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In our effort to assist community providers with the training they need to assist Service Members, Veterans and their families, we are always looking for alternate opportunities to share beyond our quarterly trainings for continued education and assistance.  Following are samples of what we are constantly researching and passing on.


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Strict Adherence to Traditional Masculinity Associated With More Severe PTSD in Vets
Emotional suppression, self-reliance, may also hinder access to and effectiveness of treatment, study says

WASHINGTON — To help service members perform better in the field, military training emphasizes the importance of certain traits associated with traditional masculinity, including suppression of emotion and self-reliance. But when veterans return home, strict adherence to these traits can become detrimental, leading to more severe post-traumatic stress disorder symptoms and making it more difficult to treat, according to research published by the American Psychological Association.

“These findings suggest that veterans with rigid adherence to traditional masculinity may be at increased risk for developing PTSD, may have more severe PTSD symptoms and may be less likely to seek mental health treatment for PTSD,” said Elizabeth Neilson, PhD, of Morehead University and the lead author on the study.

The research was published in the journal Psychology of Men and Masculinities.

Neilson and her co-authors analyzed data from 17 studies, comprising more than 3,500 military veterans, conducted in the last 25 years that involved, at least in part, measuring the relationship between adherence to traditional masculine ideals and trauma-related symptoms. The studies primarily focused on men, but one included both male and female participants. While most studies were conducted in the United States, the researchers also included studies from Canada, the United Kingdom, Israel and Vietnam.

“Overall, we found that strict adherence to masculine norms was associated with more severe PTSD symptoms in veterans, but more detailed analysis suggests that the association may specifically be caused by the veterans’ belief that they should control and restrict their emotions. In other words, they should be tough,” Neilson said. This held true for both male and female veterans.

While all members of society are exposed to aspects of traditional masculinity, members of the military receive messages that normalize, reinforce and instill values of masculinity as part of their training, according to Neilson.

“Previous research has found that military personnel report high levels of conformity to traditional masculine norms, such as emotional control, self-reliance and the importance of one’s job,” she said. “These values can promote self-confidence and skill-building in the field, but when a service member is confronted with physical or mental trauma, they can also contribute to more severe PTSD.”

Traumatic experiences, including combat and sexual trauma, can lead to feelings of powerlessness and hopelessness, both of which are in direct opposition to what society expects of men: That they should be strong and in control. The discrepancy between reality and societal expectations can exacerbate PTSD symptoms. Research estimates as many as 23% of veterans returning from Iraq and Afghanistan experience PTSD .

Adherence to masculine norms can also create barriers to getting necessary treatment, according to Neilson. Previous research on veterans returning from the wars in Iraq and Afghanistan found pride in self-reliance and a belief that one should be able to handle mental health problems on one’s own kept service members from seeking help when they needed it.

And even if veterans did seek treatment, the emphasis on stoicism and mental fortitude within both military culture and traditional masculinity could make treatment more difficult, she said. The two most widely used, evidence-based therapies for PTSD require explicit discussions of emotions, thoughts and behaviors related to traumatic experiences. PTSD is perpetuated by avoiding stimuli associated with a traumatic experience, including emotions. Successful PTSD treatment involves breaking that cycle of avoidance and confronting those stimuli, she said.

“Both military culture and traditional masculine ideals lead to the avoidance of disclosure and speaking about traumatic experiences, which may interfere with appropriate treatment,” Neilson said.

Another trend the researchers found was that veterans often try to reaffirm their masculinity following trauma, engaging in exaggerated stereotypical male behavior, such as aggression and increased sexual behavior, to compensate for the injury the trauma had on their identity, according to Neilson.

“In one study we reviewed, veterans reported engaging in frequent sex to avoid negative thoughts, because feeling sexually desirable temporarily suspended those negative thoughts about their self-worth,” she said.

APA published voluntary guidelines (PDF, 444KB) in 2018 recommending that therapists consider discussing masculine ideology and the effects of cultural expectations of men and boys when treating male veteran clients. Neilson hopes that future research will examine how clinicians already are addressing conformity to masculinity ideology in their treatment of PTSD.

“It would not surprise me if some clinicians are already considering how a veteran’s masculinity ideology contributes to their PTSD symptomology and treatment engagement,” she said. “Consistent with APA’s recommendations, I suggest that clinicians discuss beliefs and adherence to traditional masculinity ideologies with the patients. This information is important for conceptualizing patients’ mental health and identifying specific behaviors to target in treatment.”


A Better Way to Help Veterans 

Daniel M. Gade 

In the years since the United States was drawn into a global war on terrorism by the attacks of September 11, 2001, Americans have made significant commitments to support the men and women who have served on the front lines of the conflict. Tens of thousands of charities have contributed billions of dollars — and millions of volunteers have spent countless hours — assisting veterans and their families. The federal government has made an even larger investment, providing a host of services — including health care, education and job-training programs, and home loans — to those returning from war. Of the 2.4 million troops who have deployed to Iraq and Afghanistan, an estimated 1.9 million are now eligible for benefits from the Department of Veterans Affairs, including health care and disability compensation, on which the agency spends billions of dollars every year.

Few Americans question the propriety of these efforts to aid our nation's men and women in uniform. The desire to help veterans in need reflects a fitting gratitude for service rendered and sacrifices shouldered. But precisely because we know we owe our veterans a great debt, we tend not to question the particular ways in which our government goes about helping them. We therefore pay far too little attention to whether these efforts might actually be doing more harm than good. And there is reason to believe that, in many cases, well-intentioned programs to support veterans are instead preventing them from enjoying healthy, productive civilian lives after they return from war.

This is particularly true of federal policies intended to help wounded and disabled veterans. A shocking 45% of veterans from the wars in Iraq and Afghanistan are currently seeking compensation for service-connected disabilities — more than twice the application rate of troops who served in the Gulf War. There are many reasons for this increase, but a major factor is surely the design of VA benefit policies, which distort incentives and encourage veterans to live off of government support instead of working to their full capability. Adding to the problem is a culture of low expectations, fostered by the misguided understanding of "disability" upon which both federal policy and private philanthropy are often based. The result is that, for many veterans, a state of dependency that should be temporary instead becomes permanent.

America's veterans — particularly those with disabilities related to their service — deserve better. Because of the debt the nation owes these men and women, and because of the talent and experience they can contribute to our economy and society, both lawmakers and citizens should ensure that our efforts to support veterans do not undermine their recovery. By looking at the experiences of today's veterans, and by examining the perverse incentives created by current policies and charitable practices, we can develop a support system more helpful to, and more worthy of, America's defenders.


To better understand the choices facing today's veterans, it makes sense to look at just who these men and women are and what distinguishes them from their predecessors. In the particular case of wounded veterans, it is worth examining what types of injuries and conditions they are dealing with — and how prevalent those conditions truly are — to gain a more complete understanding of the problem of "disability" that government policies and private charity must address.

First, the modern military is composed entirely of volunteers, and, as a self-selected group, they are not a representative cross-section of society. As a statistical matter, they are more educated than the typical American: With very few exceptions, they are high-school graduates or have GEDs. Many even in the enlisted ranks have some college education. More than 80% of officers have bachelor's degrees, and many have graduate degrees. Moreover, because the military's current medical and physical-fitness standards are relatively rigorous, veterans of Iraq and Afghanistan are both physically and mentally healthier than the population at large. (For reference, consider that only 25% of the civilian population of suitable age can clear the mental and physical thresholds, as well as meet the requirement to be free of any serious criminal record, demanded for service in the armed forces.) It is also worth noting that the conflicts in Iraq and Afghanistan have involved record levels of Reserve and National Guard forces, who are typically somewhat older and even more educated than the active force. These men and women are also more fully integrated into civilian life.

Second, the combat experience of today's veterans is markedly different from that of veterans of most previous wars. With a few exceptions — the initial invasion of Iraq, the first and second battles of Fallujah, Baghdad during the "surge," isolated pockets of the fighting in Afghanistan, and a few other episodes — today's veterans have faced conflicts characterized by chronic, low-to-moderate levels of violence rather than by dramatic, high-intensity battles. At the same time, they have operated chiefly in theaters with no front lines and where civilians have been mixed in with combatants. This means today's veterans have often been more exposed to civilian suffering and less sure of their adversaries, which has produced distinctive psychological effects.

Third, the social environment that has awaited veterans after their service is different today than it was for some previous generations of veterans. By and large, the civilian population is now accepting of veterans and thankful for their service. This "Sea of Goodwill," as former chairman of the Joint Chiefs of Staff Michael Mullen labeled it, encompasses employers, community leaders, government officials at all levels, academics, health-care professionals, and other grateful citizens. In contrast with the experience of Vietnam veterans, today's returning soldiers and recently discharged veterans have received a warm welcome home.

Fourth, although the number of veterans to be re-integrated is high, it is still dramatically lower than in previous wars. As of last year, fewer than 2.5 million troops had served in Iraq or Afghanistan since 9 / 11. This figure is significantly smaller (especially as a percentage of the population) than the 3.4 million who served in the Vietnam theater, and is only a fraction of the 16 million Americans who served in the military during World War II.

Finally, returning troops also tend to be better off financially than their civilian peers. Both the earnings and overall incomes of veterans are higher than those of non-veterans. Among men in 2009, for instance, year-round workers averaged $51,230 in earnings if they were veterans and $45,811 if they were non-veterans. Among women, the advantage for veterans was even greater. When the measure is income — not only earnings, but also pensions and entitlements — veterans fare comparatively better still.

Thus, contrary to some conventional wisdom, most veterans are not "victims" or members of a problem class. Given their educational and health advantages, those returning from the wars in Iraq and Afghanistan are likely to be a particularly valuable asset to America's economy and society in the years ahead. It is therefore important, from a purely economic point of view, to ensure that as many of them as possible are working to their full capacity. This means targeting assistance to those veterans who are genuinely struggling with the transition back to civilian life, while avoiding giving more capable veterans reason to work below their potential (or to not work at all). And from a moral point of view, the argument for veterans' full re-integration through employment is even stronger.

Yet evidence suggests that our aid to veterans is overly broad, creating exactly the perverse incentives that encourage returning soldiers who are capable of work to instead have themselves classified as "disabled." As noted above, 45% of Iraq and Afghanistan veterans are currently seeking compensation for service-connected disabilities, and about one-third of all new veterans are being granted some level of disability benefits. The number of disabling medical conditions claimed by the average applicant has soared — from one or two among World War II and Korean War veterans, to around three or four among Vietnam veterans, to more than eight medical conditions per claimant among veterans who served in Afghanistan and Iraq.

One reason for this dramatic increase is a happy one: Thanks to improved trauma care, some servicemembers are collecting disability benefits for injuries that in past wars would have killed them. It should be noted, however, that this is a minor factor: Of the more than 2.4 million servicemembers who have served in Iraq and Afghanistan, fewer than 15,000 were wounded in action seriously enough to merit evacuation from the theater.

A bigger reason for the increase is surely VA classification procedures. The definition of "disability" in the VA system is such that most of these veterans are not in fact "disabled" in the way that most Americans understand the term. It would be far more accurate to describe these veterans as simply "having a service-connected condition."

What kinds of service-connected conditions are qualifying veterans as "disabled"? The most common condition for which veterans receive disability ratings is tinnitus, or ringing in the ears; the second most prevalent is partial hearing loss; other common conditions include afflictions like arthritis and lower-back strain. It is worth noting that, while all of these conditions can be associated with the rigors of military service, most are also caused by the normal progression of time and age. In any event, they are hardly the catastrophic injuries that capture the public's attention.

One service-related condition that captures an enormous amount of public attention is post-traumatic stress disorder. PTSD encompasses a very wide range of complaints, including intrusive memories of the traumatic event (flashbacks and dreams), avoidance and emotional numbing, and anxiety and depression. Typically, in order to receive compensation for PTSD, a veteran must experience some level of social or occupational impairment (the most serious disability rating, of 100%, is reserved for total occupational and social impairment, persistent delusions, and symptoms of comparable severity).

Assessing the true prevalence of PTSD can be difficult, and the task has been made even more complicated by two changes implemented in 2010 to VA policies regarding diagnosis and treatment. First, the VA no longer requires proof that the veteran actually experienced a specific traumatic incident (because PTSD can arise from an accumulation of stress, particularly the persistent fear of enemy or terrorist activity that characterizes service in a combat zone). Second, rather than simply observing PTSD in patients who come to clinics seeking treatment, the VA now actively pursues patients who might have the condition, using public-awareness campaigns such as "PTSD Awareness Month" (June). One result of this change is that more veterans with legitimate diagnoses of PTSD are receiving the treatment they need; another is that the claims for PTSD-related benefits, and the figures for veteran disability, have skyrocketed. Among Iraq and Afghanistan veterans, the Department of Veterans Affairs reported 261,998 cases of diagnosed PTSD as of the first quarter of 2013 — a prevalence much greater than that among previous generations of combat veterans.

The Department of Veterans Affairs is also making it easier to qualify for benefits on the basis of traumatic brain injury, or TBI. In December 2012, the agency unveiled new regulations that will allow thousands of veterans to receive benefits for five diseases not previously covered by the VA, basing the expansion on a 2008 Institute of Medicine study that found "limited or suggestive" evidence that these diseases may sometimes be linked to TBI. Incidentally, only a small fraction of the 250,000 cases of TBI diagnosed among servicemembers since 2000 are combat related: The vast majority stem from vehicle crashes, training accidents, or sports injuries.

Thankfully, relatively few of the conditions for which veterans seek compensation are caused by catastrophic injuries. Among post-9 / 11 veterans, fewer than 2,000 have undergone major amputations. Serious burns, spinal-cord injuries, and cases of complete blindness number in the hundreds.

Given the variety of service-connected conditions, there is a wide range in the extent to which veterans claiming benefits are considered "disabled." The process of applying for disability is relatively straightforward: The veteran assembles, with the help of either the VA or a veterans' service organization, a packet of medical and service records and a disability application. The claim is adjudicated by the claims staff at a VA processing center, and benefits are awarded, typically within nine months or so. Disabilities in the VA system are rated in increments of 10%, from 0% to 100%. Of the nearly half-million post-9 / 11 veterans receiving disability compensation in 2011, 28% had between 0% and 20% disability, 26% had between 30% and 40% disability, 21% had between 50% and 60% disability, 17% had between 70% and 80% disability, and 8% had more than 80% disability (including 4% who were compensated for being 100% disabled).

It is thus crucial to recognize that many veterans classified as "disabled" are in fact largely capable of enjoying active lives and performing some remunerative work. While those veterans whose injuries permanently preclude a return to the labor force deserve whatever support they require, it is just as important to ensure that veterans who can provide for themselves are not robbed of their independence by policies that incentivize unemployment. Unfortunately, however, the way our system currently provides benefits is rooted in a flawed understanding of disability — one that keeps veterans unfairly trapped in a state of needless victimhood.


Broadly speaking, a returning soldier or recent veteran benefits from assistance in three major areas: medical care, education and job training, and employment. Which services a returning soldier or veteran uses depends largely on his circumstances — whether he is redeploying with his unit, being re-integrated into civilian life, or undergoing rehabilitation for significant trauma.

For those soldiers who are returning with injuries, a rich network of service providers exists to help with recovery and transition back to civilian life — a network made up of federal programs, assistance from state and local governments, non-profit groups, church congregants, neighbors, friends, and family. Ideally, this network would treat acute and chronic medical needs, then provide rehabilitation services, and finally help veterans gain and maintain useful employment.

But many veterans never make it to the last step, in part because of the dangers lurking in the good intentions of their support networks. This is particularly true of federal programs to aid veterans, as these government benefits and support services play a dominant role in returning troops' rehabilitation. It is therefore worth examining the understanding of "disability" that drives federal policies governing benefits for wounded soldiers in order to see how those policies end up undermining the recovery process for many veterans.

There are at least two major models of disability, the first of which is the so-called "medical model." The medical model attempts to classify an impairment as a disease and to control its effects as one would treat an illness, taking a thoroughly clinical approach. The medical model of disability says that an amputee is automatically "disabled" by virtue of his limb loss — even if he is capable of leading a largely independent, normal life — and is devoted strictly to restoring, to the extent possible, the lost functionality of the limb. Support under this model focuses almost exclusively on the patient's infirmity, and in some ways defines the patient by his impairment; the disabled person is viewed as a victim, and the purpose of the disability system is seen as providing benefits, rather than encouraging a return to functionality.

A more modern approach is the broader "social model" of disability, which assumes that a physical ailment is only one component of determining whether a person is truly "disabled." The social model adds environmental and personal factors to the physical diagnosis. It takes account of the fact that a wheelchair user, for example, is much more "disabled" in an environment in which his movement is constrained by obstacles — curbs, stairs, and so forth — than he is in an environment in which he can easily get around using lifts, elevators, and ramps. Moreover, personal factors at the individual and family levels strongly affect the degree of disablement that a person will experience at the completion of his medical treatment. Many families are able to find a "new normal" after a family member becomes disabled; some are not. Some individuals are resilient in the face of daunting challenges; some crumble. The social model acknowledges these differences.

As a society, the United States has begun to move beyond the medical model of disability, preferring the social model instead. The passage of the Americans with Disabilities Act in 1990 eliminated many physical barriers to wheelchair mobility and required reasonable accommodation of disabilities in the workplace. And attitudes are changing: Because of the revolutionary effects of new prosthetic, computer, and drug technologies, we've become accustomed to seeing amputees pass us on the ski slopes. Children with disabilities are often put into "mainstream" classrooms. Adults with disabilities flourish in many kinds of jobs. Even people with serious intellectual disabilities and developmental delays can be fully employed in creative ways, and they gain both financial and social benefits from their work. Our views of what is possible for the "disabled" have been altered dramatically over the past generation.

Some government programs acknowledge the social model of disability. For example, most state-level employment programs for persons with disabilities require some version of an Individualized Education Plan as part of the re-employment process. These plans take into account the particular strengths and weaknesses of the job candidate before placing him into a tailored program of rehabilitation, education, or training in independent living.

Unfortunately, several major federal-government programs rely on the medical model rather than on the social model. The Department of Veterans Affairs disability-compensation program is one. The VA's statutory requirement (found in Title 38 of the U.S. Code) is to compensate for disabilities based on "average loss of earnings" that would be expected for a worker with a particular diagnosis. The VA's compensatory scheme thus relies on two abstractions: a diagnosis, and an estimate of the average loss of earnings of a person with that diagnosis, based on data from people in the system who have had the same diagnosis. This assessment does not take account of circumstances unique to the veteran in question — personal qualities, family support, educational potential, or other factors affecting the degree to which his injury will result in real disablement.

This means, in essence, that the VA doesn't base its compensation on "disability" — how incapacitated a veteran really is — at all. Rather, VA disability benefits are based purely on a diagnosis, regardless of what that diagnosis actually means for a particular veteran's ability to resume a normal life. By this definition, many of the athletes we see sprinting and swimming at the Paralympics — and the wounded veterans now working profitably in Wall Street banks — are "totally disabled." Indeed, some wounded troops who remain on active duty and return to the roles they had before sustaining their injuries will be labeled "totally disabled" once they leave the service.

Such a model of disability classification can have a harmful effect on veterans seeking benefits. The process of applying and proving that one is "disabled" can negatively influence the way the veteran, his family, and his community view his own capabilities. Applicants for benefits can start to rely routinely on others; personal aspiration can diminish; passivity can become normal. Having been defined by his impairment, he may no longer believe that he is responsible for his own outcomes in life. Similarly, the community may — consciously or not — begin to view the disabled person as an object of pity rather than as a citizen in full standing. Government benefits and charitable giving — to the extent that they supplant income from work — can deny the veteran the pride of self-provision and exacerbate the sense that the veteran's life is beyond his own control.

In designing government policies and private philanthropic initiatives to help veterans, then, it is crucial to keep in mind an important distinction: the difference between capacity and performance. Capacity is the best an individual can be expected to do in a particular aspect of his life. Performance is what that individual actually does. The goal of any policy intended to help ill or injured veterans should be to narrow the capacity-performance gap.

The Department of Defense offers a useful example of how this goal should be pursued. The Pentagon has its own separate disability-rating system, one based more on the "social model" of disability. The department rates disability based on whether the person in question can still perform his assigned military duties or can be re-assigned to a role better suited to his remaining capacity. By eliminating barriers and restructuring work requirements, the Department of Defense is bringing disabled servicemembers' performance more in line with their capacity. Under this model, dozens of amputees have returned to service after rehabilitation, and at least one completely blind soldier continued his Army career after losing his sight in 2005.

Unfortunately, the VA does a poor job of assessing the capacity of wounded soldiers and maximizing their performance. Private charity, too, is often more focused on what an injured soldier is not able to do than on increasing what he is able to do. These practices can seriously hinder a disabled veteran's re-entry into society — undermining the very purpose of philanthropic and government aid to injured troops.


To see how this flawed understanding of disability — and the policies that flow from it — can sabotage veterans' long-term success, it is useful to consider the experiences of three different hypothetical soldiers returning from war.

Soldier A was a sergeant in the infantry serving proudly in Afghanistan when he was hit by an improvised explosive device. He suffered penetrating trauma to his head, leaving him severely disabled. He has crippling headaches, poor mobility, and poor cognition. He depends on others to carry out daily activities like cooking, transportation, and many elements of self-care. He needs all the government and charitable assistance he can get to support extensive ongoing treatment, and indisputably requires life-long disability payments.

Soldier B is a member of the U.S. Army Special Forces. When he was hurt by small-arms fire in Iraq in 2006, his injuries were serious, and his leg was amputated below the knee. But Soldier B has many advantages. He is happily married with children; he had completed a bachelor's degree before entering the military; and he has an ambitious, resilient personality. Soldier B is thus able to put his injury behind him and remain on active duty; he even returns to combat. While this soldier will need some assistance from his friends, family, and community, he should not be perceived or treated as "disabled."

Soldier C is a college drop-out from a small town. He still has nightmares from his first tour of duty, reliving the danger of fighting the insurgency in Iraq. Four months into his second tour, in Afghanistan, an improvised explosive device killed two other soldiers and seriously injured him. He woke up at Walter Reed after two weeks of unconsciousness to find that he had suffered a mild traumatic brain injury, the amputation of his lower right leg, and minor shrapnel wounds to his arms, face, and remaining leg.

This soldier benefits from superb medical treatment and the care of his girlfriend and mother, who help nurse him back to health. He initially suffers from headaches because of the brain injury, and the shrapnel wounds take some time to heal, but after six months he can run again on his new prosthetic leg. A year after his injury, Soldier C starts his medical-board process so that he can separate from military service. Eight months later, he is a civilian. He goes to an advocacy group for disabled veterans to seek help filing his disability claim; they push him to apply for disability not only for the amputation of his lower leg but also for the shrapnel wounds, for the mild TBI, and for his nightmares, which they say is PTSD. Fortunately, the soldier's claim is handled quickly, and the government gives him a disability rating of 40% for the leg, an additional 10% for the shrapnel scarring, and 30% for the PTSD.

Soldier C has the opportunity to pursue vocational rehabilitation or to go back to college on the greatly expanded G.I. Bill and complete his degree. But his counselor from the Department of Veterans Affairs tells him that he qualifies for something called "Individual Unemployability" (IU). Through this program, a soldier whose impairments don't add up to 100% disability can receive compensation at the 100% rate, as long as he doesn't work. This soldier feels like he could work, but the difference between VA compensation at the 80% rate and at the 100% rate is significant — well over $1,000 a month. By taking IU payments, he also avoids having to make the adjustments to his life that going to work every day would entail. So he applies for, and receives, the IU benefits.

While there are some stories of wounded troops like A and B — extreme cases of need or independence — their outcomes are, by and large, exceptions. Public policy and private charity should instead be built around the far more common case: that of Soldier C, who faces real decisions and tradeoffs, which are influenced by the design of both public and private benefits.

And what incentives do today's policies provide someone like Soldier C? Consider what he gains by being dubbed "disabled." Because of his injury, this soldier receives $50,000 from the Servicemembers' Group Life Insurance Traumatic Injury Protection Program, which is intended to serve as a bridge to rehabilitation. During his recovery, this veteran enjoys free lodging; he can eat for free at the hospital or any other Army dining facility. He receives his full military salary and other benefits.

Upon leaving the Army, this soldier will receive a portion of his military retirement pay and all of his disability benefits from the Department of Veterans Affairs. Because he chose to apply for IU, he will receive compensation from the VA at the 100% disability rate — around $2,800 per month. Depending on where and when he applies, he may also qualify for Social Security Disability Insurance (SSDI) — which, for someone in his situation, is worth around $800 a month. All told, his benefits package from the government may easily exceed $4,000 per month, most of it tax free. Given that the national median monthly earnings figure for 20- to 24-year-old males who work full time is $1,976 (before taxes), Soldier C has a good reason to accept the "disability" label. Because he loses his IU benefit and his SSDI if he begins to earn above a minimal amount, he faces a stiff financial penalty for taking a job. And since he lacks a college degree, it will be very difficult for him to replace that lost income — let alone exceed it — through wages for full-time work.

