Beyond war and PTSD: The crucial role of transition stress in the lives of military veterans

Highlights

• Current interventions/supports for veterans have focused primarily on PTSD.

• PTSD in veterans is infrequent while transition stress is highly prevalent.

• Transition stress is multifaceted and can lead to serious mental health problems.

• We review and elaborate on components of transition stress.

Abstract

Although only a relatively small minority of military veterans develop Posttraumatic Stress Disorder (PTSD), mental health theory and research with military veterans has focused primarily on PTSD and its treatment. By contrast, many and by some accounts most veterans experience high levels of stress during the transition to civilian life, however transition stress has received scant attention. In this paper we attempt to address this deficit by reviewing 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 briefly consider what it means to become a soldier (i.e., what is required to transition into military service) and more 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). We end by suggesting how an expanded research program on veteran transition stress might move forward.

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.