11/11/2010 07:12 am ET | Updated May 25, 2011

How the Stress of Combat Affects Family and Work at Home

We are at war. And over one-third of U.S. soldiers deployed to Iraq and Afghanistan are not active duty, they are members of the National Guard and Reserve*: these men and women are typically older, married and employed. They are soldiers who brave the perils of combat and separation from family, work and community. One in five will develop a mental health disorder. The stress of combat, repeated deployments under persistent threat of harm means that many are returning home with extraordinary rates of mental and substance use disorders; with evident or sometime subtle problems thinking clearly as a consequence of traumatic brain injury (TBI); and with rates of suicide that now result in more self-inflicted deaths than those sustained from the enemy.

Because of these stresses, family and work problems upon return are not uncommon and can sometimes be catastrophic. What is going on and what can be done that will place a type of psychological Kevlar into the minds of these men and women to prevent harm and what can be done if they are psychologically injured to minimize illness and maximize recovery?

Over 1 million men and women have served in the Guard and Reserve since 2001. When deployed they go more frequently (many times with three or four deployments), for longer stays in combat areas and with less advance notice than in the past. This means disruption. Disruption of their lives, their families' lives and their work lives. Spouses and children are repeatedly separated from their loved one, as is the soldier from his or her family; families consequently live with more limited resources as a member is gone and under the constant anxiety about the possible injury or death of their soldier.

Work is impacted when a soldier leaves for lengthy and repeated tours that effect job performance and productivity, and test even the most supportive of employers. Imagine a business with five employees where one is repeatedly gone. When the soldier returns with PTSD, TBI, depression or is abusing alcohol or drugs then the stresses of absence and disruption are complicated by the soldier's psychic pain -- the invisible wound of war, and the impaired thinking and functioning that interfere with work and family relationships.


Twenty-six years ago, Former First Lady Rosalynn Carter began The Rosalynn Carter Symposium on Mental Health Policy. This year's meeting, held November 3 and 4 at the Carter Center in Atlanta, Georgia, was "A Veteran's Journey Home: Reintegrating Our National Guard and Reservists Into Family, Community and the Workplace." The challenge the conference presented to its invited attendees, according to Thomas Bornemann, Ed.D., Director of the Center's Mental Health Program, "... is to meet our moral obligation to serve the men and women who served and suffer ... taking a public health approach, where we understand a population of people in need and develop solutions that advance national policy and practices." I love the mission statement of the Carter Center: Waging Peace. Fighting Disease. Building Hope.

We heard from Lieutenant Colonel Anthony Mohatt of the Kansas National Guard who established a command philosophy of wanting to know and has staffed his unit of 1,700 soldiers with mental health, family support and chaplaincy staff to ensure that emotional problems are identified and help is made available. He has also proven to his men and women, over a number of years, that promotions are not denied those with mental health problems if they continue to do their job well.

Liisa Hyvarinen Temple, a freelance multimedia producer and instructor at the University of South Florida, told us about her husband, U.S. Air Force SMSgt Rex Temple, who has had four deployments and 10 overseas tours. Together the couple created a blog for his yearlong deployment to Afghanistan to connect him with her, his parents and extended family and friends which has become one of the most popular social networking sites for deployed troops with 300,000 unique visitors to date.

We heard how JPMorgan Chase pays full benefits during deployments lasting up to a year, including a special benefit to assist with childcare. They recruit soldiers because of their decision making and leadership skills. Dr. Barbara Van Dahlen, a clinical psychologist, started Give an Hour where today over 5,000 psychiatrists, psychologists, social workers and other mental health professionals across the country provide an hour a week of free mental health services to veterans and their families to complement the work of the Veterans Administration and community mental health services. Colleges are creating special entry programs for veterans to help them transition from the culture of war to the culture of the campus -- "Boots to Books" at Sierra College in California being one example. Veterans Courts are springing up around the country so that soldiers whose illnesses drive aberrant behavior are diverted to treatment instead of jail.

New York State (NYS), along with the Medical Society of the State of NY, the NYS Psychiatric Association and the National Association of Social Workers, developed and delivered basic training to 3,500 service providers on what to ask and how to recognize TBI, PTSD and other psychic injuries. Too few employers understand the value that veterans bring to the workplace, although the NYS Department of Labor and the NYS Division of Veterans Affairs have joined forces to provide returning vets with training and assistance in keeping or finding a job.

By law throughout the land since 2008 a set of reintegration services was instituted called the "Yellow Ribbon Program." Soldiers are now provided specific activities for them and their families at pre-deployment and after 30, 60 and 90 days after their return. They learn about the new normal that is their new life and are educated about the ways that trouble can emerge (including problems with anger, alcohol and drug abuse, and high risk behaviors) and how to get help. A comprehensive assessment of their health and mental health is done at 90 days. The VA, where soldiers can get medical and mental health services, has vastly expanded its programs and staffing to meet the needs of war returnees.

In other words, a lot is going on that focuses on prevention and intervention for those who have served. But not enough of those in need have workplace support and opportunities and the community services that can make a difference in enabling a successful reintegration. The numbers of veterans needing support and services are in the hundreds of thousands and growing each year. Fear of stigma or concerns about diminished career opportunities if you have a mental health or neurological problem (like TBI) keep so many soldiers from seeking care. Too few mental health professionals know the military culture or are experienced delivering effective treatments for the mental health disorders that war produces.

Our country has come to separate soldiers from the wars they are waging -- to differentiate soldiers in the war zone from whatever our politics may be about the Iraq and Afghanistan wars. This is truly an advance from the antipathy that those who served in Vietnam faced. Last year a beer advertisement had soldiers arriving at a domestic airport terminal clearly returning from someplace distant. Other travelers recognized their special role and stood and saluted. I choked up. But patriotism is not prevention and honoring the service of our soldiers is not the same as taking responsibility for their safe and successful return and reintegration. The Carter Center conference connected many across the country devoted to reintegrating veterans and challenged all of us to shape and institute effective policy and practices for the future.

I thought as I left the grounds of the Center that the fight we have to wage is not only for peace it is also for the peace of mind of those with the invisible wounds of war who served and are serving in Iraq and Afghanistan.
*Army Guard and Reserve, Coast Guard, Air National Guard, Air Force Reserve, Marine Corps Reserve and Navy Reserve.

Webcasts of the Carter Center Reintegration Conference can be found at:

The opinions expressed herein are solely my own as a psychiatrist and public health advocate.

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