Once a veteran like Soldier C chooses disability over work, he faces further harmful consequences. From a psychological standpoint, this soldier should be confident: Despite having lost a leg, he walks with only a slight limp; he has only occasional headaches or sleepless nights because of the TBI and the PTSD. But he has just spent more than two years proving to the federal government that he is "disabled," and two different federal programs have classified him as "disabled." It is easy to see how a veteran who might otherwise have a relatively bright outlook on his future could come to see himself as "disabled" as well. Moreover, a person's work is a key part of how he relates to society and is crucial to his identity. When a veteran like Soldier C chooses not to work, he is isolated at home, meets fewer people, and has a much smaller social network than does someone who goes to work every day. He is likely to be involved in fewer social activities and thus more likely to become depressed and experience other social dysfunction. More fundamentally, he lacks the meaning and sense of purpose that come from work.

Regrettably, there has not been a concerted, empirical study of the precise effects that the incentives created by these VA benefits and policies have had on this generation of veterans' work choices and rehabilitation. Most of the indicators we have are anecdotal, or inferred from other data. The fact that the VA has not undertaken a rigorous evaluation of the degree to which its policies discourage returning soldiers from working to their full capacity is itself revealing. Given what is at stake, it is a subject that cries out for further study.

In the meantime, however, there is other evidence to support the argument that someone like Soldier C is undermined by the way our government treats disabled veterans. In particular, other federal disability programs offer valuable lessons in how such efforts can be counterproductive. For example, in their recent book, The Declining Work and Welfare of People with Disabilities, economists Richard Burkhauser and Mary Daly study two massive federal programs, Social Security Disability Insurance and Supplemental Security Income (SSI). The authors find that, despite the many new legal protections and forms of assistance for the disabled that have arisen over the past generation, employment rates among disabled Americans are at an all-time low, and household incomes have been stagnant. The design of these disability programs, Burkhauser and Daly find, makes work both "less attractive and less profitable" than passively receiving benefits. The positive effects of the Americans with Disabilities Act and other efforts to mainstream people with disabilities have thus been considerably undermined by carelessly designed entitlements.

This trend is visible in the dramatic growth of disability programs of all types over the past several decades. Through our Social Security system alone, cash payments to individuals classified as "disabled" totaled $135 billion in the latest fiscal year. After reviewing the 19-fold increase in federal disability claimants since 1960, Washington Post columnist George Will warned that "gaming...of disability entitlements" has made work "neither a duty nor a necessity" — which is one major reason why the male labor-force participation rate has plummeted from 89% in 1948 to 73% today. As the American Enterprise Institute's Nicholas Eberstadt has noted, there are now more Americans of working age receiving government disability checks (more than 12 million) than there are paid workers in our entire manufacturing sector.

Disability programs for returning soldiers are no exception to this problem. Indeed, some of the best evidence to suggest that our assistance to disabled soldiers may hinder their re-entry into the labor force comes from a study of a past generation of veterans: those who served in Vietnam. In a 2007 paper, economists David Autor and Mark Duggan looked at the question of why, precisely, disability-compensation programs discourage work. Part of the reason why programs like SSDI and SSI suppress employment among recipients is a "substitution effect": As the authors explain, "because a return to work ultimately means sacrificing benefits," recipients of these disability benefits "face a financial incentive to remain non-employed." This amounts to an "implicit tax" on work. But the authors were particularly interested in the question of "income effects" — of the choices the disabled make when working carries no financial penalty in terms of reduced benefits, and when the tradeoff is between simply having more money from work and having more leisure time.

To study these effects, Autor and Duggan looked at a 2001 change in eligibility policies for veterans' disability compensation. Because an Institute of Medicine study linked exposure to Agent Orange to diabetes, the authors explained, the VA added diabetes to the list of conditions for which a Vietnam veteran would be eligible to receive disability benefits. A large number of veterans nearing retirement age suddenly had access to greater cash benefits and improved medical care. Crucially, however, they did not need to be unemployed to receive these benefits. Nor were the benefits means-tested. This disability compensation thus imposed no "implicit tax" on work. To the extent the Vietnam veterans with diabetes reduced their work in response to the new eligibility policy, the authors explained, it would be "plausibly attributable to the pure ‘income effect' of receiving an unconditional, lifetime grant of monthly income and healthcare." Such a policy change, Autor and Duggan observed, provided "an opportunity to study the income effect of receipt of disability benefits on the labor supply and retirement decisions of a relevant population of near-elderly individuals, the majority of whom were work-capable at the time of benefit receipt though not necessarily in good health."

And what did the study reveal? While the authors noted that their conclusions were preliminary, they found that the increase in unearned income resulting from the VA's 2001 policy change "substantially lowered labor supply among Vietnam era veterans." The mere availability of extra income as a result of being disabled — even when unemployment was not a condition of receiving those benefits — was enough to encourage work-capable veterans to claim disability and drop out of the labor force.

If such behavior exists among Vietnam veterans, with their long history of attachment to the labor force, it stands to reason that it is affecting the decisions of post-9 / 11 veterans, too, especially those whose only job has been their military service. To a large degree, this is common sense: Compensating individuals for their disabilities will result in more people lining up to be declared disabled, just as unemployment programs invariably increase the time that people receiving unemployment benefits remain jobless.

To be sure, this danger is not limited to government entitlements. Some charitable programs designed to honor veterans can also have negative effects. One troubling trend in charitable giving has been the growth of programs offering large gifts to veterans based on service-connected disabilities. Several programs, for example, offer free homes to veterans who have been identified as "disabled" by the government — providing extra reason for veterans to seek a disability classification, even if they might be better off thinking of themselves as able-bodied and working a full- or part-time job. Though such charitable programs have heart-warming stories to tell, they may ultimately decrease a veteran's desire to participate in the labor force and fully re-integrate into civilian society. It isn't particularly difficult to balance out the harmful incentives in such gifts — through sweat-equity requirements like those used by Habitat for Humanity, or through financial co-pays or concrete expectations that the veteran will be employed after he and his family move into their donated home. Unfortunately, however, these important details are overlooked in the design of most charitable programs.

Ultimately, volunteers, donors, policymakers, and taxpayers don't like to think that programs designed to aid veterans can instead harm them if incentives are misaligned. But a great deal of evidence indicates that poorly designed government compensation programs and charitable services are creating major hurdles for recovering veterans.


Obviously not every veteran responds to these incentives in the same way. Some people will take their disability payments and job-retraining opportunities and make dramatic successes of themselves. Congresswoman Tammy Duckworth, Wounded Warrior Project board president Dawn Halfaker, Senator John McCain, and many other former soldiers have done just that. It is important to realize, though, that the men and women who are able to resist the siren song of gifts, charity, and disability payments are the exceptions. The system should be designed around the vast majority likely to make the very understandable choice to forgo a fully independent lifestyle in exchange for the generous benefits that come with being "disabled."

It is also important to note that neither today's federal programs for veterans nor their charitable counterparts are intended to harm veterans. The negative effects of these programs are certainly unintended consequences. The question, then, is how best to mitigate these effects. Policymakers and donors would be wise to keep a few helpful principles in mind when designing benefits and services.

First, they should always take incentives into account — even negative ones. Veterans are simply people, and they respond as rationally as anyone else to the incentives they are offered. The old lesson about giving a man a fish versus teaching him to fish applies to wounded soldiers. Policymakers and charities should ask whether their benefits and services provide for veterans directly, or instead help veterans integrate into society and provide for themselves. Under this principle, it may make more sense to offer benefits to work-capable veterans only when they take jobs instead of subsidizing them in unemployment. Even though an unemployed veteran is more financially vulnerable in the immediate term, his long-term interests may best be served by policies that encourage him to find employment as quickly as possible.

Second, veterans should be viewed as resources, not as damaged goods. The percentage of veterans who leave military service totally and permanently disabled is tiny. The percentage who need or could use some help is moderate. The majority of veterans need no special help at all. Efforts to help veterans should begin by recognizing their abilities, rather than focusing exclusively on their disabilities, and should serve the ultimate aim of moving wounded soldiers from the category of "needing some help" to real self-sufficiency.

Third, lawmakers, philanthropists, the press, and the general public should be more willing to have an open, honest discussion about this question. The warnings issued here are rarely articulated, in part because they can so easily be exploited for demagogic purposes. But these are hard realities, and it does our veterans no good to deny them. Many of these observations and conclusions come from my years of academic specialization in this area. Most come from personal experience. I was wounded twice in Iraq; the second time I nearly lost my life, and did lose my entire right leg. I needed more than 40 operations before I could return to self-supporting work and family life.

During my year at Walter Reed Army Medical Center, I saw a great many servicemembers like Soldier C get sidetracked on the road to recovery by overly generous or poorly targeted assistance programs. I myself was offered forms of help that could have hindered my quest to regain independence. Fortunately, I was blessed with wiser offers from generous helpers at hundreds of points along the way, and with a supportive and loving family. Many veterans, however, are not as lucky.

A great deal of government and charitable activity surrounding veterans does wonderful things for men and women who deserve the utmost support. The challenge is to improve our distribution of benefits and services by designing policies that are smart and honest about the degree to which they discourage veterans from living the active, productive lives of which they are capable. To the extent that we can eliminate these pitfalls from our current support system, we will dramatically increase the opportunities for today's veterans to participate fully in the American Dream.

Daniel M. Gade, a lieutenant colonel in the United States Army, teaches in the Department of Social Sciences at the United States Military Academy. He served as a company commander in Iraq in 2004 and 2005. He was wounded in action twice and decorated for valor. This essay is adapted from Serving Those Who Served, published in May by the Philanthropy Roundtable. The views expressed in this article are solely those of the author, and do not represent those of the Army or the Department of Defense.


Clinician's Trauma Update Online - Publication of the National Center for PTSD
Paula P. Schnurr, PhD
Senior Associate Editor
Lauren M. Sippel, PhD
Associate Editors
Juliette M. Harik, PhD
Paul E. Holtzheimer, MD
Jennifer S. Wachen, PhD
National Center for PTSD
US Department of Veterans Affairs


Issue 13(5), October 2019

For COMPLETE summaries, see this month's CTU-Online.


Evaluation of measurement-based care in VA

VA is in its second year of an initiative to implement measurement-based care (MBC) across the healthcare system. MBC entails the systematic use of measurement in clinical decision-making and treatment planning, which can help both patients and providers.  In two studies, one quantitative and one qualitative, investigators examined the effectiveness of VA’s MBC implementation plan. Read this CTU-Online.

More evidence that initial response to PE and CPT predicts overall benefit

A full course of evidence-based psychotherapy for PTSD is typically 10-12 sessions. But what if a provider could know earlier in treatment if a patient were more or less likely to benefit? A team led by investigators at VA Ann Arbor used national VA data to examine predictors of early response (within 8 sessions), late response (after 8 sessions), and non-response. Read this CTU-Online.

New studies explore dropout from evidence-based treatments for PTSD in Veterans

Despite the efficacy of trauma-focused treatments for PTSD, many patients do not complete a full course of therapy.  Understanding the reasons why patients drop out of treatment could inform strategies to improve treatment completion. Three recent studies in Veteran samples examined predictors of dropout from evidence-based treatment for PTSD. Read this CTU-Online.

An examination of guilt in PTSD treatment among active duty Servicemembers

Some providers think that PE does not adequately treat guilt, and may even be contraindicated for patients with high levels of guilt. A team led by investigators at the National Center for PTSD was the first to examine this issue among active duty Servicemembers. Read this CTU-Online.


A brief screen for PTSD based on the PCL-5

Investigators from Harvard Medical School have developed a short form of the PTSD Checklist for DSM-5 for screening in a variety of settings. Screening is an important part of the continuum of care—an efficient way to identify individuals in need of treatment or at risk of worsening health. VA uses the 5-item PC-PTSD-5 to screen for PTSD in primary care. Read this CTU-Online.

Biomarkers for PTSD

A new study by researchers with the PTSD Systems Biology Consortium reports on biomarkers of PTSD in Veterans. Having accurate and reliable biological markers for PTSD could improve diagnosis, prognosis, and treatment selection. Read this CTU-Online.

Take Note

Review of the development of the ISTSS treatment guideline for PTSD

Members of the ISTSS Guidelines Committee published a description of the methodology behind the development of the ISTSS Guidelines for the Prevention and Treatment of PTSD, which was released in 2018.
Read the article:

Systematic review of cannabinoids for PTSD

A team led by investigators at University College London reviewed studies in which individuals with PTSD used cannabinoids for the purpose of reducing PTSD symptoms. Only 1 of the 10 studies was an RCT. The authors concluded that the current evidence base is too limited for clinical recommendations about cannabinoids for PTSD.
Read the article:

Systematic review and meta-analysis of internet-based CBT for PTSD

Investigators at Cardiff University conducted a systematic review and meta-analysis of 10 studies of internet-based CBT (i-CBT) for PTSD. The results suggested that i-CBT is more effective than waitlist, but the authors qualified that the studies had many limitations, including lack of follow-up data in 7 of the 10 studies.
Read the article:

Virtual reality for PTSD

In a systematic review and meta-analysis of 18 studies of virtual reality exposure therapy for PTSD, investigators at Chaohu Clinical Medical College in China found a moderate effect size for virtual reality compared to control conditions, with a stronger effect observed in studies comparing virtual reality to inactive controls (g = 0.017) than active controls (g = 0.327).
Read the article:

Meta-analysis of predictors of response to first-line psychotherapies for PTSD

A team led by investigators at the University of Texas Health Science Center conducted a meta-analysis of predictors of response in 28 clinical trials of PE, CPT, and EMDR, with a focus on effects of different trauma types and populations (i.e., military vs. non-military).
Read the article:

Systematic review of studies of mental and physical health comorbidities in women Veterans

Investigators at the VISN 17 Center of Excellence for Returning War Veterans reviewed 21 studies of comorbid mental health (e.g., PTSD, depression) and physical health conditions (e.g., cardiovascular disease, diabetes) and associated health behaviors in women Veterans.
Read the article:

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The Clinician's Trauma Update, CTU-Online, is an electronic newsletter produced by the National Center for PTSD, Department of Veterans Affairs. CTU-Online provides summaries of clinically relevant publications in the trauma field with links to published abstracts or full text articles when available. Please send any feedback to This email address is being protected from spambots. You need JavaScript enabled to view it..


Issue 13(5) October 2019


DoD Psychological Health and Traumatic Brain Injury, Federal Interagency Traumatic Brain Injury Research Analysis Award

The summary for the DoD Psychological Health and Traumatic Brain Injury, Federal Interagency Traumatic Brain Injury Research Analysis Award grant is detailed below. This summary states who is eligible for the grant, how much grant money will be awarded, current and past deadlines, Catalog of Federal Domestic Assistance (CFDA) numbers, and a sampling of similar government grants. Verify the accuracy of the data provides by visiting the webpage noted in the Link to Full Announcement section or by contacting the appropriate person listed as the Grant Announcement Contact. If any section is incomplete, please visit the website for the Dept of the Army USAMRAA, which is the U.S. government agency offering this grant.


What is a Veteran?
A Personal Story
 Dr. Stanley McCracken
Editor’s note:  We have addressed the question of “What  is  a  Veteran?”  (or  “Who  is  a  Veteran?”) before, both in our Foundation’s Annual Report and in The Pathfinder.   We think that answering these questions is a good way for a Veteran to tell his or her story.  What follows is one Veteran’s story.
This year marks the 50th  year since I enlisted in the  Army…to  avoid  being  drafted.   It  would feel presumptuous of me to answer the ques- tion,  “What/who  is  a  Veteran?”   However,  I can answer  the  question,  “What/Who  is  this Veteran?”
Many  of  those  who  use  the  same  color  hair dye  as  me  (i.e.,  white)  remember  that during the late ‘60’s, the country was in turmoil about many  things,  one  of  which  was  the Vietnam war.   As  an  Asian  studies  minor,  I  thought  I knew a fair amount about Vietnam, its 
history, and how we got to be involved in that country. I  was  adamantly  against  the  war.  Frankly,  I thought  it  was  a  waste  of  (mostly)  men  and resources  that  could  have  been  put  to  much better use at home in the U.S.
I  protested  against  the  war.   And  yet,  I  was raised by a father who had served in the Navy in  World  War  II.   All  of  my  uncles  on  both sides of the family served in WWII.  The message was clear, “When your country calls, you answer.”   To say I was conflicted is an understatement.   “Do I go to Canada? Do I go into the military; which  one o’ dese?”   I ended up enlisting  for  four  years  in  the  Army  to  be  a linguist—Japanese, Chinese, or Korean, and I did get an Asian language -- Vietnamese.
After 47 weeks of language school, I was sent to Vietnam to be a linguist, mostly in Phu Bai, a few kilometers south of Hue, the old provincial capital. I had a variety of duties most of which involved working as a liaison between the Viet-namese Army (Army Republic of Vietnam, or ARVN) and the U.S. Army. Thus, many days I spent more time with Vietnamese soldiers than American. I also had the opportunity to work with the Army chaplains and with the office that employed Vietnamese civilians.
One of my duties as interpreter was to provide training to soldiers newly arrived in Vietnam. My job was to educate them about the Viet-namese people and the need to treat them the way they would want to be treated—essentially an application of the Golden Rule. It didn’t occur to me that I probably wasn’t doing these soldiers any favors, since part of their training was basically dehumanizing the enemy. (It is less difficult to kill someone you don’t really think of as a person.) Law of unintended con-sequences?
While in Phu Bai, some friends and I auditioned and were accepted for Command Military Touring Shows. This was a program that would take either individual musicians or groups to spend two months entertaining troops. Basical-ly, it was like the military version of USO shows, and we spent two months playing at posts throughout South Vietnam. After the tour, I was transferred to 3rd Squadron, 17th Air Cavalry for my last few months in-country.
When I returned from Vietnam, I spent the last year or so as a legal clerk, mostly at Ft. Lewis, Washington. (Oddly, there wasn’t much need for Vietnamese interpreters at Ft. Lewis.)
So for me, “What is a Veteran” is an interpret-er, a musician and a legal clerk. It is also some-one who is still conflicted about what I saw and did. I remember seeing little Vietnamese chil-dren picking through garbage. I remember the mass grave, opened in Hue, containing more than 200 corpses murdered by the Viet Cong.
I also remember the young American and Viet-namese soldiers on stretchers at the 85th Evac Hospital. And, I remember feeling the ground shake from B-52 bombing runs in the A Shau Valley and thinking that I helped provide the intelligence used in targeting.
Is this the same as having to make a decision, made daily by the infantry, about whether to pull the trigger—absolutely not! Not even close. For people who spent their time ‘in the bush’, it is personal. There is a difference between someone lobbing a rocket or a mor-tar in your general direction versus someone looking over the barrel at you and deciding whether to pull the trigger. It doesn’t get much more personal than that.
I also remember the feeling of betrayal when the U.S. pulled out of Vietnam leaving most, if not all, of my ARVN friends behind to face the VC and NVA. To say nothing of all the brave American military whose graves will never be found. When someone asks me about Vi-etnam or my service, my standard answer is, “It’s complicated.”
So when asked: “What is a Veteran?”, all of the above describes this Veteran.
Fast forward 50 years. I have had the benefit of two University of Chicago graduate degrees paid for by the G.I. bill. I have three amazing friends (and spouses) who were language school classmates who still get together after 50 years. I have had the privilege of helping Veterans who suffered the unseen psychologi-cal scars of war. I have the privilege of work-ing with LCVFSF and the amazing team of ‘those who have been there.’
I have the privilege of being a Unitarian Uni-versalist lay service leader at Great Lakes Naval Training Center where I get to lead a service each month for some amazing young men and women who want nothing more than to be U.S. Navy sailors. I think this also is a Veteran.
Finally, a Veteran is likely to be your neighbor, father, uncle, or grandfather, since more than 50 percent of men age 72 and older served in the military (Gallup, 2012). So we are all around you. You just have to look for us.
Editor’s Note: Dr. McCracken is an esteemed Veteran and member of the LCVFSF Board. We thank him for his story. If you interested in telling your story please call us at 847-986-4622. We’ll gladly tell you what to do to appear in a future issue of The Pathfinder.


 Veteran Suicide Statistics Indicate Collective Effort Is Critical



VA Suicide Prevention Efforts
2019 Reporting

Suicide prevention is VA’s top clinical priority, and VA has adopted a public health approach to suicide prevention.
The goal of VA’s suicide prevention efforts is not to get every Veteran enrolled in VA care, but rather to equip communities to help Veterans get the right care, whenever and wherever they need it. This means using prevention approaches that cut across all sectors in which Veterans may interact, and collaborating with Veterans service organizations, state and local leaders, medical professionals, criminal justice officials, private employers and many other stakeholders.  Put simply, VA must ensure suicide prevention is a part of every aspect of Veterans’ lives, not just their interactions with VA.

Reaching Veterans Where They Live, Work, and Thrive
VA’s suicide prevention efforts are guided by the National Strategy for Preventing Veteran Suicide, a long-term plan published in 2018 that provides a framework for identifying priorities, organizing efforts, and focusing national attention and community resources to prevent suicide among Veterans while adopting a broad public health approach with an emphasis on comprehensive, community-based engagement.

The public health approach looks beyond the individual to involve peers, family members and communities in preventing suicide. This approach is grounded in four key focus areas:

  1. Primary prevention: Preventing suicidal behavior before it occurs.
  2. Whole health: Considering factors beyond mental health, including physical health,alcohol or substance misuse and life events.
  3. Application of data and research: Emphasizing evidence-based approaches that can betailored to fit the needs of Veterans in local communities.
  4. Collaboration: Educating and empowering diverse communities to participate in suicideprevention efforts through coordination.

VA Suicide Prevention by the Numbers

VA suicide prevention coordinators are managing care for almost 11,000 Veterans who are clinically at high-risk for suicide.

VA’s REACH VET program uses predictive analytics to identify Veterans with high statistical risk for suicide. Annually, 30,000 Veterans receive care review and outreach to ensure they are well engaged in care and their needs are being met.

  1. Under VA’s new universal screening for suicidal intent, almost 900,000 Veterans have received a standardized risk screen since October 1, 2018.
  2. More than 30,000 of these Veterans have received more complex screening based on a positive initial screen and more than 3,000 have received a full clinical assessment after screening positive.
  3. In FY18, VA provided more than 2.4 million same-day mental health appointments.
  4. VA hired almost 1,000 new mental health professionals in the last year.
  5. In FY18, more than 120,000 new Veterans enrolled in VA services within 60 days of their military separation.
  6. VA’s Concierge for Care program called more than 99 percent of Veterans identified within the first month of their military separation.
  7. VA Suicide Prevention Coordinators conducted more than 20,000 outreach events in FY18, reaching almost 2 million people.
  8. Since its inception in July 2007, the Veterans Crisis Line (VCL) has answered over 3.8 million calls and initiated the dispatch of emergency services to callers in imminent crisis nearly 112,000 times.
  9. The Veterans Chat, an online, one-to-one “chat service” for Veterans who prefer reaching out for assistance using the Internet, has answered over 439,000 requests for chat services since its inception in 2009.
  10. Since its inception in 2011, the Crisis Line texting service has answered nearly 108,000 requests for text services. The text number is 838255.
  11. VCL staff have forwarded more than 640,000 referrals to local VA Suicide Prevention Coordinators on behalf of Veterans to ensure continuity of care with Veterans’ local VA providers.
  12. In FY18, VCL: Dispatched emergency services for callers in immediate danger an average of 80 times per day. 
  13. Received an average of 1,766 calls per day
  14. Received an average of 203 chats per day
  15. Received an average of 74 texts per day.

Promoting VA Suicide Prevention and Mental Health Services

VA spent $12.2 million on suicide prevention outreach in fiscal year 2018, including $1.5million on paid media.

In partnership with Johnson & Johnson, VA released a public service announcement,“No Veteran Left Behind,” featuring Tom Hanks via social media and a communications plan led by Johnson & Johnson.

VA continues to use the #BeThere Campaign to raise awareness about mental health and suicide prevention and educate Veterans, their families, and communities about the suicide prevention resources available to them.

  1. During Suicide Prevention Month (Sept.), the suicide prevention program implemented a dedicated outreach effort for #BeThere, including several Facebook Live events that reached more than 160,000 people, a satellite media tour promoting the campaign that reached more than 8.9 million on television and 33.9 million on radio, partner outreach, and more.
  2. Through this outreach we generated more than 347,000 visits to the VCL website during Suicide Prevention Month.

The National Action Alliance helped spread the #BeThere campaign to hundreds of partners using #BeThere and the Veterans Crisis Line information during 2018 Suicide Prevention Month Activities, raising awareness to Be There for Veterans and Service members.

