The provision of mental health services to veterans is implied in a social contract between the American people and their warriors, a contract that has evolved over time from the colonial period to the present. The paper traces the development of knowledge regarding the long-term negative effect of war-related psychological trauma since the War Between the States. The contribution of the Vietnam veteran community to an understanding of what has come to be known as posttraumatic stress disorder (PTSD), and its effect on national mental health policy toward veterans is examined. The Vet Center system is described as an efficient and effective instrument of mental health delivery services for veterans, an institutional expression of the social contract that should continue to be available for current and future generations of American war veterans.
The Social Contract: Evolution of a Policy
That in case necessity require to send forces abroad, and there be not volunteers sufficient offered for this service, then it be lawful for the Governor and [his] assistants to press men into service in his Majesties name...provided that any that shall goe return mamed and hurt, he shall be mayntayned by the Colony duringe his life. (Plymouth Colony, 1636. [U.S. Cong., 1967, p. 21])
The unique contribution of America's warriors has been broadly recognized and publicly accepted throughout the history of the United States from the early colonial period. This recognition of the American people's social obligation to its soldiers and veterans has evolved over the years from implication to explicit legislation and institutions that form a national social contract not only for the veterans themselves but for their families as well. The locus of control in the implementation of the resulting social policy has also evolved from decentralized colonial and state government to the federal level.
The Government's obligation is to help veterans overcome special, significant handicaps incurred as a consequence of their military service. The objective should be to return veterans as nearly as possible to the status they would have achieved had they not been in military service....Particular emphasis should be placed on rehabilitating the service-disabled and maintaining them and their survivors in circumstances as favorable as those of the rest of the people....War sacrifices should be distributed as equally as possible within our society. This is the basic function of our veterans' programs. (U.S. Cong., 1956, pp. 3-4)
Categories of Benefits
Three types of veterans' benefits have emerged over the years: (a) service-connected benefits, which include medical and hospital care for injuries incurred while in service; (b) non- service-connected benefits, including pensions and burial benefits; and (c) readjustment assistance, other than for health problems, including education and training programs and employment preference programs. Service-connected benefits date from the colonial period. Non-service-connected pension benefits originated during the years following the Revolutionary War, specifically 1818. Readjustment benefits for non-disabled veterans are rooted in the World War II era, embodied in the Serviceman's Readjustment Act (GI Bill) enacted in 1944 (U.S. Cong., 1956).
Provision of Mental Health Services as a Veterans' Benefit
Mental Health policy for veterans has evolved within the social contract as a part of the service-connected category of veterans' benefits. An examination of war-related neuroses and how our Nation has responded to them over the years is essential to an understanding of how we have arrived at where we are today.
War and the Warrior
They may write home to their parents and sweethearts that they are unchanged, and they may even be convinced of it. But the soldier who has yielded himself to the fortunes of war, has sought to kill and escape being killed, or has even lived long enough in the disordered landscape of battle, is no longer what he was. (Gray, 1959, p. 27)
Human combat has negatively affected the lives of the people who experience it throughout recorded history. Jonathan Shay's (1994) Achilles in Vietnam draws striking parallels between the experiences of Greek soldiers during and after the Trojan Wars and those of American soldiers during and after the Vietnam War, some 3,000 years later. Over time the diagnostic labels for the psychological disorders sufferred by warriors as a result of battle have changed as the science of mental health has advanced and matured.
The American Experience Before the Vietnam War
The War Between the States. Firm evidence of the long-term (chronic) psychological impact of combat in America can be traced to the Civil War. In 1871, writing in the American Journal of Medical Sciences Dr. Jacob Mendes DeCosta assigned the diagnostic label "irritable heart" or "soldier's heart" to the chronic psychological problems of returning veterans (Mason, 1990; Perkal, 1992; Pollner, 1995).
Union veteran Ambrose Bierce's nightmares, persistent insomnia, heavy drinking, emotional numbing, and his insistence on having a weapon near by cost him his marriage and any prospect of a normal life. Confederate veteran Lewis Paine's lawyer, in defense of his client's participation in the plot to kill President Lincoln and Secretary of State Seward, argued that Paine had homicidal mania due to his four years as a combat soldier (Hendin & Haas, 1984).
