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Introduction: helping military personnel and recent veterans manage stress reactions.

We were pleased when Dr. Rogers asked us if we would be interested in guest-editing a special section of this journal on issues relevant to working with Operation Enduring Freedom/Operation Iraqi Freedom (OEF/OIF) military personnel and veterans. As Veterans Affairs (VA) clinician researchers we face the timeliness of these issues on a daily basis and appreciate the many ways in which the mental health community outside of the VA and the Department of Defense (DoD) can play a role in working with the men and women affected by the current conflicts. We therefore solicited original research, theoretical papers, critical reviews, and case reports from a broad cross section of disciplines. In particular, we sought manuscripts that would provide new ideas or timely reviews directly pertinent to the practice of mental health counseling with those who served in Iraq or Afghanistan. The resulting submissions were reviewed by a group of clinical scholars with expertise in the areas covered. We would like to thank our colleagues from the VA VISN 19 Mental Illness Research Education and Clinical Center and Denver VA Medical Center, Drs. Lawrence Adler, Herbert Nagamoto, Beeta Homaifar, and Jennifer Olson-Madden, and from the Zablocki VA Medical Center in Milwaukee, Dr. Michelle Cornette. We believe the articles selected present a range of ideas and techniques that address the goals of this special section. Application of this information can benefit military personnel, veterans, and their families.

The common theme of the three articles selected is deployment-related stress and ways to facilitate coping. Potter and colleagues present data on an in-theater intervention for combat stress control. They also review the types of clinical work being done in the field. Besides informing DoD clinicians about a novel means of service delivery, their article can orient VA and community-based mental health counselors to the types of care their clients may have received in-theater. Corso and colleagues have adapted a range of evidence-based PTSD treatments to use in a primary care setting. Their data suggest that integrating mental health and primary care can be effective and that a behavioral health consultation model can decrease symptoms of PTSD in clients who do not seek traditional mental health services. Finally, from a review of the suicide literature as it relates to members of the military, Martin and colleagues highlight similarities and differences in risk and protective factors for military personnel and veterans compared with the general population. Their material can inform case conceptualization and treatment planning, particularly for counselors new to working with suicidal military personnel and veterans.

Readers may be asking why a special section on such topics is necessary. Preliminary evidence suggests that the mental health needs of those who have served or are serving in Iraq and Afghanistan are significant (Lineberry, Bostwick, & Rundell, 2006; Milliken, Auchterlonie, & Hoge, 2007; Seal et al., 2008). As such, increased attention to meeting the needs of these individuals is warranted. Ideally, this will be facilitated via DoD, VA, and community partnerships, and can in part be accomplished by collaboratively pooling resources and sharing information across systems. Based on the clinical literature (Lineberry, Ramaswamy, Bostwick, & Rundell, 2006) we expect that the challenges-both physical and psychological--faced by some individuals will require significant intervention, and that the type of care needed will evolve over time.

As individuals return from deployments to Iraq and Afghanistan, clinicians will be seeing clients at differing points in their recovery. Corso et al. (this issue) highlight that many individuals are exhibiting symptoms but do not yet meet the full diagnostic criteria for PTSD. Providing treatments which help these individuals more effectively manage their symptoms may indeed lead to fewer clients developing PTSD. Early interventions (Edward, 2005; Southwick, Vythilingam, & Charney, 2005; Wagner, Zatzick, Ghesquiere, & Jurkovich, 2007) may change the trajectory of recovery in positive directions.

