Back when he started working with Vietnam veterans more than 25 years ago, Jerry A. Boriskin, PhD, CAS, saw that most helping professionals knew next to nothing about how to address the multiple needs of combat-exposed individuals. He believes that human services have come a long way since then, but says the overall response to the problems of those who have valiantly served the country still lacks a basic coherence.
“There is a lot of good intent, and resources are being put toward it, but my impression is there's a lack of integration of services and a complete continuum for individuals with complex [post-traumatic stress disorder] and addictions,” says Boriskin, founder and clinical consultant at Advanced Recovery Center in Delray Beach, Florida and a regular lecturer on the treatment of PTSD. “Everyone speaks a good game on the subject of multidisciplinary services, but you rarely see them drawn together.”
Indeed, it is not difficult these days to find examples of provider and government agencies taking steps to prepare for an influx of returning veterans and their anticipated impacts on the communities to which they return. These are among some of the recent efforts:
The Ranch, a comprehensive residential treatment facility outside of Nashville, Tennessee that specializes in trauma, has been at the forefront of a national effort to encourage treatment centers to set aside one donated bed per month for returning veterans and their families.
The nationally influential Hazelden treatment organization is working to improve treatment opportunities for veterans at several levels, including inviting Navy counselors to follow Hazelden staff at the Minnesota facility and sponsoring “recovery retreats” for veterans who want to establish a stronger foundation in the 12 Steps.
The National Institute on Drug Abuse (NIDA) in January hosted a conference that attracted more than 200 government and military researchers interested in formulating a research agenda for treatment and prevention of substance use disorders among members of the military and their families.
Boriskin finds these efforts and others like them admirable, indicating that they reflect a spirit of service to this population that is arguably stronger than ever. But at the same time he sees parallels between these individual efforts as a whole and what had plagued the military strategy in Iraq during the early years of that operation: multiple “chains of command” with little overall coordination.
Boriskin is embarking on his own new project, one that involves a direct relationship with the U.S. Department of Veterans Affairs. He says he approached the VA in an attempt to apply some of the PTSD work he has done in the private sector to the public system. He is now working with the VA to establish an outpatient program in the San Francisco area; he will continue his work with Advanced Recovery Center as the new project gets off the ground.
“We're starting slow with the outpatient project,” says Boriskin, knowing that in the future policy-makers will also need to address a dearth of transitional residential treatment programs for returning veterans with substance use problems. “I want to build model programs. I'm just a little cog in the wheel.”
The research case
Research findings are shedding new light on how pervasive substance use problems are among today's soldiers, including the “citizen-soldiers” from the National Guard and Reserves who have added a new facet to the composition of forces serving in Iraq and Afghanistan. Data published last summer in the Journal of the American Medical Association from the Millennium Cohort Study looked at personnel who completed health surveys before and after their military service, finding that prevalence of heavy drinking and alcohol-related problems were generally highest in individuals who had direct combat exposures during their service.
In the National Guard and Reserves portion of the study cohort, other risk factors for alcohol-related problems included younger age and a PTSD diagnosis. It is becoming common to hear government officials and treatment experts say that if a program is treating returning veterans with substance use problems, they had better have proficiency in treating PTSD also-and that the reverse holds true as well.
These data are relevant not only for the Department of Defense and the VA, but also for addiction treatment agencies in the community. With some returning personnel not immediately deemed eligible for VA services and others preferring for a variety of reasons not to access care through the VA, experts say community programs can expect to see at their doors an increasing number of individuals who have had combat tours.
“I was talking at [the SECAD '09 addiction conference] with a retired colonel, and he said that until recently your status as a soldier was compromised if you were found to have PTSD,” Boriskin says. Even though research has now concluded that there was about a 20% prevalence of PTSD among Vietnam-era veterans, he says, there still has been a tendency to underdiagnose the disorder in the military.
Eve E. Reider, PhD, deputy branch chief of NIDA's Prevention Research Branch, says the comorbid disorders often seen in the population of returning veterans necessitate coordinated interagency responses. The January conference was a team effort of the Prevention Research and Behavioral Integrated Treatment branches at NIDA, and attracted nearly 300 participants in all (mostly researchers from the National Institutes of Health, the military and the VA, but also some clinicians).