Rules of Engagement - Page 3

Create action plans. As I alluded to earlier, talking doesn't feel like action to most veterans, so having a plan to carry out between sessions is both functionally helpful and emotionally soothing. Start your sessions by assessing their current problems and then helping them create a plan that'll move toward relieving their symptoms. Ask them what the single most disturbing or bothersome symptom is, and work on that. Reducing their emotional pain and instilling a sense of hope requires active, ongoing assessment of symptoms and in-office interventions during each session. Before they leave a session, write down the specific, customized plan the two of you have developed that addresses their issues in concrete terms.

Be aware of suicidal tendencies. Always assessing a client's suicidality is sound practice, but never more so than with combat veterans; however, be prepared for the likelihood of suicidal thoughts, because most veterans who've endured numerous combat missions entertain the idea of suicide fairly frequently. Because combat experiences desensitize them to pain and death, the notion of their own death creates none of the usual alarm responses, and according to Thomas Joiner's book Why People Die by Suicide, this puts them at unusually high risk. Since most of them own guns and many of them carry their weapons in civilian life, you should take the risk of suicide or homicide seriously.

They may also be covertly suicidal. A soldier who volunteers for his fifth mission may be hoping that the enemy will end his pain and preserve his and his family's honor by allowing him to come home as a hero in a flag-draped coffin. Addressing this desire to die in battle frankly, calmly, and without judgment is the best intervention with this particular group.

Overprepare. Read blogs written by deployed veterans and look at some of the HBO documentaries and movies that capture a tiny portion of the war experience. Watch The War Tapes, Fighting for Life, The Messenger, and Taking Chance. Each film beautifully examines a different piece of this enormous, messy puzzle. Talk to friends and colleagues who are former military or combat veterans themselves, or have family members who are currently serving, and listen to their stories. Go online and become familiar with "military-speak" so that you don't waste time in therapy having the vet explain that a FOB is a Forward Operating Base, not a keychain decoration. They'll feel more trusting if you and your office are orderly in appearance. Expect them to call you doc, doctor, miss, mister, ma'am, or sir, and not to refer to you by your first name, no matter how many times you say they may do so. Then "gear up," get yourself "squared away," "watch your six," and get ready for the most dynamic—and extraordinarily rewarding—work of your career.

Resources

Grieger, Thomas A., Stephen J. Cozza, Robert J. Ursano, et al. "Posttraumatic Stress Disorder and Depression in Battle-Injured Soldiers." American Journal of Psychiatry 163, no. 10 (October 2006):1777-83.

Hoge, Charles W., Carl A. Castro, Stephen C. Messer, et al. "Combat Duty in Iraq and Afghanistan, Mental Health Problems, and Barriers to Care." New England Journal of Medicine 351 (July 1, 2004): 13-22.

Joiner, Thomas. Why People Die by Suicide. Cambridge, Mass.: Harvard University Press, 2007.

Testimony by Terri Tanielian, "Assessing Combat Exposure and Post-Traumatic Stress Disorder in Troops and Estimating the Costs to Society: Implications," submitted on May 24, 2009, to the Subcommittee on Disability Assistance and Memorial Affairs of the House Veterans' Affairs Committee. Taken from the RAND Corporation's research brief Invisible Wounds of War: Psychological and Cognitive Injuries, Their Consequences, and Services to Assist Recovery, ed. Terri Tanielian, Lisa H. Jaycox, et al. (http://www.rand.org/pubs/ research_briefs/ RB9336/index1.html).

Alison Lighthall, R.N., B.S.N., M.S.N., is a former captain in the Army Nurse Corps. While serving with the 7302nd Medical Training Support Battalion, she provided psychosocial training throughout the Midwest to units before and after deployment. Since 2004, she's trained civilian and military mental health professionals to assess, treat, and care for combat vets, and most recently served as the lead clinician for Fort Carson's Urgent Psychiatric Response Team. Website: www.hand2hand contact.org. Tell us what you think about this article by e-mail at letters@psychnet worker.org, or at www.psychotherapynet worker.org. Log in and you'll find the comment section on every page of the online Magazine.

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