COLORADO SPRINGS — As U.S. troops rotate home from Iraq, the psychosocial problems they bring with them tend to differ depending upon whether they are active duty or National Guard reservists, Thomas L. Jewitt, M.D., said at a symposium on addictive disorders sponsored by Psychotherapy Associates.
Reservists as a group have a lot more problems. They're also much more likely to play them up in hopes of being excused from further military duty, according to Dr. Jewitt, a psychiatrist at the Veterans Affairs Black Hills Health Care System in Fort Meade, S.D.
National Guard members experience more psychosocial difficulties because they and their families are far less prepared for abrupt call-up and deployment than are full-time military families, he said at the meeting, which was cosponsored by the Penrose-St. Francis Healthcare System.
Reservists are subject to a heavier load of low-intensity war-related stressors that begin piling up even before they reach the combat zone. These include family worries, financial difficulties, unfulfilled obligations back home, misunderstandings about the duration of deployment, and uncertainty about their civilian job security. All of this is exacerbated by sudden immersion into the hurry-up-and-wait world of military life, with its attendant boredom and overcrowding punctuated by fear.
These low-intensity stressors have traditionally been discounted by mental health authorities. The traumatic psychiatric impact of high-intensity war-related stressors—facing combat under fire, witnessing mutilated bodies and massive destruction—has been far more extensively studied. Of late, however, there has been growing appreciation that low-level war-related stressors actually make a major contribution to psychopathology in veterans, Dr. Jewitt continued.
Full-time military families are prepared for fathers or mothers to be absent periodically; their lives revolve around deployment.
These families have their share of problems, of course, but they also have a strong social support system, particularly if they live on or near military bases. In the event of family dysfunction, they also have some access to mental health and counseling services.
In contrast, reservist families are scattered throughout the country and typically get no help at all from military-affiliated mental health services, Dr. Jewitt noted.
Because the predeployment strength of National Guard units headed for the Middle East was less than expected, many reservist units were split up and their members were assigned to fill open spots in active-duty units. As a result, they often didn't bond cohesively with their new unit—and that's recognized to be a significant risk factor for combat-related psychosocial problems, Dr. Jewitt said.
Active-duty troops tend to be younger—often just 18 or 19 years old—and better trained than reservists. They also have more unit cohesiveness.
“They're much less likely to pathologize their complaints,” the psychiatrist observed. “Most of the active-duty troops want to stay on active duty. They don't want to go to the health clinic. Most times when you see these folks, at first they're quiet, reserved, polite, cautious. They don't want to be seen as having problems that could cost them promotions or job choices. Reservists may be another matter.”
Indeed, active-duty troops often present to medical or mental health clinics only after being ordered to. They are notorious appointment no-shows. Dr. Jewitt's advice to physicians and therapists seeing such patients for the first time is to ditch the medical and psychotherapy jargon in favor of concrete, readily understandable language. And focus on establishing rapport rather than information-gathering, especially during the first visit. “You're more likely that way to get them back for a second visit,” he said.
The problems that often bring veterans of the Iraq conflict to the attention of health professionals include social withdrawal, intense and difficult-to-treat hostility, substance abuse, guilt and shame, and family dysfunction.
Regardless of whether the returning veteran is with the reserves or the full-time military, however, the preventive mental health lessons learned in the aftermath of the Vietnam War still apply today. The priorities are to prevent family breakdown, social withdrawal and isolation, employment problems, and substance abuse.
Substance abuse is a big problem in combat veterans. When it occurs with comorbid posttraumatic stress disorder, long-term outcomes are considerably less favorable than with either condition alone. Studies have shown that success in reducing PTSD symptoms leads to decreased substance abuse; however, the converse is not true. State-of-the-art therapy involves treating both conditions concurrently, Dr. Jewitt said.