ranne returned with the scars of PTSD in his psyche. His family life suffered because of his mental makeup and he went through a divorce. He is now fighting court battles for custody of his children, while his ex-wife has sued him for child support. As military personnel have no roots in society, Ranne’s case has been heard across different states and he is paying multiple times for child support. There is little social help for Ranne and he is left to his own devices to survive. Burns points out that the media looks for sensational news of PTSD victims running amok and committing crimes or suicide. After the news dies down, there is little institutional or social support over the long haul for those suffering from PTSD (Burns, 2014).
Miller (2013), a veteran of three overseas deployments, recounts the challenges facing a PTSD victim as he tries to reconnect and immerse himself into the social and academic world of a civilian American. Miller finds that no one in his peer group identifies with him, as he is the only one who has frequent appointments with psychiatrists and doctors. While Miller attempts to write a doctoral thesis on PTSD and its effects on veterans, he faces emotional blocks as he tries to research the history of combat and its effects on PTSD. Miller finds that throughout history, soldiers have been invalidated out of service for ‘inexplicable’ reasons, which could only be adduced to PTSD. He also discovers the challenges in treating those affected by PTSD, as they try to avoid realization of their condition and thus postpone possible treatment (Miller, 2013).
In December 2013, the CBS show ‘60 Minutes’ followed veterans for a two-month period and documented a new form of treatment being used to battle PTSD. Although this form of therapy has been used for the treatment of rape victims suffering from PTSD, it is new to the realm of treating those diagnosed with Posttraumatic Stress Disorder due to military combat. This treatment program is being conducted at the VA Hospital in Little Rock Arkansas. This segment highlights the symptoms of PTSD while at the same time documenting the unhealthy decisions made by those suffering from this disorder (CBS, 2013).
The personal stories from blogs and social media serve to highlight the challenges confronting veterans afflicted with PTSD. As they try to evade the knowledge and realization of their condition, they delay possible treatment. Civilian society aggravates their condition, as no one around them understands what they are going through. The media remains captivated by sensational stories of PTSD victims running amok. There is little institutional support for the vast majority who struggle to bring order to their lives while coping with PTSD. All efforts to mitigate the effects of PTSD on military personnel need to take the feedback of those suffering from PTSD into account for a humane and empathetic response.
Impact of Academic Knowledge on Social Institutions: Institutional Mechanisms to Tackle PTSD
Policy and Outreach. With increased prevalence of PTSD and a growing acknowledgement of the problem, the academia and government bodies have recommended urgent steps to mitigate the problem. The American Psychological Association has recommended greater centralized oversight into the myriad programs in place to diagnose and treat PTSD. There is a need to educate military personnel at all levels to acknowledge the incidence of PTSD, so that treatment could begin early. It would be necessary for high quality mental health care to be made available to military installations. As many military installations are not within easy reach and are located in inaccessible areas, it would be incumbent on the DoD to fund such access of medical teams to military installations. The military establishment has a diverse clientele, as it includes lesbian, gay and bisexual members. Policy makers would need to take this diversity into account to create suitable intervention mechanisms to treat incidences of PTSD (American Psychological Association, 2007).
Research. There would be a need for focused research on PTSD to guide policies and program development. The government would need to co-opt military psychologists into such research. The first hand experiences of military psychologists deployed in the field needs to be dovetailed in the overall research effort. The government needs to evaluate the efficacy of existing programs to tackle PTSD (American Psychological Association, 2007).
Clinical Services. The United States’ Operational Stress Control and Readiness (OSCAR) program embeds psychologists in field units throughout their deployment cycle. Policy makers could evaluate the effectiveness of the OSCAR program. If policy makers find the OSCAR program effective, they could extend the program to all military units. Suitable impetus would be required to deepen the access of military families to TRICARE mental health services. Policy makers need to ensure that adequate psychological inputs are provided to primary healthcare providers so that they develop the correct perspective of PTSD while dealing with patient (American Psychological Association, 2007).
Service Providers. There is a need to retain trained military psychologists within the system to tackle the incidences of PTSD. Increased efforts would be required to recruit new psychologists. As military families are as much affected as the patients, it would be necessary to extend psychological care to affected families. A high standard of training would be an imperative for all practitioners in the field. All efforts would be necessary to secure the necessary budget to extend necessary support to tackle PTSD (American Psychological Association, 2007).
Institutional Synergy. The National Defense Authorization Act 2010 commissioned the Institute of Medicine (IOM) to study prevalent efforts of the Department of Defense (DoD) and the Veterans’ Administration (VA) to combat PTSD. While the DoD conducts programs like TRICARE, the VA has a focused approach to tackle incidences of PTSD amongst veterans. The DoD and VA have issued joint guidelines to cover medical conditions that occur concurrently with PTSD. Joint executive councils, coordinating offices, working groups, direct sharing arrangements between DoD and VA medical centers are other facets of cooperation between DoD and VA. The study recommends that the DoD and VA investigate the efficacy of programs in place to counter PTSD and argues in favor of an annual screening process for PTSD (Institute of Medicine, 2012).
