The Veterans Affairs system now cares for patients, male and female, from World War II through the United States’ current involvement in the Middle East and Afghanistan. Many veterans of these wars experience the debilitating condition of Post-Traumatic Stress Disorder (PTSD), an array of symptoms plaguing their physical, mental, and spiritual lives. Previously known as “shell shock” and “combat fatigue”, PTSD is most closely associated with military veterans, but police, firefighters, and virtually anyone who has experienced with violence, catastrophe, and loss may be affected. Victims of Military Sexual Trauma (MST) also experience PTSD related to their sexual trauma.
Combat exacts a strain on the mind and body unequaled in any other occupation. Death and dismemberment are acknowledged consequences, sparking developments in technology that have increased physical survivability where that had been rare. By increasing the survivability, this same technology has also created a classification of veterans who may show no outer damage, but suffer a Traumatic Brain Injury (TBI), the results of the physics of explosions and head wounds. Massive concussive waves have damaged brain tissues and caused extreme pain, and sometimes have altered the survivor’s personality, mental abilities, and coping strategies for everyday life.
The changes in the veteran’s personality or relationship to the world around him/her also have a profound impact on their family and friends. Corrosive effects resulting from the unending strain of caring for and loving a person who’s suffered such a change in circumstance is only now better understood. The returning veteran with TBI is often not the same person who left for war. Daily life filled with vim and vigor becomes a memory. In its place are mental confusion, anger issues, and possibly frequent or daily headaches; combined with a reluctance to participate in activities, and avoidance of even small crowds. To date, there have been over 360,000 diagnosed cases of TBI in the veteran community (3), leaving an unknown number of undiagnosed survivors.
About one in four women and about one in one hundred men and one in four women seen for VA healthcare report a history for MST when screened by a VA provider. MST encompasses both actual sexual assault or repeated, threatening sexual harassment that occurred while the veteran was in the military. It includes any sexual activity in which one is involved against one’s will – he or she may have been pressured into sexual activities (for example, with threats of negative consequences for refusing to be sexually cooperative or with implied faster promotions or better treatment in exchange for sex), may have been unable to consent to sexual activities (for example, when intoxicated), or may have been physically forced into sexual activities. Other experiences that fall into the category of MST include unwanted sexual touching or grabbing; threatening, offensive remarks about a person’s body or sexual activities; and/or threatening or unwelcome sexual advances. (10) It’s important to know that MST can occur on or off base, during war or peacetime, and while a Service member is on or off duty. Perpetrators can be men or women, military personnel or civilians, superiors or subordinates in the chain of command. They may have been a stranger to the active duty soldier, or even a friend or intimate partner. Veterans from all eras of service have reported experiencing MST. (11)
The specter of PTSD hovers over all of this, often the unseen, nonorganic injury that offers many of the same changes in the personality of the surviving veteran. Irritability, noise aversion, reacting with violent outbursts, horrible nightmares and, as with TBI, the returning veteran often exhibits different behaviors than before. Recent emerging news of mishandling over 90,000 veterans with PTSD while they were on active duty reveals that they received a less than honorable discharge which prevents receiving full benefits through the Veterans Administration Medical Centers regardless of mitigating factors (1) (2). Insult is added to shame for an already damaged human being, meaning they experience a much tougher life and more difficulty adjusting after service. Having that sort of discharge also strongly affects their chances of further education and employment. “The wounded, the crippled, and the dead are, in this great charade, swiftly carted offstage. They are war’s refuse. We do not see them. We do not hear them. They are doomed, like wandering spirits, to float around the edges of our consciousness, ignored, even reviled. The message they tell is too painful for us to hear. We prefer to celebrate ourselves and our nation by imbibing the myths of glory, honor, patriotism, and heroism, words that in combat become empty and meaningless.” (5)
Medical science, both inside the Veterans Administration research efforts and contributions from non-VA research, works to understand the changes that these veterans have gone through, searching for a coping strategy if not a cure. As with any long-term disease, the patient and family endure and wait for good news. The suicide rate among our veterans is much greater than that of the national non-veteran rate, partially attributed to the effects of PTSD/TBI. The number one reason cited in veteran suicides is to end the emotional suffering and pain. (4)
The VA has placed appropriate early detection methods within the triage process. Each patient is asked if they are considering harming themselves or others. Many times, the veteran recognizes the symptoms and volunteers that he/she is seeking help even before being asked. These efforts are not always successful, because they depend on the veteran self-reporting, or the family convincing the veteran to seek help and care. Failure to prevent a suicide has its own repercussions for family, friends, and care workers whose lives were touched by the departed veteran.