  1. VA created more than 30 new cross-sector partnerships to involve peers, family members, and communities in preventing Veteran suicide.
  2. VA delivers monthly partnership updates to include content about the S.A.V.E online suicide prevention training video to 60 informal and formal partners, providing communications materials (blog posts, social media, and emails) for use.
  3. To date, more than 93 percent of VA personnel have taken the training, and the video has been viewed more than 17,000 times.
  4. VA is implementing the Mayor’s Challenge to give 24 cities (expanded from seven) thetools and technical assistance needed to address Veteran suicides at the local level.
  5. VA is partnering with the Department of Defense and The Department of Homeland Security, as mandated by a 2018 executive order, to ensure that all new Veterans receive mental health care for at least one year following their separation from military service.


VA’s national Suicide Prevention Program was allocated $41 million in FY18. This does not include funding for the more than 400 Suicide Prevention Coordinators stationed at every medical center, the VCL, or clinical care for at risk Veterans.

For the latest analysis of Veteran suicide rates: For information on resources available for Veterans, families, friends, and communities, visit

Clinician's Trauma Update Online - Publication of the National Center for PTSD


Paula P. Schnurr, PhD

Senior Associate Editor
Lauren M. Sippel, PhD

Associate Editors
Juliette M. Harik, PhD
Paul E. Holtzheimer, MD
Jennifer S. Wachen, PhD

National Center for PTSD
US Department of Veterans Affairs



Issue 13(3), JUNE 2019

For COMPLETE summaries, see this month's CTU-Online.


Advantages of integrated treatment for PTSD and substance use disorder

Substance abuse disorders (SUDs) frequently co-occur with PTSD. Although in practice these disorders are often treated sequentially, integrated treatments have been developed to target both conditions simultaneously. However, these treatments are often not utilized, perhaps due to clinicians’ concerns that addressing trauma may lead to exacerbation of substance use. To address this question, several recent studies examined the effects of integrated treatments for PTSD and SUD on PTSD symptomatology and substance use. Read this CTU-Online.

PTSD treatment can reduce suicidal ideation among PTSD patients

It is critically important to understand how treatments for PTSD affect suicide risk. Investigators with the STRONG STAR consortium assessed changes in suicidal ideation among PTSD patients receiving one of two forms of PE (a trauma-focused treatment) compared to PCT (a non-trauma-focused treatment) and a minimal contact control (MCC) condition, respectively. Read this CTU-Online.

Cognitive performance combined with neuroimaging may identify PTSD patients unlikely to respond to PE

PTSD can present very differently from one patient to the next. This symptom heterogeneity has not yet been helpful in determining which treatments might be better for specific patients. A group of investigators assessed whether cognitive performance combined with neuroimaging data could define clinically meaningful subgroups of PTSD patients. Read this CTU-Online.

Compassion Meditation as a promising treatment for PTSD

Surveys indicate that many individuals with PTSD engage in alternative treatments such as meditation, which has shown promise in PTSD (see the August 2018 CTU-Online and the August 2015 CTU-Online). A new proof-of-concept pilot study suggests that compassion meditation may be an additional approach for individuals with PTSD. Read this CTU-Online.

Academic detailing within VA leads to lower prescribing of benzodiazepines for PTSD patients

Academic detailing – targeted educational outreach to providers to enhance evidence-based practice – has been implemented within VA to decrease inappropriate prescribing of benzodiazepines. Investigators at the San Diego VA conducted a national quality improvement evaluation of academic detailing targeting benzodiazepine prescribing for PTSD patients within the VA.  Read this CTU-Online.

Therapist effects on patient outcome in Cognitive Processing Therapy

Two recent studies examined aspects of treatment fidelity in delivering CPT. Treatment fidelity (including adherence to key components of the intervention and competence in delivering the treatment) is emphasized in training and implementing evidence-based psychotherapies, yet the impact of fidelity on process and outcomes is not well-documented.  Read this CTU-Online.


How to measure therapists’ knowledge about Cognitive Processing Therapy

When training therapists to use a new treatment, it is important to assess the knowledge gained in training. Of course, being able to put this knowledge into practice and doing so with fidelity and competence is critical. But the knowledge itself is foundational, so it is necessary to be able to assess what has been learned. The Knowledge Assessment of CPT Critical Skills (KACCS) Scale, and online questionnaire, provides a way to do this for CPT. Read this CTU-Online.

A new measure of Veterans’ well-being

Military service can have multiple and wide-ranging effects on a Veteran’s life. Researchers at the National Center for PTSD recently reported on the development of a new questionnaire to assess functioning, status, and satisfaction in Veterans, the Well-Being Inventory (WBI). Read this CTU-Online.

Take Note

There have been a number of systematic reviews and meta-analyses published recently.

Hamblen and colleagues updated the “guide to guidelines” for the treatment of PTSD, comparing and contrasting guidelines from the American Psychological Association, International Society for Traumatic Stress Studies, the National Institute for Health and Care Excellence, Phoenix Center for Posttraumatic Mental Health, and VA/Department of Defense. Read the article:

Several reviews focused on novel treatments—ketamine, 3,4-methylenedioxymethhamphetamine (MDMA), cannabinoids, and exercise.  One specifically focused on the use of cannabinoids for treating sleep problems. Read the articles:

Other reviews focused on more established treatments—group psychotherapy and Narrative Exposure Therapy—and one focused on transcranial magnetic stimulation, an established treatment for depression that does not yet have a conclusive evidence base in PTSD. Read the articles:

Two reviews examined factors associated with the receipt of treatment—one on receipt of trauma-focused cognitive-behavioral therapy, and the other on mental health care utilization in the VA healthcare system. Read the articles:

Lastly, two reviews focused on specific populations—one on Veterans with dementia, and the other on psychological treatment for complex PTSD defined according to ICD-11. Read the articles:

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Sign up for the PTSD Monthly Update or other publications from the National Center for PTSD.

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The Clinician's Trauma Update, CTU-Online, is an electronic newsletter produced by the National Center for PTSD, Department of Veterans Affairs. CTU-Online provides summaries of clinically relevant publications in the trauma field with links to published abstracts or full text articles when available. Please send any feedback to This email address is being protected from spambots. You need JavaScript enabled to view it..


ISSUE 13(3) JUNE 2019


A Shorter—but Effective—Treatment for PTSD
Study finds written exposure therapy may be as effective as a lengthier first-line intervention

August 8, 2018 • Science Update

First-line treatments for post-traumatic stress disorder (PTSD) often require many treatment sessions and delivery by extensively trained therapists. Now, research supported by the National Institute of Mental Health (NIMH) has shown that a shorter therapy may be just as effective as lengthier first-line treatments. The study appeared in the March 2018 issue of JAMA Psychiatry.

First-line treatments for PTSD consist of psychotherapies that focus on exposure and/or cognitive restructuring. One such therapy is cognitive processing therapy (CPT), which is widely acknowledged as an effective treatment for PTSD. Patients being treated with CPT take part in 12 weekly therapy sessions that are delivered by a highly-trained practitioner. During these sessions, patients learn to recognize and challenge dysfunctional thoughts about their traumatic event, themselves, others, and the world. In addition, patients are given homework to complete between sessions.

“While of proven efficacy, structured therapies, such as CPT, require extensive training of therapists, a relatively long series of treatments, and, as a further burden on patients, homework exercises between treatment sessions,” said Matthew Rudorfer, M.D., program chief of adult interventions in the NIMH Division of Services and Intervention Research. “A more streamlined intervention that requires less specialized therapist training and fewer sessions while maintaining therapeutic effectiveness would, therefore, be appealing for treatment of PTSD in the community.”

In this study, the researchers examined whether another trauma-focused therapy—called written exposure therapy (WET)—may provide practitioners and patients with an equally effective, but shorter, treatment option. WET consists of five treatment sessions during which patients write about their specific traumatic event. Patients follow scripted instructions directing them to focus on the details of the event and on the thoughts and feelings that occurred during the event. WET requires less specialized practitioner training and no homework assignments between therapy sessions. While WET has been shown to be effective in treating PTSD, it had not yet been tested against more commonly used first-line treatments for PTSD, such as CPT.

To compare the efficacy of WET with CPT, the researchers randomly assigned participants with PTSD to either WET or CPT. Participants were assessed for PTSD symptom severity at baseline and at 6-, 12-, 24-, and 36-weeks after the first treatment session. WET was found to be as effective as CPT at all time points. In addition, individuals assigned to WET were less likely to drop out before completion of the treatment (6.3 percent) than participants in the CPT group (39.7 percent). Participants in both treatment groups reported high levels of satisfaction with the treatment they received.

“The findings of the study suggest that PTSD can be treated with fewer sessions than previously thought and with less burden on the patient and the therapist,” said lead study author Denise Sloan, Ph.D., an associate director at the National Center for PTSD in the VA Boston Healthcare System and professor of psychiatry at Boston University School of Medicine. “Moreover, the brief treatment was well-tolerated—demonstrated by the small number of patients that dropped out. We look forward to better understanding for whom written exposure therapy works best.”

Dr. Rudorfer added that while more research is needed to identify who might require standard, more intensive therapy, the availability of the new WET intervention “offers additional options for personalizing treatment to meet the needs of the individual.”

Sloan, D. M., Marx, B. P., Lee, D. J., & Resick, P. A. (2018). A brief exposure-based treatment vs cognitive processing therapy for posttraumatic stress disorder: A randomized noninferiority clinical trial. JAMA Psychiatry. 2018;75(3):233-239. doi: 10.1001/jamapsychiatry.2017.4249


Military and Veteran Suicides: Here’s Why I Fear It Is Going to Get Much Worse


An Army colonel who experienced post-traumatic stress after two Iraq deployments explains why she believes the military's suicide epidemic is going to get worse.

From about 2003 to 2016 again and again we found ourselves going down the same green ramp to the same planes to the same landing strips on the other side of the world where people wanted to kill us and where life is as dangerous on Day 1 as on Day 364.

But it’s also dangerous on Day 366 and Day 475 when you get back home and you don’t know how to act around your friends and family. You feel for your weapon and freak out that it’s not on your hip. You swerve around trash in the road and avoid Wal-Mart like the plague. You only know how to do what you’ve done every other year for the last 10 to 15 years. Your brain operates in the 5-paragraph frago op order fashion and anything not fitting that description must not be important.

People who don’t understand all that begin to fade from the forefront of your sight picture. Sleep is a novelty, not a necessity. Necessities? Those are numbing agents — alcohol, oxy, pictures or friends who shared the experience. Mention the name of a fallen and the room damn well better go silent and rise in reverence.

This is the life of a soldier who has spent time in Mosul, Fallujah, Patika or Basra. It doesn’t matter if you were sent to kick in doors or haul water, type up casualty reports or bounce satellite signals. There are no lines drawn on today’s battlefield and IEDs, mortars and sniper rounds do not discriminate.

But your war is not over once you’ve offloaded that freedom bird. No, in some ways it’s just begun. You’re saddled with this cultural cognitive dissonance between being the badass warriors your service tells you should be and the voice inside your head’s dashboard that’s saying “warning – engine overheating.” For a couple of tours we just go to the unit physician’s assistant and get them to override the dashboard lights. But that can only last so long before the engine actually catches fire. And then, Houston, we really do have a problem.

Our warrior culture is not set up to recognize seeing problems short of losing a body part or blood gushing from an orifice. The “invisible wounds,” as they’ve been called in this war, are the hardest ones to see, explain and validate in the eyes of leaders who often dismiss warriors as malingering because they cannot see the wounds the warrior tries to describe. This makes their wounds a self-licking ice cream cone and the warrior gives up and goes back in the game playing hurt.

Over time the hurt warrior falls further down the dark rabbit hole, losing more and more hope that circumstances will ever change. Maybe somewhere along this spectrum they leave the service or maybe they remain. But the finality of letting their hope go MIA is why so many warriors take their own lives. In this state they are not in their right minds any longer and probably haven’t been for some time. At some point they have surrendered that this is their fate and they can find no way out other than ending things. That is why they choose death.

In my first tour in Iraq as a senior major I ran Casualty Operations for (MNC-I) Iraqi theater. My team and I were responsible for all the reports that left Iraq as well as the all the letters of condolence and sympathy that came from then-General Petraeus and Lt. Gen. Odierno. We had 884 KIA’s and we’ll over 10K WIA in our 15-month tour.

Every morning at 7am my first task of the day was to walk to the command group and hand the generals a 5×8 card with the previous day’s carnage, and then to answer any questions they had about the carnage that occurred. Sometimes my NCO and I would fly out to the field hospitals to fill in for our troopers there so they could go on R&R and we’d witness the carnage first-hand. It was certainly enough to make you question the cost the United States was paying in American blood. At the end of the tour, I came home.

Thirteen months later, I was back in Iraq doing almost the exact same job. I never talked about the nightmares and anxiety with anyone because I saw how we treated soldiers who spoke up, much less leaders. I was coming into zones of consideration for promotion and command and I didn’t want to let that be a black mark. How silly is that — asking for help?

I know I’ve let my hope go MIA numerous times throughout my experiences; some more recently than I’d like to admit. We as a community have to find a way to make this a safe place where hurting people can ask for help and not get chastised for it.

I most recently was the Garrison Commander for Fort Belvoir, the fifth largest post in the Army. After a year and a half I needed to step down because my PTSD issues need to be addressed full-time. Your career doesn’t get to come back from that. The stigma is still there. I’ll be medically boarded and will be medically retired within the year. The good news is I got the help I needed. The bad news is I should have done it 12 years ago.

But this is about way more than an old crusty colonel.

The biggest issue is the volume of people going through this is so vast and the shortage of clinical staff to support these issues are so few. I know the Army has begun to put Behavior Health Specialists at brigade levels (I am not sure how the other services are handling this). But a team of 2 or 3 for 3,000 to 4,000 people may not be sufficient for the task, given the sheer volume of people we have shoved through the deployment mill for the last 16 years. There is no way possible to close the gap at present with trained professionals. We have got to find a way to use a better buddy system to triage until we can get these warriors into professional care. Their lives literally hang in the balance.

The VA system is even more bleak with over 30,000 vacancies among clinicians. Behavior clinician vacancies hover around 5,000. The problem with VA is the backlog to hire and background checks and this doesn’t even begin to address the access to care issues that are so prominent in the headlines to day.

All of these factors are creating an epidemic among warriors who are already on the edge. I usually am an optimistic person — at least, I used to be — but I fear that if we do not change current course, knowing how many OEF/OIF veterans will be separating in the next 5 to 10 years, we have not yet seen the high water mark of suicides.

Col. Angie Holbrook is a human resources officer in the Army. She deployed twice to Iraq, from November 2006 to February 2008, and from July 2009 to July 2010. This article represents her own personal views, which are not necessarily those of the U.S. Army.


March 2018


First VA Study on Whether Genetic Testing Can Improve Treatment of Depression

Twenty-one Veterans Affairs Medical Centers across the country are participating in a two-year study examining the use of genetic testing from cheek swabs to aid in the prescription of antidepressants. This $12 million VA depression study is recruiting 2,000 pairs of doctors and veteran patients who have not responded well to prior treatments for depression. The genetic test analyzes the ability of participants to metabolize antidepressants to inform which type and how much of an antidepressant should be prescribed. Because people metabolize things differently based on genetics, antidepressant dosages should vary based on whether a patient is a fast or slow metabolizer. The hope is that the genetic information will contribute to improved recovery and remission rates for those suffering from major depressive disorder.

Published Empirical Research

Military Socialization: A Motivating Factor for Seeking Treatment in a Veterans’ Treatment Court
Eileen M. Ahlin & Anne S. Douds

Through interviews and focus groups with veteran participants, veteran mentors, and veterans treatment court team members, this study provides an in-depth examination of veteran culture and how it helps to distinguish veterans treatment courts from other specialized courts.

Cognitive-behavioral Treatments for Criminogenic Thinking: Barriers and Facilitators to Implementation within the Veterans Health Administration
Daniel M. Blonigen, Allison L. Rodriguez, Luisa Manfredi, Andrea Nevedal, Joel Rosenthal, James F. McGuire, David Smelson, & Christine Timko

The study examines responses from interviews with 22 specialists from the Veterans Health Administration Veterans Justice Programs to explore barriers to and facilitators of cognitive-behavioral treatments for criminogenic thinking.

Serving Those Who Served: Outcomes from the San Diego Veterans Treatment Review Calendar (SDVTRC) Pilot Program
Raquel M. Derrick, Lisa Callahan, Roumen Vesselinov, Roger W. Krauel, Judith A. Litzenberger, & Leiana Rae Camp

Using data from the first 82 participants enrolled in the SDVTRC from February 2011 until July 2014, this study examines program outcomes and relationships between program process and outcomes.

Waging War on Recidivism Among Justice-Involved Veterans
Richard D. Hartley & Julie Marie Baldwin

As veterans treatment courts become more prevalent across the country, findings from multivariate recidivism analysis reveal potentially positive results for participants, especially graduates.

An Examination of the Influence of Veteran Status on Offense Type Among an Inmate Sample
Kellie Van Dyke & Erin A. Orrick

Many scholars have failed to differentiate between incarcerated veterans who have seen combat versus those who have not. This study examines the relationship between veteran status (combat v. non-combat) and crime type among inmates in state and federal institutions.

Evaluation of the Department of Veterans Affairs Mental Health Services

National Academies of Sciences, Engineering, and Medicine Committee to Evaluate the Department of Veterans Affairs Mental Health Services

This congressionally mandated report assesses the need for mental health services among veterans, the services and resources available from the VA, and the utilization of VA services.

Ongoing Research Highlights

Navy’s $1 Million Study on Surfing’s Therapeutic Benefits for PTSD, Depression, or Sleep Problems

Columbia University Medical Center Studying Effectiveness of Horse Therapy for Veterans with PTSD

Multimedia Resources
(Webinars, Podcasts, Online Resources)
PTSD Treatment Decision Aid: Web-based and Interactive

National Center for PTSD

A free, interactive online tool that helps educate users on PTSD, effective treatment options for PTSD, and how to begin treatment and actively participate in their care decisions.

Mental Health Services at the VA: Webpage
Military Officers Association of America

This webpage discusses and lists VA mental health services and resources for veterans.

Sleep Disorder Care in the Military: Online via Adobe Connect
Center for Deployment Psychology
April 25 12:00 - 1:30 p.m. Eastern

A panel of civilian and military sleep experts will explain the role and treatments of different disciplines in sleep disorder management in the military in this 90-minute webinar, consisting of 75 minutes of learning and 15 minutes of Q&A. They will discuss the state of research on behavioral treatments for insomnia such as Cognitive-Behavioral Therapy of Insomnia and Brief Behavioral Treatment of Insomnia and describe ways behavioral health providers can support appropriate referrals to evidence-based sleep treatments through increased engagement with primary care teams.

Policy Updates
Indiana House Bill 1402: ENACTED, Effective 03/19/2018

Revises provisions relating to the military and veterans; requires a weekly electronic query cross referencing arrestee information with the names of veterans and National Guard members; provides for the needs of veterans in the court system; urges a study of a program giving rental property owners property tax deductions to reduce veteran homelessness

New Mexico House Bill 2: ENACTED, Effective 05/16/2018
Defines veterans services and permits the Second Judicial District Court to request budget increases up to $200,000 for veterans treatment court program from internal service funds/interagency transfers and other state funds from fees.

Veteran Treatment Court Coordination Act (H.R. 4345): Introduced 11/9/2017

Legislation would authorize funding for veterans treatment courts across the United States through grant programs. It has until January 3, 2019 to pass.

In the News

  • Yale Veterans Legal Clinic Files Class Action on Behalf of Less-than-Honorably Discharged Veterans with Mental Health Issues
  • VA Plans to Give Every Service Member Mental Health Benefits Post-Service
  • $500 Tax Credit for Honorably Discharged Veterans in Portsmouth, NH
  • VA on Track to Eliminate Hepatitis C in Veterans within 12 Months
  • Delay in the VA's Mailing of Veteran ID Cards
  • Injured War Veteran Receives Robotic 3-D Printed Hand Designed by Son


Choice Program Expansion Jeopardizes High-Quality VHA Mental Health Services

by Russell B. Lemle, PhD

Last summer, the Department of Veteran Affairs (VA) published the most comprehensive analysis of veteran suicide in our nation’s history. That study examined 55 million records from every state and revealed that in 2014, an average of 20 veterans died by suicide each day.1 Six of the 20 were recent users of Veterans Health Administration (VHA) services; the other 14 had not used VHA services in the prior 2 years.

Policy makers are currently deliberating whether expanding the Veterans Choice Program (VCP) is a judicious way to prevent these tragic deaths, especially for veterans who do not use the VHA. One proposal, presented at a congressional committee hearing in October 2017, advocates expanding the VCP.2 Its core tenet—allowing veterans to seek mental health care from VCP providers without needing VHA preauthorization—is similar to provisions in other subsequent VCP bills regarding Access to Walk-In Care for episodic physical and mental health care.

The original Veterans Choice Act of 2014 was enacted with $10 billion supplemental funding for the VCP as well as $5 billion to augment VHA staffing. In contrast, these recent proposals include no supplemental allocations. Veterans could bypass VHA approval, obtain VCP services on their own; the VHA would be sent the bill and payment would be taken from the VHA facility’s budgets. The set of proposals serves as a reminder of the need for further reflection and discussion about how the nation can best address the crisis of veteran suicide and, more broadly, how to optimize access to evidence-based, integrated mental health care services.

This article critiques the myths underlying the proposals’ rationale, gives factual evidence on veterans’ suicide prevention and comprehensive mental health care issues, and concludes with a cautionary warning about the risk of VCP expansion adversely impacting veterans.


Shifting funds from the VHA to mental health care providers in the community would be a more effective suicide prevention strategy. FACT: The VA is better than the community in addressing veterans’ suicides. Between 2001 and 2014, age-adjusted rates of suicide for veterans not using the VHA increased by 38%; for veterans using the VHA, the age-adjusted rate increased by 5%. For the subgroup of VHA patients with either a mental health or substance use diagnosis, the rate decreased by 25%.1 These comparative achievements occurred even though veterans who use the VHA are twice as likely to have a mental health condition when compared with veterans who do not use VHA services.4

FACT: The VHA’s approach to preventing suicides is far more comprehensive than that found in the community. Each of the 170 VA medical centers has at least 1 dedicated suicide prevention coordinator (SPC) position. The SPCs provide enhanced care coordination for veterans in VHA health care who are identified as high risk for suicide. The SPCs collaborate with the VHA’s integrated network of care providers and community partners to reduce suicide risk among vulnerable veterans.  

For veterans in VHA care who are at risk for suicide, mental health policies include regular screening, follow-ups to missed appointments, and safety planning. For high-risk veterans, suicide prevention policies also involve a medical record flagging and monitoring system with mandatory mental health appointments.

The 2010 National Strategy for Suicide Prevention report extolled VHA’s multiple levels of evidenced-based suicide prevention practices and recommended that other health care systems emulate the practices. Despite this, few community health care providers or systems have adopted a similar approach. As the Congressional Research Service observed in 2016, “Outside the VA, the use of suicide prevention coordinators has not been widely adopted.”

FACT: The VHA’s innovative use of suicide predictive analytics to recognize at-risk individuals is more advanced than those available in the community. VHA has implemented a predictive analytics program that identifies veterans at risk for suicide and offers enhanced care to these veterans. The model uses clinical and administrative data to identify VHA-enrolled patients who are at the very highest risk of suicide, with a 30-fold increased risk of death by suicide within a month.7 The system notifies each veteran’s provider of the risk assessment and enables those providers to reevaluate and enhance these veterans’ care. Some of these ultra-high-risk veterans might not have been identified as being at risk based only on clinical signs. This is a crucial distinction because many veterans who die by suicide do not have a history of suicide attempt or recently documented suicidal ideation.8-11 This cutting-edge, big-data approach allows the VHA to reach out and assist vulnerable veterans, before a crisis occurs.

FACT: The VHA can better coordinate the care of veterans who call the Veterans Crisis Line (VCL) when they are receiving care in the VHA rather than in the community.

Since its launch a decade ago, the 24-hour VCL has answered > 3 million calls from veterans and their family/friends, with > 500,000 follow-up referrals to local VA SPCs. Because the VCL links directly to VHA facilities, care coordination is more effective when a veteran’s provider is in the VHA. When the veteran is not a VHA patient, coordinating with his/her community provider is laden with logistic impediments.

MYTH: If offered, the 14 of 20 veterans outside the VHA who are the target of this proposal would prefer to use VCP mental health options to get help.

