Returning Veterans: Our Help and Our Hope


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"Returning Veterans: Our Help and Our Hope" presentation given by Ilona Meagher to participants of the "When the War Comes Home: Advocacy and Treatment for Returning Veterans" Conference at the National World War One Museum. Kansas City, MO. October 31, 2008.

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  • I’d like to thank Theresa for inviting me to be here with you today. I’m so excited to be here with you all. As a veteran’s daughter, I have a soft spot for those who wear the uniform. But, as far as my work in this area is concerned, I really just a concerned citizen. Back in 2005, I’d read some disturbing reports of serious reintegration problems taking place with some or our troops returning home from the Middle East, and wanted to learn more. Since then, as today, I’ve been honored and humbled to share time with health care professionals like you, and other experts in the field of combat trauma. I always walk away from these meetings having learned so much from those of you who are doing the real work of taking care of our military families. My hope is to be able to share some information with you that may be of some help as you continue your important work.
  • We have a lot to cover in the next hour, so let’s jump right in.I’d first like to show a recent New York Post report – it’s about 3 ½ mins long – on ‘War Vets and PTSD’. It’s a good further introduction to the topic we’ve been exploring today, and it touches on some of the stats that we’ll be looking at in-depth in my presentation.
  • So, let’s begin our journey into the data.As of the end of October, 2007, ~1.6 million have served in Afghanistan and/or Iraq , ~ ½ a percentage point of the total U.S. population. Contrast that to the WWII era, when 12% of Americans overall, a full 1-in-4 or 25% of all fighting-aged men, served in uniform. Compared to today, most people back then had a brother or cousin or uncle or neighbor or friend in the military.
  • This chart is not in your handouts, but I think it helps us visualize how much the war in Iraq has changed from one year to the next. As we move into exploring some of the more important studies gauging levels of PTSD, depression and TBI in our returning troops, think about this chart and how the escalation in violence and danger correlates with the data.
  • One last stop before diving into the research, we need to honorthe complexity and ambiguity and difficulty of nailing down combat PTSD datafully and properly. The following quote does a good job of summing things up. It’s from the Introduction to the recently-published book, Haunted by Combat.“The causal chain that gives researchers clues about how to deal with other ailments is not as clear in the case of trauma…Unlike other disabilities for which there is a site of injury, or a visible pattern, which results in pain, immobility, or impairment, the site of injury for PTSD is experience itself.”
  • The book goes on to explain that combat PTSD is a complex intersection of individual and familial beliefs, experiences and traits.A person’s social, philosophical, spiritual, existential, psychological and physiological facets all have bearing on its development, experience and treatment. Therefore, while invisible, psychological injuries are harder to determine definitively than visible, physical injuries, it’s still important to do our best to try.
  • [Top of page 3.]The first major study looking at OEF/OIF veterans arrived in 2004, published in the New England Journal of Medicine. WRAMC examined 3 Army units and 1 Marine unit 3-4 months after their 2003 deployments for PTSD, depression and related ailments.Key findings included a higher rate of PTSD was found in OIF troops (~12-20%) than OEF troops (~6-12%); combat experience (being shot at, handling dead bodies, knowing someone who was killed, etc) was strongly correlated with PTSD; and being wounded or injured was positively associated with rates of PTSD.
  • The next WRAMC study was published in the Journal of the American Medical Association in 2006. Researchers looked at the records of all returning OEF/OIF Army and Marine units deployed between May 1, 2003-April 30, 2004 who’d filled out the PDHA. Results were similar to the 2004 study. ~10% of OIF vets and ~5% of OEF vets met the criteria for PTSD and, again, combat experience was strongly correlated with PTSD. Additional findings: Hospitalization was associated with a mental health problem; and female OIF vets more likely to report mental health concern.
  • [Top of page 4.]Another 2006 WRAMC study, this one published in the American Journal of Psychiatry, showed that PTSD often takes time to develop. While 4% of combat-wounded vets evacuated to WR between March 2003 and September 2004 met the criteria for PTSD at 1 month post-deployment, this figure jumped to 12% at 4- and 7-months after deployment.Wounded vets under 25 and married vets were more likely to meet PTSD and depression criteria.
  • That same 12% PTSD figure we’ve been hovering at in the opening stages of the war was also found in returning Ft. Hood and Ft. Lewis OIF veterans deployed from January-May 2005. 25% of these same troops met the criteria for depression.
