B0038M1ADS EBOK (35 page)

(From Hoge et al., New England Journal ofMedicine 2004; 351:13-22)

Given this, how do you overcome these barriers and get help if you
need it? How do you find someone to work with? And what can you expect
from professional help?

ROAD MAP FOR GETTING HELP

Fear of "Losing Control"

The fear that many warriors express is that talking about combat memories will be like opening Pandora's box. Wartime memories may also stir up difficult experiences from childhood and other losses. Warriors often fear that
if they start talking about their problems, the dam will burst and they'll lose
complete control, along with their marriages, relationships, and jobs. This
fear reflects the intensity of the emotions, not the actual likelihood that
bad things will result from talking with a therapist. Like many fears, there's
an illogical aspect to this, because it only focuses on the what-if of seeking
help, not the what-if of continuing to try to suppress these memories and
feelings (not to mention that "What if?" itself is a trap). The reality is that
when the warrior begins to contemplate getting help for combat-related
reactions or other problems, then the floodgates have already started to
crack; their emotions are pushing to the surface, and their defense mechanisms of walling off feelings, avoiding and retreating, and staying perpetually in combat mode are no longer working so well.

Emotions are like water; they will always find a way to seep to the surface through any crack or imperfection in defenses. You can contain them
for just so long, even years, but eventually they push themselves to the
surface and force you to stare them in the face and accept them.

Is the fear of "losing control" unjustified or irrational? No. Dealing
with particularly difficult problems often leads to "losing it" in the form of
a flood of tears and other emotional expressions. But what's remarkable
is that losing it in this way actually helps to make it less likely to lose it in
other ways that could be more disastrous. It turns out that what the warrior
is most afraid of (not being able to work, losing relationships) is actually
more likely to happen if they continue to suppress or hold back their emotions than if they get help to deal with them.

What also happens after starting to talk about painful memories, emotions, and problems is that it becomes clear there isn't anything in Pandora's
box other than fear itself. Talking about painful memories may not make
them any less painful, but it somehow makes it possible to live with them,
and not have there remain a perpetual source of behavior that contributes to
further painful experiences.

The only thing you can do is have faith in the process and drive on
through it.

Overcoming Stigma

The two most important things to understand regarding stigma are a) that
your own perception of yourself is more important than anyone else's; and
b) that seeking help is a sign of strength, not weakness. Yes, mental health
treatment carries stigma in the military and in society, but that doesn't
mean that you should accept this perspective yourself. Service members
and veterans often find that their fears of being seen as weak or being
treated differently by colleagues, peers, or family members do not pan
out when they actually do get help. People realize that seeking counseling
for transition problems after combat is a normal part of the readjustment
process. In fact, since 2003, a routine part of the post-deployment process for all returning service members has included health assessments for
deployment-related physical and mental health concerns.

In other words, don't buy into the perception that seeking counseling is a sign of weakness, but view it as a necessary part of transition and
readjustment-however many days, months, or years it's been since you
returned home. Seeking help reflects strength. Everyone needs help from
time to time. Everyone faces mental health problems or challenges in one
way or another. You know that getting help to address difficult issues in
your life is not going to be easy, and it takes courage to do it. But as a warrior, you have that courage.

If you work in a profession that requires a security clearance, as many
military or former military personnel do, you may be particularly concerned
that seeking professional help could affect your career. However, in 2008, the
U.S. Office of Personnel Management Standard Form 86 used to apply for a
security clearance was changed to accommodate veterans and to reduce the
stigma of war-related mental health problems. Question 21 of this form asks
if the applicant has consulted with a health-care professional in the last seven
years for an "emotional or mental health condition." The instructions now
include two exceptions for which the applicant is requested to mark "no";
first, if they received counseling that was "strictly related to adjustments from
service in a military combat environment," and second, for counseling that is
"strictly marital, family, grief" (as long as this did not involve violence).

These two exceptions represented a huge step forward in acknowledging that there are life situations, particularly involving combat and
relationships, where counseling is expected. Although the definition of
"adjustments from service in a military combat environment" is somewhat
vague, this exception seems open to wide interpretation encompassing
much of what we've been talking about in this book. The other thing to
be aware of is that even if "yes" is marked on this form, it doesn't lead
to automatic denial of clearance, but simply a delay while another form
is sent to the mental health professional, who is asked a yes-no question
about whether there is any concern that the individual's behavior could
jeopardize security. There's no further information provided by the therapist unless they have such a concern.

Unfortunately, the positive changes in the Federal Form 86 have not
trickled down to the many different law enforcement organizations where
combat veterans like to work; many of these organizations have their own
screening processes, and don't provide an exception for combat-related
counseling. There is a widespread perception that this frequently leads to
non-selection of qualified combat veterans. This is particularly worrisome
in recent years, since mental health screenings have become routine in
the post-deployment period, and many warriors have received counseling
as part of the normal process. Hopefully, the perspective in this book will
become more widespread, and law enforcement agencies will learn that
veterans with a history of PTSD or other reactions related to combat are
often the best candidates because they are experienced, calm under fire,
and have learned how to utilize their experiences (including their PTSD
reactions) in a positive way.