FACT: There is no evidence that those veterans are VHA-eligible, otherwise uninsured, or would seek needed help. The VHA’s 2017 suicide report did not probe whether veteran suicide decedents who were not recent VHA patients were eligible for VHA care.1 It did not ascertain whether they were veterans with other-thanhonorable discharges or transitioning out of service, 2 cohorts that now qualify for VHA mental health care. It is known that the respondents’ average age was 54.3 years, an older population that in general is less prone to seek the care of a mental health provider (either in or outside the VHA) when needed.12,13 It also is known that of all enrolled veterans, only a small portion plan to forego VHA care, and they tend to be eligible for public insurance coverage (eg, Medicare, Medicaid, or TRICARE) and/or have private insurance coverage.14 Thus, establishing unrestrained Choice options may fail to capture most of those veterans such a plan purports to help.

COMPREHENSIVE MENTAL HEALTH CARE MYTH: The quality of mental health care provided to veterans in the community would be comparable with the quality of care they receive at the VHA.

FACT: The VHA expertise in treating veterans with posttraumatic stress disorder (PTSD) and depression is lacking in the community. More than 12,700 VHA mental health providers have received extensive training and supervision in the most effective evidence-based psychotherapies (EBPs). This includes more than 8,500 providers trained in prolonged exposure and/ or cognitive processing therapy for PTSD and more than 2,200 providers in 1 of 3 EBPs for depression.15 Veterans who received EBPs in the VHA have experienced clinically meaningful and robust improvement in their PTSD and depressive symptoms.

By contrast, a RAND Corporation study of therapists who treat PTSD and major depressive disorder found that when compared with providers affiliated with the VHA or DoD, “a psychotherapist selected from the community is unlikely to have the skills necessary to deliver high-quality mental health care to service members or veterans with these conditions.”23 Only 13% of community therapists were trained in and used an EBP and had veteran/military cultural competency. A separate 2017 study of community providers who treat veterans found MARCH 2018 • FEDERAL PRACTITIONER • 15 MENTAL HEALTH that only a minority reported prior training in, or use of, any EBP for PTSD.24 Also, as the industry leader in telemental health, the VHA’s delivery of EBPs to veterans in remote locations and/or having difficulty accessing clinic-based care is far beyond that of the private sector.

FACT: VHA patients are more likely to receive care consistent with the American Psychiatric Association (APA) guidelines than are patients treated in the community. Recent studies of pharmaceutical treatments for mental disorders have compared the VHA with the private sector. The studies found that for all 7 indicators, VHA performance was superior to that of the private sector by > 30%.25,26 Another study found that 1% to 12% of private sector patients treated with antidepressants received care consistent with APA guidelines (with care of racial/ethnic minorities tending to be on the lower side of this range).27 The VHA achieves higher quality because, as a unified, nationwide system, it has superior ability to assure providers’ adherence to assessment and treatment standards.

FACT: For older veterans who constitute the majority of veterans and the majority of veteran suicides, the VHA has more comprehensive and integrated mental health care services than are commonly found in community-based care. 1,4 The VHA provides comprehensive, integrated mental health evaluation and treatment services across the continuum of geriatric care, including geriatric primary care; home-based primary care; and nursing home, hospice, and palliative care.28-30 For older adults, a population that is more prone to seek behavioral/mental health services if combined with their medical care, these integrated services optimize access to mental health care when needed and facilitate holistic, interdisciplinary care.31-35 Although interest in integrated care is growing in the private sector, it is still not the norm.

VHA providers proactively screen veterans for PTSD, alcohol misuse, depression, military sexual trauma (MST), and traumatic brain injury. When problems are identified, primary care providers are able to deliver a warm handoff to mental health team members for further evaluation and intervention as needed. Such integration of services, required by VHA policy since 2008, appears related to increased detection and treatment of mental illness among older veterans.36 Referred older veterans have shown significant reduction in depressive symptoms with antidepressant medication treatment.37 Veterans with chronic obstructive pulmonary disease receiving brief cognitive behavioral psychotherapy in primary care clinics had decreased symptoms of depression and anxiety maintained at 12 months.

As the Commission on Care Final Report recognized, “Veterans who receive health care exclusively through VA generally receive wellcoordinated care, yet care is often highly fragmented among those combining VHA care with care secured through private health plans, Medicare, and TRICARE. This fragmentation often results in lower quality, threatens patient safety, and shifts cost among payers.”

FACT: VHA’s comprehensive and integrated health care response to MST exceeds what is available in the community. When screened by a VHA provider, 1 in 4 women veterans and 1 in 100 men report that they experienced MST.40 Because most veterans are men, they constitute almost 40% of all MST survivors seen in VHA. Military sexual trauma is associated with a wide range of mental and physical health conditions as well as lasting impairment in occupational and life functioning.41-43 Those who experience MST have been shown to be at increased risk of death by suicide even when data were adjusted to account for age, mental health diagnosis, and other risk factors. G

Given that many survivors never talk about their MST experience unless asked directly, the VHA’s routine screening, culturally competent sensitivity, and unflagging efforts to engage veterans are crucial ways to proactively reach survivors who might not otherwise seek care. Each VHA facility has a dedicated MST coordinator, mandatory MST training for all primary and mental health care providers, free MST-related treatment, and MST outreach efforts. All veterans enrolled in the VHA are screened for experiences of MST, and tailored treatment plans are created for survivors who need care. More than 1 million outpatient MST-related mental health visits were provided to veterans with a positive MST screen in fiscal year (FY) 2015, a 13% increase from the prior year.15 Widespread screening and treatment programs do not exist in the community-based care, where mental health care providers are less likely to have relevant experience or recognize that it is important to ask veterans about MST.

The DoD recently indicated that lesbian, gay bisexual, transgender (LGBT) service members experience disproportionately higher rates of MST, reporting sexual assault 5 times and harassment 3 times as often as non-LGBT service members.45 Civilian research consistently identifies LGBT individuals as being at greater risk for suicide.46 Although exact rates of LGBT veteran suicides are unknown, one study found that 47% of lesbian, gay, and bisexual veterans reported lifetime suicidal ideation compared with that of 22% of heterosexual veterans.47 Each VHA facility has a dedicated LGBT care coordinator who works closely with the MST coordinator and mental health treatment teams to ensure timely referrals to appropriate care. Comparable care coordination does not exist in the community, where providers also are less likely to have relevant experience and training to address veteran-specific correlates of trauma for LGBT individuals.

FACT: Veterans with serious mental illness (SMI) who use the VHA have greater life expectancy and reduced inpatient days of care. Veterans with SMI conditions who receive VHA care live much longer on average than their counterparts in the general U.S. population.48 Veterans with SMI who drop out of VHA care but then return have significantly lower rates of mortality than that of veterans who do not return. Building on this success, the VHA implemented the SMI Re-Engage Program, an outreach to veterans with SMI who have not been seen in any VHA for at least 1 year, and are thus at an elevated risk for premature death. Since implementation began in March 2012, 24% returned to VHA care within 4 months.

In the VHA’s Intensive Community Mental Health Recovery (ICMHR) program, mental health staff visit veterans with SMI at least weekly to provide recovery-oriented interventions, typically in the veteran’s place of residence, which ensures more routine follow-up and alleviates the burden of having to go to a medical facility. In fiscal year 2016, veterans enrolled in ICMHR services had an average of 12 to 27 fewer hospital days after admission to the program.

FACT: The evidence-based interdisciplinary VHA approach to pain management rarely exists in the private sector. About 50% of veterans treated in primary care report at least 1 chronic pain complaint, disproportionately higher than that of American nonveterans. Recent CDC and VA/DoD guidelines specifically recommend the use of cognitive behavioral psychotherapy, exercise therapy, and nonopioid medications as first-line treatments for chronic pain. Instead of routinely sending veterans with chronic pain to specialists, the VHA uses a stepped-care model in which patients receive biopsychosocial chronic pain care first within VHA primary care. These interdisciplinary clinics collocate and integrate primary care providers, psychologists, pharmacists and/or physical therapists to provide multimodal chronic pain care.

Preliminary results show decreases in pain, opioid risk, and opioid use as well as improved provider perception of pain care delivered in primary care. For those veterans who require a higher level of care, the VHA has mandated the creation of tertiary pain programs, based on well-established models of more intensive, comprehensive treatment shown to be effective in the treatment of chronic pain.

Although interdisciplinary pain management continues to grow in the VHA, it very rare in the U.S. private sector where health care tends to be fragmented and truncated. The VHA accounts for 40% of the U.S. interdisciplinary pain programs even though it serves 8% of the adult population. The importance of effective pain management, including behavioral interventions, is further highlighted by the fact that pain is the most commonly identified risk factor in VHA users whose suicides are reported to central office.

MYTH: Most veterans prefer a new care system that redirects funds from the VHA to VCP.

FACT: Veterans overwhelmingly want the VHA to be preserved and strengthened. 57 Veterans like the VCP when it is present in the proposals that drain money out of the VHA, they voice near unanimous opposition. The 2017 Veterans of Foreign Wars survey of 10,800 veterans found that 92% wanted the current VHA system to be improved, not dismantled. Only 5% wanted a new system of giving veterans free access to Choice care that bypasses the VHA.

Anecdotal instances do arise where veterans express discontent about VA mental health services. That is no surprise in a large pool of millions of patients. One example was a 2016 VA Center for Innovation report, quoted during the October 2017 Congressional hearing, which asked about 40 veterans and 5 family members for their criticisms. Using an unrepresentative sampling method, the report found that some of the veterans desired more privacy and easier access to mental health care. The report also noted that the VA’s 300 Vet Centers and 80 mobile Vet Centers would provide such quick, confidential access, but many veterans did not know about that resource.

CONCLUSION As VA Secretary David J. Shulkin, MD, has underscored, preventing suicide among all our nation’s veterans, is a sacred VA responsibility. The VHA must identify areas for improvement and mitigate obstacles that impede veterans receiving quality mental health care. When prompt access to VHA mental health care for enrolled veterans isn’t feasible, the VHA should continue to purchase services from VCP providers. For all veterans, their families, and non-VA professionals, the VHA should continue to share its educational and clinical expertise (as it has successfully done in efforts such as the Be There Campaign, VA Community Provider Toolkit, VA Campus Toolkit, PTSD Consultation Program and Suicide Risk Management Consultation Program.)

Nevertheless, in crafting policies, it is essential to ensure that there is no collateral damage to the overall superior quality, unique advantages, and cost-effectiveness of VHA mental health care. The guiding principle for all health care systems and providers, “first, do no harm,” must be heeded.

The VCP is intended to supplement not supplant the VHA, but the recent proposals would do the opposite. Furnishing vouchers to veterans that bypass VA preauthorization will weaken veterans’ mental health care and suicide prevention efforts. It sets in motion a gradual, persistent hollowing out of VHA care. In zero-sum budgets, VHA facilities will receive less money, vacant positions will not be filled, and mental health services will be cut. As the availability of VHA services diminishes, many veterans will be placed into VCP, leading to a vicious cycle of further VHA cuts. In the name of freedom of choice, veterans, especially the most vulnerable who depend on the VHA, will ultimately have fewer quality choices.

The stand-alone mental health clinic model runs completely counter to the VHA’s best practice interprofessional and integrated care approach. Veterans have more complex comorbidities and need greater, not less, integration of mental health services across the continuum, including primary care, specialty care, and geriatric/extended care programs.

Implementing unrestrained choice, even as a pilot for newly transitioning service members or other groups of veterans, would be the initial step on a slippery slope to vouchers for the entire VHA system. Once mental health services are privatized, the remainder of VHA services, whose overall quality also has been determined to be equal or better than that delivered in the community, would follow in quick succession.11 In January 2018, the National Academies of Science, Engineering and Medicine published an exhaustive evaluation of VHA mental health care and hailed it as the preeminent system that is “positioned to inform and influence how mental health care services are provided more broadly in the United States.” It was decisive confirmation that, first and foremost, we must guarantee that VHA mental health care is fully funded and staffed and remains the coordinator and authorizer of care.

Acknowledgments:  The considerations offered in this article are those of the author.  Click HERE to read from March 2018 Federal Practitioner


Veterans Treatment Courts — Helping Vets Seek Justice
By Lindsey Getz
Social Work Today
Vol. 17 No. 5 P. 22

[Editor's Note:  Lake County Veterans and Family Services Foundation is one of the founding parties of the Lake County Veterans Treatment and Assistance Court (VTAC) in Waukegan.  They were and continue to be a key part of the specialty court process.  To that end, at the conclusion of the following article, please read the information on working and supporting the Lake County VTAC.]

The specialty court you may not have known existed is helping vets across the country.

Problem-solving courts take a specialized approach to working with participants in addressing the underlying problems that are contributing to their criminal behavior. It's become a big trend in the United States, as we've seen the emergence of drug courts and domestic violence courts that aim to reduce reoffenses and address substance use and other issues at the heart of illegal behavior.

Similar to problem-solving courts, Veterans Treatment Courts (VTCs) have emerged as a type of specialty court that help address the underlying needs of veterans who wind up facing criminal charges. It's estimated that there are currently around 350 of these specialty courts across the country, and they differ in terms of how they run or what types of charges they adjudicate. But the overarching goal is the same: getting veterans the help they need to stay out of jail and reintegrate with society.

A recent report by the Justice Programs Office (JPO) at American University's School of Public Affairs has found that VTCs are effectively providing former members of the armed forces with the support and services they need. Though the concept is still relatively new, it's spreading, and it's proving to be effective.

Judge Robert Russell in Buffalo, New York, established the first VTC in 2008. Kim Ball, director of JPO at American University, spoke to Russell just after the court was established.

"In a nutshell, Judge Russell saw the transformative power of military camaraderie when veterans on his staff assisted a veteran in one of his treatment courts," Ball says. "But he recognized that more can be done to ensure veterans are connected to benefits and treatment earned through military service."

Getting the Help Vets Need
A big part of the problem was that many of these veterans were not connected to services, even though they were eligible for them through the VA. In Russell's court, a representative from the VA is included in the VTC team so that clients can immediately register for services and get help.

And getting help is undoubtedly the most important part of the process. "The Department of Veterans Affairs and the Veterans Justice Outreach (VJO) officer play vital roles in the VTC model," Ball says. "Through coordination with a VJO officer, the VA provides treatment to participants. The VJO also coordinates with their respective courts to provide counseling services, job placement services, and housing. Research suggests that VJOs have been successful linking justice-involved veterans to VA services that treat their high rate of diagnosed substance use and mental health issues."

Both of these are big concerns in the veteran community. According to a 2008 study by the RAND Center for Military Health Policy Research, nearly one-half million Iraq and Afghanistan veterans experience PTSD or depression. And more than 300,000 struggle with substance use. But VTCs help connect vets with services they need—all while providing a sense of "mission" that many participants say they believe they lost when they returned to civilian life.

Julie Baldwin, PhD, a professor in the department of criminology for Missouri State University, says it is this sense of "mission" that separates VTCs from other specialty courts. Because of the military history that participants share—as well as a sense of "camaraderie" that comes with it—these courts often rely on those values in order to be successful.

"Military ritualism is employed in many of these courts," Baldwin says. "You might see court begin with the color guard, hear service calls from the judge and participant, or see veterans receive their courts' challenge coin when they graduate from the program. These extra steps make the program more relatable to veterans and helps get their buy-in."

There's no question that in order for the program to be effective, veterans must believe in the system and willingly participate in what's required of them; it seems that most do.

Another way that VTCs help with the buy-in factor is by connecting them with mentors. The mentor program is a big key to VTCs success.

Ball says that the incorporation of a peer mentor program to support participants is the most noteworthy facet of the VTC system, separating it from other specialty courts. Mentors may be active or retired military and are represented across all branches of the military.

Georgia State Court Judge B.E. "Gene" Roberts is approaching his fourth year overseeing a VTC, which he says has been very effective—largely thanks to the mentoring program, in his opinion. Roberts says the mentors serve as sounding boards in many ways and allow the mentees to discuss things they wouldn't otherwise open up about. While he says they aim to pair mentees with mentors of the same branch—and ideally of the same time of service—it doesn't always work out that way. But Roberts says unlikely mentor/mentee assignments have often surprised him.

"I have one young man who just completed two tours in Afghanistan, and he has taken on an 85-year-old Marine as his mentee," Roberts says. "They've paired off well—almost like a father/son relationship—and it's worked well despite the age gap."

Ball says the model for VTCs is like the framework used for other treatment courts in that VTCs promote sobriety, recovery, and stability through a coordinated response. However, it is the incorporation of volunteer mentors and the coordination of treatment services that truly differentiate VTCs.

Baldwin adds that the programs may be lengthier to complete, and there may be quite a few different facets involved in getting the veteran help. It may involve housing services, substance use treatment, VA benefits, and more. She says there are often quite a few agencies working together for a comprehensive solution that addresses all of the issues at hand.

VTC Variations — and the Social Worker's Role
Having been in existence for less than 10 years, the entire concept of VTCs is new to many. While the objective of helping veterans to reintegrate into society is the end goal for all of these courts, how they get from point A to point B can vary dramatically. In fact, even eligibility rules governing qualification to participate in a VTC can vary from court to court.

Baldwin says these courts can be extremely different from one another, and eligibility is one of the biggest factors that they vary on. While some courts will accept only veterans who have committed a nonviolent misdemeanor offense, there are others that will accept only certain felonies. Some courts might require a substance use disorder for a vet to be eligible, while others might require a diagnosis of PTSD. It can vary dramatically. Some courts will use only the VA as the service provider, so they require VA eligibility as part of their admission criteria.

Tracy Velázquez, PhD, associate director of the JPO at American University, adds that each court sets its own rules for eligibility. Some of it has to do with what are dictated by the local rules and policies of a particular jurisdiction. She adds that participants in VTC are sometimes self-identified and that participation is voluntary. If a veteran declines to participate, he or she then goes through the traditional court process.

Ball says that as VTCs have spread, so has the realization that there is no one-size-fits-all approach for veterans. There are many issues that can come into play and need to be addressed. Ball says this may be an area where social workers can play an important role in helping. Women veterans, in particular, may be survivors of military sexual trauma and may be uncomfortable—or even retraumatized—by participating with male counterparts in court activities. But Ball says social workers can play a role in assisting court personnel—who may not be aware of these types of issues or their impact—to understand and make necessary accommodations that help improve outcomes for veteran participants.

There are other roles for social workers in VTCs as well. Some may have a leadership role in the court as the coordinator, Ball says. The coordinator is the one who ensures the smooth operation of the overall program, tracking progress of the participants and making sure all partners are on the same page.

The VA also uses social workers as VJOs, and some courts have a case manager, who is often a social worker. Ball says it's becoming more common for probation officers to be social workers.

"In fact, in some jurisdictions, a degree in social work is now required in order to be a probation officer," Ball says. "In VTCs where the probation officer is part of the team, there might be a social worker in that role as well."

Social workers can also play an invaluable role if they have personal military experience or if they've worked with veterans before.

"Just as having a veteran mentor is valuable, so is having other people on the VTC team who understand military culture," Velázquez adds. "Social workers who have been in the military or who have experience working with vets can help bridge the gap for civilians in the court who want to help but may not 'get' what it's like to have served."

VTC Success
Though the concept of VTCs remains relatively new, it is proving to be successful. The Veterans Treatment Courts: 2015 Survey Results, compiled by JPO at American University, found that VTCs—true to their intent—are in fact providing veterans with access to much-needed services. More than 80% of the courts indicated that they were able to match participants with mentors who could provide assistance both in and out of the courtroom. More than 80% of the courts conducted random drug tests for those whose offenses involved substance use. More than 90% had developed policy and procedure manuals, formal mission and purpose statements, and clearly defined roles for those who were part of the VTC team. And finally, more than 90% say they share information with the VA in order to facilitate service delivery, usually through VJOs assigned to the court.

The personal experiences of those involved in VTCs and the findings are equally powerful. Roberts says he has witnessed many transformative experiences of veterans who have gone through the program. He says that prior to the program, his typical participant had averaged 60 days in jail. After the program, that average dropped to five days in jail. That obviously equates to taxpayer savings.

It's believed that VTCs may save taxpayers hundreds of thousands of dollars that would have otherwise been spent on incarceration. Since VTCs connect eligible participants to VA benefits, there are additional savings there as well. It ultimately offsets the costs that would have been incurred by local jurisdictions if participants were to be incarcerated and receive services through them.

There are also benefits to the communities in which the veterans reside. Reducing the effects of criminal behaviors improves overall community well-being. Community members can rest assured that veterans in their area are receiving the help they need and becoming productive members of their local community.

There's also a strong feel-good aspect when veterans are getting the help they need and not falling through the cracks. Baldwin says that because of this, community buy-in is typically easy to obtain. Once people understand the benefits of VTCs, they are usually on board with the concept. Everyone wants to see our nation's veterans receive the services they require to reintegrate into society.

Roberts says that watching the life transformations has been incredibly rewarding for him personally. He has seen veterans reunited with their families and put back on their feet—as a result of going through a VTC instead of the regular court system.

"My first three participants were all homeless," Roberts says. "When they graduated from the program, all three had a roof over their head that they were paying for themselves. They had gotten jobs and driver's licenses. It's very rewarding to watch veterans who have served our country straighten out their lives and get the help they need."

Pushing for More VTCs
Research shows that VTCs can have a big impact on vets. Though they are interspersed throughout the country, there are many jurisdictions that could benefit from a VTC. There may be a role for social workers in ensuring that they become more widespread. Ball says that social workers can help spread the word at conferences and even invite participants from VTCs in their state to come talk about the work they do. Furthermore, social workers who are part of VTCs can do a lot to spread the word.

"Social workers who are part of VTCs can talk at Rotary Clubs and other civic groups about their court," Ball says. "Since in some jurisdictions judges often see themselves as more constrained in what types of public events they can participate in, social workers can really fill in that gap. They can share the challenges they see veterans facing every day."

— Lindsey Getz is a Royersford, PA-based freelance writer.

[Veterans Treatment & Assistance Court, Lake County, Illinois

About the Court
"The Veterans Treatment and Assistance Court (VTAC) is a program that provides veterans involved in the justice system help and favorable alternatives. Through VTAC the court partners in this collaborative program work to reduce recidivism, enhance public safety and reduce the cost of the criminal justice process, including incarceration, by focusing on the underlying problems that the veteran is encountering with treatment, support and structure.” The philosophy is that the VTAC Team’s help and supervision will assist the veteran in resolving the issues that contributed to the criminal behavior, will result in a permanent life change and prevent a recurrence.

Eligibility Criteria
     Honorable or General Discharge after completion of boot camp
     Service-related disability or is currently on active military duty
     Probation/supervision-eligible felony, misdemeanor, DUI, and petty offenses
     Crimes against a person must have consent of victim (excludes violent offenses with serious injuries or where death occurred)
     Pre- and post-plea participation
     Willingness to participate in the program and preferably eligible for veterans benefits
     Eligible for veteran benefits

Mentoring Program
Veteran mentors supporting the participating veterans during the program is an integral and essential component to success. It is the mission of the mentoring program to help the veterans navigate through the court process, the VA system and community readjustment. Mentors become guides, advocates and allies to the veteran. If you are a veteran yourself and interested in becoming a mentor contact Rudy Martin at Adult Probation Services at 847-377-3964.]


For all too many veterans, returning from military service means coping with symptoms of post-traumatic stress disorder (PTSD). You may be having a hard time readjusting to life out of the military. Or you may constantly be feeling on edge, emotionally numb and disconnected, or close to panicking or exploding. But no matter how long the V.A. wait times, or how isolated or emotionally cut off from others you feel, it’s important to know that you’re not alone and there are plenty of things you can do to start feeling better. These steps can help you learn to deal with nightmares and flashbacks, cope with feelings of depression, anxiety or guilt, and regain your sense of control.

What causes PTSD in veterans?

Post-traumatic stress disorder (PTSD), sometimes known as shell shock or combat stress, occurs after you experience severe trauma or a life-threatening event. It’s normal for your mind and body to be in shock after such an event, but this normal response becomes PTSD when your nervous system gets “stuck.”

Your nervous system has two automatic or reflexive ways of responding to stressful events:

Mobilization, or fight-or-flight, occurs when you need to defend yourself or survive the danger of a combat situation. Your heart pounds faster, your blood pressure rises, and your muscles tighten, increasing your strength and reaction speed. Once the danger has passed, your nervous system calms your body, lowering your heart rate and blood pressure, and winding back down to its normal balance.

Immobilization occurs when you’ve experienced too much stress in a situation and even though the danger has passed, you find yourself “stuck.” Your nervous system is unable to return to its normal state of balance and you’re unable to move on from the event. This is PTSD.

Recovering from PTSD involves transitioning out of the mental and emotional war zone you’re still living in and helping your nervous system become "unstuck."

