A new military strategy

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).

Reider says the conference discussions helped shape a request for applications for research into trauma, stress and substance use issues among military personnel and their families. “Prevention researchers want to do this work now,” she says. “People who never thought about doing research with the military are putting in applications.”

Centers step forward

The Ranch is a private-pay facility with expertise in treating PTSD, but because of its payment structure it tends not to see clients with a military background. Knowing that there was a need in the community and that they had something to offer, officials with the facility decided to try to establish a healing network of providers based on the pledge of one bed per facility per month for the veteran population.

Monnie Furlong, who works in outreach services at The Ranch, says the call went out to behavioral health providers in the “Healing Those Who Serve” campaign last fall. Several facilities have joined The Ranch in its pledge to donate a bed a month (or the equivalent in outpatient treatment, family counseling, etc.) for treatment of returning veterans and their families. Some of the participating agencies to this point are Sierra Tucson, Mayflower Center, Jaywalker Lodge, Onsite Workshops and Riverside Behavioral Health. More information about the campaign, which is supported by a fundraising organization called The Second Wind Foundation, is available at https://www.healingthosewhoserve.org.

Furlong says her center, which offers residential treatment only, has treated a handful of veterans thus far. The Ranch uses a variety of experiential therapies, from equine therapy to psychodrama, as part of its trauma program. In addressing co-occurring PTSD and substance use, the center often works with PTSD as the client's primary disorder, but the client would have to achieve abstinence in order to participate successfully in the trauma work, Furlong explains.

In some jurisdictions, treatment of veterans is mirroring treatment of the larger population in that the criminal justice system regrettably has become a common entry point for services. Officials in Tulsa, Oklahoma have established a program through the Tulsa County Drug Court in which veterans with substance use problems are being identified and are offered treatment through the local VA health system. Officials in the community have given a great deal of credit to the local VA leadership for its commitment to the cooperative venture.

Justice officials in the Tulsa area have known for some time that veterans have had a significant presence in their system; more than 150 veterans were arrested in the community during the month of October 2008, and about one-third were charged with felonies. The court system has established a track for veterans within the Tulsa County Drug Court, and it is expected that most program participants will receive outpatient services.

Advice to providers

Boriskin says he is heartened that many providers appear to want to serve those who have served the country, but he urges professionals to analyze carefully where they can make the best contribution. “These are about the most complex cases you'll ever come across,” he says.

A clinician who also happens to be a veteran can enhance a veteran's healing process merely with his/her presence, Boriskin believes, giving the veteran hope that there is a meaningful life after the pain. For others who don't identify directly with the veteran's experience, Boriskin urges clinicians not to adopt a “Lone Ranger” mentality of believing they are solely responsible for saving the individual.

Addiction professionals should see themselves as part of a healing team that also might include neurologists and other physicians, Boriskin says. “They must think in terms of multiple dimensions of addressing these complex problems,” he says.

Boriskin envisions a time when a true continuum of care would be in place, offering debriefing materials to all returning veterans and then more specialized care blending government and private resources for those who need additional help. But he believes that to get there, change will have to occur in both the military and civilian worlds in order that the systems are fully prepared to address returning veterans' complex problems.

“You've got to know when to emphasize which part of the treatment plan,” Boriskin says. “We're kind of addicted to quick fixes now.”

Sidebar

TBI complicates the picture

As challenging as it is to treat co-occurring substance use and PTSD, those interviewed for this article agree that if a traumatic brain injury (TBI) also is present in the client, many providers simply find themselves ill-equipped to do the treatment.

Usually the result of a sudden, violent blow to the head, TBI is a complex injury involving a constellation of symptoms and disabilities. “Nobody has really treated the combination of the three,” says Jerry A. Boriskin of Advanced Recovery Center in Florida. “This adds another layer of complexity, exposure, ambiguity and perhaps resistance to treatment.”

Monnie Furlong of The Ranch in Tennessee explains that the presence of TBI in a client would make it difficult for most members of the Healing Those Who Serve network to step in. These behavioral health centers generally do not operate in the same fashion or under the same regulatory structure as a medical hospital.