Military

Invisible Wounds of War: Psychological and Cognitive Injuries, Their Consequences, and Services to Assist Recovery

This report is an objective investigation into the many costs (i.e., emotional, financial, physical, etc) of the wars in Iraq and Afghanistan. It estimates "that PTSD and depression among returning service members will cost the nation as much as $6.2 billion in the two years following deployment."

The full text of the report can be found by clicking on the following link: Invisible Wounds of War (PDF). Adobe Acrobat Reader required to view the file

Due to the size of the report, it has been broken up into the following sections for ease of reading. All files are in PDF format, requiring Adobe Acrobat reader.

Part II: The Nature and Scope of the Problem

Part III: Immediate and Long-Term Consequences of Post-Traumatic Stress Disorder, Depression, and Traumatic Brain Injury

Chapter Five: Immediate and Long-Term Consequences of Post-Traumatic Stress Disorder, Depression, and Traumatic Brain Injury in Veterans of Operation Enduring Freedom and Operation Iraqi Freedom

Part IV: Economic Consequences

Chapter Six: The Cost of Post-Deployment Mental Health and Cognitive Conditions

Part V: Caring for the Invisible Wounds

Chapter Seven: Systems of Care: Challenges and Opportunities to Improve Access to High-Quality Care

Part VI: Conclusions and Recommendations

Chapter Eight: Treating the Invisible Wounds of War: Conclusions and Recommendations

Avoiding “Negative Coping”: A Guide for Service Personnel, Veterans, and Family Members

Sometimes in our efforts to survive and overcome life struggles we wind up approaching them in a way that creates additional and sometimes worse struggles. This process is sometimes termed negative coping, involving efficient, distorted, or defensive ways of coming to struggles. Following are some examples of negative coping strategies and their consequences:

Substance abuse and dependence
Excessive and unhealthy use of alcohol and other drugs is a serious problem for deployed military personnel, veterans, and for family members.
Alcohol Use and Alcohol Related Risk Behaviors
Substance Use and Co Occurring Disorders Among Military and Veterans
As attractive as these easy solutions may seem to numb emotional or physical pain or facilitate sleep, substance abuse can create other problems and jeopardize the ability to serve, function effectively on return, or maintain a healthy and supportive lifestyle as a family member. Use of tobacco and excessive eating, are also examples of dysfunctional coping strategies, and can also create additional problems.

Avoidance of roles and relationships
As do other animals, human animals may be inclined to “hibernate” and avoid others in response to situations that may cause stress, anger, or remind us of past circumstances. Self-care can involve healthy solitude, but avoidance of significant others and retreat from life roles can diminish our coping ability and enhance feelings of isolation and alienation. Distancing ourselves from others may contribute to negative thoughts or feelings of having to bear the burdens of military service or support alone.

Anger and violent behavior
An intriguing study in psychology found that when mild shock was applied to the floor of a cage in which rats were living, the rats bit one another. Similarly, anger and violence and blame are natural responses to stress, but not positive ones.

Afghan Road Rage
Anger, rage, and violent behavior can cause additional problems during or following military service, and make it yet harder to recover from the stresses of service or support. Try to work with anger rather than be overwhelmed by it.

Dangerous or self-destructive actions
Some people also cope with stress in a paradoxical way by doing additional things to increase arousal (the process being one in which we try to take control of our emotional response by being ourselves the author of our suffering). For example we may drive too fast or be quick to start a fight, or take unnecessary risks. Such strategies, while an attempt at problem-solving, may create additional problems and make things worse. Instead, find appropriate ways (through play or hobbies or recreation) to manage arousal, or affiliate with a support group of your choice to avoid self-destructive patterns.

Working too much
Work is a good thing and is part of a healthy life, whether as an active military person, veteran, or family members. Work can help us gain our livelihood, contribute to our community, learn new things, interact with others, and gain confidence. But overwork can be a form of avoidance. Veterans may be working to avoid memories or to help forget their experience, a dysfunctional strategy because it deprives them of the opportunity to work actively on healing and to spend nourishing time with your family and friends. Family members may engage in work as a form of guilt or bargaining, part of the grief process but something to be moved through rather than emphasized. Allowing work to be a meaningful rather than frantic part of life can contribute to mental health.

So how can we cope?

Talk to your family and friends about things that bother you and about your efforts to avoid negative coping. They can offer you emotional support as you change your habits or behavior.
Get involved with social and community events. Volunteer at a sporting event or holiday festival. Connect with other people through clubs or religious groups. Find hobbies and interests that bring you in contact with others.
Get involved with an appropriate support group for active duty personnel, veterans, or military family members.
Talk to an appropriate mental health professional. You may need help changing your behavior. You may have also developed dependence on alcohol or other drugs, which makes quitting on your own more difficult.
Focus on survival, resilience and recovery as ways to remind yourself that time is passing.

Some of the information in this fact sheet is based on this site. (pdf)

For additional resources, click here.

Substance Involvement and the Military Experience

Although healthy use of substances is part of many peoples’ way of being human, excessive or dysfunctional use, abuse, or dependence can lead to various problems. These tendencies are particularly common in individuals who experience stress related to military deployment, service, return home, and in support of those who serve or who have served. This fact sheet is intended to help military members, veterans, and family members make decisions about responsible substance use and to evaluate when their substance use is a problem.

Most active military personnel, veterans, and family members who drink alcohol are social or recreational drinkers. Social drinkers...

...drink simply to enhance the pleasure of normally pleasurable experiences, and that's what happens.
...don't experience problems of any kind associated with drinking.
...never feel out of control or that they've had too much to drink.
...don't think about how much or how often they drink; it's just not an issue.
...never get complaints about how much or how often they drink because there's nothing to complain about.

Alcohol and Drug Abuse

Somepeople who drink alcohol, or who use other substances, become substance abusers. People with Post-Traumatic Stress Disorder are more likely than others with similar backgrounds to have alcohol use disorders both before and after being diagnosed with PTSD, and people with alcohol use disorders often also have PTSD.