Symptoms of PTSD in veterans

While you can develop symptoms of PTSD in the hours or days following a traumatic event, sometimes symptoms don’t surface for months or even years after you return from deployment. While PTSD develops differently from veteran to veteran, there are four symptom clusters:

Recurrent, intrusive reminders of the traumatic event, including distressing thoughts, nightmares, and flashbacks where you feel like the event is happening again. Experiencing extreme emotional and physical reactions to reminders of the trauma such as panic attacks, uncontrollable shaking, and heart palpitations.

Extreme avoidance of things that remind you of the traumatic event, including people, places, thoughts, or situations you associate with the bad memories. Withdrawing from friends and family and losing interest in everyday activities.

Negative changes in your thoughts and mood, such as exaggerated negative beliefs about yourself or the world and persistent feelings of fear, guilt, or shame. Diminished ability to experience positive emotions.

Being on guard all the time, jumpy, and emotionally reactive, as indicated by irritability, anger, reckless behavior, difficulty sleeping, trouble concentrating, and hypervigilance.
Suicide prevention in veterans with PTSD

It’s common for veterans with PTSD to experience suicidal thoughts. Feeling suicidal is not a character defect, and it doesn't mean that you are crazy, weak, or flawed.


PTSD in veterans recovery step 1:

Get moving as well as helping to burn off adrenaline, exercise can release endorphins and improve your mood. By really focusing on your body and how it feels as you exercise, you can even help your nervous system become “unstuck.”

Exercise that is rhythmic and engages both your arms and legs—such as running, swimming, basketball, or even dancing—works well if, instead of continuing to focus on your thoughts as you move, you focus on how your body feels.

Notice the sensation of your feet hitting the ground, for example, or the rhythm of your breathing, or the feeling of wind on your skin.

Rock climbing, boxing, weight training, or martial arts can make it easier to focus on your body movements—after all, if you don’t, you could get injured.

Try to exercise for 30 minutes or more each day—or if it’s easier, three 10-minute spurts of exercise are just as good.

The benefits of the great outdoors

Pursuing outdoor activities in nature like hiking, camping, mountain biking, rock climbing, whitewater rafting, and skiing can help challenge your sense of vulnerability and help you transition back into civilian life.

Seek out local organizations that offer outdoor recreation opportunities.

In the U.S., check out Sierra Club Military Outdoors which offers opportunities to get out into nature and get moving.

Step 2: Self-regulate your nervous system

PTSD can leave you feeling vulnerable and helpless. But you have more control over your nervous system than you may realize. When you feel agitated, anxious, or out of control, these tips can help you change your arousal system and calm yourself.

Mindful breathing. To quickly calm yourself in any situation, simply take 60 breaths, focusing your attention on each out breath.

Sensory input. Just as loud noises, certain smells, or the feel of sand in your clothes can instantly transport you back to the combat zone, so too can sensory input quickly calm you. Everyone responds a little differently, so experiment to find what works best for you. Think back to your time on deployment: what brought you comfort at the end of the day? Perhaps it was looking at photos of your family? Or listening to a favorite song, or smelling a certain brand of soap? Or maybe petting an animal quickly makes you feel calm?

Reconnect emotionally. By reconnecting to uncomfortable emotions without becoming overwhelmed, you can make a huge difference in your ability to manage stress, balance your moods, and take back control of your life. See our Emotional Intelligence Toolkit.

Step 3: Connect with others

Connecting with others face to face doesn’t have to mean a lot of talking. For any veteran with PTSD, it’s important to find someone who will listen without judging when you want to talk, or just hang out with you when you don’t. That person may be your significant other, a family member, one of your buddies from the service, or a civilian friend. Or try:

Volunteering your time or reaching out to someone in need. This is a great way to both connect to others and reclaim your sense of power.

Joining a PTSD support group. Connecting with other veterans facing similar problems can help you feel less isolated and provide useful tips on how to cope with symptoms and work towards recovery.

Connecting with civilians

You may feel like the civilians in your life can’t understand you since they haven’t been in the service or seen the things you have. But people don't have to have gone through the exact same experiences to be able to offer support. What matters is that the person you're turning to cares about you, is a good listener, and a source of comfort.

If you're not ready to open up about what happened, that's perfectly okay.  Instead of going into a blow-by-blow account of events, you can just talk about how you feel.  You can tell the other person what they can do to help, whether it's just sitting with you, listening, or doing something practical.  Remember: people who care about you welcome the opportunity to help; being supportive is not a burden for them.  If connecting is difficult

No matter how close you are to someone, PTSD can mean that you still don’t feel any better after talking. If that describes you, there are ways to help the process along.

Exercise or move. Before chatting with a friend, either exercise or move around. Jump up and down, swing your arms and legs, or just flail around. Your head will feel clearer and you’ll find it easier to connect.

Vocal toning. As strange as it sounds, vocal toning is a great way to open up to social engagement. Sit straight and simply make “mmmm” sounds. Change the pitch and volume until you experience a pleasant vibration in your face.

Step 4: Take care of your body

Without the rush of still being in a combat zone, you may feel strange or even dead inside and find it difficult to relax. Many veterans are drawn to things that offer a familiar adrenaline rush, whether it’s caffeine, drugs, violent video games, driving recklessly, or daredevil sports. However, the symptoms of PTSD can be hard on your body and mind so it’s important to put a priority on sleep, healthy food, and calming activities.

Healthy habits

Take time to relax with relaxation techniques such as massage, meditation, or yoga.

Avoid alcohol and drugs (including nicotine). It can be tempting to turn to drugs and alcohol to numb painful feelings and memories and get to sleep. But substance abuse (and cigarettes) can make the symptoms of PTSD worse.

Find safe ways to blow off steam. Pound on a punching bag, pummel a pillow, sing along to loud music, or find a secluded place to scream at the top of your lungs.

Support your body with a healthy diet. Omega-3s play a vital role in emotional health so incorporate foods such as fatty fish, flaxseed, and walnuts into your diet. Limit processed and fried food, sugars, and refined carbs which can exacerbate mood swings and energy fluctuations.

Get plenty of sleep. Sleep deprivation exacerbates anger, irritability, and moodiness. Aim for 7 to 9 hours of quality sleep each night.

Step 5: Deal with flashbacks, nightmares, and intrusive thoughts

Flashbacks usually involve visual and auditory memories of combat. It feels as if it’s happening all over again so it’s vital to reassure yourself that the experience is not occurring in the present.

State to yourself (out loud or in your head) the reality that while you feel as if the trauma is currently happening, you can look around and recognize that you’re safe.

Use a simple script when you awaken from a nightmare or start to experience a flashback: “I feel [panicked, overwhelmed, etc.] because I’m remembering [traumatic event], but as I look around I can see that the event isn’t happening right now and I’m not in danger.”

Describe what you see when look around (name the place where you are, the current date, and three things you see when you look around).

Try tapping your arms to bring you back to the present.

Tips for grounding yourself during a flashback: 

Movement - Move around vigorously (run in place, jump up and down, etc.); rub your hands together; shake your head

Touch - Splash cold water on your face; grip a piece of ice; touch or grab on to a safe object; pinch yourself; play with worry beads or a stress ball

Sight - Blink rapidly and firmly; look around and take inventory of what you see

Sound - Turn on loud music; clap your hands or stomp your feet; talk to yourself (tell yourself you're safe, you'll be okay)

Smell - Smell something that links you to the present (coffee, mouthwash, your wife's perfume) or a scent that has good memories

Taste - Suck on a strong mint or chew a piece of gum; bite into something tart or spicy; drink a glass of cold water or juice

Step 6: Work through survivor's guilt

Feelings of guilt are very common among veterans with PTSD. You may have seen people injured or killed, often your friends and comrades.

You may ask yourself questions such as: Why did I survive when others didn’t?
You may end up blaming yourself for what happened and believing that your actions (or inability to act) led to someone else’s death.

You may feel that you’re the one who should have died.

This is survivor’s guilt.

Healing from survivor's guilt

Healing doesn’t mean that you’ll forget what happened or those who died. And it doesn’t mean you’ll have no regrets. What it does mean is that you’ll look at your role more realistically:

Is the amount of responsibility you’re assuming reasonable?

Could you really have prevented or stopped what happened?
Are you judging your decisions based on full information about the event, or just your emotions?

Did you do your best at the time, under challenging circumstances?

Do you truly believe that if you had died, someone else would have survived?

Honestly assessing your responsibility and role can free you to move on and grieve your losses. Instead of punishing yourself, you can redirect your energy into honoring those you lost and finding ways to keep their memory alive.

Step 7: Seek professional treatment

Professional treatment for PTSD can help you deal with the trauma you’ve experienced and may involve:

Cognitive-behavioral therapy (CBT) or counselling. This involves gradually “exposing” you to reminders of the event and replacing distorted thoughts with a more balanced picture.

Medication, such as antidepressants. While medication may help you feel less sad or worried, it doesn't treat the causes of PTSD.

EMDR (Eye Movement Desensitization and Reprocessing). This incorporates elements of CBT with eye movements or other rhythmic, left-right stimulation to help you become “unstuck.”

Helping a veteran with PTSD

When a loved one returns from military service with PTSD, it can take a heavy toll on your relationship and family life. You may have to take on a bigger share of household tasks, deal with the frustration of a loved one who won’t open up, or even deal with anger or other disturbing behavior.

Don’t take the symptoms of PTSD personally. If your loved one seems distant, irritable, angry, or closed off, remember that this may not have anything to do with you or your relationship.

Don’t pressure your loved one into talking. Many veterans with PTSD find it difficult to talk about their experiences. Never try to force your loved one to open up but let him know that you’re there if he wants to talk. It’s your understanding that provides comfort, not anything you say.

Be patient and understanding. Getting better takes time so be patient with the pace of recovery. Offer support but don’t try to direct your loved one.

Try to anticipate and prepare for PTSD triggers such as certain sounds, sights, or smells. If you are aware of what causes an upsetting reaction, you’ll be in a better position to help your loved one calm down.

Take care of yourself. Letting your loved one’s PTSD dominate your life while ignoring your own needs is a surefire recipe for burnout. Make time for yourself and learn to manage stress. The more calm, relaxed, and focused you are, the better you’ll be able to help your loved one.



Changes to MST-related PTSD claims processing means more help for Veterans

Women are disproportionately likely to have experienced sexual harassment and/or assault during their military service. This trauma, referred to by VA as military sexual trauma (MST), can result in conditions such as post-traumatic stress disorder (PTSD), as well as a cascading impact on all aspects of life. (Click here for more information on military sexual trauma and treatments available for resulting conditions from VA.)

Due to increased awareness of this problem and the challenges of providing corroborating evidence in many cases, VA has taken a number of steps over the years to better serve MST survivors applying for disability compensation for conditions caused by MST, beginning with relaxing evidentiary standards in 2002. Because events involving sexual trauma are not always officially reported, VA looks for “markers” (i.e., signs, events or circumstances) that provide an indication the traumatic event happened, which include but are not limited to records from rape crisis or mental health counseling centers, tests for pregnancy or sexually transmitted diseases, statements from family members or roommates, transfer requests, deterioration in work performance, episodes of depression or anxiety without an identifiable cause and relationship issues – a longer list is available here.

In response to an identified gap in the percent of claims granted for PTSD caused by MST compared to other causes, such as combat-related PTSD, additional changes were made. These include conducting special training for VA regional office personnel who process MST-related claims beginning in 2011 and offering specialized training to medical examiners who provide input on these cases in 2012.

How effective have those efforts been? The table below shows the percent of PTSD issues granted for MST-related and non-MST related claims. In FY11, there is a substantial gap: 59.5% of non-MST related PTSD claims were granted, compared to only 35.6% of MST-related PTSD claims, a nearly 24 point gap. Three years later, in FY14, the gap had shrunk to less than six points, with grant rates of 54.1% and 48.5% respectively. So far this fiscal year, the gap is only around one point, with grant rates of 54.6% for non-MST related claims and 53.4% for MST-related claims.

Impact of Changes to MST-Related PTSD Claims Processing

Impact of Changes to MST-Related PTSD Claims Processing

The dramatic narrowing of the gap, from over 20 points six years ago to virtually indistinguishable today, shows the success of those efforts. The Veterans Benefits Administration and the Center for Women Veterans will continue to analyze data to sustain these improvements in equitable decision-making.

For help with disability compensation related to MST, read more here and contact the MST coordinator at your local Veterans Benefits Administration Regional Office.


PTSD Awareness 

The links below are great resources for Veterans and staff to “Learn, Connect & Share” PTSD information.


Link to NEW PTSD Treatment Decision Aid for Veterans:

Link to National Center for PTSD

Link to Patient Education SharePoint site:


Lake County Suicide Prevention Task Force Sponsors Seminar
How to Recognize and React to Signs of Suicidal Behavior


Sharing the latest in suicide prevention trends and practices with area professionals, the Lake County Suicide Prevention Task Force sponsored a day-long seminar on April 11, 2017 at the College of Lake County’s Grayslake campus.

The event was hosted by the College’s Human Services and Social Work Department. About 175 professional social workers and other clinicians attended.

Jason I. Chen PhD, the Health Services Research and Development Fellow at the VA Portland Health Care System, travelled from Oregon to lead the seminar. Chen is a member of the Center to Improve Veteran Involvement in Care (CIVIC) team.

Dr. Chen identified several warning signs that indicate that someone may be at imminent risk of taking their own lives. These include experiencing recent changes in sleep difficulties, hopelessness, anxiety, anger, or mood swings, engaging in risky behaviors, withdrawing from family, friends and co-workers, increased use of alcohol and drugs and talking about death and dying.

These factors also may be influenced by significant stressors such as financial loss or relationship instability, Dr. Chen said. For veterans, possible additional stressors include length, frequency and type of deployment, especially if it includes combat.

Protective factors such as a social support system, a sense of purpose, and values and beliefs, may also play a role in someone’s thinking and actions, he added.

Dr. Chen told the clinicians that, if they encounter someone who is in a suicidal crisis, they can act with care and compassion by following the VA Office of Suicide Prevention’s acronym SAVE:

Signs of suicidal thinking should be recognized;

Ask the most important question: “Are you thinking of taking your own life?;

Validate the person’s experience; and

Encourage treatment while Expediting the intervention of help.

Asking about the presence of guns also is recommended. Firearms were one of the top five leading causes of injury-related deaths nationwide in 2010. Veterans are more likely to use firearms in acts of suicide than the general population.

Dr. Chen said that calling the National Crisis Line National Suicide Prevention Lifeline at 1-800-273-8255, or 911, can be effective ways to get help for people in crisis.

“We are happy that so many professionals attended today’s seminar,” said Katia Marshall, Chair of the Lake County Suicide Prevention Task Force. Marshall is a therapist with the Lake County Health Department.

The task force is comprised of members that include the Lake County Health Department, Waukegan Police Department, area first responders, College of Lake County, Lake County Veterans and Family Services Foundation, Lovell Federal Health Care Center, hospitals, agencies , counseling centers and other resources that can help people in need and in crisis.

“Getting this information to professionals is critical,” Marshall said. “It’s part of our mission to share prevention best practices and available resources with everyone in Lake County. We thank Dr. Chen and CLC for making this seminar possible.”

Copies of the task force’s Resource Guide – “Get Help, Have Hope”, were distributed to attendees. This handy guide offers the contact information for crisis-related resources across Lake County including: addiction, counseling, dental and medical, disability, domestic violence, financial, hunger, homelessness, general hotlines, military, veteran and families, and seniors.

Copies of “Get Help, Have Cope” ”are available by contacting Katia Marshall of the Lake County Suicide Prevention Task Force at This email address is being protected from spambots. You need JavaScript enabled to view it.


Meditation-based Approaches in the Treatment of PTSD

PTSD Research Quarterly
VOLUME 28/NO. 2, APRIL 2017
The latest issue of the PTSD Research Quarterly (PDF) is now available:

by Alexander M. Talkovsky, PhD and Ariel J. Lang, PhD, MPH

Moving beyond psychotherapies that focus primarily on behavior and cognitive change, the emergence of the Third Wave of Cognitive Behaviorism during the past decade, has led to the development of psychotherapies that have been influenced by Zen Buddhist teachings and mindfulness approaches that embrace acceptance of self, internal experiences, the environment and others.

This issue of the PTSD Research Quarterly provides a guide to recent clinical trials on meditation-based approaches for the treatment of PTSD.  Click here to read full article.

Tell a friend so they can subscribe to the PTSD Research Quarterly Online (RQ).

Sign up for the PTSD Monthly Update or other publications from the National Center for PTSD.


VA, DOD Study a Major Breakthrough for Understanding PTSD

March 25, 2017 - WASHINGTON — Researchers from the Department of Veterans Affairs (VA) and Department of Defense (DOD) recently released findings of a new study called Prospective Post-Traumatic Stress disorder Symptom Trajectories in va logoActive Duty and Separated Military Personnel, which examines Post Traumatic Stress Disorder (PTSD) symptoms in Veterans, compared with active-duty populations.

This is the first known study comparing PTSD symptom trajectories of current service members with those of Veterans, and is the product of a collaborative effort from VA and DOD researchers analyzing data from the Millennium Cohort Study (MCS), the largest prospective health study of military service members.

According to VA’s National Center for PTSD, the PTSD rate among Vietnam Veterans was 30.9 percent for men and 26.9 percent for women. For Gulf War Veterans, the PTSD rate was 12.1 percent. Operation Enduring Freedom/Operation Iraqi Freedom Veterans had a PTSD rate of 13.8 percent.

“Knowing there are similarities in how PTSD affects service members and Veterans makes it easier to pinpoint which treatments are the best to control the condition,” said Dr. Edward Boyko, an epidemiologist and internist at the VA Puget Sound Health Care System in Washington state, and VA’s lead researcher on the Millennium Cohort Study.

Officials involved with the project said they are hoping the collaboration will improve the understanding of Veterans’ health needs, relative to their experiences in service.

“The data that MCS researchers have been collecting since 2001 is incredibly valuable for both the DOD and VA,” said Dr. Dennis Faix, director of the Millennium Cohort Study and preventive medicine physician. “Going forward, working with VA will allow both agencies to make sure we are getting the best information to develop a comprehensive understanding of the continuum of health in current and former service members.”

The results of the joint VA DOD study will appear in the Journal of Psychiatric Research’s June 2017 issue. It is the first of many joint future publications expected to result from the collaboration between VA and MCS.

You can learn more about the study here:


Researchers found that 69 percent of veterans who were evaluated for self-reported PTSD symptoms also were at high risk for sleep apnea.

DARIEN, Ill., (UPI) -- Young veterans with post-traumatic stress disorder, or PTSD, have a high probability of obstructive sleep disorder, according to a small study.

"The implication is that veterans who come to PTSD treatment, even younger veterans, should be screened for obstructive sleep apnea so that they have the opportunity to be diagnosed and treated," said Sonya Norman, PhD, researcher at the San Diego VA, director of the PTSD Consultation Program at the National Center for PTSD, and an associate professor of psychiatry at the University of California San Diego School of Medicine, in a press release. "This is critical information because sleep apnea is a risk factor for a long list of health problems such as hypertension, cardiovascular disease and diabetes, and psychological problems including depression, worsening PTSD and anxiety."

The study was conducted based on veterans also reporting snoring and fatigue, motivating researchers to launch the investigation. Among the 159 veterans included in the study, 69 percent were seen as being at high risk for sleep apnea.

Younger veterans generally aren't screened for sleep apnea, however researchers believe that aspects of PTSD, such as disturbed sleep and sleep deprivation, psychological and physical stressors of combat, hyperarousal due to those stressors, may increase the chances of sleep apnea occurring.

The study is published in Journal of Clinical Sleep Medicine.


New Deep Relaxation Technology Therapy Arrives in the U.S.

Veterans, Athletes, Business People and Many Others Benefits from Blu Room Sessions

Yelm, Washington (PRWEB) March 15, 2017

The Blu Room, a new treatment combining relaxation, technology, music and Narrowband UVB light therapy (phototherapy), will be expanding to six locations in the U.S. in 2017. Three centers in Washington State will be augmented by Blu Rooms in Florida, Missouri and Utah.

Most scientists and the public agree on the benefits of relaxation. Peer-reviewed medical studies on meditation from Johns Hopkins* and UCLA* (see below) confirm the healing powers such as increased attention span, improved memory, relieving anxiety and depression, pain relief, and spurring creativity.

The Blu Room sessions, consisting of 20 minutes of deep relaxation inside a futuristic octagon bathed in blue UV-B light, uses music, tranquility and technology to produce some of the same results noted in those studies. The Blu Room is a non-invasive, non-surgical practice. It's not a tanning device, users wear regular clothing.

The Blu Room was invented in Yelm outside of Seattle by JZ Knight, the exclusive channel for Ramtha. Since the first Blu Room opened in 2015, there have been more than 30,000 user sessions provided.

The Blu Room experience varies from person to person. Many people have described it as being deeply relaxing, lifting their mood, and bringing about a state of slightly detached calm or peace. A common side benefit of this state is a relief from aches and pains. Some people experience dynamic shifts in perspective and spiritual insights. Since the mind is the greatest healer and the mind is inextricably intertwined with DNA, the Blu Room can augment a person's natural healing abilities. Some simply enjoy a break in their daily routine to refresh themselves.

Those enjoying the Blu Room include athletes, housewives, doctors, students, retired people and many active duty and military veterans.

Two veterans in the Olympia area with Post Traumatic Stress Disorder (PTSD) are regulars users. Cynthia Williams-Patnoe, a pilot who served in Afghanistan, returned home from war and was struck by a pickup truck, suffering a traumatic brain injury. She then started using the Blu Room. "The Blu Room was very peaceful and therapeutic," Williams-Patnoe says. She went 3-4 times per week, for 20 sessions. "My short-term memory was coming back thanks to the sessions."

Dale Vaughn, a Vietnam veteran, suffered from years of nightmares and was diagnosed with PTSD. He began using the Blu Room in late 2016. "It feels like I'm going to a place of peace, Vaughn says. "You feel healthy and happy."

The Department of Veterans Affairs estimated up to 30% of Vietnam Veterans have experienced PTSD in their lifetime.

There are 11 Blu Rooms in operation throughout the world in in Austria (2), Germany (2), Switzerland (3) and one each in Ecuador, Italy, Japan and in Quebec, Canada. Six more locations will open in 2017 in Aso, Japan; Bathurst, Australia; Calgary, Canada; Mexico City, Mexico; New Taipei City, Taiwan and Osaka, Japan.

There are medical studies on the benefits of Narrowband UVB light therapy such as relief from psoriasis such as "Therapy Of Psoriasis With Narrowband Ultraviolet-B Light Influences Plasma Concentrations Of MMP-2 And TIMP-2 In Patients," published in the Journal of Therapeutics and Clinical Risk Management in October, 2016.

Other studies mentioned include "Meditation Programs for Psychological Stress and Well-being A Systematic Review and Meta-analysis" by Johns Hopkins researchers published in March 2014 and "Forever Young(er): potential age-defying effects of long-term meditation on gray matter atrophy" published in January 2015.


If you are enrolled in the VA Health Care System, getting your flu shot at Walgreens or Duane Reade is easy.

Click to learn


This section is for Researchers, Providers, and Helpers

PTSD Research Quarterly (RQ)

RQ newsletter

The National Center for PTSD produces the PTSD Research Quarterly (RQ) newsletter.

Each RQ contains a review article written by guest experts on a specific topic related to PTSD.

The article has a selective bibliography with abstracts and a supplementary list of annotated citations.

Recent Issues


*Problems Accessing full text? VA clinicians might have privileges through their university affiliation. However, VA firewalls sometimes block the permissions to access reference materials. If you cannot access the Full Text version of any article, we suggest you contact your local librarian or web/Internet technical person.

If you usually have access to full text from the journal in which an article is published, but are not seeing it from the link provided, try accessing it directly through your university library system. Many online services have password access that only works through a user's library system.

National Center for PTSD

The National Center for PTSD does not provide direct clinical care, individual referrals or benefits information.


Suicide Among Veterans and Other Americans 2001–2014

More than 55 Million Veterans’ Records Reviewed From 1979 to 2014 From Every State in the Nation

WASHINGTON – The Department of Veterans Affairs (VA) today released its findings from the nation’s most comprehensive analysis of Veteran suicide rates in the United States in which VA examined more than 55 million Veterans’ records from 1979 to 2014 from every state in the nation. The effort advances VA’s knowledge from the previous report in 2012, which was primarily limited to information on Veterans who used VHA health services or from mortality records obtained directly from 20 states and approximately 3 million records.. Compared to the data from the 2012 report, which estimated the number of Veteran deaths by suicide to be 22 per day, the current analysis indicates that in 2014, an average of 20 Veterans a day died from suicide.

A link to the report may be found here.


An Important Perspective

In this July 12, 2010 photo, journalist and documentary film maker Sebastian Junger poses for a photo in Toronto.

