Provider Resources for Helping Returning Military Members

Over the coming months (and probably years) we can expect many active duty military personnel, as well as Guard and Reserve members, to return from war zones to civilian life. Our nation spends large amounts of time and money preparing these individuals to go to war, but very little, by comparison, on preparing them to return to civilian life. Yet for many, the latter transition is the more difficult.

As a CIGNA Behavioral Health contracted provider, you may be called upon to help some of these individuals in their transition back to civilian life, either directly or indirectly. We want to do our part by providing you with the best information and resources that we can. Following is, first, a high level overview of the dynamics involved in this transition, and the psychosocial tasks of reintegration. Second, we provide some links where you can find additional information.

Transitions

The road to war includes making an adjustment from:

• Citizen to soldier (includes sailor, airman, marine)
• Safety to danger
• Comfort to discomfort
• Order to chaos
• Law to lawlessness
• Trust to mistrust

When military members finish their tour of duty and return home they must reverse this process and make the adjustment from:

• Soldier to citizen
• Danger to safety
• Discomfort to comfort
• Chaos to order
• Lawlessness to law
• Mistrust to trust

As much as they look forward to the latter changes, those changes are not always easy, and many need help in the process.

Why should it be hard coming home?

Coming home means coming back to good things. Life is safer, easier, and more pleasant. Why, then, isn't it easy? The answer has three parts:

1. Recovery from intense events: Many have experienced the horrors of war: seeing people killed, handling body parts, having to kill. They may have had friends killed, for whom they have not been able to adequately grieve - there is little time for that in a war zone. Even those who weren't exposed to traumatic experiences have lived with major ongoing stressors, such as cramped living quarters, no privacy, undesirable food, a harsh climate, and a foreign culture. Long-term exposure to intense, stressful events can lead to social withdrawal, numbing of emotions, hyperarousal, fear, anger, irritability, and re-experiencing of the upsetting events through nightmares and flashbacks. These things don't suddenly stop when the person returns to civilian life.

2. Continued use of "battlefield skills". In a war zone, people learn a new set of skills that they need to survive. These skills are not helpful in civilian life, and are often self-defeating, but they are hard to let go of because they have become habits. Battlefield skills include:
   • Being on constant alert for danger
   • Not trusting people
   • Making quick decisions, on one's own
   • Expecting others to obey directives without question
   • Sticking to a "mission" no matter what
   • Reacting quickly and asking questions later
   • Keeping one's emotions sealed off

3. Things have changed back home, too. Children have grown, spouses have taken on new roles and responsibilities, workplaces have changed. It takes time to re-establish relationships, talk through the changes, and adjust to them. The process is exacerbated by the preceding issues, and sometimes accompanied by conflict.

What does it take to successfully make the transition?

The following are four tasks that returning military members must accomplish in order to successfully make the transition back to civilian life:¹

1. Reconnect with family, friends, co-workers, and community. War experiences often leave people feeling different and separated from others. The returning member must work to overcome this alienation and reconnect with people.

2. Move from simplicity to complexity. Life was simpler in a war zone. Things were black and white. They are more complex in civilian life. The returning member needs to learn to stop and think things through, to consider all aspects of a situation before reacting.

3. Replace war with another, healthy, form of high. War is an adventure, an adrenalin rush. Nothing in civilian life matches the intensity. The void after returning can cause extreme boredom and even depression. Some seek to remedy this with dangerous activities, such as reckless driving, sex, gambling, and drug and alcohol abuse. A better solution is to find "healthy highs", such as exercise, learning new things, sports, hobbies, and the outdoors.

4. Find meaning and purpose outside of combat. This task may be the hardest of all because it is so broad and abstract. In a war zone, there is a clear purpose and underlying meaning, and everything else is subordinate to that. That is lost upon return to civilian life, and individuals must find new sources of meaning and purpose.

Questions for assessing returning military members

Following are some questions to ask as part of your assessment of individuals who have served in the military in a war zone.

General military service history:

• Tell me about your military experience.
• When and where do you/did you serve?
• What do you/did you do while in the service?
• How has military service affected you?

Probing for traumatic experiences:
If client answers yes to any of the following, ask "Can you tell me more about that?"

• Were you a prisoner of war?
• Did you see combat, enemy fire, or casualties?
• Were you wounded, injured or hospitalized?
• Did you ever become ill while you were in the service?

Assessing for potential PTSD (Posttraumatic Stress Disorder):
Have you ever had an experience so frightening, horrible, or upsetting that, in the past month, you...

• had nightmares about it or thought about it when you did not want to?
• tried hard not to think about it, or went out of your way to avoid situations that reminded you of it?
• were constantly on guard, watchful, or easily startled?
• felt numb or detached from people, activities, or your surroundings?

Further resources for clinicians

The following resources have been compiled to further help you assist servicemen and women and their families as they transition in and out of military service.

Iraq War Clinicians Guide: www.ncptsd.va.gov/war/guide/index.html Guide for helping professionals who are assisting returning military members and their families.

Deployment Health Clinical Center: www.pdhealth.mil/ Contains post-deployment health information designed to assist clinicians in the delivery of post-deployment healthcare to military members.

US Department of Veterans Affairs - "The War in Iraq" www.ncptsd.va.gov/topics/war.html Comprehensive resource for all aspects of readjustment to civilian life. Includes "Returning from the War Zone: A Guide for Military Personnel" and "Returning from the War Zone: A Guide for Families".

Department of Veterans Affairs: Facts About Posttraumatic Stress Disorder (PTSD) www.ncptsd.va.gov/facts/index.html Information on PTSD, including general facts, associated problems, treatment for veterans, disasters and traumatic stress, specific audiences and topics, and further reading.

The Military OneSource Programs:
Provides a full array of EAP and work/life services for military personnel and their families.
Marine Corps: Call 800-869-0278 or go to www.mccsonesource.com
Army: Call 800-464-8107 or go to www.armyonesource.com
Navy: Call 800-540-4123 or go to www.navyonesource.com
Air Force: Call 800-707-5784 or go to www.airforceonesource.com.

Deployment Link (Department of Defense resources): http://deploymentlink.osd.mil/deploy/post_deploy/post_deploy_intro.shtml Post-deployment articles and information for all branches of the military.

Readjustment Counseling Services: Call 800-827-1000 or go to www.va.gov/rcs and click "Find your nearest vet center". This is a Veterans Administration outreach service and is available in all 50 states.

Books of Interest: "Down Range: To Iraq and Back" by Bridgett Cantrell and Chuck Dean; and "Courage After Fire" by Keith Armstrong, Suzanne Best, and Paula Domenici. Access at www.namvetbook.com and www.amazon.com, respectively.

Article from the American Psychological Association: http://helping.apa.org/featuredtopics/feature.php?id=6 Title "The Road to Resilience"; includes sections on what is resilience?; 10 ways to build resilience; learning from your past; staying flexible; and places to look for help.

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¹This section adapted from a presentation by Major John Morris of the Minnesota National Guard.

This material is provided by CIGNA Behavioral Health, Inc. for informational/educational purposes only. It is not intended as medical/clinical advice. Only a healthcare provider can make a diagnosis or recommend a treatment plan. For more information about your behavioral health benefits, you can call the member services or behavioral health telephone number listed on your healthcare identification card.