President Lincoln's eloquent second inaugural address in 1864 stated clearly the nature of the social contract "...to care for him who shall have borne the battle and... his widow, and his orphan..."
President Theodore Roosevelt echoed the essence of the social contract in 1903, "A man who is good enough to shed his blood for his country is good enough to be given a square deal afterwards" (p. 294).
World War I. During the Great War, psychological casualties were said to have "shell shock." But many military leaders and physicians attributed causality to unseen physiological damage or even cowardice or weakness in soldiers so affected (Scott, 1990). Later, it became clear that mental health problems were not limited to the battlefield. By 1922, 50,000 British veterans were receiving monetary compensation for mental problems, and by 1929 that figure had risen to 65,000 (Mason, 1990).
Soon after World War I (1919), Sigmund Freud concluded that war neurosis (shell shock) was indeed psychological in origin. He differentiated it from other common neuroses that develop during childhood, and recommended psychoanalysis as its treatment (Scott, 1990). Freud suggested that there were two broad and long-lasting responses to trauma: "(1) attempts to remember or repeat the trauma, and (2) attempts to avoid or defend against memories and repetitions" (Brett, Spitzer, & Williams, 1988, p. 1232).
Other prominent members of the psychiatric community soon followed Freud's lead, and the physiological explanations for shell shock lost ground among mental health professionals. However, much of the American military establishment continued to hold on to the notion that war neurosis was a problem only experienced by weaklings (Scott, 1990).
Major General Smedley Butler, United States Marine Corps, a two-time recipient of the Congressional Medal of Honor, was an exception to the traditional military attitude regarding war neurosis. The text of this letter, written in 1936, almost two decades after World War I, illuminates an ominous situation that bears no small resemblance to the plight of the Vietnam veteran 40 or 50 years later:
On a tour of this country, in the midst of which I am at the time of this writing, I have visited 18 governmental hospitals for veterans. In them are a total of about 50,000 destroyed men... men who were the pick of the nation 18 years ago. The very able chief surgeon at the government hospital in Milwaukee, where there are 38,000 of the living dead, told me that mortality among veterans is three times as great as among those who stayed home. Boys with a normal viewpoint were taken out of the fields and offices and factories and classrooms and put into the ranks. There they were remolded; they were made over; they were made to "about face;" to regard murder as the order of the day. They were put shoulder to shoulder and, through mass psychology, they were entirely changed. We used them for a couple of years and trained them to think nothing at all about killing or being killed. Then, suddenly, we discharged them and told them to make another "about face!" This time they had to do their own readjusting, sans mass psychology, sans officers' aid and advice, sans nation-wide propaganda. We didn't need them anymore. So we scattered them about without any speeches or parades.
Many, too many, of these fine young boys are eventually destroyed, mentally, because they could not make that final "about face" alone. (p. 30)
After World War I, President Calvin Coolidge cautioned the country against abandoning the social contract with its warriors, "The nation which forgets its defenders will itself be forgotten" (p. 109).
World War II and Korea. In World War II, despite efforts to screen out psychologically maladjusted inductees, over 10 percent of US casualties were psychiatric, the label in this war being "combat fatigue" (Hendin & Haas, 1984; Scott, 1990). The military had recognized during World War I that men could be psychologically broken by combat, and had provided psychiatric treatment in the combat theater. This practice was repeated in WW II and Korea with some success in returning psychiatric casualties to the battlefield.
There were long-term effects of combat trauma, however. In 1993, 22,273 veterans aged 65-79 (placing them squarely in the WW II era) spent 2,005,404 days in VA hospitals for psychiatric illnesses. The average length of stay was 90 days (VA, 1994). Although there are no data to show the prevalence of what we now know about PTSD in this group of veterans, it is safe to assume that many had war-related PTSD, but were being treated under another diagnosis.
Two significant research studies emerged in the 1960s that should have alerted the mental health community to the chronic psychological effects of combat service. Archibald, Long, Miller, and Tuddenham (1962) published the results of their research on American veterans of World War II. Fifteen years since the war's end they found a cluster of symptoms which they described as "combat veteran syndrome...a severely disabling condition involving startle reactions, sleep difficulties, dizziness, blackouts, avoidance of activities similar to combat experience, and internalization of feelings" (p. 321). They did not think the veterans found to be suffering from this condition to be psychotic.