Alcohol and drug abusers, or substance abusers...

... use alcohol or other drugs to help them change the way they feel about themselves and/or some aspect(s) of their lives.
... experience some problems associated with their alcohol or other drug use but use those experiences to set appropriate limits on how much and how often they drink or use.
... seldom, if ever, repeat the alcohol- and drug-related behaviors that have caused them problems in the past.
... know what their limits are and drink or abuse within those limits - unless they have a good reason not to.
... get complaints about their drinking or using and accept those complaints as expressions of concern for their well-being.

Substance use can become dysfunctional when it becomes the preferred or sole way to manage life struggles such as:

Sleep problems
Anxiety
Grief, loneliness, or boredom
Escape from the present situation
Difficulties in relationships with others
Unpleasant memories or traumatic events

Here are some questions that you can ask yourself to see if you are developing a problem:

Have friends or family members commented on how much or how often you drink?
Have you have found yourself feeling guilty about your drinking or drug use?
Have you found yourself drinking (using) more over time?
Have you tried to cut down your alcohol (drug) use?
Does your drinking (using drugs) ever affect your ability to fulfill personal obligations such as parenting or work?
Do you drink (use) in situations that are physically dangerous such as driving or operating machinery while under the influence?
Have you found that you need more alcohol (drug) to get the same effect?

If you find that you are answering “yes” to one or more of these questions, perhaps it is time to reevaluate your use, cut back, and seek help from friends, family, or a professional.

Alcoholism and Drug Addiction

Some people who drink alcohol or who use other drugs become alcoholics and/or substance addicts. Alcoholics and drug addicts...

...experience negative consequences associated with drinking or using but continue to drink or use despite those consequences.
...set limits on how much or how often they will drink or use but unexpectedly exceed those limits.
...promise themselves and/or other people that they will drink or use in moderation but break those promises.
...feel guilty or remorseful about their drinking or using but still fail to permanently alter the way they drink or use.
...get complaints about their drinking or using and resent, discount, and/or disregard those comments and complaints.

Alcohol and Drug Use Management

Social drinkers and users, substance abusers, and alcoholics and addicts can best manage their relationships with alcohol and drugs in different ways.

Social drinkers are fine. They need do nothing. Drinking is not in and of itself the issue. If it's really not a problem, then it's not a problem.

Alcohol abusers may not need to abstain completely from the use of alcohol, but they need to deal with the problems and issues that make them want to change the way they feel, even it means getting professional help.

Alcoholics and addicts need to abstain completely from all addictive and potentially addictive mood- and mind-altering substances, and they will almost surely need professional help and/or support to accomplish that goal. Getting help is the most useful tool in decreasing or stopping problem drinking or drug use, even if you have doubts about being able to quit or if you are feeling guilt about the problem. Call your health provider, contact a physician or therapist, call your local VA hospital, or contact your local Alcoholic’s Anonymous for guidance in your recovery. These contacts can help you on the road to the life you want.

Information in this fact sheet is based on information from this site. (pdf) and a fact sheet from the National Center for PTSD called Stress, Trauma, and Alcohol and Drug Use.

Additional Resources

National Institute on Alcohol Abuse and Alcoholism: Frequently Asked Questions
(pdf)

This 4-page article provided by the National Center for PTSD explores how PTSD and alcohol use are related.

The Five Phases of Homecoming: A Guide for Veterans and Their Loved Ones

Throughout this website we have emphasized that recovery from disasters is a process, and not an event. It takes time and requires personal meaning-making adaptation to change. As with other processes, having a “map” or a guide can help us in navigating the territory. Here are some guidelines to help veterans and their loved ones during the homecoming process.

Many veterans and their families merely assume that homecoming will go well, or “hope” that it will. But preparing for homecoming, and having a sense of where veterans and their families are in the process, can help you all meet the challenges you and your family may encounter. The five phases of homecoming are as follows:

1. Anticipation 2. Reunion 3. Realization of Changes 4. Acceptance 5. New Normal

Phase 1: The Anticipation Phase
This phase can begin as soon as the service member leaves for deployment and is sometimes the single most important motivation for coping with life’s challenges while they serve and anticipate eventual homecoming. Similarly, loved ones are anticipating the veteran’s return, and this anticipation is the beginning of the homecoming process.

Phase 2: The Homecoming Reunion Phase
This phase can be both exhilarating and terrifying for all involved. So many wants, needs, and expectations are present but not clearly defined. We have included information elsewhere on this website to assist with this reunion process.

Phase 3: The Realization of Changes Phase
Veterans and their loved ones become aware of this phase when they begin to realize fully the subtle and significant changes that have occurred in family or system members, and in the context in which the family or system resides, during the time apart from each other. Change is a necessary and unavoidable part of the military experience -- and of the human condition in general. During this phase it will be helpful to try to not label change and growth as positive or negative. In reality, the only thing that is definite is change; all people grow and adapt to cope with their surroundings. The key to dealing with these new realizations in order to move to the next phase of homecoming is communication.

Phase 4: The Acceptance and Adaptation Phase
Once we take the time to observe and acknowledge the reality that the veteran has been apart and has returned, and that changes have occurred in him or her and in the family system, it is up to us to learn how to grow and accept these changes so that we can then begin to adapt to them. Acceptance allows us to move to the next phase of homecoming. Some of this process involves grieving (link to Grief pdf found on General Public FS, tab Grief and Loss) the old ways of being and moving toward acceptance of the fact of military involvement and its consequences for veterans and their families.

Phase 5: The “New Normal” Phase
We begin to enter this phase when we feel a settling awareness that our time apart and individual experiences have created a new and different understanding of what is now normal for ourselves and others.

Homecoming is a process, not an event, and it occurs over time. Knowing the phases of homecoming can help veterans and their families adjust to the realities of the military service experience.

