November 2005
Soldiers, Psyche, and the Department of Veterans Affairs: What Are the Lessons of Vietnam?
The psychological toll of Operation Iraqi Freedom and Operation Enduring Freedom “could well be [our] generation’s Agent Orange syndrome,” one veterans’ advocacy group warns. A bill to increase federal spending on mental health treatment for our troops is under consideration in the House. Its sponsor says returning soldiers could suffer post-traumatic stress disorder (PTSD) at rates “roughly comparable” to Vietnam War veterans. With the Department of Veterans Affairs being pushed to treat a new generation of veterans, it now seems a good time to reassess our psychological care of Vietnam’s veterans. What did our work with them teach us about effective rehabilitation?
There is no simple answer. We can never know how many Vietnam veterans were afflicted by PTSD, but some suggest that care provided through the Veterans Administration (now the Department of Veterans Affairs) medical centers--despite the best of intentions--played a role in many veterans’ becoming chronic psychiatric patients. This resulted, some clinicians speculate, from a confluence of practices considered state-of-the-art in the1970s and 1980s, when Vietnam veterans first began to seek care. Many VA Veterans Affairs mental health workers commonly believed--and many still do--that participation in war automatically results in post-traumatic stress disorder. In communicating this notion to veterans, they set up the expectation of illness. In addition, treatment itself was regressive, involving the incessant re-telling of war stories with insufficient emphasis on practical problem-solving. Finally, generous Veterans Affairs entitlements for chronic PTSD may have created financial incentives for veterans to claim psychological disorders and reduced the motivation to recover.
At a November 7 panel discussion, experts discussed the Vietnam generation’s lessons for veteran rehabilitation and how to apply those lessons to the treatment of new veterans.
Dr. Sally Satel
AEI
As of this week 430,000 troops have returned from fighting in Iraq and Afghanistan. A number of these soldiers will suffer from psychological difficulties and require care from the Department of Veteran Affairs mental health facilities.
The last time the Department of Veteran Affairs dedicated such an amount of resources to veteran rehabilitation was in the wake of the Vietnam War. What we have learned from that era can be used today in dealing with our returning veterans.
Some mental health professionals continue to operate under the assumptions fostered during the Vietnam era that treat war as inevitably psychologically damaging. Although war may be inevitably psychologically changing, the observation that it damages and cripples vast amounts of people is untrue. Furthermore, many who work at the VA currently endorse outmoded treatment processes.
Dr. Simon Wessely
King’s College London
The history of psychiatry erroneously explains our denial of the realities of war and its effects until the Vietnam War, after which we gradually moved toward enlightenment and the embrace of post-traumatic stress disorder (PTSD). This depiction is simply not true. The psychological consequences of war were understood well before the Vietnam War. In 1916 and 1917, based on the numbers of shellshocked victims, no one could deny war’s psychological casualties. What has changed since then are our views of the causes of the disorder.
A British-appointed commission in 1922 investigated the causes. Perhaps the costs of war were just too great, and even the strongest nerve could crack. Another view determined the problem to be in the man himself. As the military replaced many of its lost soldiers with a volunteer, citizen army, perhaps these soldiers just did not have “the right stuff.” War was a test of character, and the cause of a breakdown lay in the person, the nature of one’s training, and one’s leadership.
These views changed by World War II due to American studies in 1941 on the nature of combat motivation and breakdown. Men did not fight for ideas as had been thought previously; rather, they fight for each other. Breakdown occurs when one has lost that feeling that he is part of an all-powerful group. Therefore, the job of both the military and military psychiatrists was to sustain that group feeling and combat motivation as the best way to prevent breakdown.
Another finding of the American studies was that even if men were properly led and trained, anyone could break. This was in contrast to the beliefs held about World War I.
The final finding was that the breakdown would be relatively short-lived, provided the person was properly managed and was stable before the war. The consequences of battle fatigue would be temporary.
