For many veterans, military service and operational deployment lead to a strong sense of identity and belonging. For clinicians working with veterans, demonstrating an understanding of the military experience can greatly enhance the therapeutic alliance and the delivery of effective treatment. Veterans are more likely to engage with health care practitioners whom they feel understand, or seek to understand their mental health problems within the context of their military service. This chapter provides a demographic overview of Australia’s veteran population, common mental health problems within the veteran community, and a summary of the military experience.
Since federation, approximately 1.4 million Australian men and women have served with Australian military forces in wars and peacekeeping operations. Amongst those alive today, the majority are males aged 60 years and over. World War II veterans are the largest group (around 77,400), followed by Vietnam veterans (around 47,000) and approximately 14,700 veterans of the Korean War, Malayan Emergency, Indonesian Confrontation and other operations in Southeast Asia. The 1990s saw the Australian Defence Force (ADF) engaged in a new wave of overseas deployments, with approximately 1200 personnel serving in the First Gulf War and an estimated 5000 engaged in peacekeeping operations in places such as Cambodia, Somalia and Rwanda. Since 1999, it is estimated that a further 45,000 ADF personnel have served in peacekeeping operations and in areas of conflict, including East Timor, Afghanistan and Iraq (Department of Veterans’ Affairs, 2011).
Practitioners may see veterans or ex-service personnel, either men or women, ranging in age from as young as 18 to over 80, with increasing numbers of women joining the veteran ranks. As the composition of the veteran population changes, so too have their mental health needs. At one end of the spectrum are the World War II, Korean and Vietnam veterans, for whom issues of ageing and chronic disease can be an important consideration. At the other end are currently serving and recently discharged ADF personnel who have engaged in a range of warlike, peacekeeping and peacemaking deployments, as well as disaster response operations. These younger, or ‘contemporary’ veterans are more likely to have experienced multiple, high tempo deployments. Apart from deployment cycles, frequent relocations within Australia can result in a sense of dislocation for the veteran and their family, and combined with the often remote locations of ADF bases, this can limit consistent access to medical and mental health services. Currently serving veterans may also be concerned about career progression and limited opportunities for re-deployment when mental health issues are identified.
Recent conflicts and peacekeeping missions arguably involve fundamentally different types of conflict to previous engagements. For example, deployment to the Middle East may involve the ongoing threat of insurgent combatants, urban conflict amongst non-combatants, and increased prevalence of Improvised Explosive Devices. Many veterans describe the extraordinary demands of constantly facing the threat of death or serious injury. Additionally, complex rules of engagement and lines of command within multinational forces can increase the level of stress on Defence members on deployment, particularly in peacekeeping and peacemaking operations.
Veterans’ common mental health problems
The common mental health problems of veterans fall into five broad and overlapping clusters.
Common mental health problems amongst veterans
- Depression problems: major depressive disorder, dysthymia and complicated grief
- Anxiety problems: generalised anxiety disorder, panic disorder, agoraphobia and social anxiety
- Substance use problems: problem drinking, alcohol dependence, medication misuse, and illicit drug use
- Trauma and stressor-related disorders: posttraumatic stress disorder (PTSD)
- Somatic problems: medically unexplained symptoms, e.g., psychogenic pain
While many of these presenting problems may be sufficiently significant to meet full diagnostic criteria, a large number of veterans are likely to present with partial syndromes of a disorder.
Comorbid mental health problems are common, particularly posttraumatic mental health problems, where substance use problems are present. For some veterans, many years may have elapsed between the time when mental health symptoms first appeared and when they were recognised and treated. This may have led to additional difficulties, as their relationships, their ability to participate in work and social activities, and their health may have been affected over long periods of time.
Many veterans present with more generic yet significant complaints such as sleep disturbance, problematic anger, vocational, parenting or relationship problems. Where practitioners identify such problems, they should investigate potential underlying mental health issues.