Sebastian Junger: Over-Valorizing Vets Does More Harm Than Good


Click here to read entire Interview 


About Traumatic Brain Injury

Falls are the leading cause of traumatic brain injury for all ages. Those aged 75 and older have the highest rates of traumatic brain injury-related hospitalization and death due to falls.

Doctors classify traumatic brain injury as mild, moderate or severe, depending on whether the injury causes unconsciousness, how long unconsciousness lasts and the severity of symptoms. Although most traumatic brain injuries are classified as mild because they're not life-threatening, even a mild traumatic brain injury can have serious and long-lasting effects.

Traumatic brain injury is a threat to cognitive health in two ways:

1.   A traumatic brain injury's direct effects, which may be long-lasting or even permanent, can include unconsciousness, inability to recall the traumatic event, confusion, difficulty learning and remembering new information, trouble speaking coherently, unsteadiness, lack of coordination and problems with vision or hearing.

2.    Certain types of traumatic brain injury may increase the risk of developing Alzheimer's or another form of dementia years after the injury takes place. 

If Head Injury Occurs

If you or someone you're with experiences an impact to the head and develops any symptoms of traumatic brain injury, seek medical advice even if symptoms seem mild. Call emergency services for anyone who is unconscious for more than a minute or two or who experiences seizures, repeated vomiting or symptoms that seem to worsen as time passes. Also seek emergency care for anyone whose head was injured during ejection from a vehicle, who was struck by a vehicle while on foot, or who fell from a height of more than 3 feet. Even if you don't lose consciousness and your symptoms clear up quickly, a brain injury still may have occurred.


Symptoms of a brain injury include:

·         Unconsciousness

·         Inability to remember the cause of the injury or events that occurred Immediately before or up to 24 hours after

·         Confusion and disorientation

·         Difficulty remembering new information

·         Headache

·         Dizziness

·         Blurry vision

·         Nausea and vomiting

·         Ringing in the ears

·         Trouble speaking coherently

·         Changes in emotions or sleep patterns

The severity of symptoms depends on whether the injury is mild, moderate or severe.

·      Mild traumatic brain injury, also known as a concussion, either doesn't knock you out or knocks you out for 30 minutes or less. Symptoms often appear at the time of the injury or soon after, but sometimes may not develop for days or weeks. Mild traumatic brain injury symptoms are usually temporary and clear up within hours, days or weeks, but they can last months or longer.

·      Moderate traumatic brain injury causes unconsciousness lasting more than 30 minutes. Symptoms of moderate traumatic brain injury are similar to those of mild traumatic brain injury but more serious and longer-lasting.

·      Severe traumatic brain injury knocks you out for more than 24 hours. Symptoms of severe traumatic brain injury are also similar to those of mild traumatic brain injury but more serious and longer-lasting.


Evaluations by health care professionals typically include:

·     Questions about the circumstances of the injury

·     Assessment of the person's level of consciousness and confusion

·     Neurological examination to assess memory and thinking, vision, hearing, touch, balance, reflexes and other indicators of brain function

Depending on the nature of the traumatic brain injury and the severity of symptoms, brain imaging with computed tomography (CT) may be needed to determine if there's bleeding or swelling in the brain.

Causes and risks

Falls are the most common cause of traumatic brain injury, and falling poses an especially serious risk for older adults. When a senior sustains a traumatic brain injury in a fall, direct effects of the injury may result in long-term cognitive changes, reduced ability to function and changes in emotional health.

Vehicle crashes are another common cause of traumatic brain injury. You can reduce your risk by keeping your vehicle in good repair, following the rules of the road, and buckling your seat belt.

Sports injuries are also a cause of traumatic brain injury. You can protect your head by wearing a helmet and other protective equipment when biking, inline skating or playing contact sports.

Other causes include:

·         Indirect forces that jolt the brain violently within the skull, such as shock waves from battlefield explosion

·         Bullet wounds or other injuries that penetrate the skull and brain

 Dementia and Traumatic Brain Injury

Over the past 30 years, research has linked moderate and severe traumatic brain injury to a greater risk of developing Alzheimer's disease or another type of dementia years after the original head injury.

·     One of the key studies showing an increased risk found that older adults with a history of moderate traumatic brain injury had a 2.3 times greater risk of developing Alzheimer's than seniors with no history of head injury, and those with a history of severe traumatic brain injury had a 4.5 times greater risk.

·      Other studies — but not all — have found a link between moderate and severe traumatic brain injury and elevated risk.

·     Emerging evidence suggests that individuals who have experienced repeated traumatic brain injuries (concussions) or multiple blows to the head without loss of consciousness, such as professional athletes and combat veterans, are at higher risk of developing a brain condition called chronic traumatic encephalopathy (CTE) than individuals who have not experienced repeated brain injuries.

·      Current research on how traumatic brain injury changes brain chemistry indicates a relationship between traumatic brain injury and hallmark protein abnormalities (beta-amyloid and tau) linked to Alzheimer's.

·     Some research suggests that traumatic brain injury may be more likely to cause dementia in individuals who have a variation of the gene for apolipoprotein E (APOE)called APOE-e4. More research is needed to understand the link between APOE-e4 and dementia risk in those who've had a brain injury.


Treatment and outcomes

The most serious traumatic brain injuries require specialized hospital care and can require months of inpatient rehabilitation. Most traumatic brain injuries are mild and can be managed with either a short hospital stay for observation or at-home monitoring followed by outpatient rehab, if needed.

Treatment of dementia in a person with a history of traumatic brain injuries varies depending on the type of dementia diagnosed. Strategies for treating Alzheimer's or another specific type of dementia are the same for individuals with and without a history of traumatic brain injury.

Alzheimer's disease and other dementias that may occur as a long-term result of traumatic brain injury are progressive disorders that worsen over time. As with all dementias, they affect quality of life, shorten lifespan and complicate the effort to manage other health conditions effectively.


                     “After Services: Veteran Families in Transition”                  

Excerpt “What happens to families after separation from the military? Joy and optimism at the return of a loved one may compete with painful realities and adjustments.”

Sections include

·         Today’s Military Veteran Family

·         Life Reshuffled

·         Physical and Cognitive Wounds of War

·         Assessing Veterans and Families: A Provider’s Key Questions

·         Links to NCTSN Military and Veteran Families Questionnaire (MVFQ)

·         Exploring Solutions and Collaborations

·         Community Provider Toolkit- Serving Veterans Through Partnership

·         Resources and Links

Please share these resources with others in your organizations and networks! Thank you to our Veterans and their Families for your service. We hope these materials will assist our Veteran Families in their transitions.

Gregory Leskin, Ph.D.

Director, NCTSN Military and Veteran Families Program

LCVFSF3-18-16NCTSN Veterans Families Page 1

To Read the Entire Report, Click Here


 These Are The New Therapies Being Used To Combat PTSD In War Veterans

Traditional psychotherapy may combat the effects of post-traumatic stress for many veterans — but not all of them. Seattle's Veterans Affairs hospital on Beacon Hill has started using several different methods to help our wounded warriors. These new ways to treat and alleviate PTSD didn't come from a government bureaucrat, a clinical study, or an act of Congress. Instead, local agencies and experts around Seattle decided to see if several new programs could work. So far, these innovations seem to be working, and here's why.

Via The National Center for Telehealth And Technology (T2)


Traditional psychotherapy may combat the effects of post-traumatic stress for many veterans — but not all of them. Seattle's Veterans Affairs hospital on Beacon Hill has started using several different methods to help our wounded warriors. These new ways to treat and alleviate PTSD didn't come from a government bureaucrat, a clinical study, or an act of Congress. Instead, local agencies and experts around Seattle decided to see if several new programs could work. So far, these innovations seem to be working, and here's why.


One interesting therapy involves fly fishing experts from Project Healing Waters Fly Fishing. These experts teach some veterans how to catch fish using handmade flies, reports Seattle Magazine. Many veterans use this time to concentrate and relax, as fly-tying gives their minds something else to concentrate on through the detailed work involved. Once they finish tying flies, veterans test them out on fishing trips. This low-tech therapy counters some high-tech ways to ease PTSD.


A virtual reality tool developed at the University of Washington also helps bring soldiers back into the memories of their trauma in the hope that they can reduce anxiety symptoms. The virtual reality program, called IraqWorld, has visuals and sounds similar to what soldiers may experience in a real combat zone. Once warriors confront the PTSD symptoms, psychologists believe that symptoms lessen and eventually dissipate completely. Aside from real-world experiences, actual physical activity may also alleviate symptoms.

Via National Center for Telehealth And Technology (T2)


Movement therapies help with PTSD symptoms as well. One such therapy combines yoga, philosophy, and traditional psychotherapy into one session. Yoga helps calm the mind and body while the wounded warrior focuses on breathing and the psychological aspects needed to ease PTSD. Yoga therapies are used at many military installations, notes the New York Times.

It's important that complementary therapies are used because different people process stress in different ways, and every wounded warrior needs treatment. Many of these complementary activities don't feel like therapy. Approximately 30 percent of veterans in combat zones have PTSD symptoms, says the City of Seattle. As many as half of veterans diagnosed with psychological issues don't seek treatment for fear of social stigmas or lack of drive to confront their problems. Fly fishing, mobile apps, yoga, and virtual reality all attempt to lessen those concerns while providing a wide range of possibilities for therapy.

Via Project Healing Waters Fly Fishing, Inc.

Because PTSD is so widespread among veterans, it is important we make more therapies available to these soldiers. Tell the VA to follow Seattle's example and approve more therapies for PTSD.





Pilot study shows meditation can help US veterans manage chronic pain

WASHINGTON, D.C. (Feb. 5, 2016) --They return to the United States with multiple types of trauma, and suffer from one of the highest rates of chronic pain of any population in the United States. They are U.S. veterans. A major challenge for health care providers is how to help them alleviate pain that will last a lifetime. Now, a new study suggests veterans may be empowered to help themselves with the practice of meditation.

A small pilot study conducted at the Washington, D.C. Veterans Affairs Medical Center reveals that veterans who practiced meditation reported a 20 percent reduction in pain intensity (how bad pain hurts or feels), as well as pain interference, how pain interferes with everyday aspects of life, such as sleep, mood, and activity level. The reductions were consistent across several methods by which doctors commonly measure pain in patients.

"Meditation allows a person to accept pain and to respond to pain with less stress and emotional reactivity. Our theory is that this process increases coping skills, which in turn can help veterans to self-manage their chronic pain," said Thomas Nassif, Ph.D., a professorial lecturer in American University's Department of Health Studies, researcher at the D.C. Veterans Affairs Medical Center, and lead author of the new study published in Military Behavioral Health.

Pain is a significant health issue among the approximately 2.6 million service members who have served in Operation Enduring Freedom in Afghanistan and Operation Iraqi Freedom in Iraq since these conflicts began in 2001, according to the Veterans Health Administration. Musculoskeletal pain conditions are the most frequently diagnosed medical issue, exceeding any other medical and psychological concern. Chronic pain is also found in most combat veterans who sustained a traumatic brain injury.

The form of mindfulness meditation administered in the study, Integrative Restoration Yoga Nidra, or iRest, is used at Veterans Health Administration medical centers and active-duty military facilities nationwide. The Army surgeon general's Pain Management Task Force has cited iRest as a Tier I intervention for managing pain in military and veteran populations.

The pilot study consisted of four male veterans who received iRest meditation treatment, and five who did not. All study participants served in combat and returned to the U.S. with chronic pain and moderate TBI. The study participants attended meditation sessions twice weekly at the D.C. Veterans Affairs Medical Center and were given iRest recordings to engage in self-practice as well. By the end of eight weeks, the study participants had acquired useful mindfulness skills that empowered them to use meditation as a tool to help manage their pain, Nassif said.

"In many cases, primary care physicians are the ones expected to help individuals overcome their chronic pain," Nassif said. "One of the most commonly used tools we have in our toolbox is opioids. Veterans in this study, and many who come to meditation sessions, find that opioid medication is a short-term solution. Meditation could be a useful tool to help veterans manage their pain over the long term."

The study calls on health care providers to promote self-management in patients by disseminating strategies and techniques to help patients prevent, cope with, and reduce pain, and concludes that iRest represents one promising self-management approach. More research should be conducted, Nassif said, and future studies should include quantitative measures and a greater number of participants.

Author contributors include Julie C. Chapman, Psy.D., director of Neuroscience, Neurology Service, Veterans Affairs Medical Center, Washington, D.C.; Deborah O. Norris, Ph.D., founder and executive director, The Mindfulness Center, Bethesda, Md.; Friedhelm Sandbrink, M.D., neurologist and pain specialist, Neurology Service, Veterans Affairs Medical Center, Washington, D.C.; Karen L. Soltes, LCSW, iRest Instructor; Matthew Reinhard, Psy.D., director, War Related Illness and Injury Study Center, Veterans Affairs Medical Center, Washington, D.C.; and Marc R. Blackman, M.D., Associate Chief of Staff for Research and Development, Veterans Affairs Medical Center, Washington, D.C.

American University is a leader in global education, enrolling a diverse student body from throughout the United States and nearly 140 countries. Located in Washington, D.C., the university provides opportunities for academic excellence, public service, and internships in the nation's capital and around the world.

Disclaimer: AAAS and EurekAlert! are not responsible for the accuracy of news releases posted to EurekAlert! by contributing institutions or for the use of any information through the EurekAlert system.


New PTSD Perspective


What Does a Parrot Know About PTSD?

An unexpected bond between damaged birds and traumatized
veterans could reveal surprising insights into animal intelligence.

Charles Siebert,  JAN. 28, 2016

Nearly 30 years ago, Lilly Love lost her way. She had just completed her five-year tour of duty as an Alaska-based Coast Guard helicopter rescue swimmer, one of an elite team of specialists who are lowered into rough, frigid seas to save foundering fishermen working in dangerous conditions. The day after she left active service, the helicopter she had flown in for the previous three years crashed in severe weather into the side of a mountain, killing six of her former crewmates. Devastated by the loss and overcome with guilt, Love chose as her penance to become one of the very fishermen she spent much of her time in the Coast Guard rescuing. In less than a year on the job, she nearly drowned twice after being dragged overboard in high seas by the hooks of heavy fishing lines.    Continue Reading


The War Disorder Beyond the Battlefield

Click here to read


Clinician Certification and Equine Therapy Scholarships Are Available


A fully accredited Gestalt Equine Therapy sessions for clinicians are conducted by Helena Lee, MA, LPC, RN of Urban Balance in Denver, Colorado. The session entails learning basics about horses followed by intense interactions between student and horse. The objective of the training is to enlighten clinicians about how humans and animals build trust through various forms of interpersonal communications. The benefits that are derived from re-living the powerful experience of learning how to trust another can be applied as a basic building block in many forms of recoveries.

The day's seminar prepares each clinical participant to accurately assess and refer consumers for one of 12 ten-week equine therapy scholarships to be conducted at Horsefeathers by Urban Balance that LCVFSF will award over the course of the year.

The scholarships are for active duty military, Veterans and/or their family members who are actively seeking relief from the trauma of deployment: pre, during or post. These include: PTSD, Traumatic Brain Injury, sexual trauma, grief, suicide, re-integration, or substance abuse. Gestalt Equine Therapy is conducted at Horsefeathers Therapeutic Riding Center in Lake Forest, IL. Each scholarship is for 8 weeks of riding. The first 3 weeks will be a one ½ hour session per week. The second 5 weeks will be two ½ hour sessions per week. We are currently recruiting candidates for the awards. To refer a consumer for scholarship application please contact us 847-986-4622

If you are a clinician and are interested being accredited for Gestalt Equine Therapy, we are recruiting for the second class. To apply for the session, contact M.J. Hodgins, Director of Communitry Development for LakeCounty Veterans and Family Services Foundation: MHodgins@lake> or (847) 986-4622.


Veterans with PTSD at Higher Risk for Sleep Apnea


Researchers found that 69 percent of veterans who were evaluated for self-reported PTSD symptoms also were at high risk for sleep apnea.

DARIEN, Ill., May 20 (UPI) -- Young veterans with post-traumatic stress disorder, or PTSD, have a high probability of obstructive sleep disorder, according to a small study. 

"The implication is that veterans who come to PTSD treatment, even younger veterans, should be screened for obstructive sleep apnea so that they have the opportunity to be diagnosed and treated," said Sonya Norman, PhD, researcher at the San Diego VA, director of the PTSD Consultation Program at the National Center for PTSD, and an associate professor of psychiatry at the University of California San Diego School of Medicine, in a press release. "This is critical information because sleep apnea is a risk factor for a long list of health problems such as hypertension, cardiovascular disease and diabetes, and psychological problems including depression, worsening PTSD and anxiety."

The study was conducted based on veterans also reporting snoring and fatigue, motivating researchers to launch the investigation. Among the 159 veterans included in the study, 69 percent were seen as being at high risk for sleep apnea.

Younger veterans generally aren't screened for sleep apnea, however researchers believe that aspects of PTSD, such as disturbed sleep and sleep deprivation, psychological and physical stressors of combat, hyperarousal due to those stressors, may increase the chances of sleep apnea occurring.

The study is published in Journal of Clinical Sleep Medicine.


 An instructor with Joined Forces Yoga teaches a class for Soldiers with the 2nd Brigade Combat Team, 101st Airborne Division (Air Assault) offered by Joined Forces Yoga at Fort Campbell, Kentucky, April 23, 2015. (U.S. Army photo/ Sgt. Sierra A. Fown)

An instructor with Joined Forces Yoga teaches a class for Soldiers with the 2nd Brigade Combat Team, 101st Airborne Division (Air Assault) offered by Joined Forces Yoga at Fort Campbell, Kentucky, April 23, 2015. (U.S. Army photo/ Sgt. Sierra A. Fown)

VA Weighs PTSD Care that Avoids Traumatic Memories

NAPLES, Italy — Revisiting a traumatic event in a therapy session can open a door to relief for those suffering from post-traumatic stress disorder. But confronting bad memories may not be the answer for everyone.

After years of emphasizing trauma-focused psychotherapy as a preferred treatment for PTSD, researchers and clinicians with the Department of Veterans Affairs are considering forms of therapy that steer clear of traumatic memories, including those focusing on mindfulness.

Although relatively new and backed by less research than other therapies, the treatments could expand practitioners’ options and could offer patients a greater say in their care, a top VA clinician said. That, in turn, could lead to better outcomes.

“I think the coming years will be a maturation of the field, the realization that there’s more than one door,” said Harold Kudler, chief consultant for VA Mental Health Services.

Since 2008, the VA has largely recommended therapies that focus on trauma. Among the most common is cognitive-processing therapy, or CPT, which pushes patients to readjust their associations with negative memories. Another, prolonged exposure, seeks to reduce the power of a negative memory by having the patient confront it repeatedly.

A study published this month in the Journal of the American Medical Association suggests a number of new possibilities. VA researchers in Minneapolis found that a group of PTSD patients enrolled in a program with yoga and breathing meditation over nine weeks reported greater improvement in symptoms than their counterparts in a control group that taught coping skills.

“It demonstrates that we can have another important arrow in our quiver,” Kudler said of the study. “Because there are many people who aren’t ready to do these kinds of (trauma-focused) therapies.”

Alternative therapies likely will receive more discussion next year as the VA begins work on an updated set of guidelines for PTSD treatment, Kudler said. The publication, a collection of research and clinical studies with recommended treatments, affects thousands of veterans and servicemembers by educating the practitioners who see them.

The VA recommends trauma-focused treatments like cognitive-processing therapy and prolonged exposure because they are considered evidence-based, meaning the substantial weight of research shows they relieve symptoms of PTSD, said Paula Schnurr, executive director of the VA’s National Center for PTSD.

“Right now, a person’s best chance of having a meaningful improvement in PTSD, in remission, in getting relief, is with the trauma-focused therapies,” she said.

But engaging and retaining patients in such therapies has been a challenge. A recent Minneapolis VA review of cases for a large sample of veterans offered cognitive-processing therapy or prolonged exposure found that roughly 50 percent never began or dropped out of their program.

Some patients simply may not be ready for intense psychotherapy, Kudler said, a consideration often overlooked by therapists.

“I think in the rush to do good and the belief in what they do, you’ll hear, ‘Well this is good therapy, you should do this,’ ” Kudler said. “The part that is missing is the patient. Therapy is about the patient. Working with veterans is always about the veterans.”

As mental health care for veterans moves toward a patient-centered care model that emphasizes patient preference, clinicians will need more options at their disposal, Kudler said, even if that means getting ahead of the science and using alternative treatments.

The researchers in the mindfulness-based stress reduction study noted the tentative nature of their findings, calling them “promising” but in need of validation by further studies. Schnurr has authored a forthcoming study on a different mindfulness-based treatment, called acceptance and commitment therapy, that shows patients received no more relief from PTSD symptoms than those in a control group.

To date, little research has been done into matching therapies with patients, Schnurr said. For example, the needs of a Vietnam veteran with a history of abuse as a child may differ than those of another patient. “Right now, I think patient preference is incredibly important because we don’t have the science to know if a particular treatment will benefit them,” she said.

For Kudler, trauma-focused therapies are still the best options for patients. But the clinical side of mental health care has a long history of flexibility, he said.

“We won’t, and needn’t, wait for science to say different treatments will work better for certain patients,” he said.

© Copyright 2015 Stars and Stripes. All rights reserved. This material may not be published, broadcast, rewritten or redistributed.


Efficacy of PTSD treatments questioned

By Patricia Kime, Staff writer

Two treatments for post-traumatic stress that are considered the gold standard for treating the condition in combat veterans are not significantly more effective than some other approaches, including medication, stress management therapy and mindfulness, according to a new study.

Two types of therapy that focus on confronting and dealing with trauma — cognitive processing therapy and prolonged exposure therapy — are largely considered front-line treatments for PTSD.

But a review of PTSD treatment studies dating back to 1989 found that while the two therapies reduce symptoms, they also have high dropout rates and low follow-through, making them less effective and less likely to completely alleviate symptoms.

According to the research, published in the Journal of the American Medical Association on Aug. 4, nearly a quarter of patients who tried CPT or PE dropped out.

Still, nearly 70 percent of those who received one of the two front-line therapies saw a decrease in symptoms, even as two-thirds still met the criteria for having PTSD after treatment.

"When we looked hard at how effective these two treatments were, as well as some other psychotherapies, we found they are reasonably effective — but they are not as definitively helpful as we would like," said Dr. Charles Marmar, a psychiatrist at NYU Langone and one of the article's authors.

According to the review, conducted by Marmar and other researchers at the Cohen Veterans Center for Post-Traumatic Stress and Traumatic Brain Injury and NYU Langone Medical Center, medications, as well as therapies that teach personal skills and coping strategies or focus on relaxation, mindfulness, yoga and exercise, were nearly as effective as the CPT and PE therapy.

Roughly 13 percent of Iraq and Afghanistan veterans have been diagnosed with PTSD, while 10 percent of Persian Gulf War veterans and 11 percent of Vietnam veterans still have symptoms, according to the study.

To treat the disorder — characterized by intrusive thoughts such as anxiety and nightmares, feeling "on edge" or hyper-aroused, or being detached or disconnected, among other symptoms — clinical practice guidelines used by the Veterans Affairs and Defense departments recommend trauma-related exposures like CPT and PE to treat PTSD.

But other therapies, including conventional medications like antidepressants and some complementary and alternative treatments, appear to help many affected veterans nearly as much as those frontline treatments and could help those who have tried either but failed to respond, according to the study authors.

Marmar recalled two World War II veterans whom he treated while working at the San Francisco VA Health System: One had experienced daily nightmares for 40 years with medication, the other sought marriage counseling with his wife for marital problems that began as soon as he returned from the war.

Neither therapy cured the veterans' PTSD. But they helped eliminate symptoms, Marmar said.

A dose of medication let the first veteran sleep peacefully, with the intrusive nightmares retreating to twice a month. The couple embraced coping strategies that improved their marriage, even after nearly 50 years together.

"My experience is one of great optimism," Marmar said. "Don't give up if the first treatment or second treatment doesn't work. ... It's a lot of trial-and-error work, but with persistence, flexibility and compassionate commitment for the veteran, every patient should to be able to get the assistance they need."

For some veterans, treatment may mean group therapy in a structured mindfulness session. Another study published in the same JAMA edition found that in a group of 116 veterans with PTSD, those treated with mindfulness-based stress reduction experienced a greater reduction of symptoms than those treated with "present-centered" therapy, which focuses on managing current problems in a patient's life.

That study was conducted by the Minneapolis Veterans Affairs Health Care System,

Dr. David Kearney and psychologist Tracy Simpson with the VA Puget Sound Health System, said the two articles indicate that proven alternative therapies could be beneficial to veterans.