In order to address the needs of returning military personnel and veterans, clinicians need to be aware of the factors which may differentiate these clients from members of the general population. According to Hoge and colleagues (Hoge, Auchterloine, & Milliken, 2006), 65% of Soldiers who served in Iraq reported a history of combat experience. For some, such exposure results in injuries, whether physical or emotional. Recent work by Terrio et al. (2009) suggested that 22.8% of Soldiers in one Brigade Combat Team may have a history of clinician-confirmed traumatic brain injury (TBI), with 7.5% of these individuals continuing to endorse sequelae at post-deployment. The potential long-term impact of these symptoms (e.g., headaches, irritability) on psychosocial functioning is unknown. Further complicating assessment and intervention is the co-occurrence of TBI and psychiatric conditions including PTSD. In a recent report by the RAND Corporation (Tanielian & Jaycox, 2008) the range of prevalence estimates for PTSD (5% to 15% of persons deployed) and depression (2% to 10% of persons deployed) were applied to the 1.64 million service members who have already been deployed. In doing so, it was estimated the number of individuals with PTSD and depression will be 75,000 to 225,000 and 30,000 to 50,000 respectively.

In part, clinicians' ability to facilitate treatment for those with PTSD will be enhanced by understanding that symptoms such as hypervigilance are adaptive while in theater. For some, the long-term adoption of such strategies may have been reinforced across multiple deployments. Upon returning home, these same symptoms can impede reintegration with the civilian community.

Clinician awareness of issues related to re-entry and re-integration is also warranted (Doyle & Peterson, 2005). According to Doyle and Peterson programs aimed at improving this process will normalize the experiences of military personnel. For active duty personnel, this is facilitated by military community support; however, for Reservists and Guardsmen "reintegration largely is shouldered by the communities from when they came" (p. 367), including services offered by mental health counselors.

Another component of successful reentry is including families in the process (Doyle & Peterson, 2005). In doing so it is important to attend to the needs of both the returning service member and the family. Even without deployments military marriages face significant challenges, such as moves and separations, loss of friends and jobs secondary to reassignment, and parental absence (Gambardella, 2008). Recent work by Eaton and colleagues (2008) indicated that military spouses are screening positive for major depression or anxiety disorders at rates similar to that seen among military personnel returning from combat. Lincoln, Swift, and Shorteno-Fraser (2008) suggested that although most children are resilient to the effects of deployment, those with pre-existing psychological conditions (e.g., anxiety and depression) may be particularly vulnerable. Compared to children ages 3 to 5 without a deployed parent, those with a deployed parent experience greater behavioral symptoms independent of the non-deployed parent's stress and depressive symptoms (Chartrand, Frank, White, & Shope, 2008). Whereas the spouses studied by Eaton and colleagues were much more likely to seek care for mental health-related complaints than their partners, mental health services are only available on-post for Soldiers. Mental health care of spouses and children are "outsourced" (p. 1052) to civilian care providers (Eaton et al.), thereby highlighting the need for DoD, VA, and community collaborations.

In addition to becoming familiar with the relevant areas of the treatment literature we have discussed so far, there are steps that community mental health providers can take to enhance their ability to work with returning military personnel and their family members. As suggested above, the military is a unique culture. We therefore believe it is important to find a common language for working with those who have served. One resource that can help to facilitate this is Battlemind training (Walter Reed Army Institute of Research [WRAIR], 2007). These educational materials were developed by the DoD to aid war fighters' transition back home after deployments. Battlemind may also serve as an orientation to military culture and a starting point for discussions with clients. As is true when working with a member of any cultural group that differs from that of the clinician, it is important to understand how cultural beliefs shape the client's worldview (Ridley, Chih, & Olivera, 2000), and how these cultural differences may or may not affect treatment. Another valuable resource is the new website (D. H. Meichenbaum, personal communication, January 2, 2009). This social networking site was developed for service members with the goal of facilitating resiliency by giving them access to the stories of other war fighters. It is hoped that this will decrease their sense of social isolation. Because access to the site is not limited to military personnel, the material provided is a potential educational resource for all clinicians. Exploring this website and discussing the content with clients can serve as a means of bridging veteran and civilian cultures.