Impact of military service
A veteran’s military experiences may have taken place many years in the past or more recently, and they may have been deployed to different types of operation. Some ex-ADF members may not have participated in deployment that involved war or peacekeeping duties but may have nonetheless been deeply affected by experiences such as humanitarian deployments (such as the one to Aceh following the 2004 tsunami) or training accidents (e.g., the 2006 Black Hawk training accident or the 1964 HMAS Melbourne-Voyager collision that resulted in 82 deaths). Regardless of their timing or nature, a veteran’s experiences can have a lasting and profound influence. There are at least two readily identifiable reasons for this enduring impact. First, most veterans join the services as young adults, an important time in life for shaping values, beliefs and attitudes. Because they were socialised into military culture at a time when they were malleable, many will have adopted military values and ideals as their own. Second, during service, many of the highest impact experiences will have occurred during times of extreme stress, in some cases during life-threatening situations. What is learned under these conditions can be resistant to change because it is associated with survival. There is a range of service-related experiences that may need to be considered when working with a veteran. While some of these experiences can help protect a veteran from the impact of stress and mental health problems, they can also lead to tension, particularly in a civilian setting. Others can contribute to, or exacerbate mental health problems. These experiences do not apply to all veterans, nor are the mental health problems described in this Advice Book an inevitable consequence of the events experienced. This summary includes recent research findings and subjective reports of many veterans with mental health problems. It is important to note that while some veterans readily identify the impact of service-related experiences on their current feelings and behaviours, for others, the connection may not be as evident, particularly if habits linked to their military experience were formed many years ago.
Military as family
An important component of socialisation into military culture is strong identification as a member of the group (often referred to as ‘family’) over and above an identity as an individual. Veterans often describe this socialisation as being achieved by breaking down the individual identity through means such as:
- a regimented lifestyle
- having the same uniform and hair cut
- the inculcation of a common set of attitudes, beliefs and moral values.
Identity as a member of the group is then further reinforced through:
- group consequences for an individual’s actions
- the emphasis on strength as a member of the group
- the inculcation of the belief that the survival of the individual and group are inter-dependent
- a perception of vulnerability as an individual
- a belief in the superiority of service personnel over civilians.
The legacy of military service can often be seen in a veteran’s strong identification with other veterans, which brings with it a sense of personal identity and value, a sense of belonging and connectedness, as well as affording a sense of security or protection. The other side to this coin can be a mistrust of others who are not part of the ‘group’ and the uncritical adoption of attitudes and beliefs expressed by one or more of the group with whom the veteran may identify.
Standards and expectations
Military training promotes strict conformity to high standards of behaviour in terms of discipline, punctuality, orderliness, cleanliness, obedience and attention to detail. Lives may depend on these behaviours in the face of a military threat. Training also promotes aggression in the face of perceived threat. With the combination of these factors, veterans can react in what may be judged by others to be an ‘over the top’ way, for example, when they are kept waiting or when things do not run according to plan. These high standards of behaviour can influence parenting, for example, the veteran’s expectations around ‘normal/acceptable’ child/teenage behaviour may differ from other parents. In addition, veterans may also have difficulty adapting to the less rigorous and less structured nature of non-military life.
The military culture privileges strength, competence and the ability to adapt and overcome. Veterans can strongly believe that they should be able to cope without assistance and that seeking help is a sign of weakness (Gibbs, Olmstead, Brown, & Clinton-Sherrod, 2011). For veterans who are still serving, there can be fears about the repercussions of seeking help and whether this will affect re-deployment, and these fears can transfer to another career path they may have chosen post separation (Hoge et al., 2004).
Exposure to inhumanity
Beyond military culture and training, many veterans have had experiences in the course of service which have led them to think of themselves as fundamentally different to civilians. Many of these experiences relate to their exposure to people’s capacity to behave inhumanely towards others. In war, service people are required to overcome their natural reluctance to kill another human being, which requires, amongst other things, learning to ‘dehumanise the enemy’. Many struggle within themselves to reconcile this with their personal values and beliefs, and feel that they have been changed as a result. This is often described as a ‘loss of innocence’. Some peacekeepers refer to the ‘soul-destroying’ experience of witnessing atrocities of one group of people against another. They have the training to intervene, but often they do not have the authority.
This direct experience of inhumanity can result in veterans feeling different and misunderstood by civilians. Some are left with hatred and closely aligned fear of people from the ethnic group who were ‘the enemy’. For some veterans, the sights and sounds associated with particular cultures can serve as powerful triggers to re-experiencing trauma.
Some veterans may question whether a non-military practitioner could help them without having experienced conflict themselves. Other veterans may fear that the practitioner will not be able to cope with the information provided to them about the veteran’s experiences of conflict.