Parts of this fact sheet are excerpted and modified from this pdf.

Additional Resource

This 3-page article provided by the National Center for PTSD titled Homecoming After Deployment: Dealing with Changes and Expectations explores tips for soldiers, spouses, and children.

10 Tips for Parents and Teachers of Preschool Children in a Time of War

Talk with your children. When they have questions, answer them honestly but simply and with reassurance. Ask them what they think is happening, and listen to their answers. Be ready for questions that may be difficult to answer, such as, "Why do they hate us?" and "Will Daddy die when he's fighting over there?"
Use your family like a security blanket for your children: Wrap them up in family closeness. Especially during a time of war, make sure your children have lots of family time. Spend more time with your children playing games, reading to them, or just holding them close.
Limit the amount of news your children watch during a time of war. Turn off the TV or radio when war coverage is on. You don't need to hide what's happening in the world from your children, but neither do you have to expose them to constant stories about war. Put away newspapers and magazines that have extensive photo coverage of war or frightening covers.
During a time of war, map out a routine and stick to it. Young children like routines and rituals. If bedtime is the time you read stories to your children, make sure you keep that time for stories. Your child may be less able to handle change at home when the world situation is unstable.
Make sure you take care of yourself. Your children read your face for clues as to how to feel. If they fall down and see concern on your face, they will be much more likely to decide that the fall hurt. Similarly, if your face reflects the stress and fear you may feel in a time of war, they will pick up on that. Many people find that turning to a higher power, whether through organized religion or privately, can help. Take care of yourself so that you can take care of your children.
Use play to help your children express their fears about what is happening. Encourage them to use art or pretend games to express what they may not be able to put into words.
Tell your children that they will be all right. Reassure them that they will be protected. Have an emergency plan for the family and share whatever parts of it you think your children can understand. You might tell them, for example, that home is "base" if something happens, but that Aunt Carol's house is another safe place you can visit.
Watch your children for signs of fear and anxiety they may not be able to put into words. Have your children become extra clingy, needing more hugs and kisses than usual? Have your children started wetting the bed or sucking their thumb after you thought they had outgrown that behavior? They may be feeling the pressure of what is going on in the world around them.
Enlist your children's help. Just because your children are very young does not mean they can't do age-appropriate chores, even if it's just putting placemats on the table. If your children know that they have a role to play and that they can help, they will feel more in control and more confident.
Put things into a positive perspective for your children. Your children have not been around long enough to know that things can change and that wars end. But, they may have experienced something bad or scary that they overcame, and you can point out a time when they had courage before. When you talk about bad times, make sure you talk about the good times in the future as well.

This fact sheet is based on information found here.

Coping and Anxiety Management for Deployed Personnel and Veterans

Military service is a difficult, disruptive, and sometimes life-threatening experience. As a result it is common to experience traumatic stress and perhaps even some symptoms of depression and anxiety during and following this life experience. Military service may also influence physical problems such as changes in sleep and appetite, digestive problems, more susceptibility to colds or other illnesses, and increased use of alcohol and other substances. Persons on active duty and veterans may also have emotional responses such as fear, irritability, nightmares, difficulties concentrating, feelings of betrayal, and loss of interest in everyday activities.

How can deployed personnel cope with the stresses of military service, and how can veterans manage and integrate the stressors of military service into their life experiences? Here are some helpful suggestions:

Whether deployed or having returned, you may use grounding, a technique designed to keep your experience in the “here and now” and remind you that you are alive and present to life.

Focus on breathing as a calming and centering strategy. A natural part of our "fight or flight" response to threat or anxiety is to breathe rapidly and deeply, which can often result in hyperventilation. Hyperventilation produces uncomfortable or even frightening sensations that can actually increase anxiety, creating a "vicious cycle" in which anxiety or fear provokes hyperventilation, which in turn increases anxiety and fear. Breathing training can help stop this cycle before it gets out of control.
Experiment with watching your thoughts to identify those that may be catastrophic or lead to feelings of hopelessness and helplessness. Whether deployed or having returned, realistic and present-centered thoughts can contribute to a sense of presence and stability.

Challenge negative beliefs. Replace such thoughts as, "It is always going to be like this” with, "This experience is something that will pass.”
Adjust self-talk. Convert negative messages into positive ones, for example, replace "I’ll never get through this," with "I can do this, but it’s normal and okay to feel scared and overwhelmed."
Use previous ordeals that have been successfully overcome as a "power base."
Consider alternative outcomes for worst-case scenarios, for example, "I can still see my friends, I can enjoy the little things in life."
Imagine how this event will be viewed in the future, remembering how things do change over time.

Learn to manage anxiety through such strategies as guided imagery and relaxation.

Mobilize a support system or group to reach out and connect with others, especially those who may have shared the stressful event. Although there are professional resources to organize and facilitate recovery following military service, there is a lot we can do on our own. Consider joining a veterans’ support group.
Talk about the traumatic experience with empathic listeners in your circle of colleagues, friends, family, and spiritual community.
Cry if that works for you, or laugh or yell, but do something to express yourself emotionally “Getting things out” helps.
Exercise can contribute to greater well-being following military service.
Use prayer, meditation, or other spiritual practices are helpful coping strategies
Look for opportunities for service to others, that even in the midst of your own challenges while being deployed or on your return can help enhance coping.
Use creativity to fill your life with “food for your soul.” There are some wonderful pieces of art and music being created by deployed military persons and by veterans.
Nourish yourself through healthy eating and drinking, and avoid self-medication, alcohol, or other drugs.
Write about your experience in detail, just for yourself or to share with others

Remember that as difficult as military service is, it is possible to pass through and integrate it as a meaningful part of your life. Focusing on your coping during your service and upon your return will nurture inner strength, compassion for others, self-awareness, and a perspective on your service and its meaning for you and others.