Impact of Active Citizenship on PTSD
Active citizenship is a framework where citizens do not wait for the government to solve all their problems, and instead take necessary steps as citizens to be part of the solution. Given the breadth of the problems posed by PTSD, it would be virtually insurmountable for the government to provide the solution on its own. A coordination mechanism between communities and government agencies is one of ways forward to create a system of synergy to identify and monitor people suffering from PTSD. Early warning signs of people suffering from PTSD would be best available from within communities. If such cases were to be brought to the notice of hospitals and medical authorities early, it would be possible to avoid cases from degenerating into chronic PTSD.
Involved communities also have a role in mitigating the taboo associated with PTSD and other mental problems afflicting soldiers and veterans. So long as the affected individuals do not seek help, their condition would only worsen. Self help groups and community-led focus groups would play the crucial role of a bridge between the patients and the institutional mechanisms attempting to tackle the disease.
Conclusion
PTSD has become a fact of life for US troops and their families. It is necessary for renewed research into the various nuances of PTSD so as to cover the genuine cases with more intensity and care. The financial aspects of pecuniary benefits being given for disability should not result in more veterans claiming to be suffering from PTSD; if this situation were to continue, substantial resources of the state would be spent in trying to treat non-essential cases. The DoD and the VA need to coordinate their efforts to ensure quality treatment for those genuinely suffering from PTSD. In such an effort, it is important to coopt society through community outreach programs to reduce the taboo associated with PTSD and to draw in more affected veterans and soldiers to seek critical help for rehabilitation.
References
American Psychological Association. (2007). The psychological needs of US military service members and their families: A preliminary report. Retrieved 07 Oct 2014, from http://www.ptsd.ne.gov/publications/military-deployment-task-force-report.pdf
Burns, M. (2014). A veteran father struggles with family court and child support. [Web log post]. Retrieved 19 Oct 2014, from http://ptsdasoldiersperspective.blogspot.in/2014/08/a-veteran-father-struggles-with-family.html
CBS. (2013). 60 Minutes Advanced PTSD Therapy. Retrieved 19 Oct 2014, from You Tube: http://www.youtube.com/watch?v=7frOWBiU8D4
Fissette, C. L., Snyder, D. K., Balderrama-Durbin, C., Balsis, S., Cigrang, J., Talcott, G., & Smith Slep, A. M. (2014). Assessing posttraumatic stress in military service members: Improving efficiency and accuracy. Psychological Assessment 26/1, 1-7. doi:10.1037/a0034315. Retrieved 19 Oct 2014, from http://eds.a.ebscohost.com.proxy-library.ashford.edu/eds/pdfviewer/pdfviewer?vid=2&sid=9a25f77d-ba89-45c2-a0eb-df93dcae41a5%40sessionmgr4005&hid=4210
Library of Parliament, Canada. (2013). Post traumatic stress disorder and the mental health of military personnel and veterans. Background paper. Publication No. 2011-97-E. Ed. Pare, J.P. Retrieved 07 Oct 2014, from http://www.parl.gc.ca/Content/LOP/ResearchPublications/2011-97-e.pdf
McNally, R.J., & Frueh, B.C. (2013). Why are Iraq and Afghanistan war veterans seeking PTSD disability compensation at unprecedented rates? Journal of Anxiety Disorders 27, 520-526. Retrieved 07 Oct 2014, from http://mcnallylabcom.ipage.com/beta/wp-content/uploads/mcnally-frueh-2013-jad-disability-rates1.pdf
Miller, J. (2013). Impairment honesty without sacrificing goals. [Web long post]. Retrieved 19 Oct 2014, from http://ptsdasoldiersperspective.blogspot.in/2013/01/impairment-honesty-without-sacrificing.html
Iraq and Afghanistan Veterans of America (IAVA). (2009). Invisible wounds: Psychological and Neurological injuries confront a new generation of veterans. Williamson, V., & Mulhall, E. (Eds.). Retrieved 07 Oct 2014, from http://iava.org/files/IAVA_invisible_wounds_0.pdf
RAND Corporation. (2008). Invisible wounds of war: Psychological and cognitive injuries, their consequences, and services to assist recovery. Tanielian, T. & Jaycox, L.H. (Eds.). Retrieved 07 Oct 2014, from http://www.rand.org/content/dam/rand/pubs/monographs/2008/RAND_MG720.pdf
Sundin, J., Fear, N.T., Iverson, A., Rona, R.J., & Wessely, S. (2009). PTSD after deployment to Iraq: Conflicting rates, conflicting claims. Psychological Medicine 40, 367-382. Retrieved 07 Oct 2014, from http://www.kcl.ac.uk/kcmhr/publications/assetfiles/iraqafghan/Sundin2010-ptsddeploymentiraq.pdf