In a 20-year follow-up study of the same veterans with a number of Korean War veterans added to the study population, Archibald and Tuddenham (1965) validated and enhanced the results of their previous work:
The combat fatigue syndrome, which was expected to vanish with the passage of time, has proved to be chronic, if not irreversible in certain of its victims. Nor can the persistent disorder be dismissed as compensation neurosis, since many have never received compensation and are only now appearing for treatment as aging exacerbates their symptoms. This severely disabling condition is characterized by irritability, jumpiness, difficulties in concentrating and in memory, wakefulness, fatigability,, depression, dizziness, abdominal discomfort, sighing, shortness of breath, sweating, etc, and is accompanied by difficulties in work and family relationships, impaired efficiency, social isolation, and narrowing of interests. The syndrome is apparently found in different parts of the world and among victims of different kinds of stress, although it may be called by different names. (p. 481)
Summary. The costs in human suffering of America's veterans and their families over the years is impossible to gauge. The social contract between the Nation and its warriors continued to grow through federal and state legislation intended to provide a full range of benefits for veterans in all three categories. A major shortcoming was in meeting the mental health needs of returning combat veterans. In our opinion, this was not due to any conscious or flagrant neglect of veterans' mental health needs by the American people or their representatives in government. It was more likely due to the lack of knowledge among the community of mental health professionals about war- related trauma and its long term effects on those who fought.
Before the Vietnam War forced the mental health community to recognize war-related psychological trauma, many afflicted veterans suffered without relief, making the lives of their families as miserable and dysfunctional as their own (Mason, 1990 & Matsakis, 1988). Many wandered far and wide across the country, unable to get and maintain adequate employment (Archibald & Tuddenham, 1965). Many became homeless. Those with critical psychological distress may have been diagnosed as schizophrenics or manic-depressives, there being no appropriate diagnostic criteria to describe and validate their problems.
1964-1980: Strains in the Social Contract
Institutional rejection. Prior to 1980, the returning Vietnam veteran had few options to which to turn for help with war- related psychological stress. Many veterans found themselves ineligible for treatment at VA hospitals because they had been discharged with no physical or mental disabilities. The VA hospitals themselves, the federal government's institutional response to the medical and mental health needs of veterans, were found to be dismal in treatment of their psychiatric patients. Psychiatric staff were found to be under-qualified and understaffed throughout the system. Patients were found to be over-medicated, while receiving very little psychotherapy, as little as 2.9 average planned treatment hours per patient per week (National Research Council, National Academy of Sciences, 1977).
Societal rejection. The unpopularity of the war with much of the citizenry, particularly among academic and professional elites, as well as the fact that it was perceived by many to have been fought at the cutting edge (the high war-zone stress environment) in disproportionate share by the poor, undereducated, and people of color (Kulka, et al., 1990; U.S. Senate, 1988) also served to weaken the social contract. On the controversial racial issue, Freidel (1990) points out that:
Among blacks and those with Spanish surnames there were disproportionately high casualties. On the other hand, it was not disproportionately a black man's army. Between 1964 and 1971 it contained 29 percent of the total pool of white eligibles, and 26 percent of the blacks. (p. xv).
Much of America was ready to abandon and even castigate their warriors for participation in what they perceived as a bad war. To make matters worse, some individual veterans and mainstream veterans organizations publicly disdained their fellow veterans who were unable to immediately readjust.
Warriors and healers: A unique alliance. Rejection by the VA and by a large portion of the American society at large brought several hundred bitter and disillusioned veterans together in "rap groups" established by the veterans themselves in New York City and other large urban centers. Prominent psychologists and psychiatrists, many of whom admittedly had strong political and moral objections to the war, were invited by the veterans to join the rap groups. Working together, wounded warriors and professionals began to recognize a cluster of symptoms that seemed to characterize the psychologically disturbed veterans, particularly those who had actually experienced combat first hand.