Additional Resources

This 3-page article offers several techniques for anxiety management.

Common Responses to Trauma & Coping Strategies is the title of this 3-page article, which examines different reactions to trauma including both the physical and the emotional. It also explores several excellent coping strategies for dealing with trauma.

Medline Plus explores how to cope with disasters and provides a large database with links to additional information which can be explored based on an individual’s experience and needs.

This 4-page article, entitled Become a Survivor: How to Find Peace of Mind Following Life's Traumas, examines what to do when a disaster occurs, how to best handle a disaster, and discusses when a professional may be most helpful in becoming a survivor, rather than a victim, of trauma.

SAMHSA provides this 3-page brochure that explores stress and what to expect when a disaster occurs.

This 4-page article, provided by the University of Arizona and entitled Promoting the Health and Well-Being of Families During Difficult Times, focuses on several areas including stress management after a disaster, defining stress, symptoms of stress, and possible coping skills.

Coping with Deployment: A Guide for Family Members

When a family member goes to war, the impact upon those left at home can be daunting. Here are some suggestions for managing the stress associated with the deployment of a family member.

The Emotional Cycle of Deployment
When a loved one is deployed, fluctuating emotions such as pride, anger, fear, and bitterness can add to the distress of uncertainty. Various emotions continue during the person’s deployment, based upon changes the family encounters as they adjust to the departure and absence of their family member, these emotions tending to occur in the following cycle:

A short period of intense emotions, such as fear and anger, often results when news of deployment is released to the family.
Detachment and withdrawal increase as departure grows closer.
Renewed intense emotions such as sadness, loneliness, and tension tend to be common at the time of departure; this can last several weeks or longer.
Adjustment to routine tends to follow during the first weeks of deployment, as families make meaning of the family member’s absence and develop new roles and routines.
Anticipation and stress tend to occur as the end of the deployment period draws near, and the family adjusts to the return of the service member.

Deployment and Patterns of Family Interaction
Deployment is always challenging, but sometimes these challenges become excessive. Here are some things to keep in mind:

Changes in family circumstances, such as those involved with deployment of a family member, always exaggerate preexisting family patterns. For example, if a family already has difficulty communicating with one another, such problems may worsen during times of stress, and add strain to the family.
Families that are flexible with respect to roles and responsibilities tend to do much better than families that attempt to maintain a rigid structure without the participation of the deployed member. A spouse or significant other may have struggles with income, employment, and childcare and discipline. Your military contingency officer and your employee assistance program can provide you with childcare referrals, including before- and after-school programs and in-home care. Getting information about difficult issues, such as separation anxiety, discipline, raising adolescents, and sibling rivalry, may help make care easier.
Denial, as for example those deployed downplaying the potential for danger in order to protect the family from excessive worry, can make family members feel their feelings of fear are being invalidated.
When certain family members, particularly children, do express their fear or anger, families should not view these feelings as too sensitive or as an annoyance. Instead, realize that those feelings may be emotions that everyone shares, but perhaps not everyone is courageous enough to acknowledge.
Fear of the unknown, as for example occurring when there is minimal communication with the deployed family member, may heighten anxiety and stress. Reliance on the media or even military channels for information may involve frightening commentary and images. Online discussion groups can also be a source of unreliable information that creates needless distress. Learn what you can about the issues from trustworthy resources, such as public libraries and published books. Put the risk in proportion so that you are in a better position to think realistically. For example, remind yourself that even though you hear regularly about deaths in the military, the vast majority of deployed troops are not harmed.
There are special concerns when the primary caretaker is deployed.

Suggestions for Families of Deployed Military Personnel:

Take time to listen to each other.
Know that deployment will be a painful and frightening time, particularly for children. Spend time listening to family members without judging or criticizing what they say. People may need to just express themselves during this time. The more family members can communicate with one another, the less long-term strain there will be on the family.

Limit exposure to news media programs.
Families should minimize exposure to anxiety-arousing media related to the war. News programs often emphasize fearful content and frightening images to create a "story." Watching a lot of TV news programs, for example, can create needless distress. When children worry about war, let them know that the war is far away. Acknowledge children's fears, and let them know that parents, teachers, and police are here to protect them.

Remember the deployed member is still a part of the family.
Find ways to keep a symbolic representation of the deployed member visible to the family. Keep photographs of your loved one in prominent locations. Get children's help in keeping a family journal of each day's events for the deployed member to look at when he or she returns.

Understand feelings.
Emotions such as fear, anger, and feeling "numb" are normal and common reactions to stress. Family members need to make sure these emotions aren't turned against one another in frustration. It will help family members manage tension if you share feelings, recognize that they are normal, and realize that most family members feel the same way.

Spend time with people outside of the family
Coping with stressful events is easier when in the company of caring friends. Ask for support from your family, friends, church, or other community group.

Join or develop support groups.
Forming support groups for the spouses of deployed military personnel helps spouses cope with separation from their loved ones. Peer-support groups, led by spouses of deployed service members, can be a tremendous aid to family functioning. Spouses can share ideas with each other, trade childcare or other responsibilities, and encourage each other if they are feeling taxed.

Keep up routines.
Try to stick to everyday routines. Familiar habits can be very comforting.

Take time out for fun.
Don't forget to do things that feel good to you. Take a walk, spend time with your pets, or play a game you enjoy.

Help others.
It is beneficial for everyone in your family, and your community, to find ways you can productively channel energy together. Helping other families and organizing neighborhood support groups or outings can help everyone involved.

Self-care.
The more emotionally nurturing and stable the remaining caretaker is able to be, the less stress the children will feel. Trying to "do it all," however, can lead to exhaustion. Signs of caregiver stress include feeling as though you are unable to cope, feeling constantly exhausted, and/or feeling as though you no longer care about anything. It is especially important for caretakers to devote time to themselves, exercise, and get plenty of rest.