Community mental health counselors should also become familiar with the resources available, and services offered, at their local VA. Encouraging veteran clients to make use of these resources not only expands the services they can access but communicates that the counselor is open to exploring multiple options for promoting their mental and physical health. At the same time it would benefit VA and DoD clinicians to become familiar with the mental health and social services available in their communities and how to access them. Increased awareness should reinforce the notion that all members of the mental health community are on the same team.

Besides increasing awareness of military culture, clinicians should explore evidence-based interventions aimed at decreasing stress-related symptoms. For example, exposure-based therapies have been shown to be effective for individuals with combat-specific PTSD (Black & Keane, 1982; Fairbank & Keane, 1982; Keane & Kaloupek, 1982; Resick & Schnicke, 1992). More recently, Orsillo and Batten (2005) have argued that Acceptance and Commitment Therapy (ACT; Hayes, Strosahl, & Wilson, 1999) could be particularly useful in reducing avoidance of unpleasant emotions and facilitating exposure and positive changes in clients' lives. Helping returning military personnel establish and maintain healthy relationships with those outside the military/veteran community may require extra effort (Brenner et al., 2008). For that reason we recommend couples or family therapy (e.g., Sherman, Zanotti, & Jones, 2005), possibly supplemented by targeted social skills training (e.g., Turner, Beidel, & Frueh, 2005) as supportive elements during transition periods. Working with these clients to help them establish and maintain the best possible trajectory to recovery will take increased effort and creativity on the part of all involved. Ultimately, it is the responsibility of DoD, VA, and community providers to work together and learn from each other to meet the needs of returning military personnel, veterans, and their families.


Black, J. L., & Keane, T. M. (1982). Implosive therapy in the treatment of combat related fears in a World War II veteran. Journal of Behavior Therapy and Experimental Psychiatry, 13, 163-165.

Brenner, L. A., Gutierrez, P. M., Cornette, M. M., Betthauser, L. M., Bahraini, B., & Staves, R J. (2008). A qualitative study of potential suicide risk factors in returning combat veterans. Journal of Mental Health Counseling, 30, 211-225.

Chartrand, M. M., Frank, D. A., White, L. F., & Shope, T. R. (2008). Effect of parents' wartime deployment on the behavior of young children in military families. Archives of Pediatric and Adolescent Medicine, 162, 1009-1014.

Doyle, M. E., & Peterson, K. A. (2005). Re-entry and reintegration: Returning home after combat. Psychiatric Quarterly, 76, 361-370.

Eaton, K. E., Hoge, C. W., Messer, S. C., Whitt, A. A., Cabrera, O. A., McGurk, D., et al. (2008). Prevalence of mental health problems, treatment need, and barriers to care among primary care-seeking spouses of military service members involved in Iraq and Afghanistan deployments. Military Medicine, 173, 1051-1056.

Edward, K. (2005). Resilience: A protector from depression. American Psychiatric Nurses Association Journal, 11, 241.

Fairbank, J. A., & Keane, T. M. (1982). Flooding for combat-related stress disorders: Assessment of anxiety reduction across traumatic memories. Behavior Therapy, 13, 499-510.

Gambardella, L. C. (2008). Role-exit theory and marital discord following extended military deployment. Perspectives in Psychiatric Care, 44, 169-174.

Hayes, S. C., Strosahl, K. D., & Wilson, K. G. (1999). Acceptance and commitment therapy: An experiential approach to behavior change. New York: Guilford Press.

Hoge, C. W., Auchterloine, J. L., & Milliken, C. S. (2006). Mental health problems, use of mental health services, and attrition from military service after returning from deployment to Iraq or Afghanistan. Journal of the American Medical Association, 295, 1023-1032.

Keane, T. M., & Kaloupek, D. G. (1982). Imaginal flooding in the treatment of posttraumatic stress disorder. Journal of Consulting and Clinical Psychology, 50, 138-140.

Lincoln, A., Swift, E., & Shorteno-Fraser, M. (2008). Psychological adjustment and treatment of children and families with parents deployed in military combat. Journal of Clinical Psychology, 64, 984-992.