These mental health clinicians, as well as others who had worked with other non-war-related trauma sufferers such as rape and burn victims, approached the American Psychiatric Association (APA) as it was developing its third revision of the Diagnostic and Statistical Manual of Mental Disorders. The APA had recognized war neuroses under the label "gross stress reaction" in its first DSM in 1952, but had inexplicably dropped it from its DSM II (1968), even though many psychiatrists considered "gross stress reaction" to be valid and useful. The APA validated and reinstituted war neuroses in its DSM III in 1980 under the diagnostic label of PTSD (Scott, 1990).
The PTSD diagnostic criteria has been continued with minor revisions in the DSM III (R) (1987) and DSM IV (1994). Advances in the treatment of psychological trauma from all causes have steadily taken place since 1980. In our opinion, recognition of the PTSD phenomenon in the mental health community is the foremost and most enduring legacy of the Vietnam veteran's tragic experience.
1981-Present: Contract Revitalized--permanent or temporary?
The government responds, finally. As a response to a mental health crisis of major proportions, the Congress, in 1983, mandated the National Vietnam Veterans Readjustment Study (NVVRS) to establish "the prevalence and incidence of PTSD and other psychological problems in readjusting to civilian life" among Vietnam veterans (Kulka, et al., 1990, p. xxiii.). The findings were alarming:
...the study...reveals (that) 829,000 of the 3.14 million--over one-fourth--of the veterans who served in Vietnam are currently suffering from some degree of PTSD....15.2 percent of the male Vietnam theater veterans (479,000) and 8.5 percent of the female theater veterans (610) are currently suffering from full-blown cases of PTSD....Another 350,000 theater veterans suffer from PTSD symptoms that adversely affect their lives but are not of the intensity or breadth required for a diagnosis of PTSD. These data indicate that, over 20 years later, psychological problems associated with service in our most divisive war since the Civil War continue to take a terrible toll on the lives of those who served in Vietnam. (Kulka, et al., 1990, pp. v-vi)
Strengthening the VA. The VA was elevated to cabinet departmental status during the Bush presidency, and the provision of mental health services improved. Reaffirming the social contract, its Chief Medical Director stated while addressing Congress, the VA remains, "...committed to ongoing excellence in treating the psychological as well as the physical trauma of war...." (Committee on Veterans Affairs, U.S. Cong., 1988, cited in Grady, 1990, p. 287).
Resources followed the revitalization of the social contract. Fifty-four (54) posttraumatic stress units (inpatient) were operating in VA medical centers throughout the country in FY '94. Eighty-seven (87) post-combat trauma clinics (outpatient), based at VA hospitals, were also operating during the same period, their purpose to provide on-site and outreach clinical therapy for individual veterans and groups. Formal evaluations of these programs show them to be effective (Fontana, Rosenheck, Spencer, & Gray, 1995). The VA's Readjustment Counseling Service, authorized and funded by the Congress in 1979, currently operates 205 storefront Vet Centers in communities across the Nation.
Because PTSD is a disorder that affects the veteran's family in a variety of negative ways, families are offered VA services in all three of the PTSD service delivery systems (Figley, 1993; Mason, 1990; Matsakis, 1988; U.S. Cong., May 18, 1994; Williams & Williams, 1985).
Contemporary Community Mental Health Models
Vet Centers represent a successful community mental health model that has been generalized to other trauma treatment settings. Community mental health models emphasize the normalizing of psychological and emotional adjustment problems in an outpatient treatment setting. Counseling may involve the inclusion of significant others in the treatment process. A primary goal of the treatment setting is to eliminate the stigma that individuals may feel when seeking help for psychological and emotional adjustment problems. Interventions commonly involve identification of stressors, strengthening coping skills, and enhancing social support connections. In addition, community mental health models are specifically organized to eliminate logistic, economic, social, and psychological barriers to services (Cutler, 1992; Fellin, 1996; Stockdill, Haggard, & Michaelson, 1992; . Community mental health settings provide a noninstitutional, apolitical treatment climate. So do Vet Centers.
Community-based Vet Centers were established and implemented by the VA in 1979, following extensive Congressional testimony by experts on war-related readjustment problems and 10 years of resulting legislation. The treatment setting is informal and provides a wide variey of services from meeting resource needs to individual counseling. If warranted, clients are referred to VA medical centers for more intensive treatment and/or medications. Vet Centers have developed or participated in extensive community outreach activities such as "Standdown Operations" for the homeless veteran population.
