Stress, Suicide and Homicide: How Do We Help Our Veterans Cope?

In the aftermath of the tragedy at Fort Hood last week, too many people are focusing on the religious affiliation of the alleged perpetrator, rather than on a more important and pressing issue: the lack of adequate psychosocial care for women and men in uniform. It matters not that the individual who will be charged with these heinous crimes had not been in combat; his long-term and very intimate association with the combat wounds of others clearly seem to have left him seriously damaged.

So why do these dangerous public examples of mental problems of servicemen keep happening, and why are we not doing more about it? Why do so many veterans and their families complain they are not getting the help they need with psychological problems?

Our military and Veterans' Administration facilities are swamped with massive numbers of veterans with physical injuries and serious mental health problems. As with all previous wars, it takes time to gear up after hostilities begin to provide requisite veteran services. It also takes public support to fund those services, and insist on excellence in their delivery.

There's been plenty of time, and lots of lip service paid to "supporting the troops," but the sad reality is that service members and veterans are not receiving the care they need.

In today's Veterans Administration health care system, there are not enough trained psychiatrists, psychologists, social workers and other mental health professionals to treat over 300,000 veterans already diagnosed with PTSD. Additionally, there are many other physically disabled personnel beset by psychological trauma who need care, not to mention the many veterans having real difficulty readjusting to civilian life.

These warriors return as changed persons to jobs, families, marriages and communities in which they experience real alienation and conflict. Unemployment, divorce, family violence, deep emotional anxiety, drug abuse, prison, depression and suicide are too often the result.

We as a nation don't really understand mental illness and deep emotional distress in general and we give insufficient attention to its causes and likely course. We tend to feel deep-down that those with emotional problems are somehow weak, undisciplined, maybe malingering, and even perhaps genetically defective. We don't fund mental health treatments adequately, nor do we devote sufficient research and development funds to finding better ways to help people learn to overcome it.

For some time now, Senator Tom Coburn (R-OK) - who professes to "support the troops" - has single-handedly blocked passage of an appropriations bill which would increase spending for our nation's military veterans. This kind of political posturing may win him votes in some quarters, but it condemns honorable veterans to mediocre medical care, at best, or none at all, at worst.

Mental health problems in the military are misunderstood, even by the military, recent events would argue. A soldier as part of his training learns to be hard and to suppress emotion, deny fear, ignore feelings, keep a stiff upper lip. Disciplined to obey orders and to engage in even the most terrifying or repulsive acts, he survives to the extent that he focuses on the team, the mission, and on carrying out the acts of war he was trained and ordered to do. Deemed necessary for combat, the culture demands that orders be followed no matter how dangerous, how destructive of others (or self), and how it much it makes the soldier do things he or she would never do in civilian life.

Some individuals, after prolonged exposure to the external threats of combat, and physical and spiritual exhaustion, find that their learned ability to deny and suppress emotions no longer works, and new troubling thoughts begin to raise questions about the purpose of it all, the morality of the acts they have committed, or a deep-seated fear that they might be terribly wounded or not even survive. This undermines the lessons of boot camp and the person is often left with nagging, relentless conflict and fear.

Without adequate help, that conflict and fear can become toxic to them and others.

The persistent wars on two fronts over the past seven years have shown that some soldiers who never even "leave the wire" experience stress symptoms similar to, or sometimes worse than, those involved directly in firefights, mortar attacks, or roadside bombs. It seems not at all far-fetched, then, that the alleged shooter last week, who'd never been deployed, but spent the last few years listening to the physically and psychologically maimed recount their horrors to him on a daily basis, lacked the necessary training to identify his own descent into the nightmare of untreated combat stress reaction.

This is unacceptable. American military personnel, who freely volunteer to serve, deserve the best medical/psychological care available, both during and after their time in uniform.

Far too many veterans are languishing without adequate care, across the United States. It should not be a crap-shoot as to whether a veteran will live close enough to a "good" V.A. Hospital, or whether she or he will get "the good therapist." There should be no argument whatsoever about funding top-flight research and treatment programs for all military personnel and their families.

When home, after these kinds of experiences, the veteran, beset by sleeplessness, flashbacks, anger and self-doubt, and seeing how much he feels alienated from what was once comfortable and joyous, often falls prey to self-pity, blame of others and feelings of rage which sometimes turn to violence, or depression and withdrawal.