Lineberry, T. W., Bostwick, J. M., & Rundell, J. R. (2006). U. S. troops returning home: Are you prepared? Current Psychiatry, 5(1), 13-22.

Lineberry, T. W., Ramaswamy, S., Bostwick, J. M., & Rundell, J. R. (2006). Traumatized troops: How to treat combat-related PTSD. Current Psychiatry, 5(5), 39-52.

Milliken, C. S., Auchterlonie, J. L., & Hoge, C. W. (2007). Longitudinal assessment of mental health problems among active and reserve component soldiers returning from the Iraq war. Journal of the American Medical Association, 298, 2141-2148.

Orsillo, S. M., & Batten, S. V. (2005). Acceptance and commitment therapy in the treatment of posttraumatic stress disorder. Behavior Modification, 29, 95-129.

Resick, P. A., & Schnicke, M. K. (1992). Cognitive processing therapy for sexual assault victims. Journal of Consulting and Clinical Psycholog3; 60, 748-756.

Ridley, C. R., Chih, D. W., & Olivera, R. J. (2000). Training in cultural schemas: An antidote to unintentional racism in clinical practice. American Journal of Orthopsychiatry, 70, 65-72.

Seal, K. H., Bertenthal, D., Maguen, S., Gima, K., Chu, A., & Marmar, C. R. (2008). Getting beyond "Don't Ask; Don't Tell": An evaluation of US Veterans Administration post-deployment mental health screening of veterans returning from Iraq and Afghanistan. American Journal of Public Health, 98, 714-720.

Sherman, M. D., Zanotti, D. K., & Jones, D. E. (2005). Key elements in couples therapy with veterans with combat-related posttraumatic stress disorder. Professional Psychology: Research and Practice, 36, 626-633.

Southwick, S. M., Vythilingam, M., & Charney, D. S. (2005). The psychobiology of depression and resilience to stress: Implications for prevention and treatment. Annual Review of Clinical Psychology, 1, 255-291.

Tanielian, T., & Jaycox, L. H. (Eds.). (2008). Invisible wounds of war: Psychological and cognitive injuries, their consequences, and services to assist recovery (RAND Corporation Monograph Series). Santa Monica, CA: Center for Military Policy Research.

Terrio, H., Brenner, L. A., Ivins, B. J., Cho, J. M., Helmick, K., Schwab, K., et al. (2009). Traumatic brain injury screening: Preliminary findings in a US Army brigade combat team. Journal of Head Trauma Rehabilitation, 24, 14-23.

Turner, S. M., Beidel, D. C., & Frueh, B. (2005). Multicomponent behavioral treatment for chronic combat-related posttraumatic stress disorder: Trauma management therapy. Behavior Modification. 29, 39-69.

Wagner, A. W., Zatzick, D. F., Ghesquiere, A., & Jurkovich, G. J. (2007). Behavioral activation as an early intervention for posttraumatic stress disorder and depression among physically injured trauma survivors. Cognitive and Behavioral Practice, 14, 341-349.

Walter Reed Army Institute of Research (WRAIR) U.S. Army Medical Research and Materiel Command. (2007). Battlemind training II: Continuing the transition home. Retrieved April 2, 2008, from 20Months%20PDHRA/Battlemind%20Training%20II%20Brochure%2013%20SEP%2006.p.

Peter Gutierrez and Lisa A. Brenner are affiliated with the University of Colorado School of Medicine. Correspondence concerning this article should be addressed to: Peter Gutierrez, Ph.D, VA VISN 19 MIRECC, 1055 Clermont Street, MIRECC, Denver, Colorado, 80220. E-mail:
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Author:Gutierrez, Peter M.; Brenner, Lisa A.
Publication:Journal of Mental Health Counseling
Article Type:Report
Geographic Code:1USA
Date:Apr 1, 2009
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