ReviewBeyond war and PTSD: The crucial role of transition stress in the lives of military veterans
Introduction
More than 1.7 million of the 2.6 million soldiers deployed to Iraq and Afghanistan have transitioned back to civilian life with another one million expected to do so over the next five years (Zoli, Maury, & Fay, 2015). It will likely be many years before revelation of the full psychological impact of these recent military campaigns is made known (Steenkamp & Litz, 2013). Such protracted military engagements, combined with the varying duration of service commitment lengths, make it difficult to discretely identify, track, and compare affected at risk groups (Lineberry & O'connor, 2012) both during the period of service and beyond. Even more problematic, despite the looming uncertainty of future treatment needs, currently available interventions for returning veterans have focused narrowly on extreme psychopathology, and typically only on Posttraumatic Stress Disorder (PTSD).
The narrow focus on PTSD and its treatment has proved to be problematic for several critical reasons. First, transitioning veterans who might need services often do not seek PTSD treatment. Their reluctance is driven by concerns about stigmatization (Hoge et al., 2004, Stecker et al., 2007), beliefs they do not meet criteria necessary to qualify, or that their treatment preference is in conflict with offered or prioritized services (Markowitz et al., 2016). The latter is particularly salient as the Veterans Administration (VA) currently mandates the prioritization of prolonged exposure (PE) and cognitive processing therapy (CPT) for PTSD (Friedman, 2006, Institute of Medicine, 2007, U.S. Department of Veterans Affairs and Department of Defense, 2010, Yehuda and Hoge, 2016a, Yehuda and Hoge, 2016b). Correspondingly, mental health care providers within the VA and military treatment facilities (MTF) are highly trained in PE and CPT following a nationwide rollout (Rauch et al., 2012, Smith et al., 2013) and these treatments are tracked with institutional performance measures (Yehuda and Hoge, 2016a, Yehuda and Hoge, 2016b). Thus, a large proportion of funded research at academic VAs and MTFs prioritizes the research of PTSD (Congressionally Directed Medical Research Programs, 2016) and on optimizing the efficacy and recruitment of Veterans to only PE and CPT (Yehuda and Hoge, 2016a, Yehuda and Hoge, 2016b). More troubling however, even among veterans who do participate in these clinical treatments, a majority continue to suffer elevated symptom levels while dropout rates have remained extremely high (Steenkamp, Litz, Hoge, & Marmar, 2015), suggesting an urgent need for new types of interventions and supports (Steenkamp, 2016a, Steenkamp, 2016b).
Second, and perhaps even more imperative, although the serious and often debilitating nature of PTSD is beyond question, the available empirical evidence indicates that PTSD typically occurs in only a relatively small population of returning veterans. Studies of veterans deployed in the recent conflicts in Afghanistan and Iraq (OIF/OEF) have estimated the range of PTSD prevalence between 4.7% and 19.9% (Magruder & Yeager, 2009). However, the upper-limit of these estimates is likely exaggerated due to variability in the quality of the studies. Notably, studies employing methodologically rigorous design elements, such as prospective data collection and population sampling procedures, have consistently documented PTSD rates under 10% (Berntsen et al., 2012, Bonanno et al., 2012, Donoho et al., 2017, McNally, 2012).
We propose here that in order to address the expanding needs of returning veterans, veteran treatments and supports need to move beyond their nearly exclusive focus on PTSD to consider the wider range of challenges, rewards, successes, and failures that transitioning Veterans might experience, as well as the factors that might moderate these experiences. To illuminate this argument, we begin by briefly considering what it means to become a soldier (i.e., what is required to transition into military service) and crucially what kind of stressors veterans might experience when they attempt to shed that identity (i.e., what is required to transition out of military service). One of the primary reasons for past failures in veteran treatments, arguably is that the dominant focus on PTSD has obfuscated other, often highly pressing transition issues. Research has documented, for example, that many returning veterans may struggle regardless of whether they have PTSD or not. Recent population survey studies have suggested that 44% to 72% of Veterans experience high levels of stress during the transition to civilian life, including difficulties securing employment, interpersonal difficulties during employment, conflicted relations with family, friends, and broader interpersonal relations, difficulties adapting to the schedule of civilian life, and legal difficulties (Morin, 2011). Struggle with the transition is reported at higher, more difficult levels for post-9/11 veterans than those who served in any other previous conflict (i.e. Vietnam, Korea, World War II) or in the periods in between (Pew Research Center, 2011). Crucially, transition stress has been found to predict both treatment seeking and the later development of mental and physical health problems, including suicidal ideation (Interian et al., 2014, Kline et al., 2010). What is more, the majority of first suicide attempts by veterans typically occur after military separation (Villatte et al., 2015).
There has been considerable discussion of Veterans and the transition from military to civilian life in the media and popular press (e.g., Jenkins, 2014, Junger, 2010, Junger, 2016, Rose, 2017), but at present there is little empirically-derived evidence to substantiate many of these experiential and observational claims. Despite the imperative need for greater knowledge about how different aspects of transition stress might influence veterans' long-term adjustment, at present most of the research on veteran transition has been limited to cross-section self-report studies. The lack of theoretical framework and empirical support to more precisely identify salient factors before, during, and after the transition, has impeded the development of new forms of transition programming. And as a result at present almost no resources are available to address the cognitive, emotional, behavioral, or psychological impacts of the soldier-to-civilian transition. Our goal in the current manuscript is to elucidate a preliminary outline of what we believe to be the most promising areas for future study and for the development of possible interventions and supports, and to suggest ways these areas might be more systematically examined.
Section snippets
Becoming a soldier
Individuals who choose to serve must first undergo an explicit period of training in which they are instructed and immersed in practical skills training and indoctrinated in military standards, ethics, and values (Lieberman et al., 2014, McGurk et al., 2006). The crucible of entry level training is meant to strip away the vestiges of the civilian identity and transform men and women into Soldiers, Sailors, Airmen, and Marines. The transition from civilian to military life requires rapid
Moving forward
The various transition factors we've reviewed above suggest an obvious imperative for a broader clinical and research agenda regarding veteran psychological health. In this final section, we consider what such a framework might look like and offer suggestions about how the field might move forward. To begin with, there is a clear need for greater study and understanding of the heterogeneity in veteran mental health outcomes. In making this point, we want to be perfectly clear that we are in no
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