As we entered the Vietnam era, smaller groups of soldiers became the more strategic tactic. Consequently, preserving the fighting strength was more important than preserving the group ethos. In order to prevent combat exhaustion, the policy of DEROS (date of expected return overseas) was utilized. Soldiers knew that they would be in the combat theater for a year and only a year, after which they would return home.
The policy seemed to show good results. It is notable that within the first five years of Vietnam prior to 1968, psychological breakdown was far less common than in the Korean War, World War I, or World War II. However, the short-term characteristic of DEROS preserved the fighting strength at the cost of the small-group identity that other studies had shown to sustain people through adversity.
There were two problems that arose from DEROS. The first was that people had never really bonded while in theater. One’s self-identity with the military occurred after their return to the United States. The second problem was America’s and psychiatrists’ feelings toward the Vietnam War. Both had started to turn against the war, and veterans became a symbol of a combat which itself was and in which everyone involved were thought to be insane.
Although the standard teaching was that if one left the combat theater without a breakdown one would stay that way, anti-war psychiatrists felt something was missing. By the end of the 1960s, they were looking for evidence that all was not well with the returning veterans. Demonstrating this search by the psychiatrists is a 1973 paper which admitted that stress problems were not being spontaneously reported by veterans at Veterans Affairs mental health hospitals. Yet at the same time that an educational program was begun, new stress problems were reported. The predictions of the anti-Vietnam psychiatrists seemed to be coming true.
Until the arrival of PTSD in 1980, it was assumed that if one broke down in battle due strictly to the war, one would improve relatively quickly. However, if improvement did not occur, the breakdown was attributable to some other stimuli which occurred before combat. There were two explanations for chronic illness: it was attributable either to one’s genes of to one’s early life and upbringing. But both of these explanations laid out one’s trajectory: if one enlisted and was mentally stable, one could break down, but improvement was inevitable. However, if one did not improve, the breakdown was inevitable and not attributable to combat stress.
In 1980 the introduction of PTSD did not change our belief that war could cause psychological problems; however, now the problems were not necessarily short-lived--one could experience chronic disorders which were not attributable to genes or to upbringing. Vietnam did not open our eyes to the psychological effects of war; it changed our beliefs about why one experiences those negative effects.
It is important to note that the epidemiology used to document PTSD did not exist before 1980 but was introduced after the introduction of PTSD itself. Society and the media’s stereotypes of Vietnam veterans had taken root long before any evidence existed to support them.
Presently, psychiatrists and the military are no longer working together. The military continues to focus on the importance of combat motivation and the importance of the group; psychiatrists focus on the victimized individual. What matters for psychiatrists is the fact that one is ill; the military focuses on how one has become ill. There is no singular explanation for why people break down in battle but many ideas and theories. The problem is that these ideas are not biological truths that we discovered; rather they are phenomena of culture.
Colonel Charles Engel
Uniformed Services University
The psychiatric approach in the battlefield is focused on minimizing the acute psychological effects of war. Psychiatric casualties have long been recognized as an important battlefield problem from the time we first documented it in World War I.
Depending on the intensity and duration of conflict, the actual proportion of psychiatric casualties can vary. The Vietnam conflict had some of the lowest rates of acute casualties in the battlefield because the battle was considerably less intense. Psychiatric casualties made up only 5 percent of war casualties in Vietnam as opposed to 50 percent in World War II.
The principles of forward or combat psychiatry are relatively straightforward. Coined in the 1960s, they make up the acronym PIES (proximity, immediacy, expectancy, and simplicity). Proximity and immediacy reflect the necessity to be nearby to the distressed soldier so that care may be administered as quickly as possibly. Expectancy embodies the belief that from the moment of initial contact, the expectation that is communicated to the soldier is that contact with assistance is short and basic and that afterwards he will return to his unit to accomplish the goal. Simplicity reflects the basic needs (food, rest, shelter) that, if given, will enable the soldier to return to battle after a short duration.