The central focus of Vet Center interventions is the treatment of PTSD by assisting the client to work through troubling war experiences and their impact on the veteran's present life. Service delivery is performed by male and female staff, psychologists, social workers, nurses, clinical counselors and paraprofessionals, the majority (60%) of whom served in the war zone themselves. Specific needs of ethnic minority, disabled, and women veterans are also addressed.
Vet Centers offer six categories of service. First, an assessment to determine the presence of PTSD is conducted whenever possible, ideally in all cases. Second, if and when the assessment indicates counseling would be beneficial, it is made available. Third, since PTSD is known to adversely effect interpersonal relationships, the veteran's family may be included in counseling (Figley, 1993). Vet Centers also offer employment and educational informational services linking veterans to job opportunities, universities, community colleges, and other training programs. Finally, when comprehensive services are needed, case management may be offered to the veteran. Emphasis on service delivery varies, depending on the needs of the veteran within the context of the community in which he or she resides (Blank, 1993).
Vet Centers are organized within the Veterans Health Administration of the VA. However, their operations-- policymaking, management, fiscal control, and supervision-- are directly under a special office designated the Readjustment Counseling Service (RCS). RCS is responsible for the management and operations of the Vet Centers. It is one of several other special groups within the VA such as public affairs or medical education. Ninety-five per cent of the leadership of the RCS and its regional management are Vietnam veterans. Individual Vet Center staffing consist of both Vietnam theater veterans (60%) and Vietnam era veterans (25%) (Blank, 1993).
Vet Center services are normally delivered by a four-person team. Staff may include psychologists, social workers, or other mental health counselors, nurses, and paraprofessionals. Each Vet Center is responsible to a RCS regional supervisory and support office at a VA medical center (VAMC). Vet Centers often refer veterans to VAMCs for more intensive treatment and frequently provide after-care for released patients. This reciprocal arrangement provides for a continuum of care for the veteran and family.
Each Vet Center organizes its service delivery to meet the needs of the user population, in contrast to other mental health facilities which are often organized around the needs of service provider staff, the staff's prefferred treatment modalities, or the facility itself (Blank, 1993). Keeping evening hours and holding treatment groups at hours which enable working people to participate are common examples of such an approach. This ground- up focus is rare in a world where high-tech professionalized care and staff-centered service delivery have become the norm.
According to Blank (1993) and Batres (Pollner, 1995), the philosophical approach to Vet Center organization, management and methods of operation bears resemblance to that of an Army Special Forces organization. The goal is to be flexible, adaptable and immediately responsive to a broad range of challenges. This is a stark contrast to the traditional medical model approach which often fails to recognize emergent needs, solely attends to physical problems, and often ignores psychosocial needs.
While most Vet Center staff are veterans, others include individuals with a professional interest and commitment to working with veterans and experience in the assessment and treatment of PTSD. The Vet Center culture of veterans providing services to veterans has created a safe, nonthreatening climate within which veterans can and are treated with dignity and respect (Blank, 1993). The staff may work as an interdisciplinary team, each member bringing his or her own expertise to its clientele. In addition to their clinical expertise, staff may also be involved in other aspects of community involvement at the macro-level such as making educational presentations to the community, engaging in outreach, talking with employers and community leaders, and participating in conferences to educate other professionals about the work of the Vet Centers. It is unlikely that a staff member would be involved in only one aspect of Vet Center operations (Blank, 1993).
Another important aspect of the staff is their skill in the treatment of the effects of unresolved traumatic material. This involves not only listening and helping a client to process painful and frequently horrible experiences but also managing the therapist's own vicarious traumatization (Cerney, 1995; Pearlman & Saakvitne, 1995) which follows repeated exposure to hearing traumatic material. The effectiveness of Vet Center staff depends upon their skill with clients and how staff members support each other (Catherall, 1995). The treatment of trauma is rapidly evolving and frequent training is required to maintain currency in clinical skills.