Get professional help if needed.
When stress becomes overwhelming, don't be afraid to seek professional help. Ongoing difficulties such as exhaustion, apathy, worry, sleeplessness, bad dreams, irritability, or anger-outbursts warrant the attention of a professional counselor. The military employment assistance program provides free counseling for family members impacted by the stress of deployment. Contingency planning personnel are available on bases around the country to help.

Much of this information is based on this document.

Additional Resources:

This 4-page section of a Department of Veteran Affairs guide entitled The Impact of Deployment on the Military Family discusses the emotional cycle of deployment, children’s responses to deployment, and what parents can do for themselves and their children.

Issues in Mental Health Help-Seeking for Veterans and Their Families

Some recent research indicates that one in three veterans returning from Iraq and Afghanistan suffer from significant to severe stress, anxiety and or trauma, yet close to 60% of them do not seek help, typically for one or all of the following reasons:

Fear of being stigmatized by peers and superiors

Fear of having documentation in their medical records that could prevent future advancement or civilian employment opportunities

An emphasis on self-reliance that may make it difficult to ask for help

A discomfort or aversion to counseling and to sharing or reliving difficult experiences, especially if the counselor is a non-Veteran or non-Combat Veteran
The lack of availability of culturally sensitive or financially practical help sources

Psychotherapy involves talking with a trained mental health professional, such as a psychiatrist, psychologist, social worker or counselor. The professional helps people gain insight into their feelings, change behaviors, resolve problems or learn how to deal with feelings like stress, grief, loss, fear and sadness. Talk therapy is sometimes combined with homework assignments between sessions. Therapy can be held one-on-one, with couples, families or even in groups. Participation in short-term counseling or psychotherapy can help active personnel, veterans, and family members recognize and begin to recover from the influence of trauma related to military service and its consequences. Millions of Americans have found help changing some aspect of their life through psychotherapy, also known as talk therapy or counseling.

Consider Therapy If...

You feel an overwhelming and prolonged sense of helplessness and sadness, and your problems do not seem to get better despite your efforts and help from family and friends.
You are finding it difficult to carry out everyday activities: for example, you are unable to concentrate on assignments at work, and your job performance is suffering as a result.
You worry excessively, expect the worst, or are constantly on edge.
Your actions are harmful to yourself or to others: for instance, you are drinking too much alcohol, abusing drugs, or becoming overly argumentative and aggressive.

This fact sheet is based on information contained at the following websites:

APA Help Center (pdf)

Brainguidance.com (pdf)

Additional Resources

VA Medical Center specialized PTSD programs and VA Readjustment Counseling Service Vet Centers are sources of psychotherapy services for active duty personnel, veterans, and their family members.

This website from the National Center of PTSD describes the various specialized treatment programs offered by the U.S. Department of Veteran Affairs.

This brief document from NCPTSD provides helpful information to anyone seeking a therapist, including issues to consider when choosing a therapist, how to find a therapist, specific help for veterans, and how to find a support group.

The American Psychological Association also offers a resource for finding a psychologist in your area.

Managing the Homecoming Process

Much of our experience of events is influenced by our expectations about them, and having realistic expectations of one another and of the process during the homecoming transition can contribute to mental health. Here are some common tendencies regarding the homecoming process and some suggestions for managing them:

Normal parts of the process for Veterans:

You may miss the excitement of the deployment for a while.
Some things may have changed while you were gone.
Face-to-face communication may be hard at first.
Sexual closeness may also be awkward at first.
Children will have grown and may be different in many ways.
Roles may have changed to manage basic household chores.
Spouses may have become more independent and may have learned new coping skills.
Spouses may have new friends and support systems.
You may have changed in your outlook and priorities in life.
You may want to talk about what you saw and did. Others may seem not to want to listen. Or you may not want to talk about it when others keep asking.

Normal parts of the process for Significant Others:

Veterans may have changed.
Veterans, used to the stimulation and the open spaces of the deployment, may feel closed in.
Veterans also may be overwhelmed by the noise and confusion of home life.
Veterans may be on a different schedule for sleeping and eating.
Veterans may wonder if they still fit into the family.
Veterans may want to take back all the responsibilities they had before they left.
Veterans may feel hurt when young children are slow to hug them.

Normal parts of the process for Family Members:

Babies less than 1 year old may not know the returning veteran and may cry when held.
Toddlers (1-3 years) may also show fear and be slow to come to the returning veteran.
Preschoolers (3-5 years) may feel guilty over the separation and be scared.
School-age children (6-12 years) may want a lot of time and attention from the returning veteran and also the significant others.
Teenagers (13-18 years) may be moody and may appear not to care.

Tips for Veterans for managing the homecoming process:

COMMUNICATE! Try to involve your significant other in the homecoming experience by sharing your emotions (nervous, scared, happy, uncertain), and Listen. The best way to get through the re-acquaintance jitters and to regain closeness with your loved ones is to talk and actively listen
If you are not comfortable talking or being close to people around you try to help them understand by communicating in a calm and sincere way that you are in need of some private decompression time and ask for their patience.
Be aware of how the intensity of your surroundings has changed and how your circumstances may require less intensity and confrontation than during your deployment. If you experience quickness to anger try to catch yourself sooner in the reactive process. It is normal to feel keyed up and on edge after deployment.
Be prepared to make some adjustments, and go slowly in finding a role in the family.
Be supportive of good things that your family has done.
Take time to talk with your significant other and children, making time for each.
Intimacy and closeness may feel distant at first. Again, be patient and communicate with your partner. You may have been in a dangerous environment where you had to put your emotions and feelings safely away to focus on your job. It is normal to need time to reopen these areas of intimacy and closeness. Expect that sex may be awkward at first.
Take time to listen and to talk with loved ones.
Avoid excessive drinking or use of other substances during the transition time. Although these may seem harmless and fun and you may have a sense of “deserving” the relaxation, substance struggles are a serious problem among veterans.

