“It is well that war is so terrible. We should grow too fond of it.” – Robert E. Lee at the Battle of Fredericksburg, December 13, 1862

War is hell!  We know that….there is no debate.  Although we would all like to believe that the war is over for the brave men and women once they return home, for many it is upon returning home when the harshest battles begin.  Rigorous and exhaustive training prepares our troops for warfare, but what training do they have to readjust when they return home?

War changes everyone involved in waging it.  Our troops and their families are transformed in ways non-military individuals may never be able to fully appreciate.  Not to be overshadowed by the challenges, there are some very positive changes that occur.  Service members develop new skills, take on immense responsibilities, and become better leaders.  Their family members learn to become more independent, and develop capabilities often beyond what they ever thought possible.

There are, of course, the challenges.  Our troops are faced with life threatening assaults, explosions, destruction, and death.  Families are separated from their loved one, and must move ahead in their day-to-day lives and taking on new and additional responsibilities, all the while concerned about their deployed family member.   Following deployment, God willing it all goes well; the families are once again united.  And although the safe homecomings are the ones celebrated, often with great fanfare, the tale of our troops does not end there.  The process of reintegration puts new stresses upon our returning troops and their family members who waited patiently at home for their safe return.

Cameron, a 36-year-old Army National Guard Captain, returned three months ago from deployment in Afghanistan.  While deployed he witnessed the detonation of over a half-dozen improvised explosive devices (IEDs), and was involved in three intense firefights.  During a prior deployment he again began smoking; having quit eight years earlier, after getting married.  Now, as he reintegrates back in to his civilian and family life he is experiencing sleep difficulties, including nightmares, and is described as being ‘jumpy’ all the time.  He struggles in his attempts to reconnect with his wife, two sons, and a daughter.  The company he worked at for years before his deployment shut down a few months prior to his return as a result of the economic downturn.  Now, Cameron cannot focus or concentrate well on his job search, cannot sleep, has lost his appetite, and is feeling anxious “pretty much every moment I’m awake”.

Upon returning home from deployment everyone experiences some level of normal reintegration problems.  In order to function to their greatest extent, and thus having the greatest chance for survival, troops quickly develop a battle mind-set, which, upon returning home, must be reset to match the home environment.  Family members who managed life alone at home may feel their warrior spouse/parent lacks an appreciation of how difficult and challenging it was to have them in harms way for such an extended period of time.  All family members face challenges adjusting back to civilian life together…. ‘the way it was’.

All of our returning troops have to deal with the normal, and somewhat expected, psychological responses to the traumas of war.  These responses often include emotional, physical, cognitive and interpersonal challenges.  Emotionally there is numbing, helplessness, anger, guilt, and grief.   Physically one often experiences a heightened startle response, increased tension, and insomnia.  Cognitively there are the unwanted memories, self-blame, self-flagellation, memory loss, and difficulty concentrating.  Interpersonally one may experience irritability, withdrawal, distrust, and feeling of rejections.  Given a reasonable amount of time, most will readjust back to the home/work environment, but significant mental health disorders develop in a sizeable minority of our returning troops.

By far the most comment mental health problems seen in our returning troops are depression, substance use/abuse disorders, and post-traumatic stress disorder (PTSD).  They oftentimes also experience sleep difficulties and pain syndromes.  It is these mental health issues that lead to behavioral problems commonly seen amongst our returning service people.  Such behaviors may include:  family conflict, marital issues, getting in trouble with the law, job loss, diminished work motivation and performance, poor school performance, and general risky behaviors, as well as others that can all lead to a severe feeling of disconnect.  Many of our service personnel and their families also grapple with severe financial and career issues which further exacerbate their underlying mental health issues.   As a result of the complex nature of the issues involved, these folks need much more than just treatment for their mental/emotional disorders.

Treatment professionals need to take great pains to not “over-pathologize” their patient relative to any mental health issues as there still remains, even today, a significant stigma associated with this sort of complaints and diagnoses.  For many, the fear that seeking treatment may somehow damage their career adds even more stress to an already fragile situation.

Many well-structured studies have demonstrated the critical importance that social support provides in helping prevent the onset of PTSD.  The United States, as a society, learned a very hard lesson from our less than prideful response to our returning troops from Viet Nam, and, in part as a result, there is now strong support for the returning men and women who have sacrificed so much in deploying to Iraq and Afghanistan.  But, there is much more that can be accomplished.  Although hardly ever reminded these days by the media, remembering that we are a country dealing with war, and its effects on our heroes that serve, is a critical piece to the overall reintegration of our troops.

It is important that families, employers, associates and friends of our returning troops understand what is normal to expect.  Normal reactions early on include emotional distancing, nightmares, and jitteriness.  Normal integration takes time.  Our returning service members are not going to be ‘just the way they were’ immediately stepping back on U.S. soil.  It is when these ‘normal’ symptoms are of such intensity, disruptiveness, and persistence that the presence of PTSD is strongly considered.  This becomes even more likely when the problems increase over a few months post-deployment, or if they cause considerable problems in their day-to-day functioning.

Because the aftereffects of war involve potentially complex and interwoven conditions, integrated services and interagency approaches are needed.  Services ranging from physical or vocational rehabilitation, financial assistance, social support, relationship assistance, or spiritual counsel may also be needed.  As a result of the multiple issues involved in reintegrating our troops back into their ‘normal’ lives back in the United States, an array of federal and state agencies have been working together over the past several years to ensure that a comprehensive safety net is provided to help ensure an efficient re-entry process and to simplify access to services.

The U.S. Department of Defense (DoD) and the U.S. Department of Veterans Affairs (VA) have led the federal institutional support.  The VA provides the largest network of care facilities in the world, specifically aimed at our nation’s veterans. Medical centers and clinics span the country, providing physical and mental health care. VA mental health programs are a key resource in finding effective therapy.  VA centers are a confidential option for combat veterans, and they also provide family care.  VA benefits include a range of educational, financial, and other services. Some example programs include PTSD psycho-education and the VA PTSD program locator (www.ptsd.va.gov); the Veterans Justice Outreach program, created to help struggling veterans get into care instead of into the legal system; and a toll-free 24/7 Veteran Crisis hotline, offered in partnership with the Suicide Prevention Lifeline (800-273-8255, press 1 for veterans).

The DoD is another large provider of resources for returning service personnel.  Military One Source offers 24/7 assistance for troops, families, and veterans.  The DoD Centers of Excellence for Psychological Health and Traumatic Brain Injury created the Web site afterdeployment.org (www.afterdeployment.org) as well as a wealth of other programs and services.  The National Guard Bureau supports Family Assistance Centers in all 50 states and provides family services for all branches of the military.

In addition to offerings by the DoD and the VA, States offer a wealth of services at the local level to veterans and families.  Each State has its own office of Veterans Affairs that provides additional services and connections to Veteran Service Offices, such as the American Legion, Veterans of Foreign Wars, Vietnam Veterans of America, Veterans of Modern Warfare, and Disabled American Veterans.  These organizations can serve as advocates for veterans and families.

So, if you or a loved one, or for that matter anyone you know, is struggling with issues of post-deployment reintegration please take advantage of accessing one of these support organizations.  Doing so will help ensure a healthy mind and healthy future.