Problems in marriage, conflicts with children, difficulties in finding satisfying work now that he has many new unevaluated and un-integrated competencies, a sense that he no longer understands himself or can get himself to do anything, difficulty in getting medical help, feeling like an outsider in his community, tempted by alcohol and drugs, he has few of his previous satisfactions from marriage, friendships, family, work and the camaraderie of the group. Talking about it all is so painful, he avoids it and this leads to greater isolation.

Now in civilian life and lacking the exo-skeleton of the military order and culture to help make his choices, he faces an entirely new challenge of learning -- how to develop the softer side of his nature.

To cope with his marital, career, and spiritual dilemmas, he must use his internal strengths, he must develop his capacity for psychological insight into his problems, become more aware of the needs of others, and expand his understanding of relationships. Moreover, he must take initiatives to learn to understand his emotional side, learn about his predictable problems, gain experience with emotional problems whose solution require a very different language, process, specialized knowledge, and an internal way of approaching problems that he may never have learned before. And much of this is directly contradictory to what the military and his combat experiences taught him.

Clearly he needs expert help, someone to help him understand his problems and to guide his understanding of his feelings, his thinking about new concepts and knowledge and to facilitate his movement toward new behavior, as he defines his new options, choices, goals, and tries things, fails and succeeds and learns from both.

But psychotherapy and counseling, the current treatment methods have several limitations. They require time and the services of well-trained professionals in many individual or group sessions. The VA has done it well over the years, but it is expensive and time consuming and this severely limits its availability to many who need help.

Also, psychotherapy and counseling are by their very nature talk-centered forms of learning, and thus a rather inefficient form of learning unless talk is accompanied by opportunities to get information in other ways, see others performing the new behaviors they need to learn and be able to practice new methods of communication and problem-solving in the protected setting of a classroom.

Thus the new challenges now faced by the military hospitals and the VA and the mental health agencies of America include how to create new learning programs to extend services that can help persons with mental health problems learn about their softer sides and how to gain insight into their feelings and problems, learn new ways of defining and perceiving them, acquiring new knowledge of how to cope with them and engaging in observed behavioral exercises to practice new, more effective interpersonal communication, or conflict resolution strategies or decision-making strategies that can be specifically applied to the predictable problems veterans face as marital partners, as parents, as workers, as developing persons facing new tasks of development, as health care recipients and as members of a community.

Fortunately in creating new programs to extend psychological learning and supplement psychotherapy, much progress has been made in developing better methods of making use of cognitive and behavioral therapy concepts by other delivery methods. There has been extensive work in the development of models for learning Life Coping Skills which deliver new therapeutic learning through carefully researched and designed multimedia exercises in small groups that help a person acquire new concepts, new knowledge and expand his behavioral repertoire in coping with such predictable problems as career choice, marital communication, parent-child disciplinary rules, time management etc.

Using these models of learning, new workshops could also be focused specifically on such problems as marital communication or planning or on helping people develop a greater systematic understanding of their interests, aptitudes, values and personality which are relevant to sound career and educational choices, or helping a father practice the application of clear consistent rules in dealing with a behavioral problem of his son or daughter. Or helping a person develop self-discipline by practicing ways of coping behaviors by viewing modeling video vignettes and role-playing new roles with video playback and peer feedback. With a learning model that engages the learner in actual new activities and experience, the learner learns early that he must be an active participant in his own learning.

What's more, if the workshops are well designed and based on a careful understanding of how veterans view their problems and what they need to learn to solve them, the workshops can be used with thousands of veterans in hundreds of institutions. Moreover, there is a further saving of funds since the Life Coping Skills Workshops, as expert systems of learning, can be delivered by specially trained masters degree or even bachelor degree level adult educators or counselors instead of much more expensive doctoral level psychotherapists.

If you want to honor the sacrifice and service of America's veterans, contact your elected representatives - and especially Tom Coburn - and demand that they support the troops by providing for the care they richly deserve, and for which so many have paid with their blood.

God bless America and her women and men in uniform.

Winthrop R. Adkins, PhD, Prof. Emeritus of Psychology, Columbia Univ. served as a naval officer and interned in three VA hospitals. He is the author of Life Coping Skills programs in use throughout the USA. Former Army Capt. Luis Carlos Montalván served two tours in Iraq, was wounded in combat and has experienced various forms of treatment within the systems of the VA, DOD and private sector. He is a freelance journalist and veterans' advocate.