The goals of forward psychiatry can be described as a “force multiplier.” The first and foremost goal of the military is to sustain the battle or to ensure adequate people to fight the battle. Therefore, it is important to maximize the immediate effects of care; it is not concerned with the long-term effects of war on the soldier. Returning soldiers to their unit to perform their duties is the primary goal of forward psychiatry.
The main method used to accomplish this goal is to avoid the medicalization of the soldier. Referring to combat fatigue or combat exhaustion as a medical disease enhances the soldier’s belief that he should be relieved of his duty and combat responsibilities on account of his illness. Another method used is keeping the treatment brief so that the soldier does not come to his own conclusion that he has a medical condition and therefore cannot fight. Lastly, it is important to bolster the soldier’s desire to return to battle with his companions under the premise that his unit is not functioning as well without him.
The cognitive-behavioral mechanism, used throughout psychiatry and psychology, is seen in forward psychiatry as well. A soldier’s response to his own symptoms depends on his beliefs and appraisal of his symptoms. If a soldier believes that his symptoms are persistent or that they are symptoms of a medical disease, he will succumb to a level of disability that he would not have otherwise accepted. On the other hand, if he believes the symptoms are limited and if he is concerned more about the success of his unit, the soldier will get over his battle fatigue and return to battle.
Some real-life examples indicate how powerful the beliefs and expectations of a soldier are. Critical incidence stress debriefings, in which soldiers are shown the long-term effects of battle fatigue and methods of assistance, seem to be unhelpful in decreasing PTSD. In fact, some of the better studies indicate that those soldiers receiving debriefing tend to do worse. A second example is in multidisciplinary pain programs. For people with lower-back pain and other pain problems, deemphasizing the medical nature of their pain tends to return them to functioning more quickly and effectively. The last example traces an occupational program to pick up hypertension in the workplace in the 1970s. The researchers found that even if people were asymptomatic, if they had been diagnosed with hypertension, their level of disability and missed work increased by participation in the program. These examples indicate the real and important effects of a person’s expectation of illness.
The outcomes of forward psychiatry are somewhat unreliable due to the fact that the data were used to impress the military leaders that the methods were working. In World War I 65 percent of soldiers returned to duty and 4 percent experienced a relapse. World War II had 54 percent returning to duty and 66 percent relapsing. Relatively few of those returning to duty would not go back to a combat duty but rather other military duties. The Korean War experienced a 70 percent return to duty, and in Vietnam only about 5 percent of the casualties were psychiatric casualties. Psychiatrists of the Vietnam era declared victory for forward psychiatry due to the low numbers; however, given the fact that the location of the “front line” in the Vietnam War was one of the major problems, this claim could be an over-amplification of forward psychiatry’s success. An Israeli observational study after the 1982 conflict compared the rates of relapse and subsequent rates of PTSD with people who were treated on the front line versus those treated at home while on leave. They found that rates of return to duty were considerably greater and rates of subsequent PTSD were considerably lower in those treated on the front line. It is important to remember that this was an observational study and that where one is treated is an important indication of the severity of combat fatigue.
In summary the efficacy of forward psychiatry, although the universal model, is unclear at best and will probably never undergo a randomized test. Forward psychiatry’s objectives are clearly military related. However, we can take from this the notion that forward psychiatry attempts to maximize the functioning of soldiers. The disability or capability to function is behavioral and can be shaped by incentives and disincentives. The forward psychiatry approach to disability is cognitive and behavioral rather than medical; furthermore, this approach matches the beliefs of multidisciplinary approaches.
Christopher Frueh
Charleston Veterans Affairs Medical Center
According the U.S Army Surgeon General, 30 percent of Operation Iraqi Freedom forces have a psychiatric disorder and 15 percent have PTSD. The latest number of troops that have returned from combat is 433,398, according to the VHA Office of Public Health and Environmental Hazards quarterly report of October 21, 2005. Twenty-eight percent of those have sought Veterans Affairs care, and 31 percent of those have been diagnosed with a psychiatric disorder. Thus, 8.5 percent of Operation Iraqi and Enduring Freedom returnees have received a psychiatric diagnosis from the VA, and 3.7 percent have been diagnosed with PTSD.