"Given the large number of individuals with PTSD, not all of whom will opt for or benefit sufficiently from existing approaches, additional treatments suitable for broad implementation are needed," wrote the two in an editorial accompanying the studies


Chaplain Reflects on Service, Impact of War on Psychological Health

Posted by Carol Roos, DCoE Public Affairs on July 30, 2015

As the Army Chaplain Corps celebrated its 240th anniversary yesterday, retired Army Chaplain David Smith reflected on how his personal experience of war and resiliency – particularly his own recovery from posttraumatic stress disorder (PTSD) brought on during his time in Iraq – affected his work.

As members of the clergy, chaplains possess some advantages that other leaders don't. They are able to listen and counsel service members without prejudice. They can offer spiritual guidance to all faiths no matter the denomination. Service members know that anything they share with a chaplain is confidential.

Smith was deployed nine times during his 30 years in the Army. Nothing brought the war closer than his deployment to Al Anbar Province with the 82nd Airborne Division from August 2003 to April 2004.

"Within a month and a half of being there, I had four near-death experiences with improvised explosive devices and a helicopter hard landing," Smith said. The area was part of the Sunni Triangle, and the insurgency "exploded" in the 82nd's area of operations. He was the task force chaplain supporting 25,000 soldiers. Smith's mission was to be there for others, but Smith found he also needed someone to be there for him.

"The challenges of my mission and the threat were ever-present and presented much stress," he said. "I came back changed." He remained stressed and hypervigilant through three more deployments.

Smith's reactions to the attacks surprised him. Prior to deploying, Smith would prep himself spiritually, emotionally, professionally and physically, and he believed this rendered him somewhat immune to the challenges of the battlefield.

"I thought that this [prep] would have allowed me to be resilient so that no matter what I would go through I would bounce back and continue with the mission," he said. While his preparation helped him get through deployment, Smith learned he was not invincible.

When he returned home from his last deployment in Afghanistan, Smith went to a psychological health professional and submitted to three days of testing.

"The psychotherapist in my outtake session asked me, 'So why are you denying you have [posttraumatic stress disorder (PTSD)]?'"

It was the first time he had been asked that question. Smith was shocked at his diagnosis of something he thought only affected those engaged in fighting. To learn more about PTSD, he volunteered in a pilot program that used cognitive processing therapy. The experience reshaped his ministry, and Smith began applying a different approach to counseling service members with psychological health concerns. Later, he deployed to Afghanistan with two psychologists to assess high-risk soldiers and make sure resources would be available in their communities before they returned home.

"In all, the method was successful," he said. "There was no suicidal ideation, no spouse or family abuse. It [cognitive processing therapy] had a positive effect."

In Smith's final deployment as a senior chaplain in Afghanistan, he served as mentor, coach and trainer for 450 chaplains and chaplain assistants.

Smith's use of psychological health counseling is increasingly shared by chaplains in the military. In a recent pilot, chaplains teamed up with psychological health professionals to prepare service members for mission readiness before and during deployment.

The Army Chaplain Corps, one of the oldest branches of the military, was established July 29, 1775, to serve with the Continental Army. Since then, approximately 25,000 chaplains served in more than 270 major wars and combat engagements.


Kevlar for the Mind: Helping Professionals for Veterans

Like the decade following the end of World War II, the end of the wars in Iraq and Afghanistan has been marked by a tremendous influx of veterans into the classroom. Traditional "brick and mortar" and virtual universities and schools are frantically trying to keep pace with the opportunities afforded to troops through the Post-9/11 GI Bill.

And these opportunities range from technical and scientific fields as found in the Professional Program for Veterans and Military Personnel at California State University to business as exemplified by the Master of Business for Veterans degree at the University of Southern California.

The allure to veterans of "helping professions" like psychology, counseling and social work has been noted for some time. It's believed that many veterans choose these professional careers because they align with the military culture of service, the desire to help those who are most vulnerable. Fortunately, schools have recognized this draw and are responding accordingly.

The Adler University in Chicago offers a fully online master's degree in military psychology, which is popular among active-duty members and veterans.

Offering courses in the areas of operational psychology, trauma and military ethics, the university prepares entry-level clinicians to effectively work with those who have served. The school also offers a specialization in military psychology within its doctoral program in clinical psychology. Program leaders and many faculty members are former military, which makes for a unique and focused experience.

The Massachusetts School of Professional Psychology specifically recruits veterans and reservists into its doctoral program in psychology, called Train Vets to Treat Vets. Former and current troops are learning about the impact of deployment on military families, effective ways for combating post-traumatic stress, and the impact of addictions on veterans and their loved ones. The school also offers critical field experience working with homeless veterans and teaches traditional psychological skills such as individual and group psychotherapy, psychological testing and research.

Based in "Military City USA," the University of Texas at San Antonio hosts a doctoral program in psychology that focuses on the health of military personnel and veterans. Different from the programs above, this degree prepares psychologists for laboratory and field-based research as opposed to clinical work.

As the need for mental health clinicians and researchers continues to grow, particularly in the area of military psychology, public and private universities and schools will continue to respond.

Caring for our nation's warriors through career training and developing culturally aware mental health providers is a good idea and a necessary response to more than a decade of war.

Bret A. Moore, Psy.D., is a board-certified clinical psychologist who served two tours in Iraq. Email him at This email address is being protected from spambots. You need JavaScript enabled to view it.. This column is for informational purposes only and is not intended to convey specific psychological or medical guidance, 


Chicago Area Hines Veterans Hospital Sited In Mass VA Scandal

New Generation Of Veterans Has Higher Suicide Risk, Study Finds

By LISA CHEDEKEL Conn. Health I-Team Writer
Mental Health Research Medical Research U.S. Department of Veterans Affairs Richard Blumenthal Joe Courtney Tom Coburn U.S. Department of Defense

Justin Eldridge's family will never fully understand why nothing seemed to ease the anguish of the young Marine and father of five as he wrestled with post-traumatic stress disorder and traumatic brain injury after a deployment to Afghanistan in 2004-05. Despite stints in VA hospitals and an array of medications, he killed himself in his Waterford home on Oct. 28, 2013. He was 31.

"He did his part — he followed the treatment they gave him," said his widow, Joanna Eldridge, who is now raising their children alone. "It just wasn't enough, in terms of following up with him and figuring out why he wasn't getting better. ... We just have to do better at helping these guys after they get home."

A new study suggests that the suicide risk for Eldridge and other veterans who served in the recent wars in Iraq and Afghanistan is significantly higher — 41 percent to 61 percent higher — than for the general population. The study, led by federal Department of Veterans Affairs and Army researchers, is the most comprehensive look to date at the suicide risk for veterans who were on active duty during the recent wars.

The analysis — to be published next month in the journal Annals of Epidemiology — found that the suicide rate was the highest among veterans during the first three years after leaving military service, and that the risk was elevated for both deployed and non-deployed service members. Suicide rates were not significantly different for those who deployed once, like Eldridge, and those who deployed multiple times.

The study notes that before the Iraq and Afghanistan wars, the suicide rates among active duty and former military personnel had been 20 percent to 30 percent lower than the U.S. general population. But the recent wars are "substantially different" from Vietnam or the first Gulf War, with veterans serving longer tours, deploying multiple times and suffering different kinds of injuries, many from blasts.

In addition, absent a military draft, the recent conflicts might have attracted more volunteers "who may have a higher level of risk-taking behaviors" and who face economic stress and employment problems when they transition home.

The study comes as U.S. Sen. Richard Blumenthal, D-Conn., pushes efforts to revive a suicide prevention bill that died last year. The bill, which passed the House earlier this month, would require an outside review of existing suicide-prevention programs at the Department of Defense and the VA to gauge their effectiveness, and make recommendations for improvement. It also calls for more online and community outreach mental health services and includes incentives to attract psychiatrists to work with veterans.

Dubbed the Clay Hunt Suicide Prevention for American Veterans Act — named for a Texas Marine who killed himself in 2011 — the bill was blocked last year by Republican Sen. Tom Coburn, who has since retired from the Senate.

The new study does not propose reforms to stem veterans' suicides, but instead examines patterns within the 1,868 suicide deaths of veterans who had served between 2001 and 2007 and who left the military during that time. It identified suicides through Dec. 31, 2009.

In contrast to previous studies, the review found that deployment to the war zone did not contribute to an elevated suicide risk. In fact, after controlling for age, sex, race and other factors, veterans who had deployed were at a slightly lower risk of suicide than those who had never deployed.

The authors speculated that troops with psychological and behavioral problems might have been held back from deploying, and that troops who did deploy might have received more screening, counseling and treatment than those who did not.

Male veterans were three times more likely than female veterans to kill themselves, the study found. But the suicide risk for female veterans, when compared to women in the U.S. population, was greater than the difference in risk between male veterans and civilians.

In terms of overall deaths, veterans had a 25 percent lower "all-causes" mortality risk, compared with the general population. The authors attributed that lower risk to the so-called "healthy soldier effect": Military members are believed to be healthier than the general population because of the initial screening for service, requirements to maintain certain standards of physical fitness and access to medical care.

Blumenthal, who has called the suicide prevention bill his "first priority," has cited Eldridge's death in discussing the need for legislation. The two men had met when Eldridge helped form a chapter of the Marine Corps League in southeastern Connecticut, Blumenthal said.

"I cannot express in words how deeply sorry I am that [Eldridge's] treatment evidently proved unsuccessful — perhaps not the result of the VA or its doctors or its hospital, [but] because we are only beginning to learn as a country and society how to confront post-traumatic stress and traumatic brain injury with the specialized diagnosis and care that these diseases demand," Blumenthal said in a speech on the Senate floor last fall.

Joanna Eldridge, who was in Washington on Tuesday to attend the State of the Union address as Blumenthal's guest, said she supports the proposed bill and wants to help bring attention to the need for more resources for veterans with PTSD.

In the five years before Justin's death, she said, he struggled with depression and alcohol and drug addiction. After his first suicide attempt, in 2008, the VA told the couple that Justin would have to wait three weeks for specialized treatment, she recalled. She contacted her congressman, U.S. Rep. Joseph Courtney, and Blumenthal, then the state's attorney general, to intervene. The VA admitted Justin three days later.

Although she is grateful for the help that her husband did receive, Joanna said, "I just don't feel like he got the correct treatment. There was a lot of changing his medications — sometimes he'd be in a zombie state." She became his full-time caregiver, supporting him as he kicked alcohol and drugs — but watching helplessly as he spiraled into despair.

"I think he just had enough of the pain," she said. "He didn't want to see it and feel it anymore."

This story was reported under a partnership with the Connecticut Health I-Team (



Working Effectively with Military Families: 10 Key Concepts All Providers Should Know

New Military Families Product!  

The NCTSN is pleased to announce a new product for providers working with military families. Working Effectively with Military Families: 10 Key Concepts All Providers Should Know is now available. This brief tip sheet outlines the top ten things to keep in mind when working with military families and, for each key concept, includes links to additional information.

   Also, the NCTSN childhood Traumatic Grief Committee has developed three new factsheets:

Collateral damage: The mental health issues facing children of veterans

Not all our casualties of war served overseas in combat. Some are children who never left our shores. Collateral damage, some might call it. Our Cover Story from Martha Teichner:

How many of these homecomings have you seen on television since we went to war in Iraq and Afghanistan more than a decade ago? How many children, looking into a returning soldier's eyes for the parent who went away?

These are supposed to be happy endings, happily-ever-after moments. But often they are anything but.

"Before his deployment, he was always kind of the fun parent," said 15-year-old Abigail Barton, who lives in Newburgh, Ind., Her father, Aaron Barton, is a veteran of the Iraq war.

"I just figured he'd come home and he'd start, just like he used to, start taking us to the park, playing basketball, getting ice cream, all that stuff," said Abigail. "And it just immediately changed, it was completely gone."

"Yeah, I was scared to go out of the house at the time," said Aaron. "Crowds make me nervous. I'm always still looking for snipers."

Barton was a specialist in the Army National Guard. His two deployments in Iraq, in 2005 and again in 2007, left him with injuries to his brain and spine, and post-traumatic stress disorder. He's able to work as a butcher for a local supermarket, as long as he works alone.

"I just get to a point where the rage takes over," Barton said. "I can't control that. It's like a Dr. Hyde-Jekyl thing, you know? It scares me almost as bad as them."

Asked what he tells his children when something happens, Aaron replied, "I usually say, 'Leave me alone.' I would never intentionally harm them." Facing his daughter Abigail, Barton said, "You're my life."

The stories of veterans' lives upended by PTSD are all too familiar to us -- the struggles of their children practically unknown.

"I would get so angry," said Abigail. "I would just think, 'This is what Iraq did to my father.' I'd start blaming it on America's military, you know? I would be like, 'You guys stole my father.'

"So yeah, I developed depression over the time and a lot of anxiety."

"Did your school understand?" asked Teichner.

"No, no. I haven't gotten any help through school. All of my, I guess, depression and anxiety help, it's come from other places -- through our family doctor."

Abigail Barton's brother Alex is 18, and uncomfortable speaking on camera. A year ago, he attempted suicide and spent four days on life support.

What's it been like for Alex, Teichner asked. "Devastating, devastating," said his mother, Wendy Barton, "to see the changes in his dad, and to feel helpless."

"I don't think that America is intentionally neglecting these kids by any means, but I think that they need to wake up," said Wendy Barton, "because this is a real problem, and it is certainly not just my children that are suffering."

It's estimated that as many as five million kids have had a parent or sibling serve in Iraq or Afghanistan since 9/11.

Ron Avi Astor, professor of social work at the University of Southern California, said, "The vast majority of the kids and families, even with a lot of deployments and a lot of moves, about 70 percent or more depending on the issue you're looking at, are doing fine."

But Astor says the other thirty percent -- up to a million and a half kids -- are not doing fine. He studied 30,000 high school students in eight California school districts. Particularly troubling: Astor found one out of four military kids is likely to consider suicide -- significantly more than non-military kids.

And what does the Veterans Administration do for the children and siblings of people who've come back from the war? Not much, said Astor.

The VA spent almost $500 million last year for PTSD treatments for veterans of Iraq and Afghanistan. But their family members (a VA spokeswoman informed us by email) may receive counseling "if determined to be essential to the effective treatment and readjustment of the veteran."

In other words, veterans' kids who have psychological issues are largely on their own, if they get help at all.

Abigail Aaron said that every day when she walks out her door she puts on her "normal" act: "It's like putting on a shirt now. It's incredibly easy. You just walk outside, put on a smile."

Her experience is typical. Her salvation has been soccer.

"Every time I step on the field or anything, all stresses go away," Abigail said. "I don't think about anything but the game, you know?

Christal Presley told Teichner, "My mom had asked me not to talk about the things that were happening with my father. In fact, if my mom mentioned the word Vietnam, it was with a whisper."

Soldiers' kids can be collateral damage in our nation's wars -- all their lives. Presley said, "I was feeling very suicidal, very depressed, very angry, anxiety-ridden."

Until, at the age of 30, Christal did what terrified her most: she asked her father, a Vietnam veteran with PTSD, to talk to her about the war.

"Why do you think at that point he said yes?" Teichner asked.

"Well, I know now it was also because he felt like there was also a hole in his soul and that he never really knew his daughter."

Delmer Presley returned to rural Virginia shattered by the killing he witnessed and participated n in Vietnam, and by the hatred he encountered when he got home.

When he couldn't control himself, he would lock himself in his room and play his guitar, or just face the wall.

"I felt ashamed of myself," he said. "I figured rage would get out, I'd maybe harm somebody or something like that, you know?"

"So while my dad was hiding away in his room, I would lock myself away in my room," Christal said. "I would vacillate between depression and rage just like my father."

It was as if she, too, had PTSD, and by her own admission it was eating her alive, when she first picked up the phone for that first of 30 phone calls.

"He said, 'I don't want to talk about the war, I don't know anything about a war,'" Christal said.

And what was her response?

"We hung up the phone, and slowly but surely, over the next few weeks, he started really opening up to me."

Teichner asked Delmer, "Do you think those conversations helped you?"

"Oh yeah, yeah," he replied. "I mean, sometimes when you have an episode, I just feel like calling her and talking to her, and that helps, you know?"

After a lifetime of telling no one, Christal Presley dared to go public, in a blog that -- to her astonishment -- went viral, and eventually became a book,

She's received emails from thousands of veterans and the children of veterans as far back as WWII. She's begun a website and Facebook group called United Children of Veterans.

"I think part of me still feels the relief of, 'Christal, you're not alone,'" she told Teichner. "And the other part of me feels so sad, because I wasn't alone."

Counting small victories, Christal Presley no longer considers herself a victim of her father's war, but a survivor.

"I understand now that talking can be a matter of life and death," Christal said. "Sharing your story can be a matter of life and death."

When asked what was the best thing that came out of his telephone conversations with Christal, Delmer replied, "For me, just knowing that, I hope she knows I love her, and always have."


 On "Transitioning" An Email from an Iraq Veteran

Hi, Im a 17 year old girl Making a Documentary based on PTSD in soldiers as part of my college work. If there is any way you could be of help, (answering questions honesty) id be grateful

Thank you

Kind Regards

Veteran: I'd be happy to help you however I can.

Girl: Thank you sooo much! If possible could you answer this question? Was the transition between soldier and civilian hard? If yes, why? Can you describe (if not too painful) what it was like? Thank you again

Veteran: The transition from being a soldier in combat to being a civilian is hard. It is worth mentioning that making the transition from civilian life to combat is easy. I know you didn't ask this question, but I'm telling you anyway. Pretty much 100% of the people I've ever spoken to about my combat service have been shocked to hear me say this. I've told them that if it were them, they would see how easy it is too. They all disagree with me because they want to think that I am different from them, but they are wrong. We're all the same. Humans are built to fight and survive. Put a human in a situation where she needs to fight and survive, she'll do just fine. She'll find a way and she'll make that transition almost instantly. But once that switch has been flipped, it is not easily unflipped.

Coming home is a motherfucker. "Transitioning" back to civilian life? There is no transition. You never really transition. You either learn to cope or you kill yourself.

When veterans, and civilians who care about veterans, discuss this topic, they usually refer to it as the "civilian-military divide". You can think of it as a wide gap between the experiences of the veteran and the experiences of the civilian. They want to connect—mostly it's the civilian who is making an effort to find an empathetic connection with the veteran. A lot of work is being done to bridge this gap, but I'll let you in on a secret: it will never be bridged. The gap cannot be closed. There will always be a gap. But that's okay. Veterans will usually easily understand other veterans, and civilians will try their very best to understand veterans, and many will do (and are doing) a pretty decent job, but there is not a way you can directly bridge this gap. It's a frustrating predicament. Anyone who thinks otherwise is dangerously naive and will ultimately do more harm than good.

I want to tell you what it feels like to transition back to civilian life, but after trying over and over and over again at social gathers and in casual conversation I have come to the conclusion that there is no way to explain what it's like. Not directly at least. The best way I can think to explain what it is like is like this:

Imagine you worked really hard in high school and after you graduated you got accepted into a fantastic Ivy League school. While at this school you met so many people who were so smart and motivated and brilliant and with them you learned more than you ever thought you could learn. You had incredible experiences, created imaginative work, and made bonds with so many different types of people in so many different ways. You had no idea there was so much that could be experienced in life, you never knew you could feel so much, and so deeply. You grew up, you matured, you were sharp, and mostly you learned how to really care. Now let's say you graduate, and you move back home for a while before going out into the world and deciding what to do next, like get a job. But when you get home, the entire world is a kindergarten class. There are all these ridiculously little chairs and little desks. There's a teacher who is older than dirt and sucks at her job and you can't get her attention to ask her what the hell is going on. Everyone is 4 or 5 years old. They can barely speak English, yet alone talk to you about all your new passions and experiences. When you do try to talk to someone, they just cry, or walk away, or babble stupidly. One kid just peed his pants, another actually shit himself and won't stop laughing. The best part of the day is art time, but everyone just finger-paints badly and makes a mess, all the activities are meant entirely for small children and you are bored out of your mind because the entire world has suddenly become one huge kindergarten class and there isn't one single person you can talk to in an adult voice or about one single thing you care about. Now do this for days. And weeks. And years. It never ends. So you try to act normal, you try to fit in. You try to act like you enjoy finger-painting and you try to act like you enjoy sing-along time and you try your best to not be rude or impatient with Susie when she talks to you about her American Girl doll. But it's all an act. You still know you're trapped in this fucking kindergarten class and you have to either learn to assimilate or go mad. I doesn't matter what anyone says—an adult will never have a meaningful connection with a pants-shitting kindergartener.

This transition is probably something akin to overcoming addiction. The way Alcoholics Anonymous approach it is by first admitting that you are an addict, then working your way from there. I think that once you've been in combat and you've gotten The Addiction (and trust me, it is a powerful addiction), you have to first realize that coping with The Addiction is a life-long process. It's this dark companion you will always have. And if you're smart and healthy about it, you'll look for real ways to live with it. It's different for everyone, but it almost always involves years of therapy. In my humble opinion, I think the best thing for veterans to do is to find an occupation or a hobby where they get to make something. I'm a writer (sometimes), but these days I'm a software engineer.

Being a soldier is about service. True service is something that is done for its own sake and once you've done it there is no record of it; nothing persists. That's the nature of service and that's what makes it great. You do it for the fuck-all of it; you do it for glory; you do it for duty; you do it for love; you do it because someone's gotta do it and you feel like it might as well be you. Service is one of the greatest things you will ever be able to experience as a human: helping other humans. And when your service is complete, it is my opinion that the person who has served should turn to something creative. Something that persists. Something that exists not just for it's own sake but the sake of something else. You've served. Now build.

Jason is the author of the memoir, Just Another Soldier: A Year on the Ground in Iraq, published in 2005 by HarperCollins.


One Deployment Didn't Win Afghanistan...And That's OK — Reflections of a Veteran via Lynch, Frank Lynch

Why Society Needs Reintegration — The performance and discipline of the civilian workforce is an unpleasant sight. I fail to find a reason to "reintegrate" into a culture ...

The Remarkable Impact of Yoga Breathing for Trauma

Emma Seppala on January 31st, 2014
"Military guys doing yoga and meditation?" I've been asked in disbelief. It's true that when they first arrived to participate in my study (a yoga-based breathing program offered by a small non-profit organization), the young, tattoo-covered, hard-drinking, motorcycle-driving all-American Midwestern men didn't look like your typical yoga devotees. But their words after the study said it all: "Thank you for giving me my life back" and "I feel like I've been dead since I returned from Iraq and I feel like I'm alive again." Our surprisingly positive findings revealed the power that lies in breath for providing relief from even the most deep-seated forms of anxiety.

As many of us know, there is an unspoken epidemic that is taking 22 lives a day in the U.S.

Who is impacted? Those who are willing to make the ultimate sacrifice in protection of others: Veterans.

How? Suicide.

Why? War trauma.

Average age? 25.

After a long deployment of holding their breath in combat, these men and women often return to civilian life no longer knowing how to breathe. Though the military trains service members for war, it doesn't train them for peace. Ready to give up their life for others, service members embody the values of courage, integrity, selflessness, and a deep commitment to serving. They've trained under extreme conditions to do things most civilians don't encounter: lose parts of their body, kill or injure another human being under orders or by mistake, get right back to work and keep fighting hours after seeing a friend killed, be separated from families and loved ones for months and even years, and live with the horrendous physical and emotional consequences thereof upon their return home.

The National Institutes of Health estimates that 20-30 percent of the over 2 million returning Iraq and Afghanistan war veterans have symptoms of post-traumatic stress disorder (PTSD). This anxiety disorder involves hyper-alertness that prevents sleep and severely interferes with daily life, triggers painful flashbacks during the day and nightmares at night, and causes emotional numbness that leads to social withdrawal and an inability to relate to others. Side effects of PTSD include rage, violence, insomnia, alienation, depression, anxiety, and substance abuse. PTSD symptoms are associated with higher risk of suicide, a fact that may explain the alarming rise in suicidal behavior amongst returning veterans.

While traditional treatments work for some, a large number of veterans are falling through the cracks. Dropout rates for therapy and drug treatments remain as high as 62 percent for veterans with PTSD. Symptoms can persist even for veterans who actually undergo an entire course of psychotherapeutic treatment and drug treatment results are mixed.

Our research at the University of Wisconsin-Madison and Stanford showed that the week-long Project Welcome Home Troops intervention was successful, with our analyses showing significant decreases in PTSD and anxiety. Improvements remained one month and one year later, suggesting long-term benefit. More telling even than the data are the veterans' words; with a veteran of the war in Afghanistan writing:

A few weeks ago shooting, cars exploding, screaming, death, that was your world. Now back home, no one knows what it is like over there so no one knows how to help you get back your normalcy. They label you a victim of the war. I AM NOT A VICTIM... but how do I get back my normalcy? For most of us it is booze and Ambien. It works for a brief period then it takes over your life. Until this study, I could not find the right help for me, BREATH'ing like a champ!