For nurses confronted with more outward symptoms of PTSD, it can be difficult to distinguish between acting out and personality disorders. The nurse should assist the veteran to feel as welcome as possible by speaking in a respectful tone of voice and attempting to address their needs for feeling more comfortable. Standing too close, or standing over them while they are sitting can seem threatening. Collecting vital signs or laboratory samples should always be explained calmly. Initial reluctance to submit to any testing is not abnormal. The nurse should recognize that the patient already feels threatened, and invasion of their personal space more alarming. If placing them in a room, ask if the door or curtain may be closed to give them more privacy. Some are very wary of a closed room and want the door open and uncovered. The nurse should always employ motivational interviewing techniques such as asking open-ended questions which allows the veteran to feel less like the questions are not an interrogation and giving her/him space to answer; nods and affirmations let the patient know that you are listening to what he/she is saying; doing a recap of what has been said along with explaining that this is to ensure a clear understanding. Patients respond well to the focused attention of active listening. For some of them, this may be the first time they have felt acknowledged as a person. This is a great opportunity to ask if they are getting help for their PTSD. These questions are more focused, less open-ended than before. If the patient has begun to trust the nurse, these extra questions may offer a way to guide them to further assistance: Are they followed by a mental health professional? Are they involved in a support group of peers? Are they aware of twenty-four-hour hotlines they can use to talk with a professional to help them anytime they need someone to hear them? (12)
Patients treated for PTSD often have a coping strategy that allows them to manage many of their symptoms as they heal their inner wounds. One self-help app offered by the VA, Mindfulness Coach, which is available for iPhones, offers nine guided exercises and information on mindfulness; it is intended to be used in conjunction with professional help (6). Another app is PTSD Coach available for both Android and Apple iPhone (7), which also includes guided exercises to recognize and manage stress. Nurses who are expected to treat the veteran who presents with PTSD can access an app PTSD Toolkit for Nurses, available for iPhones and Android phones. This app can help guide the nurse in assessment by re-enforcing the techniques mentioned above from the website. (8)
Those veterans not enrolled in a treatment plan often are not aware of those options or have a mistrusting attitude towards mental health providers and/or the system. The backlog of all claims continues to be a problem in spite of efforts on the part of Congress and the VA to come up with a remedy. (9) Meanwhile, these wounded vets continue to deal with their altered realities, doing so mostly in silence.
On Veteran’s Day, November 11th, we continue to honor our fallen and our living veterans, but we need to make a special effort to recognize those who also gave all; a different sacrifice that those Wounded Warriors live with daily.
- McCarthy, Peggy, Conn. Health I-Team Writer http://www.ctpost.com/
local/article/Fairfield-veteran-sues-to-upgrade-thousands-of-11078002.php
- Meshad, Shad What Happens When a Veteran’s Discharge is Less than Honorable?
January 25, 2017 https://nvf.org/less-than-honorable-discharge
- Defense and Veterans Brain Injury Center http://dvbic.dcoe.mil/dod-worldwide-numbers-tbi
- Military Suicide Research Consortium http://www.msrc.fsu.edu
- Hedges, Chris The Death of the Liberal Class New York: Nation Books, c2010. 55
- Mindfulness Coach https://mobile.va.gov/app/mindfulness-coach
- PTSD Toolkit for Nurses https://itunes.apple.com/us/app/ptsd-toolkit-for-nurses/id1051925634?mt=8 and https://play.google.com/store/apps/details?id=com.wolterskluwer.ptsd&hl=en
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