Treatment Modalities for PTSD
Interventions for PTSD are challenged by the pervasiveness with which they are comingled with additional psychological distress and dysfunctional coping mechanisms such as substance abuse (Kulka, et al., 1990; Meichenbaum, 1994). Veterans often seek treatment for PTSD symptoms--particularly anger and control issues, assistance with relationships, dysfunctional coping skills, and generalized distress. Treatment modalities for PTSD emphasize the growth-enhancing potential of traumatic experiences (Figley, 1993; Herman, 1992; McCann & Pearlman, 1990; Meichenbaum, 1994; Racek, 1985; Tedeschi & Calhoun, 1995 ). Various treatment modalities address the intrusive and recurrent memories of traumatic experiences, emotional numbing, hyperarousal and avoidance of trauma experience symbols, and withdrawal from family, friends, and others.
There are common characteristics among treatment approaches to traumatic experiences (Figley, 1993; Marshall & Dobson, 1995; McCann & Pearlman,1990; Meichenbaum, 1994; Racek, 1985; Tedeschi & Calhoun, 1995). Treatment specifically involves: (a) relationship building with self and others; (b) emotional and cognitive connection with the traumatic experience(s); (c) examination of values; (d) awareness of helplessness and loss of control; (e) engaging in a meaningful interpretation of traumatic experiences; (f) becoming aware of dysfunctional coping mechanisms and replacing them with effective coping responses; and (g) strengthening social skills. Two important features of interventions is the recognition that, in most cases, PTSD is not curable but is treatable (Center for Disease Control, 1988; Kulka, et al., 1990). Consequently, treatment involves the recognition of symptoms, their fluctuations, and counseling support as needed. The second important feature is the normalizing of individual responses to traumatic experiences. Treatment may be provided to individual veterans or individual family members (62%), in groups that may include only veterans, veterans' families, or a combination thereof (34%), and conjoint family therapy (4%) (RCS 1995a; Flora, C. [RCS] personal communication, May 6, 1996).
Individual. Individuals are provided counseling in one hour visits as long as is needed. Counseling addresses the previously described components in the context of their impact on the individuals life, his or her recovery, and focuses on growth (Figley, 1993; McCann & Pearlman,1990; Meichenbaum, 1994; Racek, 1985; Tedeschi & Calhoun, 1995). Positive and productive use of skills learned in the context of the military and war zone is emphasized (Blank, 1993). In addition, regrets over actions and losses are explored in the context of the war zone and resolved. Over time, the veteran tells his or her story, integrating personal experiences, finding meaning in them, and discovering how they relate to the present. The veteran comes to see his or herself as a survivor of traumatic experiences, taking pride in their strengths, their choice of commitment to their country, and in their military service. The process of individual counseling varies among veterans. Some veterans may become involved in long- term therapy and others may have just a few counseling sessions.
Group. Group sessions are also provided and may be part of individual treatment. Groups of four to ten individuals usually meet weekly to discuss progress and issues for which the veteran is seeking support. Groups are a valuable part of follow on for post in-patient treatment and for maintenance of newly learned coping skills. The group also functions as a form of social support for its members. Special attention is given to gender differences in the context of the group. Care is taken to avoid letting female veterans become caregivers to male veterans thus reliving their former roles while leaving their own issues unattended (Price & Knox, 1996).
Family. One of the more important aspects of counseling is attention to significant others and family relationships. Research has documented the negative effect of PTSD in the veterans' lives and those of spouses and children (Hiley-Young et al., 1993; Matsakis, 1988; Motta, 1990; ). Peebles-Kleiger & Kleiger (1994) found in a study of Vietnam veterans that 38% of marriages broke up within six months of coming home. Other studies have documented the contagion of PTSD from veterans to spouses and children (Solomon et al., 1992).
In additon to the impact that the veteran's PTSD may have on his or her family some veterans experience pressure from family, relatives, friends, and other veterans to "forget it," and not talk about their Vietnam experience (Blank, 1993). Others may be pressured to get "fixed" by family members who fail to recognize that they too have been powerfully affected by the veterans experience. When a veteran seeks counseling the growth they experience will likely affect their family. Family members are encouraged to learn about PTSD and recovery.
When necessary, family members may become involved in counseling with the veteran. Family counseling involves increasing information and normalizing the impact of PTSD on the family, identifying dysfunctional coping mechanisms and learning positive coping skills, developing skill in recognizing PTSD symptoms and responding to them, and seeking support when necessary (Figley, 1993).