Overcoming Other Barriers and Taking the First Steps

Although there are numerous ways to get help and various mental health
professionals to choose from, the system is complex and often not very
welcoming. Unfortunately, all too often when a warrior finally makes the
decision to get help, they're met with various material hurdles, like the
unavailability of an appointment for several weeks. There is nothing quite
as effective at destroying a newly emerging help-seeking attitude than being told precisely at that moment when you most need help (and are
finally ready to receive it) that you have to wait for several weeks. Not to
mention that you have no idea if the person you'll eventually see will have
the knowledge and ability to help you.

But being told that you have to wait several weeks means you've
already successfully navigated figuring out who to call in the first place.
That first step alone can present a significant-enough barrier to send warriors back into their foxholes. So how do you navigate this process, or even
get started? Here are some routes to consider:

A) Get Advice from Fellow Warriors, Veterans, Veterans' Organizations

One of the best sources of information for how to begin finding treatment
is from fellow warriors and veterans' organizations. Given the complexity
of the medical system in the VA, DoD, and in civilian health-care settings,
it's helpful to talk with others who have navigated this. Many have experience with how to get into the system and recommendations of mental
health professionals who they found helpful. Also, they're often in the best
position to both observe how a fellow warrior is doing and to encourage
that warrior to seek help when needed. There are also many outstanding
veterans' organizations that can provide information, assistance, and advocacy in the journey. For example, see wwwl.va.gov/vso/ for a searchable
directory of veterans' organizations.

B) Primary Care Referral

One of the easiest places to begin is to contact your primary care provider
in whatever health-care system you're in and ask for a referral. Many systems require that care is coordinated through the primary care provider,
so this is often the first place to start.

Your primary care provider (who's usually a family medicine or internal medicine physician, nurse practitioner, or physician's assistant) will
be very willing to assist you with this referral, although they may at times
choose to initiate treatment themselves, making a referral only if the treatment doesn't work. This is relatively common for mild to moderate depression, mild to moderate anxiety, or sleep problems. However, treatment options are limited only to medications, since primary care professionals
are generally not trained in providing therapy.

If you're experiencing anything more than minor difficulties, insist
on being referred to a trained mental health professional, and don't let
the buck stop in primary care. One exception to this is if there are mental
health professionals working inside the primary care clinic (often referred
to as a "collaborative care" program).

C) VA Vet Centers

One of the most unique resources available to U.S. combat veterans is
the VA-sponsored Vet Centers. If you're fortunate to live near one of the
230-plus Vet Centers across the nation (and U.S. territories), I highly
recommend going for a visit, as they have the most specific post-combat
readjustment counseling programs available anywhere. You're eligible for
these services at no cost if you have served in any combat zone or you're
a family member of a warrior. You don't have to be enrolled in the VA to
receive Vet Center services. All Vet Centers are staffed by combat veterans,
which means you'll find staff members who understand what you've been
through and have been there themselves. Vet Centers offer individual and
group counseling, marital and family counseling, bereavement services
for family members of warriors killed in action, alcohol/drug assessments,
counseling for veterans who have experienced sexual trauma in the military, and other services. You can find out where the nearest facility is by
visiting www.vetcenter.va.gov. Don't be discouraged by the sparse information on their Web site, because this program has a tremendous amount to
offer and is very welcoming to combat veterans and their family members;
it's a great place to start your counseling journey.

D) Mental Health Clinics

Although there are numerous mental health professionals in private
practice or associated with clinics and medical facilities, the challenge is
navigating your particular health-care system to find the professional who's
right for you. Unfortunately, in many civilian systems, people end up paying out of pocket for some of these services due to limitations in men tal health insurance coverage, lack of available professionals that accept
specific insurance plans, or lack of appointments at convenient hours that
don't interfere with work or child-care duties. These are some of the many
barriers characteristic of mental health services. The other issue in civilian
mental health care settings is that there are often problems finding professionals who have any experience with the military or with treating trauma.
There isn't a good answer to these realities, other than to acknowledge
them and try to do the best you can to find a professional who you can work
with. It's helpful to be armed with the knowledge in this chapter of what different professionals can offer and the types of treatment that are available.

For service members, mental health clinics are widely available at military treatment facilities, and many of the professionals are in the military
themselves or have worked with the military for a long time. In most treatment facilities, it's possible to walk into the mental health clinic without an
appointment (a "self-referral") and get seen on the same day. Another good
resource available to military service members and their families is Military
OneSource at www.militaryonesource.com or 1-800-342-9647. Military OneSource has free confidential counseling options available in person, by telephone, and online. This counseling is generally limited to short-term issues
involving stress or marital difficulties, and is not the best option for serious
problems with PTSD, depression, or alcohol abuse. However, one of the nice
things about Military OneSource is that you can speak with someone quickly,
and if they feel you need a referral to another professional, they'll facilitate it.