Service people deployed overseas in war zones or peacekeeping missions are required to ‘put their lives on the line’ for their country. While this is accepted as part of the job, it can become a source of bitterness and resentment for veterans who feel that the public or government have not appreciated their sacrifice, or the ‘ultimate sacrifice’ of mates who have been killed. Many veterans from both past and present conflicts feel let down by the government and society for whom they were prepared to die, when they are left with mental health problems following their service and feel that they have to fight for recognition. While they may indeed be entitled to care as defined in legislation, eligibility needs to be established in each case. Some veterans may have a low tolerance for the process of establishing entitlement.
The experience of Vietnam veterans highlights the difficulties caused by public opposition to a conflict. The experience of many Vietnam veterans was that instead of being welcomed home as heroes, they were confronted with moratoriums, ostracised by their peers, and vilified as ‘baby killers’. Many speak of leaving a war zone only to be confronted by another ‘enemy at home’. While there were many locally organised welcome home parades for Vietnam veterans, there was no official national welcome home parade until 1987, almost 15 years after the war in Vietnam had ended. For many Vietnam veterans, this was a devastating experience, which reinforced their perception that there was a clear divide between ‘them’ (civilians) and ‘us’ (veterans) and the associated mistrust of those outside the group. Some Vietnam veterans do not, even now, disclose their service to others, for fear of negative judgment.
Due to the experience of Vietnam veterans, care has been taken by politicians and the public opposed to Australia’s participation in war or peacekeeping missions, to separate their opposition to government policy from their opposition to the troops themselves. Although there has been more support for the veterans of recent deployments, these veterans can still experience difficulty reintegrating and redefining their role within the community and their family. Indeed, some veterans claim that reintegration can be more difficult than the experience of deployment. Similar to Vietnam veterans, veterans of more recent operations may also feel unable to discuss their military experiences with the general community, believing that their experiences would not be understood, or that the community may judge their actions.
First impressions and relationship building
Generally, military culture values strength and stoicism over ‘softer’ emotions such as fear or sadness. The acknowledgement of mental health problems can be seen as personal failure and associated with shame. However, this is unlikely to be acknowledged at the outset and may be concealed behind a shield of anger or blame. Difficult emotional, relationship or behavioural problems are also unlikely to be acknowledged at the start of treatment and may be concealed or minimised. In addition, veterans may hold a belief that the problems that they are experiencing will resolve over time without input from a health professional, or conversely, that their mental health issues will never resolve and that there is little to be done that can help.
Veterans may not present to a general practitioner or mental health professional with apparent mental health issues, instead they may present with physical health symptoms which may mask their mental health symptoms such as fatigue or difficulty sleeping (Cooper, Creamer & Forbes, 2006). In addition, it may be unclear that the person presenting to the service is a veteran. Practitioners should take notice of whether a client has a history with the Defence forces, or have accepted conditions or claims pending with DVA.
Practitioners who seek to understand the veteran’s experience are much more likely to gain their trust. To varying degrees, demonstrating understanding can help to establish rapport, assist the development of an appropriate treatment plan via case formulation, and provide insights into potential barriers to treatment. Practitioners need to be prepared to give the process of engagement and assessment sufficient time, such as providing a longer initial consultation time. Veterans need to feel that practitioners have the time and inclination to listen and have the capacity to tolerate what veterans tell them whilst still maintaining a positive regard for them. It is important for practitioners to be aware of their own thoughts and biases about war and military service and to be mindful of the effect of these on their work with veterans.
The following are four important practices, derived from the principles of motivational interviewing (Miller & Rollnick 2002), for effectively helping people with mental health problems:
- Express empathy — acceptance and reflective listening facilitates change and ambivalence is normal.
- Promote awareness of the consequences of unhelpful behaviours — discrepancies between present behaviour and important goals will motivate behaviour. The veteran should ultimately present his or her own arguments for change.
- Avoid argument — arguments are counterproductive as defending breeds defensiveness. Take resistance as a signal to change strategies. Often labelling the veteran with a diagnosis is unnecessary. Offer, but do not impose new perspectives, as the veteran is the most valuable resource for finding solutions.
- Support a belief in the possibility of change — this is an important motivator. The veteran is responsible for choosing and carrying out most interventions, and there is a range of interventions available to choose from.
Veteran case studies
The following case studies illustrate the range and diversity of veterans’ mental health problems and available treatments. The cases of Ron, Tim and Lisa can be found on the accompanying DVD, and are referred to in Chapter 12 on comorbidity and case formulation.