Tips for Significant Others for managing the homecoming process:

Avoid scheduling too many activities.
Go slowly in making adjustments.
It is okay if you and your veteran need time individual time at first to reestablish your roles in the family and your relationship to one another.
Remind the veteran that he or she is still needed in the family.
Discuss reallocating family responsibilities and chores to involve the veteran.
Try to begin the process of making decisions together that you have formerly had to make individually during the deployment. This includes decisions about finances and activities and friendship relations.
Along with time for the family, make individual time to talk just to each other.
Be patient with yourself and your partner.

Tips to help Children in managing the homecoming process:

Go slowly, be patient, and try to understand the roles and routines and rules already in place before changing them. Delay making changes in rules and routines for a few weeks.
Let the child set the pace for getting to know the veteran again.
As a veteran try to learn from and build on how your spouse or significant other managed the children in your absence. Don’t make sudden disciplinary changes.
Be available to your child, both with time and with your emotions.
Expect that the family will not be the same as before you left; everyone has changed.
Focus on successes with your children; limit your criticisms. Expect changes in both your significant other and in your children. Adapt accordingly, remembering that most of the changes mean growth and maturity. If some of the changes are negative, be patient; you and your family will have plenty of time to bring things back around to a position of comfort.

Reunion is part of the deployment cycle and is filled with joy and stress. The following tips can help you have the best possible reunion.

Much of this information is modified and adapted from this source. (pdf)

Additional Resources

This 15-page brochure provided by the Veterans and Families Homecoming Support Network is entitled Homecoming Preparedness for Veterans and Families. Itexplores various ways veterans can more easily transition from military life to civilian life.

This website provides information for those involved with the military, including information regarding parenting, deployment, and transitioning back home after deployment.

Mental Health in Time of War: 10 Principles for Military Members, Veterans, and their Families

Make connections.
Keep in touch with family, friends, and others. Connecting with people provides social support and strengthens resilience. Some people find comfort in connecting with a higher power, whether through organized religion or privately.
Help yourself by helping others. Assisting others in a time of need, such as doing volunteer work at a community organization or helping families of active reservists or military personnel serving in the war, can be empowering.
Maintain a daily routine.
Keeping up with your daily routine of work, errands, household chores, and hobbies can provide you with a feeling of stability when the world around you seems chaotic. Sticking with a routine can be comforting to your children as well.
Take care of yourself.
Make time to eat properly, exercise, and rest. Schedule time for things you enjoy, such as hobbies and social activities. Caring for yourself and even having fun will help you stay balanced and enable you to better deal with stressful times.
Give yourself a "news" break.
Be sure to control the amount of time you and your family spend watching and reading war-related news coverage. Although it's natural to seek out the news to keep informed, too much news can make you more anxious. Consider limiting your news intake to no more than one hour a day, and try not to watch the news right before you go to bed, when you need to "wind down." It's okay to turn off the TV or radio and allow yourself to focus on non-war-related things.
Have a plan.
Having an emergency plan in place will make you feel in control and prepared for the unexpected. Establish a clear plan for how you, your family, and friends will respond and connect in the event of a crisis. Have a family or neighborhood meeting to talk about whom to call in emergencies or designate a place to meet if you can't reach someone by phone. Make a plan for your pets and a list of items you will need to take in an emergency.
Prepare a security kit.
When pulling together an emergency kit, remember to include those things that give you comfort and security, such as a favorite book, a journal, or pictures of loved ones. Also include a list of your loved ones' phone numbers so that you can reestablish connections with them as soon as possible.
Nurture a positive view of yourself.
Recall the ways you have successfully handled hardships in the past, such as the loss of a loved one, a divorce, or a major illness. Draw on these skills to meet current challenges. Trust yourself to solve problems and make appropriate decisions.
Keep things in perspective.
Even when facing very painful events, try to consider the stressful situation in a broader context and keep a long-term perspective. Remember that wars end, and circumstances can ultimately improve. Previous generations have faced war and gone on to prosper--use their examples to inspire you.
Maintain a hopeful outlook.
An optimistic and positive outlook enables you to see the good things in your life and can keep you going even in the hardest times. There are positive things in everyone's life, such as good health, a comfortable home, and strong friendships. Taking the time to identify and appreciate them will enhance your outlook and help you persevere.

This fact sheet is based on information contained in this brochure.

Mental Health Issues in Military Personnel and Veterans: An Overview

Traumas are events in which a person has the feeling that he or she may die or be seriously injured or harmed, or events in which he or she witnesses such things happening to others. Trauma is of course common among active military persons and veterans, and in addition to the immediate consequences of intense fear, helplessness, or horror, there are sometimes longer-lasting stress reactions that can be surprising, distressing, and difficult to understand. This fact sheet is intended to help military personnel, veterans, and their family members understand the nature of trauma and its consequences.

In reviewing the list of effects of trauma below, keep in mind that:

It is very common to have problems following exposure to war or other trauma. But traumatic stress reactions often become less frequent or distressing as time passes, even without treatment.
People with traumatic stress often worry that they are going crazy. This is not true. Rather, what is happening is that they are experiencing a set of common symptoms and problems that are connected with trauma.
Problems that result from trauma are not signs of personal weakness. Many mentally and physically healthy people experience stress reactions that are distressing and interfere with their daily lives following exposure to traumatic experiences. But if traumatic stress reactions continue to cause problems for more than a few weeks or months, treatment can help reduce them.