Normalization of PTSD. Regardless of the treatment modality, an underlying goal is to normalize PTSD as a consequence of war trauma. Vet Center counselors emphasize that within a psychohistorical interpretation and context the development of posttraumatic stress is a normal and expected response (Figley,1993; Meichenbaum, 1994), and that it is the normal consequence of threat appraisal and coping (Lazarus & Folkman, 1984). Thus, PTSD is not to be regarded as pathologic but rather the normal response to traumatic experience(s) that can become manageable through treatment.
Indicators of Success and Outcomes
Organization and cost effectiveness. The ground-up, adaptive, flexible character of the Vet Center Community Health Model has brought great scrunity from both the DVA and the Congress. Congressional oversight hearings and VA internal reviews have resulted in the Vet Centers being found to be efficient and effective (VA, 1981, 1986, 1987; U.S. Cong., 1981, 1982; U.S. Cong., 1988). Another significant outcome is that service delivery at a Vet Center is more cost effective than VA outpatient services, notably about one-third to one-fourth the cost (Pollner, 1995). Vet Centers have become part of the network of social services found in most communities (U.S. GAO, 1987).
Dedicated staff. Another indicator of successful community impact is the large number of volunteers, lay and professional who offer their time to assist in the Centers. The Vet Centers are also attractive to professionals and paraprofessionals who seek employment there despite federal pay scales that lag behind those in the private sector (Blank, 1993). Filling positions in spite of such pay discrepancies suggests success. Vet Centers experience relatively low incidence of staff burnout and turnover. Despite the high degee of exposure to traumatic material and the likelihood of vicarious traumatization, turnover rates are stable at 12%, comparable to other DVA employees (Blank, 1993).
Client satisfaction. In 1990, following service delivery to over one million veterans, only 45 complaint letters have been received by the DVA (Blank, 1993). The largest number of initial referrals to Vet Centers are by word of mouth, buddies bringing in buddies, following their own successful experiences at a Vet Center. In a recently conducted study, 1,112 randomly selected former Vet Center clients responded to a client satisfaction questionnaire (RCS, 1995b). This client sample had received services in 1988 and 1991. 69.4% of the respondents were Vietnam veterans, and the remainder were veterans of the Persian Gulf, Korea, WWII and other theaters of conflict. 90.4% of respondents indicated that they would recommend the Vet Center to other veterans. Several wrote that the Vet Center had saved their lives. One commented, "I was suicidal until I came to the Vet Center. Now I can cope with my wounds and my demons" (RCS,1995b, p. 16). The respondents also indicated that posttraumatic stress and depression were the problems for which they most frequently sought treatment.
Veterans reported that learning better ways to cope with their problems was the most helpful intervention they received. Over one third of the veterans indicated that the Vet Center had helped them in specific ways most notably the listening and attention they received in a safe place where they could work on their issues. One remarked, "Listened to my problems with out being judgmental and was able to relate to my problems as he was a Vietnam veteran and went through the same types of problems" (RCS, 1995b, p. 46). Another wrote, "He let me know that I wasn't a loser and baby burner. He made me feel good about myself" (RCS,1995b, p. 46).
In commenting on what they had specifically learned, one veteran wrote, "Made me aware that a lot of my actions were common reactions to my combat experiences" (RCS, 1995b, p. 47). another wrote, "(learned) my feelings were normal and I am not crazy. Feel good about myself and service. Got rid of the guilts" (RCS, 1995b, p. 47). Veterans also offered criticisms and identified ways in which the Vet Center could be improved. Overall, the 90% satisfaction rating is a strong indication that the Vet Center is successful in achieving its mission and goals (RCS, 1995b).
Recent combatants and older warriors use Vet Centers. Operation Desert Storm (ODS) veterans are using Vet Center counselors to address the problems they are experiencing (Ehlich,1994,). While there are some similarities to the experience of the Vietnam veteran counselors are learning that each group has its own uniqueness and individual needs. Older veterans from WWII and Korea area also seeking out Vet Center assistance. Since the Centers are currently prohibited by law from serving these older veterans, Centers staff refer them to VA treatment facilities. The post-war Vietnam veteran experience has made it possible for warriors of all generations to talk about their own war-time experiences, to understand how their experiences have affected them, to find meaning in their pain, to learn new ways of coping, and in some cases to reconnect to pride in their service.
