September 22, 2015

By Mary K. Sullivan, MSN,  forensic nursing educator/consultant at the Veterans Affairs Health Care System in Phoenix, Arizona and Paul Thomas Clements, PhD, associate clinical professor, Division of Graduate Nursing and coordinator for the Forensic Trends in Healthcare Certificate Online Program at Drexel University

Reintegration of combat veterans into civilian society is often fraught with multilevel challenges that disrupt the stability of this vulnerable population. There is a dearth of treatment options and sadly, much less for the immediate families of these men and women. The Veterans Affairs Health Care System has been significantly challenged with large numbers of returning veterans requiring targeted treatment for post-traumatic stress disorder (PTSD), traumatic brain injury (TBI) and other injuries. Increasingly, veterans are seeking care in the civilian world only to find very few appropriate treatment choices.

Upon return from deployment, returning veterans often discover that family systems have been altered and disrupted. Relationships with significant others have changed, small children have grown and are now teens who have withdrawn into their own worlds, and veterans who have suffered obvious or not so obvious injuries have no idea how to navigate around these changes. Families find themselves confronted with the veteran's decreased ability to complete daily activities of living, a very poor tolerance for affectively charged situations, poor impulse control, and unanticipated responses to environmental cueing reminiscent of wartime experiences.  

Often, during reintegration to civilian life, veterans are confused by surroundings and situations that changed during their absence and can manifest in depression, anxiety, substance misuse and violent displays such as intimate partner violence and episodes of rage disproportionate to the reality of the situation. There is often a lack of understanding, subsequent marginalization by family and society, and a potential decrease in employment opportunities. These situations in turn lead to forensic scenarios, with confrontations with the legal and correctional systems. Many veterans have been arrested and charged with Domestic Violence, as this legal charge is an umbrella term for several types of behavior and actions under ones roof. This not only includes a man hitting a woman, but any threatening type of behavior in the household where one or both lives. Once the charges are upheld and the veteran is in the justice system, it is extremely difficult for the veteran to keep or find employment that can ultimately lead to possibly losing his home. The significant other can keep him from seeing the children. This can impact same sex couples as well.

The veteran often does not experience the expected camaraderie he is used to. No one has “his back”; in fact the significant other who he believes is supposed to “have his back” may actually now be potentially perceived as a threat. Ordinary relationship situations, such as spousal arguments, financial instability or childcare issues, can create conditions that lead to intense emotional distress. In these cases, veteran response or behavior is triggered by a stimuli or experience of a traumatic event and each person’s ability to process that specific event results in different behavior characteristics. Frequently, the emotions the veteran experiences will result in a perceived loss of control, even if it is not so. These perceptions run counter to ingrained military training and performance standards and can potentially accelerate various negative behavioral manifestations and associated actions and reactions. It is critically important for healthcare providers to understand this point and remind and reorient the veteran as often as needed until he is able to reframe events within civilian standards and expectations.

Media reports have often highlighted the role that military service has played in police shooting, suicides, homicide and other crimes. However, these reports are reactive in nature and tend to sensationalize the incident, as well as the possible causative factors. Rare is the report that focuses on ways to isolate causal variables and provide mitigation strategies or prevention programs.  Hopefully this will continue to adapt and change; for example, there are Veterans Courts now in nearly every state. These can assist veterans already involved in the criminal justice system. Additionally, there are VA Justice Outreach Specialists in every VA Medical Center, with responsibilities that include: direct outreach to veterans in jail or prison; individual case management; liaison with local justice system partners; providing training for law enforcement on veteran specific issues.

What is needed now is for ongoing expansion of treatment approaches and programs, including within the government system and civilian setting, designed to provide enhanced healthcare to returning veterans. The possibilities for clinical research into this arena are endless. In the meantime, society as a whole, including healthcare providers across the nation, owe these men and women as much help as they need to return to being whole again, even those in the criminal justice system.