Here are some common (often temporary) consequences of trauma:

Unwanted remembering or re-experiencing
Almost all veterans experience difficulty controlling distressing memories of military experience, particularly when there has been combat experience. Although these memories are upsetting, on the positive side, the memories provide an opportunity for the person to make sense of what happened and gain mastery over the event. The experience of these memories can include:

Unwanted distressing memories as images or other thoughts
Reexperiencing of the original traumatic situation, or the feeling like it is happening again (flashbacks)
Dreams and nightmares
Distress and physical reactions (e.g., heart pounding, shaking) when reminded of the trauma

Physical activation or arousal
The body's fight-or-flight reaction to a life-threatening situation helps prepare persons in a dangerous situation for quick response. Unfortunately sometimes this pattern of activation or arousal continues long after the event is over. Signs of continuing physical activation, some of which are somewhat common following military experience, can include:

Difficulty falling or staying asleep
Irritability, anger, and rage
Difficulty concentrating
Being constantly on the lookout for danger (hyper-vigilance)
Being startled easily for example, when hearing a loud noise (exaggerated startle response)
Anxiety and panic

Shutting down: Emotional numbing
Another survival response involves the shutting down and numbing of emotional response in times of trauma. As a result, some military personnel and veterans may have difficulty experiencing loving feelings or feeling some emotions, especially when upset by traumatic memories.

Active avoidance of trauma-related thoughts and feelings
Painful memories and physical sensations of fear can be frightening, so it is only natural to try to find ways to prevent them from happening. One way that many trauma survivors including veterans might do this is by avoiding anything people, places, conversations, thoughts, emotions and feelings, physical sensations that might act as a reminder of the trauma. This process can be helpful if it is selective and specific (for example, in avoiding upsetting news or television programs). But when avoidance is used too much, it can have two big negative effects. First, it can reduce the ability to live life fully and with enjoyment as people become isolated and limited in where they go and what they do. Second, avoiding thoughts and emotions connected with the trauma may reduce the ability to recover from the trauma. It is through thinking and talking about the traumatic experience with trusted others, a process that some term “working through the trauma,” that survivors may come to manage and integrate the traumatic experience. By constantly avoiding thoughts, feelings, and discussions about the trauma, this potentially helpful process can be short-circuited.

Depression
Most persons who have been traumatized experience short-term depression. But when this experience lasts too long it becomes an area of concern, and may involve:

Feelings of helplessness and hopelessness
Loss of pleasure in usual activities
Lower energy
Pervasive and extreme sadness (“I don’t know why, but I’m just crying all the time,” some people with depression say)
Changes in appetite and sleeping patterns

Depression is a serious and life-threatening struggle, it is important to let others know about feelings of depression and, of course, about any suicidal thoughts and feelings, which are sometimes a part of feeling depressed.

Self-blame, guilt, and shame
Many military personnel and veterans, in trying to make sense of their traumatic war experiences, blame themselves or feel guilty in some way. They may feel
bad about some thing(s) they did or didn't do in the war zone. Feelings of guilt or self-blame cause much distress and can prevent a person from reaching out for help. Therefore, even thought it is hard, it is very important to talk about guilt feelings with a mental health professional.

Interpersonal problems
Not surprisingly, the many changes noted above can affect relationships with partners, family, friends, or co-workers. Particularly in close relationships, the emotional numbing and feeling of disconnection that are common after traumatic events may create distress and drive a wedge between the survivor and his or her family or close friends. The survivor's avoidance of different kinds of social activities may frustrate family members and contribute to isolation. And other people who don’t understand trauma may respond in ways that worsen the problem rather than help recovery. They may become angry with the active duty person or veteran, communicate poorly, and fail to provide support. Just as the military person needs to learn about trauma and its effects, people who are important to him or her also need to become educated so as to be empathic and kind.

Physical symptoms and health problems
Because many traumas result in physical injury, pain is often part of the experience of veterans. This physical pain often causes emotional distress, because in addition to causing pain and discomfort, the injury also reminds them of their trauma. Because traumas stress the body, they can sometimes affect physical health, and survivors may experience stress-related physical symptoms, such as headaches, nausea or other stomach problems, and skin problems.

Some of the information in this fact sheet is based on information found here. (pdf)

Resiliency in Military Personnel, Veterans, and Family Members

Mental health professionals have spent a long time studying post-traumatic stress disorder as a response to such stressors as being deployed in the military or experiencing a loved one’s absence. But more recently they have focused on resiliency, defined as “the ability to spring back from and successfully adapt to adversity,” and defined by a 15-year-old high school student as, "Bouncing back from problems and stuff with more power and more smarts." Resiliency is also sometimes referred to as psychological hardiness, wellness, and positive psychology. Regardless of the name we give it, resiliency and the ability to “bounce back from (life stressors) with more power and more smarts” is an important goal of mental health, and knowing the principles of resiliency can facilitate mental health in deployed military members, in veterans, and in family.

Each of us has a built-in capacity for resiliency, "a self-righting tendency" that operates best when we have resiliency-building conditions in their lives. These resiliency conditions take place along three dimensions of our experience: I AM, I CAN, and I HAVE. This fact sheet will discuss each of these as it relates to the military experience.

I AM refers to personal characteristics, including:

Self-esteem, or the sense that we have of ourselves as capable, loveable, and worthy. Psychological research suggests that our beliefs about how we can cope may be as important as coping behavior itself.
Mastery, confidence, perceived control, hope, and optimism have been shown to relate positively, strongly, and consistently to mental health in both the short-term and long-term recovery from disaster as illustrated in powerful personal stories such as this.
Recognition of personal strengths as well as suffering. Although military service and the absence of loved ones must be acknowledged with compassion and empathy and patience for ourselves, we must also remind ourselves of our capacity to master this experience. Others have survived these experiences and we can too.

I CAN as an element of resiliency refers to recognition of not just self-esteem, but self efficacy, which is different from recognizing our personal strengths. It is the difference between “I am a good reader,” (self-esteem) and “I can read” (self-efficacy). In self-efficacy we have a sense of our specific abilities and assets and talents as they relate to recovery. Recognizing our problem-solving skills as they relate to enduring and managing and recovering from military service and its consequences enhances resiliency, and promotes our ability to “bounce back with more power and more smarts.” In building this element of resiliency, as a present member of the military, veteran, or family member, you might ask yourself:

What can I bring to this experience, in terms of talents and skills, which maybe only I can bring? It may be as simple as acts of kindness to your squadmates or volunteering with a veteran’s organization or organizing an e-mail support group for friends and relatives, or something more complicated.
What tools do I possess in terms of kindness or gratitude or perspective-taking that I can bring to this experience? How can I bring them courageously and clearly? What gifts do I have, to give?

