It is wrong to assume that all combat soldiers will seek help from the VA if they need mental health services after they return from Iraq or Afghanistan. Many will use their Tricare benefit and others may use insurance they receive from their spouse. Conducting a needs assessment and formulating a treatment plan with a combat veteran requires understanding the unique experiences and needs of that population. In order to provide the appropriate understanding and empathy the clinician needs to appreciate the various types of events the soldier may have lived through and participated in. Certainly knowing how to identify trauma without retraumatizing the soldier is essential.
According to the Department of Veterans Affairs National Center for PTSD here are the issues you should explore as you conduct a mental health assessment with a veteran.
• Preparedness – some veterans are angry because they feel they were not appropriately prepared for what they experienced abroad. Anger at these issues will usually show itself with feelings of helplessness unpredictability in the warzone which leaves the soldier at greater risk for PTSD.
• Combat exposure – Soldiers tend to minimize the exposure to battlefield stressors such as armed combat, being fired upon, witnessing death and injury and being in situations where they believed they were going to die. Even a single such issue can lead to PTSD.
• Aftermath of battle – Handling remains, dealing with prisoners of war, observing or participating in the devastating of communities and the smells of dying may remain extremely disturbing to the returning soldier.
• Perceived threat – Panic attacks may be triggered and anticipatory anxiety may occur when the potential to combat circumstances exists – like the discussion of war issues on the TV.
• Difficult living and working environment – Day to day irritation, lack of privacy, uncomfortable living conditions and other non-traumatizing issues may invoke war memories or at least stress coping resources.
• Concern about life and family disruptions – National Guard and Reserve troops never expected to be deployed and the impact their leaving has had on their families is often a serious concern for them as it is for all enlisted personnel. The appropriateness of including family members in therapy must be based on the assessed impact of those concerns.
• Sexual or gender harassment – Harassment may come as the result of gender, minority, or social status. Though it is a violation of military rules it still exists and needs to be assessed. Victims who have experienced this often display rage, resistance to authority, deliberate sabotage and make indirect threats.
• Ethocultural stressors – Minority soldiers may experience racist remarks, Americans of Arab decent have experienced this during the Iraq and Afghani incursions.
• Perceived radiological, biological and chemical exposure – While many soldiers have not experienced this type of exposure the concern that they have leads to hypervigilance and other somatic complaints.
Rather than encouraging the vet to rehash their combat experiences focus of current needs and experiences – like their work environment and family relationships. Determine how they are functioning socially and what they are doing for recreations and relaxation and self care. Do not require questions to have responses if the soldier declines. Over time, most information will come forth. A complete assessment may take some time to finish and it may, in fact, always be a work in progress.
Iraq War Clinician Guide, Department of Veteran Affairs, National Center for PTSD.