Implications and Future Directions
Normalization of PTSD. The evolution and application of the PTSD diagnosis is impacting military service and the treatment of veterans. Posttraumatic stress is a potential occupational hazard of military service and a normal response to traumatic experiences. It is not pathology. It has also established that each person's war zone experience is unique and must be individualized. The normalization of PTSD has made it possible for soldiers with more recent war zone experience such as Lebanon, Grenada, Panama, ODS, Somalia, and Bosnia to seek help for themselves and their when they experience readjustment difficulties.
Women veterans and sexual trauma. Another area of impact has been the development of the Women Veterans Sexual Trauma Counseling Program. In February, 1992, RCS (1996a) began to investigate the prevalence of sexual trauma among women veterans. It was found that 40% of women veterans being seen in Vet Centers had experienced sexual trauma at some point in their lives and 65% of those had been sexually assaulted while on active duty military service (RCS, 1996b). Women veterans can now be seen by Vet Center counselors for sexual trauma, assault, or harassment. In fiscal year 1995, 5,375 women veterans made 32,163 visits to Vet Centers for sexual trauma (RCS, 1996b).
Ethnic minorities and disabled veterans. A final area of improvement has been work on sensitizing, refining, and improving services to ethnic minorities and physically disabled veterans (RCS, 1988, 1992, 1995c). Working groups have been formed to develop reports on unique and individual needs of various veterans groups. They also identify future work that needs to be addressed. This agenda is an ongoing component of the Readjustment Counseling Service Office.
Treatment efficacy. Finally, future directions involve developing methodologies to determine treatment efficacy. This goal is consistent with the present state of evaluation of psychosocial interventions and outcomes (Lawlor & Raube, 1995). This development will contribute to improving quality of care, clinical outcomes, satisfaction with services and contribute to cost efficiency.
The outlook for maintaining and strengthening the social contract in general, and Vet centers in particular, at this point in time is fraught with more threat than promise. The very future of the VA health care system was brought into question during the 1993 congressional debates on revamping the Nation's health care system (U.S. Cong., 1993).
The takeover of the Senate and House by Republicans brought demands for fiscal restraint and reform from representatives of the appropriate age to have served in Vietnam, but for various reasons did not serve. Led by a non-veteran Speaker of the House, and ironically juxtaposed against a Democratic administration rife with anti-military and anti-veteran sentiment, the Congress has in its deliberations tended to view all federal government veterans' benefits, including those earned on the battlefield as dubious entitlements.
Add to this governmental opposition to the contract, the voices of a few Vietnam veterans, former officers, who from their financially secure positions of power, prestige, and privilege in academia and government have recently attacked both the premise of PTSD, the character and credibility of those warriors who suffer its consequences, and the Vet Centers which provide them the vital services they need (Crandell, 1995; Pollner, 1995; Spinrad, 1994; Vaughan, 1995). Those most likely to suffer the most from PTSD--the high war-zone stress combatants who bore the brunt of the fighting, the ones most likely to have fought the war up close and personal and to have become casualties, the economically disadvantaged, the undereducated, and by some interpretations the ethnic minorities (Freidel, 1990; Kulka, et al., 1990; U.S. Cong., 1988)--are being abandoned again. This time the rejection is not by an ungrateful, often hostile, albeit generally unknowing society, not by an insensitive VA, not by mainstream veterans organizations, but by their own so-called comrades-in arms. One is reminded of the the words of Aeschylus, as quoted as preface to Anton Myrer's Once An Eagle:
So in the Libyan fable it is told, That once an eagle, stricken with a dart, Said, when he saw the fashion of the shaft, "With our own feathers, not buy others' hands, Are we now smitten." (npn).
None of this bodes well for the social contract between the Nation and the military women and men who risk life and limb in defense of its way of life. At present, American soldiers are deployed in dangerous areas of the former Yugoslavia, Africa, and the Middle East. They and their families are dependent on the social contract for treatment of the physical and psychological wounds that are occupational hazards for those who serve in the American profession of arms. There are approximately 27 million veterans in the United States (VA, 1994) as well as their 75 million(+) family members. How quickly we forget those who by their blood and tears lease and maintain our freedom.
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