With mental-illness rates climbing as high as 40 percent among American veterans of the wars in Iraq and Afghanistan, conventional wisdom holds that the U.S. must spend more on therapists for returning soldiers. In an upcoming article, a Veterans Administration psychiatric researcher suggests a different approach: Focus on services like job training and housing assistance.
Many veterans returning from Operation Enduring Freedom (Afghanistan) and Operation Iraqi Freedom, like those coming home from Vietnam a generation ago, experience difficulties re-adjusting to civilian life. Particularly in Iraq, the mental perils of combat are exacerbated by unpredictable urban warfare and constant risk of roadside bombs.
Rates of post-traumatic stress disorder tripled among one sample of post-9/11 deployed soldiers compared with peers who did not face combat. As many as four in 10 may require mental health treatment, and several hundred have already become homeless, often after psychological or substance abuse problems made it difficult for them to function.
Dr. Daniel Luchins, a longtime University of Chicago psychiatry researcher, last June became chief of Mental Health Research at Chicago's Jesse Brown Veterans Administration Medical Center, part of the Veterans Health Administration, the largest medical system in the United States. Luchins' introduction to the VA came via a three-month stint treating mentally ill inpatients, primarily middle-aged Vietnam vets. Like many of their brothers-in-arms, they suffered from a variety of issues: "These people were homeless, strung out on heroin, alcoholics — whether they had PTSD or not is a minor issue compared to the sheer enormity of their psychosocial problems," Luchins said.
While millions of Vietnam veterans are thriving in civilian life, men such as those Luchins saw are one reason mental illness accounted for 28 percent of military hospital bed-days during the 1990s. Hundreds of thousands of veterans live on the streets, comprising one-quarter of the U.S. homeless population. As Luchins began treating veterans of current conflicts, he wondered what went wrong for so many Vietnam vets and whether the VA was doing enough to prevent such tragic outcomes from striking his youngest patients.
Among Iraq and Afghanistan soldiers at Jesse Brown, Luchins said, most complained of problems with families and spouses, or a lack of jobs and education.
"Very few come in and say, ‘I have PTSD, I can't sleep at night,'" he said. While Luchins doesn't dismiss the idea of aggressive psychiatric treatment for suffering soldiers, he believes that cases are "better understood as adjustment issues of young people coming back home after many years away." For these vets, social services like vocational training or education benefits may be just as important as talk therapy and pills.
Yet that's not how health centers treat veterans, Luchins and other researchers say. After physical maladies are taken care of, care for mental disease is the frame through which most treatment is given.
"The mental health perspective has become so dominant, at the expense of providing social services. It's emblematic of the way that we treat people who've been in stressful situations," said Rutgers University sociologist Allan Horwitz.
Therapy isn't detrimental to veterans — and for those suffering from severe trauma, it's crucial — but it may fail to address social disadvantages among ex-soldiers. In one government study, rates of post-traumatic stress were double among Vietnam vets who had no high school degree, were unemployed or had a low income. While researchers argue whether mental illness causes social disadvantage or vice versa, Luchins said the VA's treatment methods fail to properly account for the relationship between them.
The system may even be encouraging soldiers to overreport symptoms of PTSD because benefits, such as housing, are at times linked to illness. "If you get well, you lose your services," Horwitz said. "It's a perverse system where it rewards illness."
To be sure, not all VA doctors focus exclusively on psychological issues, and at least one prominent VA doctor discouraged diagnoses of PTSD. Vets may also shy away from the social stigma of receiving psychiatric treatment.
Even after successful mental health treatments, many disadvantaged veterans continue to struggle. It's a common dynamic, said Northwestern University's Dan A. Lewis, who has tracked state mental patients and welfare recipients within similar systems practicing what he calls "mental health exceptionalism."
"This idea that you give the person the mental health service first, that makes them well, and then they're OK," he said, "doesn't give due credit to the economic and social situation.
"Even if you do better with your mental health problems, that doesn't help you to overcome the hole you're in economically. That's very hard to dig out of."
With an all-volunteer military, social disadvantages among members of the armed forces may be higher than during past conflicts. "We're sending people to war who often don't have much else going for them," Luchins said. "They come back and now they can shoot a gun and drive a tank. That's not what employers are looking for, and it starts the process of going downhill."
Luchins said a VA more focused on social services could offer programs using the "housing first" model, which offers mentally ill substance abusers housing without contingent requirements. It might also spend more time screening soldiers for social disadvantages, more efficiently targeting scarce therapeutic resources. The bulk of program dollars, though, would go to education, employment, legal and financial assistance for all veterans — like the Servicemen's Readjustment Act (better known as the GI Bill of Rights) passed during World War II.
A spokesman for the Department of Veterans Administration declined to comment on Luchins' suggestions. But the federal government already offers billions of dollars worth of social service benefits to soldiers. At Jesse Brown, for example, a Veterans Benefits Administration offers financial advice and other services adjacent to the medical center campus, and social workers refer soldiers to public and private organizations such as the Veterans of Foreign Wars. Several states offer generous university scholarships, and the current Montgomery GI Bill offers significant funding toward education.
"The reality is veterans can right now receive all of these services, independent of any psychiatric diagnosis," Col. Janet Kamer, a clinical psychologist and consultant to the Air Force Reserve, wrote in an e-mail.
Yet Congress has found that several such programs, including the housing-oriented Grants and Per Diem Program and the Vet Centers that offer counseling and job assistance, aren't meeting current needs.
Efforts by Sens. James Webb, D-Va., and Chuck Hagel, R-Neb. — both Vietnam veterans — to grant full tuition for Iraq and Afghanistan veterans have been unsuccessful, though the Senate may debate the proposal again next week. Both Republican presidential candidate John McCain and the Bush administration have criticized the Webb-Hagel bill, claiming it will encourage active duty servicemen to bolt for civilian life, further taxing an already-stretched-thin military.
While Luchins' ideas are far from a comprehensive proposal, he offers direction for change of a system that may not be all that it can be.
"It needs a lot more work to be a viable alternative, but he's made a real contribution by raising these issues," Lewis said.
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