Vietnam era Veterans and Co-occurring PTSD/S

Historical Experience as a whole and relevance to Social Work practice:

    Vietnam Veterans upon returning home presented the social work community with a variety of issues that required professional level assistance. These issues included homelessness, domestic violence, post-deployment readjustment, and substance abuse to name but a few. In keeping with the NASW code of ethics, Social Workers focus their skills on several areas of competence, but in particular, the Dignity and Worth of the Person, the value and importance of enhancing human relationships as relevant to the issues facing this population.
    Social Work plays a pivotal role in the delivery of services to the Vietnam Veterans. On the micro level, direct practice efforts strive to empower the individual through direct counseling by designing outcomes that advance personal efficacy.
    On the mezzo level Social Work partners with community organizations to broker support networks by connecting clients with medical and mental health services, mutual help groups, housing, and the appropriate social welfare programs designed to meet their needs.
    Macro level focus includes broad community planning, coordination, advocacy and integration of services on the federal, state, county and local levels. Social Work, because of its leadership, flexibility, and commitment to "Putting Veterans First", continues to thrive as a profession in the current health care environment.

Vietnam Veteran History of Advocacy    

Vietnam Veterans of America (VVA) is the only national Vietnam Veterans organization congressionally chartered and exclusively dedicated to Vietnam-era veterans and their families.
      By the late 1970s, there was as yet no legislation to address the needs of this particular segment of the Veteran’s population. In January 1978, a small group of Vietnam veteran activists came to Washington, D.C., to rally support for creating an advocacy organization devoted exclusively to the needs of Vietnam veterans. VVA, initially known as the Council of Vietnam Veterans, began its work. At the end of its first year of operation in 1979, the total assets were $46,506.

Addressing Congress, council members hoped to gain political support for creating supportive policy and programs to meet the specific needs of Vietnam veterans and their families. However, despite persuasive arguments before Congress, they failed to win even a single legislative victory. It became apparent that social justice arguments made by a small group alone would not be sufficient. The U.S. Congress would respond to the legitimate needs of Vietnam veterans only if they had political strength. Following an intensive strategic membership drive, the Council of Vietnam Veterans by 1979, had transformed into the service organization Vietnam Veterans of America.
Building further upon its advocacy successes, in 1983, VVA founded its associate legal services department, the Vietnam Veterans of America Legal Services (VVALS) organization to broker on behalf of Vietnam veterans seeking benefits and services from the government. Over the next several years VVA grew in size, stature, and prestige. VVA's professional membership services, veterans service, and advocacy work gained the respect of Congress and the veterans community. In 1986, VVA's exemplary work was granted a congressional charter, formalizing its legitimacy.

VVA’s mission is to promote the educational, economic, health, cultural, and emotional readjustment of the Vietnam-era veteran to civilian life. Relative to these goals, the organization’s practice skills are directed toward three realms: lobbying, mobilizing constituents, and engaging media support to realize its agenda. Legislative victories establishing the Vet Center system, passage of laws providing for increased job-training and job-placement assistance for unemployed and underemployed Vietnam-era veterans, laws assisting veterans suffering from Agent Orange exposure, and landmark legislation (i.e., Judicial Review of veterans claims) permitting veterans to challenge adverse VA decisions in court. All were enacted largely as a result of VVA's legislative efforts. Though much has been done, there is still so far to go to address the unmet needs of this population.

Comprehensive review of the literature about Vietnam Veterans and Post Traumatic Stress Disorder and Substance Use Disorder
 