  • As we can see, we’ve moved beyond the opening years of the war.If you recall, casualties are now mounting; reports reveal that troops are using scrap metal to reinforce their humvees; and soldiers and Marines are finding themselves serving their second and third deployments – long and dangerous deployments. Noted combat PTSD author, VA psychiatrist and Genius grant winner Jonathan Shay often refers in his work to 3 supports the military is obligated to provide its combat forces in order for them to feel prepared, protected and confident in their mission:In-depth/realistic training in what they will face in battle, and the proper equipment to do their job; 2) Unit community and stability (cohesion); 3) Capable, moral, and reinforced leadership.Shay called these supports “themis,” Greek for “what’s right,” and said they were necessary to help protect troops not only physically on the battlefield, but also psychologically after they returned home.
  • In early 2006, Le Moyne College and Zogby International conducted a first-ever poll of troops deployed in Iraq. It gave us an idea of what our troops were thinking and feeling at the time. It wasn’t necessarily good news.72% felt their mission was complete and wished to exit Iraq by the end of the year. Only 1-in-5 said they wanted to “stay as long as needed” to finish the job. 58% said their mission was clear, 42% said it was not. The survey also revealed how much more dangerous their work had become in Iraq by this time, 50% indicating that they “felt in great danger of being killed.”Disillusionment and exhaustion had begun to creep in.
  • [Top of page 5.]WRAMC’s data reflected this asthe PTSD rate for Army combat infantrymen rose to nearly 17%.
  • After earlier WRAMC research showed that PTSD takes some time to develop and can’t be completely gauged immediately after returning from the combat zone, in 2006, the DoD implemented another self-report intake form: the PDHRA.It would be administered 6 months after troops returned home. From it, WR researchers learned that more than 2 times as many new PTSD cases (~17% active/~25% reserve) showed up at 6 months than the PDHA had found at 1 month post-deployment (~12% active/~13% reserve). Note the higher rates among National Guard and Reserve troops.
  • Our “weekend warriors,” we began to find out, were more susceptible to PTSD. Serving in capacities well beyond the scope of their usual job description, National Guard and Reserve forces, while only receiving 8% of the overall DoD budget, now accounted for ~40% of U.S. fighting forces in Iraq and ~50% in Afghanistan . Some states had 75% of their Guard activated, with 90% of their equipment sent overseas to boot. One statistic I believe reflects the operational pressures on the DoD and their need to retain as many forces as possible. While 16% of Army reservists received permanent retirement for disabilities in 2001, during the hottest period of fighting and dying in Iraq, only 5% had their permanent disability claims approved in 2005.
  • The late Dr. Charles Moskos, a respected sociologist and war researcher, reflected on the increased PTSD rates of the “weekend warrior.”Can you can spot any issues that might relate to Shay’s 3 “what’s right” supports?Problems included: 1) Routinely serving longer in combat than active-duty troops, often not knowing when they could come home; 2) Being used as “fillers” and serving alongside strangers they did not train with or know very well; 3) Worry over lack of support services for loved ones left behind; 4) Dissatisfaction with inferior training and equipment compared to active forces, making them feel as second-class soldiers; 5) Fear (or actuality) of losing their civilian jobs or small businesses while in combat.
  • Guardsmen and Reservists weren’t the only ones enduring longer and multiple deployments – active forces were, too. And, with each deployment, troops were placed at greater risk for acute stress and PTSD. While12% of troops suffered acute stress during their 1st tour, this rate increased to 18% with their 2nd deployment.
  • [Bottom of p. 5.]And so, when the Army conducted a survey of its forces returning from Afghanistan and Iraq between February and July 2005, they found that 30% met the criteria for PTSD and 38% for depression. This time, junior enlisted and separated/divorced service members reported higher levels of PTSD and depression.
  • Everyone must be nearing data fatigue at this point, and so we’ll wrap this section up with a look at this year’s landmark RAND Corporation study, which estimated that at least 300,000 OEF/OIF veterans have PTSD; 300,000 are coping with depression; and 320,000 have at least mild TBI.  At least 1/3 of our troops have at least one of the above conditions; 5% are coping with all three.
  • Now’s a good time for another short 3 minute video break.This clip spells out some of the struggles of those returning veterans and military families dealing with both PTSD and TBI.
  • That video does a remarkable job of showing just how important all military family members are to the strength of our country. They support and care for our defenders.It’s a far cry from the WWII slogan: “If the Army wanted you to have a family, they would have issued you one.” Today:~55% OEF/OIF troops married10-15% of spouses also a member of the military24% of servicemembers are parents6% are single parents
  • You can find a lot more information on military family demographics in the chart on the bottom of page 7.