The Project Welcome Home Troops program teaches a specific breathing practice – Sudarshan Kriya Yoga – taught by certified instructors. (To learn more about the science why breathing can help us overcome anxiety and trauma, see this post on the science of breath.) Research in non-veteran populations shows that it's helpful for anxiety, depression, stress, and even gene expression for immunity. An award-winning documentary filmmaker, Phie Ambo, shadowed our entire study and filmed the veterans' transformation. It is called Free the Mind, and you can see trailers on my website.

Although many of the participants in my study were a little reluctant when they first walked in, expecting this to be "hippy dippy sh_ _" or even a "cry fest," they took to the breathing practices immediately. Why? Because the practices are fundamentally empowering – which is what being a service member is all about. Veterans don't easily embrace victim-hood. "I am not a victim." A man or woman with the courage to go to war isn't the type to feel sorry for him or herself. Instead, he or she seeks to take responsibility. Yoga-based practices allow veterans to take responsibility because they don't require dependence on a therapist or drug. The veterans learn how to take care of their own mind and well-being using their own breath.

Besides, the military and yoga have another important element in common: an emphasis on service to society. Empowered and relieved of their anxiety, the veterans I've worked with often reconnect with the spirit of service that led them to volunteer for the military in the first place. Now, their spirit of service is directed in new ways: toward helping other veterans. Travis Leanna, the one who said, "Thank you for giving me my life back," is a veteran of the U.S. Marine Corps and a veteran of the Iraq war who participated in our study and then decided to become an instructor with Project Welcome Home Troops so he could help other vets.

Project Welcome Home Troops would like to help more veterans. But because the organization offers programs free of charge, it needs funds. It recently launched an online fundraising campaign, and a sign of the success of the program is that many of those who have pledged to raise funds and many of those who are donating are none other than veterans themselves!

Inspired by the results that I've seen in our research, I've also created a fundraising page for their campaign, which you can find here. If you feel moved to do so, please start your own fundraising page or donate what you can to mine. Even if you're not able to help financially but wish to contribute, you can do so by sharing this article or the cause on your social networking sites.

For more information on Project Welcome Home Troops and how veterans can attend classes free of charge, please visit this website.
 For more on the science of breathing, see here. 
To see the trailers of the Free the Mind film made about the research we conducted, see here.
 And non-veterans who wish to learn Sudarshan Kriya Yoga can attend classes through the Art of Living Foundation.

Emma Seppala, PhD, is associate director of Stanford's Center for Compassion and Altruism Research and Education and a research psychologist at the School of Medicine. She is also a certified yoga, pilates, breath work and meditation instructor. A version of this piece originally appeared on Psychology Today.

See more at:

Suicides of Young Vets Top Those of Active Duty Troops

Greg Zoroya, USA Today

Whatever torment has driven troops to commit suicide in historically high numbers is following them as they leave the service, according to data released by the Department of Veterans Affairs.

Young veterans just out of the service and receiving health care from the government committed suicide at nearly three times the rate of active-duty troops in recent years, according to data released Thursday by the Department of Veterans Affairs.

VA officials say the data show that severe personal issues driving self-destructive tendencies for those in uniform follow them when they leave the military. The figures were released through a USA TODAY public records request.

"The rates ... are honestly alarming. This group of young veterans appears to be in some trouble," says Janet Kemp, head of the department's suicide prevention program.

The Army has struggled with suicide among active-duty troops more than other service branches during the wars in Iraq and Afghanistan, and the risk persists after soldiers return to civilian life.

Veterans ages 18-24 enrolled in the VA's health program killed themselves at a rate of 46 per 100,000 in 2009 and nearly 80 per 100,000 in 2011, the latest year of data available, according to the figures.

Non-veterans of the same age had a suicide rate during 2009 and 2010, the most recent data available, of about 20 per 100,000, according to data from the Centers for Disease Control and Prevention.

Thirty-six young veterans receiving some form of VA health care committed suicide in 2009 and 65 died by their own hand two years later. Among those in the broader age group 18-29, the suicide numbers rose from 88 in 2009 to 152 in 2011.

The overall suicide rate for active-duty personnel in the Army hovered at 22 per 100,000 during 2009-11, according to military figures.

The number of soldier suicides peaked at 185 in 2012 and a record rate for the Army that year of 30 per 100,000. Numbers for 2013 are not yet available.

Kemp says a preliminary analysis shows that most of them were not receiving mental health therapy but had been treated for other health issues by the VA.

"They're young. They've just gotten out of the service," she says. "They're more concentrated on going home, getting jobs, for the most part. They're not coming in for mental health care."

VA epidemiologist Robert Bossarte says a similar pattern was found among veterans in the past.

"There were were several studies after Vietnam that showed increases in suicide and other forms of injury/mortality for about the first five years following return from service," Bossarte says. "Those rates (eventually) came down to be about the same as the rest of the population."

A positive sign in the new data, Kemp says, is that suicide rates for male veterans of all ages who are diagnosed and treated for mental health problems by the VA have fallen steadily from 2001-2011, in contrast to suicide patterns among non-veteran males.

The same is not true for female veterans, whose suicide rates have not improved and remain higher than women who are not veterans, according to the VA data.

Kemp says recent success in reaching veterans through social media offers hope that more young people can be brought into therapy.

Online chat connections with veterans through the VA's suicide prevention office (hotline number is 1-800-273-8255) have increased from several hundred in 2009 to nearly 55,000 last year, VA data show.

"If we can get them engaged in (mental health) services, we can make a huge difference, and that's encouraging," she says.



Why Veterans of Combat Need SoulRepair

The Silent Suffering Caused by Moral Injury and Unprocessed Grief

Click to Watch Soul Repair

New opportunities and information available on the Army One Source Resource Center

Treating the Invisible Wounds of War

Over 1.6 million men and women have served in Operation Iraqi Freedom and Operation Enduring Freedom (OEF/OIF) to date. Almost half of those Service Members are married, and almost half have dependent children--the majority 5 years old and younger. In today's unique combat situation--where there is no front line and constant vigilance must be maintained on the ground, where individuals are serving as many as four deployments that are longer in duration than in the past, and where Service Members and Families are asked to give more because of our all-volunteer military--we're learning that, "The wounds of war are not limited to the battlefield."

Army OneSource has launched a formal campaign, supported by the U.S. Army, to encourage civilian health and Behavioral Health providers to complete a FREE online course in the series titled, "Treating the Invisible Wounds of War." This series of courses was designed to help primary care physicians, case workers, mental health providers, and other professionals - who may see a veteran or family member on an unrelated issue - develop a better understanding of the culture in which Service Members and Veterans, as well as their Families, live and work. The course also provides best practices for identifying, assessing, and treating Behavioral Health problems that result from the trauma of war.

1.Treating the Invisible Wounds of War (TTIWW): PTSD/TBI Length: 4 Hours Credit Type(s): 4.0 NBCC Hours - Provider #5470; 4.0 CNE Contact Hours (AP004-1211); 4.0 DC Contact hours; Contact Hours; 0.4 CEU; 4 Contact Hours (category B) CE for NC Psychologists

2. TTIWW: A Primary Care Approach Length: 1 Hour Credit Type(s): 1.0 AMA PRA Category 1 Credit, 1.0 AAFP Prescribed

3. TTIWW: Issues of Women Returning from Combat Length: 3 Hours Credit Type(s): 3.0 Contact Hours NBCC (Provider #5470), 3.0 CNE Contact Hours (AP004-1212), 3.0 Contact Hours, 0.3 CEU; 3.0 DC Contact hours; 3 Contact Hours (category B) CE for NC Psychologists

4. TTIWW: Recognizing the Signs of mTBI during Routine Eye Examinations Length: 2 Hours Credit Type(s): 2.0 COPE Hours (Course ID: 32660-NO), 2.0 Contact Hours, 0.2 CEU

5. TTIWW: Understanding Military Family Issues Length: 3 Hours Credit Type(s): 3.0 NBCC Credit Hours (Provider #5470); 3.0 Contact Hours; 0.3 CEU

In addition to better supporting Service Members, those who complete the course will:\ receive a poster to display in their offices inviting Service Members and their Families to talk to a health professional about any troubling symptoms, receive a Certificate of Completion suitable for framing, be eligible for FREE Continuing Education Unit (CEU)


From your browser, go to

Step 1: Click on New Users tab at the top of the screen

Step 2: Create a personal user account following the instructions on the screen *NOTE: Be sure to enter your Army OneSource referral code: LMVFS in the space provided. If you don't have a referral code, contact your local Army OneSource Community Support Coordinator.

Step 3: Login to the system using your new ID and password Step 4: Click on Courses tab at the top of the screen

Step 5: Select a course you wish to complete.

Step 6: Click on Register Once you complete the course, your CEU will be recorded, and you will have access to download and print a Certificate of Completion.

Thank you for your support!


Don't forget to check out the NEW "Returning Service members" maps on your state information page. Click here for direct access to the state search page.

  1. here and login to the AOS Resource to Learn, Exchange or Engage.

Questions, comments or suggestions can be emailed to This email address is being protected from spambots. You need JavaScript enabled to view it..

Department of Veteran Affairs Community Provider Toolkit

The Department of Veteran Affairs website is a comprehensive source of information for providers regarding the mental health needs of veterans.  We found this particular page focused on community providers including a "toolkit" including military culture information and mini-clinics.  We hope you find it helpful. Click Here.

Suicide Prevention Strategies and Resources to Improve Services for Service Members, Veterans, and their Families

The archive of the webinar entitled, "Suicide Prevention Strategies and Resources to Improve Services for Service Members, Veterans, and their Families," is now available for viewing. Sponsored by SAMHSA's Service Members, Veterans, and their Families (SMVF) Technical Assistance Center, the webinar provided an overview of the risk and protective factors associated with SMVF suicide. Resources and strategies that can be used to help SMVF who are in crisis were discussed. The webinar also included a review of a comprehensive suicide prevention plan and examples of what states, communities, and organizations are doing to reduce SMVF suicides.

Presenters: Janet Kemp, R.N., Ph.D., National Mental Health Program Director, Suicide Prevention and Community Engagement, U.S. Department of Veterans Affairs, Julie Ebin, Ed.M., Senior Prevention Specialist, Suicide Prevention Resource Center, Casey Olson, Prevention, Response, and Outreach Strategic Initiatives Program Manager, National Guard Bureau, Luana J. Ritch, Ph.D., Nevada Policy Academy State Team Leader, Quality Assurance Specialist III, Veterans & Military Families, Nevada Mental Health Services

Please click here to view the webinar replay and access materials:

DHCC Daily News

Deployment Health News 14 September 2015

Welcome to the Deployment Health News, now distributed by Gov Delivery! Please be sure to add the new addressThis email address is being protected from spambots. You need JavaScript enabled to view it. to your contact list so that your computer will recognize the address and not place the newsletter in your spam box.

Summit: ‘As Good As It Gets’ Not Good Enough, Speakers Say

DCoE News, 10 September 2015

“A top Pentagon official this morning hammered home the message of the 2015 Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury Summit: providers need to continue improving treatment for psychological health and traumatic brain injury (TBI). ‘We need to continue to push the boundaries of what we know now,’ said Dr. Karen S. Guice, principal deputy assistant secretary of defense for health affairs, to 1,750 live and virtual conference registrants. ‘Look into that next approach, that next better treatment, that next better protocol that gives us a better outcome.’”

Panel: Stigma is obstacle to mental health care

Military Times, 11 September 2015

“The Pentagon and VA have ‘nudged the needle’ forward in promoting mental health treatment to troops and veterans but many still refuse to get care, concerned about stigma, their jobs and psychiatric medications, a panel of experts said Wednesday at a military and family symposium in Washington, D.C. Negative perceptions of mental health conditions and treatment continue to keep troops and veterans from seeking care, but the issue is larger than just the stigma of a diagnosis; it is complicated by concerns over keeping their careers and not wanting to be medicated, panelists said.”

Military medicine tackles suicide with prevention tools for patients, families and providers, 8 September 2015

“When it comes to preventing suicide, the military provides resources for individuals, friends, families and providers who can make a difference and help save lives. The Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury (DCoE) and other Department of Defense experts collaborated with the Department of Veterans Affairs (VA) to develop a new set of tools, released last year in support of the 2013 clinical practice guideline for the assessment and management of suicide risk.”

Anxiety Contributes to Suicide Risk

U.S. News and World Report, 1 September 2015

“The majority of Americans view mental health as important for overall health, but only half understand that anxiety is a risk factor for suicide and many perceive that getting help is difficult, according to a new survey, which suggests that reforms under President Barack Obama's health care law are still far from effective. The survey, released Tuesday, ahead of the Sept. 3-7 National Suicide Prevention Week, was conducted by the Harris Poll from Aug. 10-12 and included 2,020 adults ages 18 and over. It was commissioned by the Anxiety and Depression Association of America, the American Foundation for Suicide Prevention and the National Action Alliance for Suicide Prevention.”

Possible new weapon against PTSD

MIT News, 31 August 2015

“About 8 million Americans suffer from nightmares and flashbacks to a traumatic event. This condition, known as post-traumatic stress disorder (PTSD), is particularly common among soldiers who have been in combat, though it can also be triggered by physical attack or natural disaster. Studies have shown that trauma victims are more likely to develop PTSD if they have previously experienced chronic stress, and a new study from MIT may explain why. The researchers found that animals who underwent chronic stress prior to a traumatic experience engaged a distinctive brain pathway that encodes traumatic memories more strongly than in unstressed animals.”

Study Reports High Prevalence of Military Sexual Trauma Among Recent Veterans, 31 August 2015

“ Interview with: Shannon K. Barth MPH, Department of Veterans Affairs, Office of Public Health, Post Deployment Health, Epidemiology Program. Medical Research: What is the background for this study? Response: This study used data from the “National Health Study for a New Generation of U.S. Veterans,” a population-based health study of a sample of 20,563 Operation Iraqi Freedom and Operation Enduring Freedom Veterans and their non-deployed counterparts, conducted in 2009-2011…”

The number of child abuse cases in the military hits a decade high

The Washington Post, 2 September 2015

“Confirmed cases of abuse and neglect of military children increased markedly in 2014, Defense Department data showed on Wednesday, prompting concerns among Pentagon about efforts to safeguard the nation’s over 1 million military children. In fiscal year 2014, officials tracking family violence within the military confirmed 7,676 cases of child abuse or neglect, an increase of 10 percent from the previous year, according to annual statistics on child abuse and domestic violence. Confirmed cases of neglect – which excludes physical and sexual abuse – rose by 14 percent, military officials said.”

Army works to prevent suicide through education, intervention, 3 September 2015

“The International Association for Suicide Prevention and the World Health Organization will observe World Suicide Prevention Day, Sept. 10, with the theme ‘Preventing Suicide: Reaching Out and Saving Lives.’ This observance acts as a call to action to both individuals and organizations that suicide can be prevented through education and intervention.”

Mission Family: Help your family deal with your PTSD

Army Times, 6 September 2015

“It’s the elephant in the room for too many military families — post-traumatic stress. It doesn’t affect just the individual. It affects entire families. In heartbreaking ways, it can change relationships with family members who may not understand the changed behaviors that are manifesting, particularly children, who often have minimal insight into or understanding of the combat experience.”

Injured Heroes, Broken Promises (Part 4) – From marching orders to doctors’ orders

The Dallas Morning News, 3 September 2015

“James Moffatt was as gung-ho as they come. His goal: to become the top enlisted soldier in the Army. But combat changed that. During deployments to Afghanistan and Iraq, he was exposed to multiple explosions, suffering head, neck and spinal injuries. He had achieved the rank of a staff sergeant when he began to suffer symptoms of post-traumatic stress disorder.”

How the Army is Unlocking Soldier Suicide

Government Executive, 8 September 2015

“The phrase ‘war is hell,’ perhaps first uttered by Union Gen. William Tecumseh Sherman during the Civil War, is both a concise description and partial justification for what happens when opposing blades, bullets and bombs meet human flesh. But for some soldiers, those three brief words signify something darker and far more personal. One of the most troubling statistics to emerge from the wars in Iraq and Afghanistan that followed the Sept. 11, 2001, terrorist attacks has been the suicide rate among military personnel.”

Womack clinical trial: Old treatment offers new hope for post-traumatic stress

Fayetteville Observer, 8 September 2015

“It's not a cure-all or a magic bullet, but a century-old medical treatment finding new use among those fighting post-traumatic stress has given new hope to providers and patients on Fort Bragg. Officials at Womack Army Medical Center are on the front lines of treating combat-related post-traumatic stress with a procedure known as a stellate ganglion block.”

3 Ways Modern Technology Increases Veterans' Likelihood of PTSD

Huffington Post, 9 September 2015

“Over the last decade or so, the American public's appreciation for soldiers has generally increased. I've witnessed dozens, possibly hundreds, of people thanking uniformed soldiers for their service, in stores, cafes, and airports. This commercial beautifully reflects that sentiment. We'll celebrate through local parades and discounted prices by major retailers who may or may not do anything special for veterans.”

Across much of US, a serious shortage of psychiatrists

Associated Press, 7 September 2015

“It is an irony that troubles health care providers and policymakers nationwide: Even as public awareness of mental illness increases, a shortage of psychiatrists worsens. In vast swaths of America, patients face lengthy drives to reach the nearest psychiatrist, if they can even find one willing to see them. Some states are promoting wider use of long-distance telepsychiatry to fill the gaps in care. In Texas, which faces a severe shortage, lawmakers recently voted to pay the student loans of psychiatrists willing to work in underserved areas. A bill in Congress would forgive student loans for child psychiatrists.”

Psychology Is Not in Crisis

The New York Times, 1 September 2015

“Boston — IS psychology in the midst of a research crisis? An initiative called the Reproducibility Project at the University of Virginia recently reran 100 psychology experiments and found that over 60 percent of them failed to replicate — that is, their findings did not hold up the second time around. The results, published last week in Science, have generated alarm (and in some cases, confirmed suspicions) that the field of psychology is in poor shape. But the failure to replicate is not a cause for alarm; in fact, it is a normal part of how science works.”

Disclaimer: These published news articles are offered as a service to DoD health care beneficiaries and their health care providers. Articles are selected for dissemination solely based on the military health relevance of the topic. Provision of these articles is intended to rapidly inform clinicians of information that is publicly available to patients, because that information sometimes causes patients to seek medical advice and care. A wide-range of views, positions, and publications are represented in these articles. These views, positions, and publications are not endorsed by nor do they necessarily represent the views of the Deployment Health Clinical Center or any other US government agency or department.


About Traumatic Brain Injury

Falls are the leading cause of traumatic brain injury for all ages. Those aged 75 and older have the highest rates of traumatic brain injury-related hospitalization and death due to falls.

Doctors classify traumatic brain injury as mild, moderate or severe, depending on whether the injury causes unconsciousness, how long unconsciousness lasts and the severity of symptoms. Although most traumatic brain injuries are classified as mild because they're not life-threatening, even a mild traumatic brain injury can have serious and long-lasting effects.

Traumatic brain injury is a threat to cognitive health in two ways:

  1. A traumatic brain injury's direct effects, which may be long-lasting or even permanent, can include unconsciousness, inability to recall the traumatic event, confusion, difficulty learning and remembering new information, trouble speaking coherently, unsteadiness, lack of coordination and problems with vision or hearing.
  2. Certain types of traumatic brain injury may increase the risk of developing Alzheimer's or another form of dementia years after the injury takes place. 
    Learn more.

If a Head Injury Occurs

If you or someone you're with experiences an impact to the head and develops any symptoms of traumatic brain injury, seek medical advice even if symptoms seem mild. Call emergency services for anyone who is unconscious for more than a minute or two or who experiences seizures, repeated vomiting or symptoms that seem to worsen as time passes. Also seek emergency care for anyone whose head was injured during ejection from a vehicle, who was struck by a vehicle while on foot, or who fell from a height of more than 3 feet. Even if you don't lose consciousness and your symptoms clear up quickly, a brain injury still may have occurred.


Symptomsback to top

Symptoms of a brain injury include:

  • Unconsciousness
  • Inability to remember the cause of the injury or events that occurred Immediately before or up to 24 hours after
  • Confusion and disorientation
  • Difficulty remembering new information
  • Headache
  • Dizziness
  • Blurry vision
  • Nausea and vomiting
  • Ringing in the ears
  • Trouble speaking coherently
  • Changes in emotions or sleep patterns

The severity of symptoms depends on whether the injury is mild, moderate or severe.

  • Mild traumatic brain injury, also known as a concussion, either doesn't knock you out or knocks you out for 30 minutes or less. Symptoms often appear at the time of the injury or soon after, but sometimes may not develop for days or weeks. Mild traumatic brain injury symptoms are usually temporary and clear up within hours, days or weeks, but they can last months or longer.
  • Moderate traumatic brain injury causes unconsciousness lasting more than 30 minutes. Symptoms of moderate traumatic brain injury are similar to those of mild traumatic brain injury but more serious and longer-lasting.
  • Severe traumatic brain injury knocks you out for more than 24 hours. Symptoms of severe traumatic brain injury are also similar to those of mild traumatic brain injury but more serious and longer-lasting.

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Diagnosisback to top

Evaluations by health care professionals typically include:

  • Questions about the circumstances of the injury
  • Assessment of the person's level of consciousness and confusion
  • Neurological examination to assess memory and thinking, vision, hearing, touch, balance, reflexes and other indicators of brain function

Depending on the nature of the traumatic brain injury and the severity of symptoms, brain imaging with computed tomography (CT) may be needed to determine if there's bleeding or swelling in the brain.

Causes and risksback to top

Home Safety and Dementia

Use our online tool, Alzheimer's Navigator, and get a personalized action list on how to prevent falls and make your home safe for someone with dementia. Learn more

Falls are the most common cause of traumatic brain injury, and falling poses an especially serious risk for older adults. When a senior sustains a traumatic brain injury in a fall, direct effects of the injury may result in long-term cognitive changes, reduced ability to function and changes in emotional health.

Vehicle crashes are another common cause of traumatic brain injury. You can reduce your risk by keeping your vehicle in good repair, following the rules of the road, and buckling your seat belt.

Sports injuries are also a cause of traumatic brain injury. You can protect your head by wearing a helmet and other protective equipment when biking, inline skating or playing contact sports.

Other causes include

  • Indirect forces that jolt the brain violently within the skull, such as shock waves from battlefield explosion
  • Bullet wounds or other injuries that penetrate the skull and brain

Dementia and traumatic brain injury

Over the past 30 years, research has linked moderate and severe traumatic brain injury to a greater risk of developing Alzheimer's disease or another type of dementia years after the original head injury.

    • One of the key studies showing an increased risk found that older adults with a history of moderate traumatic brain injury had a 2.3 times greater risk of developing Alzheimer's than seniors with no history of head injury, and those with a history of severe traumatic brain injury had a 4.5 times greater risk.

Does every hit to the head lead to dementia?

Not everyone who experiences a head injury develops dementia. There’s no evidence that a single mild traumatic brain injury increases dementia risk. More research is needed to confirm the possible link between brain injury and dementia and to understand why moderate, severe and repeated mild traumatic brain injuries may increase risk.

  • Other studies — but not all — have found a link between moderate and severe traumatic brain injury and elevated risk.
  • Emerging evidence suggests that individuals who have experienced repeated traumatic brain injuries (concussions) or multiple blows to the head without loss of consciousness, such as professional athletes and combat veterans, are at higher risk of developing a brain condition called chronic traumatic encephalopathy (CTE) than individuals who have not experienced repeated brain injuries.
  • Current research on how traumatic brain injury changes brain chemistry indicates a relationship between traumatic brain injury and hallmark protein abnormalities (beta-amyloid and tau) linked to Alzheimer's.
  • Some research suggests that traumatic brain injury may be more likely to cause dementia in individuals who have a variation of the gene for apolipoprotein E (APOE)called APOE-e4. More research is needed to understand the link between APOE-e4 and dementia risk in those who've had a brain injury.

Treatment and outcomesback to top

The most serious traumatic brain injuries require specialized hospital care and can require months of inpatient rehabilitation. Most traumatic brain injuries are mild and can be managed with either a short hospital stay for observation or at-home monitoring followed by outpatient rehab, if needed.

Treatment of dementia in a person with a history of traumatic brain injuries varies depending on the type of dementia diagnosed. Strategies for treating Alzheimer's or another specific type of dementia are the same for individuals with and without a history of traumatic brain injury.

Alzheimer's disease and other dementias that may occur as a long-term result of traumatic brain injury are progressive disorders that worsen over time. As with all dementias, they affect quality of life, shorten lifespan and complicate the effort to manage other health conditions effectively.

Paula P. Schnurr, PhD

Senior Associate Editor
Lauren M. Sippel, PhD

Associate Editors
Juliette M. Harik, PhD
Paul E. Holtzheimer, MD
Jennifer S. Wachen, PhD

National Center for PTSD
US Department of Veterans Affairs