Ron: 62 year old Vietnam veteran
Ron is presenting for counselling following his reaction to a television program commemorating the anniversary of the Battle of Long Tan. He has attended counselling intermittently over a number of years. Ron has been retired for the last six years after he had a claim accepted for alcohol abuse and PTSD in relation to several events in Vietnam involving deaths in his platoon and civilian deaths. He is highly avoidant of reminders of Vietnam. Ron has a long established pattern of dependent drinking, consuming between 10 and 20 standard drinks per day. He is on high levels of codeine in relation to a hip injury sustained in Vietnam. He has very high social anxiety and has experienced panic attacks, so he prefers to stay at home. He gets very upset at perceived criticism of having served in Vietnam. Ron and his wife have little interaction but no intention to separate. His relationship with his children is also distant. He has difficulty remembering the steps needed to accomplish tasks he used to do on a routine basis and this is the case even when he has not been drinking. He is easily frustrated when trying to complete these tasks.
Ron’s diagnoses include PTSD, alcohol dependence, social anxiety and panic disorder. Ron’s chronic hip pain is also a significant issue which leads to potential prescribed medication misuse and which may be exacerbating his PTSD symptoms. Although Ron has attended counselling intermittently for a number of years, his case notes indicate that he has not engaged particularly well and has experienced little change in presenting problems.
Adam: medically discharged army private
Adam is presenting to his GP seeking advice regarding further surgical options for his knee, which was injured during training. At 22 years of age, Adam was given a medical discharge from the army because he did not regain full use of his knee following reconstruction surgery.
Adam is unable to return to military duties even after his reconstruction surgery, and has been medically discharged from the ADF. He is struggling with his transition to civilian life. He is also feeling bitter and angry about his unsuccessful appeal against his discharge. He is angry and agitated by his inability to recover from his knee injury and to return to the army. He feels a loss of control about his future as he is now unable to pursue his chosen career. Contributing to Adam’s distress is his concern about his financial security, future medical expenses and uncertainty about his career options.
Adam appears restless and irritable and says that he has not been sleeping well since the appeal decision. He has trouble enjoying any activity and he has become increasingly pessimistic.
Adam’s diagnosis is of an adjustment disorder with both anxiety and depression. These problems have been caused by the stress associated with his knee injury and subsequent loss of function.
Adam is referred to a private psychologist who provides cognitive and supportive therapy and psychosocial rehabilitation. Adam discusses antidepressant medication with his GP, and they identify further psychological care as his symptoms are beginning to settle. Given the importance to Adam of being active and productive, he sets a treatment goal with his psychologist to be well enough to resume employment. After six further sessions his symptoms are sufficiently settled, allowing Adam’s GP to refer him to the DVA Veterans’ Vocational Rehabilitation Scheme. He is then sent to the Commonwealth Rehabilitation Service where active vocational rehabilitation begins.
Frank: World War II veteran
Frank is an 86-year-old married, retired boot maker presenting to his GP with breathing difficulties and chest pain. Recent medical investigations have cleared him of significant cardiac disease and he has mild emphysema because he is an ex-smoker. He had successful surgery five years ago to remove a bowel cancer, suffers tinnitus and has painful knees due to osteoarthritis. He is concerned he will have a heart attack and that his wife will not cope without him. She has arthritis in her hips and he doesn’t want her to have joint replacement surgery in case she has to be away from home for too long. Frank also mentions his concerns about his 52-year-old daughter who has just gone through a divorce. Other fears are expressed, including his ability to pay bills, the future of the country, and worries about young people in general.
Frank’s wife reports that her husband gets very panicky and agitated watching the television news, and has become increasingly forgetful. He lost his car at the shopping centre recently, muddles his medications and has forgotten his grandson’s name. He has taken to reminiscing mainly about the war and his veteran mates who have died.
Examination reveals slightly increased heart and breathing rates, sweaty palms and a fine tremor. A mental state examination reveals memory impairment with 0/3 recall, disorientation in time, and two errors performing serial 7s. He is unchanged medically, but conveys considerable anxiety and excessive worry. Frank is diagnosed as having generalised anxiety disorder, health anxiety, cognitive decline and medical comorbidity.
Treatment is aimed at anxiety management, specifically his generalised and health-related anxiety. An aged care assessment will involve a home assessment to consider aids and services that may improve the couple’s functioning. A referral to a memory clinic or geriatrician may lead to nootropic treatment if Alzheimer’s dementia is diagnosed. Psychotherapy aiming to provide relaxation skills, psychoeducation and support can be complemented by suitable group therapy where socialisation, reminiscence and occupational therapy can be provided. Introduction of low-dose antidepressant medication, cautiously monitored and increased as required, may also reduce the severity of the anxiety.