The Vietnam War recalls the controversial treatment of veterans when they returned home, and the abuse encountered upon arrival only added to the already damaged psyches of many of the vets.  “Only the veterans of Vietnam have endured a concerted, organized, psychological attack by their own people” (Grossman, 1996, p. 280). This was the first time since the advent of televised media, that coverage of a war would inflame such a virulent public response. After the war subsided, eventually, the problems veterans were having post-deployment as they transitioned back to civilian life became self-evident.  However, it was not until 1980 that the term Post traumatic Stress Disorder became the branding that would identify this specific cluster of symptoms as a formal diagnosis in the Diagnostic Statistics Manual. 
    The DSM-IV-TR describes a traumatic stressor as “involving direct personal experience of an event that involves actual or threatened death or serious injury, or other threat to one’s physical integrity of another person; or learning about unexpected or violent death, serious harm, or threat of death or injury experienced by a family member or other close associate.” (American Psychiatric  Association, 2002, p. 463). It must involve a response of “intense fear, helplessness, or horror” and the resulting symptoms are what characterizes PTSD.
    The consideration of PTSD as a new diagnosis did not occur until many years after the Vietnam War veterans had returned home and tried to bring attention to their issues.  Even in 1980, there was still much to learn about Post Traumatic Stress Disorder.


In May of 2001, a comparative study done by the Department of United States Veterans Affairs released data on the Socioeconomic Status of Veterans and on VA Program Usage. This study compared veterans and non-veteran counterparts on several measures of socioeconomic status.
    Conclusions drawn from this study show that there were several contributing risk factors at play for Vietnam Veterans who were later diagnosed with PTSD following their release from combat duty. These include socioeconomic disadvantage, low education level, unemployment status, and poverty level and substance use. Education level seemed to figure prominently in that veterans with lower levels of education had a greater risk for mental health problems following exposure to trauma. Low education attainment when coupled with drug and alcohol usage increase potential for post traumatic stress disorder among veterans exposed to combat trauma.
    When considering the before and after profile of a young man who was enlisted during the time of the Vietnam War era it is helpful to take into account these social ecological factors contributing to shaping the pathway to post traumatic stress disorder.  This is  supported by the research done on Vietnam Veteran’s relative to the onset of post traumatic stress.  Soldiers who started using drugs during high school for recreational purposes would be most likely to continue engaging in the practice, however, under duress of active combat duty, the utility would shift from mere recreational usage to substance abuse in order to escape feelings associated with psychological distress associated with trauma. Therefore, they would likely become candidates for the progression of the disease and its later stage development into a state of disorder. At the time of this study, in the year 2001, those who were age 54 years of age at the time, would now be 64, well within the age range of those who had served. Upon release from the service, unaware of the progressive and debilitating nature of substance abuse on all the organisms health systems and sub systems, it is unlikely that those who returned to normal lives as civilians gave up the practice of use of substances to numb psychological pain. Discharged, addicted, and traumatized, their continued use only served to reinforced the advance toward disorder. 


The impact of military service on long-term health is reemerging as a vital policy question, particularly as the United States conducts concurrently several major military operations. Health professionals, based on findings of years of ongoing research projects specifically aimed at Vietnam Veterans note that significant numbers of retired military personnel representative of this era are experiencing problems that are detrimental to both their psychological and physical health.
    Substance abuse has become, among others, the primary coping mechanism for Vietnam Veterans who suffer from unresolved Post Traumatic Stress relative to commonly co-occurring diseases. For example, in one of the early papers in this literature, Card (1987) finds that Vietnam Veterans are much more likely to report problems associated with post traumatic stress disorder including ‘‘nightmares, loss of control of behavior, emotional numbing, withdrawal from the external environment, hyper-vigilance, anxiety, and depression.’’ Later, Jordan et al. confirm this finding (1991), further documenting that “exposure to combat in Vietnam is associated with higher prevalence of specific psychiatric disorders, including post traumatic stress disorder”. Dobkin and Shabini present evidence of a strong link between post traumatic stress disorder and substance abuse (The Health Effect of Military Service: Evidence for the Vietnam Draft, 2007) In “Vietnam Combat Veterans: Treatment Problems, Strategies and Recommendations, by J. Michael Murray, MS, and Tom Williams, PsychD,  the authors, who are themselves Vietnam veterans have interviewed or treated more than 2,000 combat veterans and their families and have found that 80% of the veterans seen have had alcohol related problems, further supporting the evidence presented by others, that these disorders are often correlated. 

