It’s a common sight at airports to see troops welcomed home from war. It’s heartwarming, but most soldiers returning from Iraq and Afghanistan need more than a hug and applause from grateful citizens to make a successful transition from military to civilian life.
"There are enormous psychological and social stressors in readjusting to life at home," said Kerry Traviss, manager of the Operation Iraqi Freedom/Operation Enduring Freedom/Operation New Dawn (OIF/OEF/OND) program at the Atlanta VA Medical Center.
Many veterans face mental health issues related to combat. Multiple deployments have interrupted careers and strained marriages, causing higher divorce rates.
“The state of the economy has not helped. Not being able to find a job adds financial stresses to the mix,” said Traviss, LMSW, ACSW, CCADC.
Fortunately, the U.S. Department of Veterans Affairs and Shepherd Center in Atlanta offer programs and health care professionals to help soldiers find their way home.
Veterans Affairs created the OIF/OEF/OND program for soldiers returning from Iraq and Afghanistan in 2007.
“We realized that the Vietnam vets did not get all the services they needed, so we’re taking a different, more holistic approach now,” Traviss said.
She supervises a team of six care managers and several outreach coordinators who are experts in VA health services and community resources. “We function like a triage unit to get veterans up and running in our health care system,” she said.
The numbers are sometimes overwhelming. Despite an average caseload of 100 to 300 clients, care managers take a personal approach.
“Their job is to establish trust and make the first therapeutic experience a good one,” Traviss said.
Some clients come to the center soon after their discharge from the miltary and others seek help months or even years later. Research has shown that symptoms of traumatic brain injury (TBI) and post-traumatic stress disorder (PTSD) — the signature injuries of these wars — can occur long after the incidents that caused them. Team outreach members visit every returning military unit to talk about benefits. They also seek out homeless vets to enroll them for services.
“We work closely with the Department of Defense but being government agencies, there are sometimes hiccups between the two systems. The care manager’s job is to break through red tape and get the veteran and his family the support they need,” Traviss said.
‘A nurse can make a difference’
Yvonne Carter, a VA care manager for three years, loves the autonomy, caregiving and problem-solving opportunities that come with her nursing role. There are no time limits during visits, which may be scheduled appointments or walk-ins during a crisis.
“I may spend two or three hours with a suicidal client, making sure he is safe and admitted,” said Carter, MSN, RN, CCM. “And I often think outside the box to help a client find employment.”
Sometimes the biggest challenge is getting a client to open up and to realize that he needs counseling.
“Many of these guys returned without a lot of family support. A nurse can make a difference,” Carter said. “Every vet who walks out the door has my number and a backup number. They know they can call, text or come in anytime.”
That starts with listening, said Glenda Jackson, RN, a nurse with the primary care Gold Clinic that treats OIF/OEF/OND clients, as well as other veterans.
“They may not seem [to be] in crisis, but when you begin to talk with them, red flags start cropping up,” Jackson said.
Initial evaluations include taking vital signs, a depression screening, an alcohol screening and a complete family and medical history, paying particular attention to combat experiences that could have caused trauma.
“Screening is a great tool that allows us to capture a lot of information. It helps primary care providers make appropriate referrals for treatment, therapies and support,” Jackson said. “It also brings relief to patients and their families to have problems identified and know they can get help. At discharge, many soldiers are so focused on getting home that they don’t really take in all the benefits available to them through the VA.”
Clinic nurses take time to educate veterans about conditions and services. “Our clients leave with a heavy folder of literature and information about benefits and multiple numbers to call for advice, emergency help or prescription refills,” said Victoria Miller, LPN.
Veterans have access to a 24/7 telephone advice program, a crisis hot line, support groups and My Healthy Vet, an initiative that allows them to talk virtually with primary care providers.
“We start by thanking each and every one of them for what they’ve done for us, and we let them know that we’re here for them, that we’ll never turn them away,” Miller said.
‘One-stop shop’ for treating brain injuries
After seeing reports about the overwhelming number of soldiers suffering from traumatic brain injuries, former Home Depot CEO Bernie Marcus decided to do something about it in 2007.
“He knew our expertise in treating acquired brain injury and donated initial funding for the SHARE [Sharing Hope and Recovery Excellence] Military Initiative,” said Susan Johnson, director of the acquired injury program at Shepherd Center in Atlanta.
Paid for by military insurance, Medicaid and charitable funding, military clients who have been diagnosed with mild TBI and PTSD come to the Shepherd Center for a comprehensive three-month recovery program.
“We put together a one-stop shop and a dedicated team of professionals that includes physical therapists, occupational therapists, speech pathologists, psychologists, nurses and recreational therapists,” said Johnson, MA, CCC-SLP, CCM. “There’s a more intense mental health component to the program because of the unique needs of combat soldiers. It’s sad that it took a war to raise people’s awareness about brain injury, but we’re all learning more through research and practice every day.”
Clients undergo an intense two-week evaluation, followed by eight to 12 weeks of outpatient treatment and therapies. Housing is available for out-of-town clients.
“They call TBI and PTSD ‘invisible wounds,’ because these soldiers walk, talk and don’t look like they have any problems,” said Irene Pennington, MSC, case manager for the SHARE Military Initiative.
But the symptoms can be debilitating. They include sleep disorders, balance issues, central auditory problems, memory cognitive deficits, executive brain function loss, light sensitivity, dizziness, muscular/skeletal issues, migraine headaches, fatigue and depression.
In 2009, the military began screening all veterans for TBI. Research has shown that it doesn’t take a direct hit for a soldier to be affected by an improvised explosive device blast. In 2010, the Defense Centers of Excellence, whose mission is to improve soldiers’ lives by advancing excellence in psychological health and TBT prevention and care, set new clinical standards for treatment.
“Our first job is to build trust and rapport,” Pennington said.
Recovery is a long-term process. “People think of TBI as an episodic event, but it’s a disease. The effects can improve, but they don’t just go away,” Johnson said.
Shepherd Center clients learn strategies they can use for the rest of their lives. Some need the experts of the Sleep Study Center; others use the services of occupational therapists to relearn to drive. Mind-relaxation techniques and medical procedures like sphenopalatine-ganglion nerve blocks can lesson headaches and decrease dependence on pain medication.
Group therapy sessions address anger management, organizational skills and goal-setting. Recreational therapists help clients reconnect to old interests or discover new hobbies, like horseback riding, glassblowing, pottery or swimming with whale sharks at the Georgia Aquarium. Community outings help them overcome social anxieties.
Case managers follow clients at home for a year, and encourage them to keep using coping strategies and following their pursuits. For example, they recently found a local group of fly-fishing veterans for a client to join.
For clients who come in suffering emotionally and physically, it’s about diagnosing the programs and then dealing with them.
“We tell them that they have a disease and that it’s real. And then we give them hope and better ways to handle it,” Johnson said.
“It’s so rewarding to be part of the process of helping people reclaim their lives,” Pennington said.
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