Tim: 28 year old, ex-ADF
Tim is presenting for his first counselling session. He has served in Afghanistan and has witnessed multiple deaths, including that of a mate, and once felt threatened and trapped for several hours when under fire. Tim has had a claim accepted for PTSD. He experiences frequent nightmares and daytime intrusive images of events in Afghanistan in which feelings of helplessness and fear overwhelm him. He consumes 15 or more standard drinks over three to four hours several times a week. He tends to use alcohol when he is feeling vulnerable or frustrated. He smokes two to three cannabis joints daily. Occasionally he will use methamphetamine at a party.
Tim has intermittent bouts of extremely low mood associated with suicidal ideation. In fact, there have been a number of occasions when Tim was involved in self-destructive impulsive behaviours (e.g., driving at full speed towards a tree and stopping at the last minute) following a drinking bout. Angry outbursts are common for him. Tim has been involved in a few fights outside nightclubs. On several occasions he has hit his girlfriend after she resisted his attempts to limit her access to friends or when he has been unable to contact her. Tim’s diagnoses include PTSD, substance and alcohol abuse and depression.
Tim currently lives with his girlfriend, has limited contact with his sister and almost no contact with his mother and father. As a child, Tim was frequently “belted” by his veteran father for disobeying directives. Tim has presented at treatment after an ultimatum from his girlfriend to receive help or otherwise she will leave the relationship. Tim is adamant that he will be OK if other people do not “get on his case” or in his way.
Tim is easily frustrated, and he reports feeling generally negative and cynical, including being sceptical as to the value of treatment. Tim states that he is not interested in talking about his experiences in Afghanistan. He states that no amount of talking will change the way he feels and that only people who have served in Afghanistan can understand his experience.
An assessment of risk, both in terms of self-harm and harm to others, is one of the first steps in Tim’s treatment. A separate interview with his girlfriend will need to be conducted in order to establish her safety. A treatment plan is developed which will initially focus on psychoeducation about PTSD and reducing Tim’s substance and alcohol intake. By reducing Tim’s substance and alcohol use, he will be better able to address his PTSD symptoms. To help prepare Tim to address his PTSD and to minimise the risk associated with his impulsive behaviours, the counsellor will also need to spend time helping Tim learn to manage and regulate his emotions. Tim will then begin confronting his traumatic memories through trauma-focussed therapy.
Lisa: 32 year old, ex-ADF peacekeeper
Lisa served in East Timor when she was 23 years old. She has presented for counselling to address poor sleep patterns. When she lies awake at night she thinks about her experiences in East Timor over and over again and sometimes has nightmares. In East Timor, she felt powerless to affect much change amidst what she saw as widespread devastation and need, and now feels guilty that she returned to Australia just when she felt some children had begun to trust her. She also becomes frustrated when faced with everyday concerns of civilians, stating that it distresses her greatly when Australians “complain about trivialities”, when the people in Timor were facing very difficult conditions. She is unable to resume sleep for the night unless she takes a “sleeping tablet” prescribed by her GP. She is concerned about the fact that she has begun to use the medication to manage her anxiety during the day. She has started to doctor-shop to meet her increased need for medication. Her mood is low; she has a low energy level, and has lost interest in activities that used to be important to her.
All aspects of Lisa’s life have been unravelling, leaving her without the support or sense of accomplishment she needs. Her difficulty in concentrating at work, and frequent absenteeism, is being “performance managed” by her supervisor, an experience she describes as “humiliating”. Lisa lives alone in a small flat. Her relationship with her once close family (specifically her sister and her mother) is deteriorating; she does not return their calls. She now finds socialising very stressful, and tearfully said that it’s “all becoming too much to bear”.
Lisa’s initial diagnosis includes depression characterised by difficulty sleeping, rumination, guilt, low mood and reduced energy. She is also showing strong indications of substance dependence.
Lisa is referred to her local VVCS where she receives cognitive behavioural therapy aimed at reducing her use of sleeping tablets and her depressive symptoms. Lisa agrees to ask her mother and sister to attend a counselling session to provide them with psychoeducation about depression and provide an insight into Lisa’s experiences. She also agrees for the counsellor to talk to her workplace and organise support so that she does not lose her job and has a plan to return to more meaningful duties.