I HAVE refers to the supports around each of us that promote resilience. These are like the airbags in our cars that even when we crash can keep us from being wounded too seriously: the “I have” of resiliency in the military experience might include:

our access to service agencies that can provide us with support during this time
our relationships with significant others and with our those we are serving or served with influence our mental health, but are particularly important during times of military service, when relocation and other influences may disrupt our interactions with support systems. An important feature of the “I have” component of resiliency involves maintaining our relationships with family and friends, and when necessary “rebuilding relationships" in the same way that we might rebuild homes or schools.
our participation with communities such as spiritual or religious groups, schools, and service organizationscan remind us that we are not alone, that our experiences are not entirely unique, and that we can endure the military experience and its consequences.

In summary, relatively few military personnel, veterans, or family members experience become depressed or develop PTSD: most of us exhibit resiliency-the ability to deal with adversity without becoming overwhelmed by it. We can learn to respond to adversity with resiliency rather than depression and hopelessness.

Additional Resources

This 7-page brochure provided by the American Psychological Association defines resilience and explores the factors of resilience, how to build resilience, how to learn from the past, and where to look for help.

This 1-page article defines what resiliency is in simplistic and easy to understand terms.

The Hardiness Institute provides this story about stress and how it relates to physical, emotional, and performance breakdowns.

Returning Home After Military Deployment: An Overview for Personnel and Family Members

Military service is a difficult and unique life experience in which personnel face challenges and disruption and even threats to safety and well being. They experience things that most people – including families, friends, and co-workers – could not begin to understand or appreciate, things far apart in time and space and power from everyday lives. One of my practicum students spoke of an “airlock” between the hospital entrance and the psychiatric inpatient ward, in which he experienced the distance between that space and the space in which he ordinarily lived, both going into and coming out of that space. Here are some general suggestions, excerpted and elaborated from this document, on how to ease the airlock transition from military service to your home.

Return is a Process, not an Event. I think in my own work about the process of atmospheric reentry: too direct an approach to returning home and you burn up, too indirect and you bounce off. Try to get it just right. Returning veterans should be patient with themselves and with family members in their reentry, and family members should also be patient with themselves and with veterans. It is a process with predictable phases (see Managing the Homecoming Process above).

Rest. One of the common features of military service is a disruption in sleep and eating and exercise and other well strategies, and personnel returning home may feel exhausted. It may requite days or weeks to regain health (as opposed to merely staying safe), and veterans, their family members, and employers need to make time for rest and recovery.

Pace and Routine. Military service frequently demands a fast-paced and even frantic task approach in which efficiency and speed are required instead of the more purposeful and deliberate approach generally available at home. Returning personnel, and their families, need time to “synchronize” their task approach. Similarly, military service (described by more than one veteran as “lots of boredom sprinkled with moments of sheer terror”) often requires an abandonment of many familiar routines as tasks emerge and must be managed spontaneously. Again, it may take time for military personnel and their families to “get in step” together with routine.

Sharing. Returning veterans may want with family members and co-workers about their experiences, and family members may be eager to “catch veterans up” on their experience. The military service experience may seem in contrast much more dramatic and significant, but veterans should try to remember that family members’ experiences are as important to them as yours are to you. In dealing with children try to explain your military involvement in a way that is appropriate to their level of development (link to Geared to the child’s age and interest pdf found on General Public FS, tab Reassuring Children), and involve them in disaster preparedness efforts (link to Prepared pdf found on General Public FS, tab Introduction to Preparedness and Planning) for your family.

Emotions When you return home, some feelings or emotional swings associated with stress (link to Stress pdf found on General Public FS, tab Traumatic Stress) may surprise or frighten you. If you anticipate some of these emotions, you can manage them better.

Disappointment: Returning veterans may find that others are not interested in hearing about your experiences, or that your reunion with your family and co-workers does not live up to your expectations. You may expect they will be happy to have you home and be surprised to find they are angry at your absence. Similarly, family members may be puzzled or disappointed at elements of homecoming. Anticipating this response will help all of you in managing it.

Frustration and conflict: Veteran’s needs may not match those of family or colleagues. Although you may want nothing more than to resume a simple and predictable life, family members may have changed.

Anger: The problems and challenges of everyday life experienced by veteran’s family, friends, or co-workers may seem very trivial compared to those you have witnessed and experienced. Try to remember that the folks at home feel that their problems are just as important to them right now. Appreciate how your own anger and grief (link to Grief pdf found on General Public FS, tab Grief and Loss).

Survivor identification: The actions or characteristics of people at home may remind you of your experience in military service. You may experience emotional reactions that can surprise and confuse not only you, but also them. Try to make others understand the reasons behind your reactions.

Daydreaming: This on the part of veterans is a normal response to trauma and is a part of healthy dissociation. Veterans may be confused at how they are reliving their service experience, and surprised at how distant they may feel at times from daily life and routine. This is all a normal part of return.

Mood swings: These are normal for veterans after returning from a deployment and are one of the ways to begin to experience and resolve conflict feelings you may have experienced related to your military experience. Veterans may change from happy to sad, tense to relaxed, or outgoing to quiet without much warning. When you have time to put your military work into perspective, these sudden changes in mood will pass.

Returning from military deployment is a difficult process Practicing self-care and developing resiliency during the process of your return will allow you to continue giving your gifts.

Additional Resources

This website provides information for those involved with the military, including information regarding parenting, deployment, and transitioning back home after deployment.