  • Returning to my final couple of stats and the RAND study published earlier this year…some data that directly concerns your efforts to extend care to our military families. Only 23-40% of veterans with mental health problems actually seek out care, and of those who do, only 50% receive minimally adequate treatment, and even fewer receive quality care – defined as treatment demonstrated to be effective.
  • On page 6 in your handout packet, looking at the chart to the left, you’ll see a list of barriers to care given by respondents to the RAND survey. Immediately below their fears that prescribed medications may have too many side effects, veterans said they were afraid to seek help for fear that doing so may harm careers or deny security clearances, and fears that coworkers and superiors will view them differently (having less confidence in or respect for them).Fortunately, the past year or two has seen the military and the VA really making great strides in destigmatizing access to mental health care. They are also broadening mental health care horizons. For example, the U.S. Army had devoted $4 million to researching more holistic ("whole picture") mind-body-spirit treatment methods including spiritual ministry, transcendental meditation, yoga and bioenergy therapies. For over a year now, some of these same treatments are already being used successfully in the new Warrior Resilience program at the appropriately-named Fort Bliss.So, we are finally seeing some exciting changes in the military mental healthcare field.Even so, having confidential, alternative community mental health care choices – located conveniently, within easy reach – will greatly increase the number of military families who access care when they need it most.And, of course, this is where you come in.
  • Strengths of the community supports you can provide military families include already having nearby services in place. Veterans may only need to travel tens of miles rather than hundreds to the nearest VA for their care. Your ability to assist them through their period of transition offers them the privacy and confidentiality they crave.
  • The following advice comes from a book that I failed to list in the Recommended Reading section – and yet it’s actually the book that speaks directly to you: counselors treating military families. Highly, highly recommend it, so you might want to jot his name down (Larry Dewey, War and Redemption). Dewey has been counseling veterans for several decades and has information I know you’ll want to explore.It may be highly unusual for an author to read a passage from another author’s work, but that’s exactly what I’d like to do right now.
  • The work that you’re doing has you on the leading edge of a wonderful movement taking place in communities across the country. Texas, Minnesota, Tennessee, California…and Maine, too.
  • As I close my presentation with the following quote, which I’ll leave for you to read, I’d like to reinforce for you the invaluable work that you are embarking on as you help our veterans heal from their experiences. Your efforts will not only be seen in the day-to-day progress of those in your care, your work will also have a direct and powerful effect on the progress of our greater society as well. Thank you so much for all you do.
  • Returning Veterans: Our Help and Our Hope

    1. 1. Returning Veterans:Our Help and Our Hope<br />When the War Comes Home: Advocacy and Treatment for Returning Veterans<br />10/31/08 Conference at the National World War One Museum<br />By Ilona Meagher, author of Moving a Nation to Care and editor of PTSD Combat: Winning the War Within<br />
    2. 2. Intro to OEF/OIF PTSD Statistics<br /><br />
    3. 3. OEF/OIF Troops Deployed<br />Troops who have served in Afghanistan and/or Iraq: ~1.6 million<br /><ul><li> U.S. population that fought in WWII: 12%
    4. 4. …in Vietnam War: 2%
    5. 5. …in OEF/OIF: 0.5%</li></li></ul><li>OIF WIA and KIA<br />
    6. 6. Reality of Combat PTSD is Messy<br />“The causal chain that gives researchers clues about how to deal with other ailments is not as clear in the case of trauma…Unlike other disabilities for which there is a site of injury, or a visible pattern, which results in pain, immobility, or impairment, the site of injury for PTSD is experience itself.” <br />-- Jeffrey Kirkwood, Haunted by Combat<br />
    7. 7. Understanding Combat PTSD<br />Complex intersection of individual and familial beliefs, experiences, and traits <br />Social<br />Philosophical<br />Spiritual<br />Existential<br />Psychological<br />Physiological<br />
    8. 8. NEJM WRAMC 2004 Study<br />
    9. 9. JAMA WRAMC 2006 Study<br />
    10. 10. AJP WRAMC 2006 Study<br />
    11. 11. JAMA 2006 Ft Hood/Ft Lewis Study<br />
    12. 12. Military Obligations to Its Soldiers<br />Jonathan Shay’s thémis or “what’s right” supports necessary for troop protection<br />To prevent some (not all) post-combat symptoms, soldiers need:<br />In-depth/realistic training in what they will face in battle, and the proper equipment to do their job<br />Unit community and stability (cohesion)<br />Capable, moral, and reinforced leadership<br />