The clinical syndrome of PTSD in veterans is often associated with co-occurring psychiatric disorders; chronicity; impaired social, familial, and occupational functioning; and historically, significant medical co-morbidity and health service use.
The number of veterans receiving VA disability for PTSD increased 80 percent from 1999 to 2004, while all other disabilities increased 12 percent during that period. PTSD disability payments increased 149 percent (to $4.3 billion annually), while payments in all other categories increased by 42 percent. A recent report by the Office of the Inspector General suggests that fraud and abuse are common (up to 25 percent of all cases), putting the potential monetary risk at $19.8 billion extrapolated over the lifetime of these veterans.
About 75 percent of veterans treated within PTSD specialty clinics are already seeking disability compensation when they come to the VA. It is noteworthy that veterans seeking disability show greater distress across all domains and also appear to be exaggerating symptoms on psychological inventories.
A Freedom of Information Act request for U.S. military records of one hundred consecutive VA patients seeking treatment for Vietnam combat trauma found that only 41 percent had clear evidence of Vietnam combat exposure well documented in military records. The vast majority had Vietnam service well documented, but it was unclear what their roles were there. Five percent of them had had no military roles in Vietnam. British government pension files from the Boer War, World War I, and World War II suggest that disability pensions for combat-related psychiatric problems tend to “inhibit the natural process of recovery and consolidate distressing symptoms.”
Data show that PTSD among civilians is amenable to mental health treatment, including psychiatric medications and cognitive-behavioral psychotherapy strategies. These are similar to some of the principles of forward psychiatry. However, the research in the VA has failed to show that these same treatments are effective for veterans with PTSD. Given what we know about the impact of contingencies on human behavior, why would we expect veterans to get better when the financial incentives to remain ill are so great?
Some key questions follow. Are reliable evaluation procedures being currently used in the disability evaluations that the VA uses for PTSD? It is suspected no. The Office of Inspector General’s report and some independent research have shown quite dramatic regional variations in evaluations, leading one to believe there is no standard across VA facilities. Another question is whether the VA’s psychiatric disability policies are current? The policies were developed at least twenty years ago and may have been slightly modified along the way. There has been a great bit of research done even in the last five years looking at psychiatric rehabilitation, supported employment, and a variety of other strategies designed to help people with severe mental illnesses adjust financially to their impairments.
Are we setting harmful expectations for returning veterans regarding the likelihood of developing a “total and permanent” disability? How do VA disability policies effect our ability to diagnose, treat, and study PTSD among veterans? We have to acknowledge that there are good data to suggest that our disability policies create some type of disincentives and distortions to which we must be attuning ourselves. How can disability benefits be re-conceptualized as an effective and flexible safety net? Re-conceptualizing would serve our veterans much better due to impairment fluctuations over time. It would allow disabled veterans to access benefits and assistance when they need them but allow them to work and have flexibility with their impairments when the are able to work.
The following improvements are being implemented in the VA clinic in Charleston. We have started to make clinical access easier, including same-day access so veterans, identified in primary care or anywhere else in the system, who come in do not need to wait for an appointment. We are also communicating with Department of Defense workers to ease the transition into our clinics as they return from combat.
We also provide clinical services for a wide range of difficulties: anger, family/marital, substance abuse, depression, anxiety, and PTSD. This is a response to the feeling by many veterans that they had to meet the narrow requirements of PTSD to qualify for help.
We de-emphasize diagnostic labels and the medicalization of combat stress. Rather, we focus on readjustment and role functioning. It is critical to emphasize the goals of living a productive life and to downplay the idea of having a disability. Lastly, our therapy is active, time-limited, and outpatient. It is cognitive-behavior therapy, focusing on changing behaviors in tune to specific problems.
AEI research assistant Jonathan Stricks prepared this summary.