 
The topic of Trauma, PTSD, and substance abuse are co-related according to the article titled ‘Post-traumatic stress disorder, drug dependence and suicidality among male Vietnam veterans with a history of heavy drug use” (2008). According to this article, generally speaking, PTSD and substance abuse problems are often diagnosed together.
    In the general population, up to three quarters of those who have survived violent trauma report substance abuse problems. Comparatively, 60-80% of Vietnam Veterans need of treatment for co-related diseases of PTSD substance abuse. Veterans over the age of 60 with PTSD are at higher risk for a suicide attempt where substance abuse and dependency problems co-exist with depression.  The significance of these findings are such that they indicate practical and clinical implications not only for the well-being of the veterans themselves, but for family members and the health care system at large.


The Practical Implications: different types of trauma result in the syndrome of PTSD, and the disease will manifest itself uniquely for each individual, since each individual has unique endogenous and exongenous variables impacting his circumstances. This implies that there is no single solution for treatment, and assessments will require interventions that often extend beyond the ken of a single discipline’s scope of field. Those in the mental health and medical services delivery field who will come in contact with these individuals will need to apply a psychological diagnostic skill set that incorporates a combination of substance abuse and recovery therapy, direct counseling services, group work, and family counseling, in addition to medical interventive techniques.
    Clinical Implications: The burden on the health care system is even larger when comorbid substance abuse exists (Virgo et al., 1999; Piette et al, 1997). Patients with both PTSD and SUD (substance use disorder) have a more severe clinical profile than those with either disorder alone The challenges across medical and psychological disciplines will require purposeful planning and building of therapeutic alliances that serve the intersecting health needs of this population. Practitioners in the Behavioral, Neurobiological, Medical disciplines must be integrated simultaneously to counter previously held assumptions that beginning trauma therapy before reduction or elimination of substance use will lead to an increase in substance use. This has not been found to be the case at all.  (Towards Integrated Treatments for PTSD and Substance Use Disorders, Suzy B. Gulliver, PhD (Director, Center of Excellence for research on Returning War Veterans, Waco TX ) and Laura E. Stoffen, BA. 

..........Social Workers have done much to support the needs of this population, however, much more can be done to help this population become a more visible and viable segment of the local community. By treating the community itself as a target system, Social Workers can team with other community social organizations and mental health and medical service professionals to advocate on behalf of Vietnam Veterans by creating community outreach programs to raise awareness and educate the community about the plight of the population.These advocacy groups could identify gaps in services/resources and put into effect systems changes that are responsive to veterans’ changing needs.
    Efforts at inclusivity include; inviting local Vietnam Vets organizations to participate in community picnics and parades, by hosting community events such as bingo’s, spaghetti dinners and fish fry’s, teaming them with local Boy Scout organizations in order to provide role models and good PR for future military involvement; this and similar activities will help this population establish a niche as a visible and important presence in the community.
      By breaking down the invisible curtain that separates this population behind a veil of mystique, social workers can help mediate the process of mainstreaming the population into the larger culture.

References

• Post-traumatic stress disorder, drug dependence, and suicidality among male Vietnam veterans with a history of heavy drug use,  Journal of Drug and Alcohol Dependence 76S S31–S43. Rumi Kato Price et al. © 2004
• Post-Traumatic Stress Disorder and Substance Abuse in Vietnam Combat Veterans: Treatment Problems, Strategies and Recommendations. Journal of Subsrance Abuse Treatment. Vol. I, pp. 87-97.19.  J. Michael Jenlinek, MS,Tom Williams, PsyD ©1984
• Civilian Social Work: Serving the Military and Veteran Populations, Savinsky et al, 2009.
• Websites Referenced:
• United States Department of Veterans Affairs National Center for PTSD: http://www.ptsd.va.gov/public/pages/ptsd-alcohol-use.asp
• Substance Abuse and Mental Heal Services Administration (SAMHSA)
• http://www.samhsa.gov/MilitaryFamilies/
• http://www.oas.samhsa.gov/aging/chap9.htm: Utilization of Veterans' Health Services for Substance Abuse: A Study of Aging Baby Boomer Veterans Brenda M. Booth,* Ph.D.,
• Frederic C. Blow, Ph.D.
• National Survey on Drug Use and Health (NSDUH) http://www.oas.samhsa.gov/2k7/veteransDual/veteransDual.htm