    13. 13. Le Moyne College/Zogby 2006 Poll<br />OIF troops wishing for a 2006 exit of Iraq: 72%<br />OIF troops wishing to &quot;stay as long as needed&quot; to finish job: 1-in-5<br />While 58% say mission is clear, 42% say U.S. role is hazy<br />OIF troops indicating &quot;felt in great danger of being killed&quot; on DoD demob form: over 50%<br />
    14. 14. AJP WRAMC 2007 Study<br />
    15. 15. JAMA WRAMC 2007 Study<br />
    16. 16. National Guard/Reserve Forces<br />Portion of total overall military force: &gt;1/3<br />OEF/OIF vets activated from Guard/Reserve: 403,089 (vs. 384,107 active duty)<br />Portion of forces serving in OIF, 2004: 40%<br />Portion of overall DoD budget: 8%<br />Approved reservist permanent retirement disability claims, 2001: 16%<br />Approved reservist permanent retirement disability claims, 2005: 5%<br />
    17. 17. Unique Guard/Reserve Stressors<br />Northwestern University Professor Emeritus of Sociology Charles Moskos’ triggers for increased PTSD risk in OIF vets:<br />Routinely serving longer in combat than active-duty troops, often not knowing when they could come home<br />Being used as “fillers” and serving alongside strangers they did not train with or know very well<br />Worry over lack of support services for loved ones left behind<br />Dissatisfaction with inferior training and equipment compared to active forces, making them feel as second-class soldiers<br />Fear (or actuality) of losing their civilian jobs or small businesses while in combat.<br />
    18. 18. Deployments<br />Typical tour of duty, Vietnam: 1 year<br />Typical tour of duty, OEF/OIF: extended up to 2 years, multiple deployments<br />Troops under acute stress, 1st Iraq tour: 12%<br />Troops under acute stress, 2nd+ Iraq tour: 18%<br />Increased risk of acute combat stress in those serving multiple tours: 50%<br />
    19. 19. JTS Army/Tarleton SU 2007 Study<br />
    20. 20. RAND Corporation 2008 Study<br />Most returning service members readjust successfully<br />Survey respondents affected by:<br />PTSD: 14 % (est. 300,000)<br />Major Depression: 14% (est. 300,000)<br />TBI: 19% (est. 320,000)<br />At least 1/3 have at least one of the above conditions<br />5% coping with all three: PTSD, major depression and TBI<br />
    21. 21. Experience of the Military Family<br /><ul><li></li></li></ul><li>Military Spouses<br />“If the Army wanted you to have a family, they would have issued you one.”<br />Today:<br />~55% OEF/OIF troops married<br />10-15% spouses also in uniform<br />24% are parents<br />6% are single parents<br />
    22. 22. Military Kids<br />Active duty military children: 1.8 million<br />Reserve/Guard forces dependant children: 700,000<br />At any given time, kids with a parent deployed to OEF/OIF: &gt;500,000<br />
    23. 23. Military Family Demographic Trends<br />
    24. 24. RAND Corporation 2008 Study<br /><ul><li>Only 23-40% with a mental health problems seek out care. Of those who do reach out for help:</li></ul>Only 50% receive minimally adequate treatment<br />Even fewer receive quality care, defined as treatment demonstrated to be effective. <br />
    25. 25. RAND Corporation 2008 Study<br />
    26. 26. Strengths of Community Healthcare<br />Services already in place and ready to help<br />&gt;2,000 community-based mental health and addictions organizations serving 6 million/year<br />Less travel time for veterans and their families because they can receive hometown care <br />Privacy and confidentiality eases fears<br />
    27. 27. On Counseling Veterans<br />Read/learn about the experiences of combat veterans and their families. <br />“Because veterans have experienced so much pain in their lives, they grow accustomed to it and often think that life itself is inevitably painful. They do not relate to people and lifestyles of self-fulfillment and self-actualization because their personal mythology sees the world as one of total danger.” <br />-- Haunted by Combat<br />
    28. 28. On Counseling Veterans<br />Forces that cause veterans to break down:<br />Overwhelming grief<br />For fallen battle buddies<br />Exhaustion<br />Guilt<br />“Aren’t we all murders?”<br />Fear<br />That they may have let comrades down at some crucial point, that they could not do what they needed to do<br />- Larry Dewey, War and Redemption<br />
    29. 29. Veterans: Our Help<br /><br />
    30. 30. Veterans: Our Hope<br />“Veterans are the light at the tip of the candle, illuminating the way for the whole nation. If veterans can achieve awareness, transformation, understanding, and peace, they can share with the rest of society the realities of war. And they can teach us how to make peace with ourselves and each other...”<br />-- ThichNhat Hahn, Vietnamese Buddhist monk who worked tirelessly for reconciliation between North and South Vietnam during the Vietnam war<br />