Speaking of Psychology - Veterans' Mental Health with Terri Tanielan, MA, and Rajeev Ramchand, PhD

Episode Date: November 20, 2019

To mark Veterans Day 2019, in this episode we are discussing the mental health challenges that many veterans deal with, some of the latest psychological research into their care and the complexities of modern warfare and its effect on veterans. Our guests are Rajeev Ramchand, PhD, a fellow at the Bob Woodruff Foundation, who researches the prevalence, prevention and treatment of mental health and substance use disorders in veterans and other populations, and Terri Tanielian, MA, a senior behavioral scientist at RAND Corp., who researches military and veterans health policy, military suicide and the psychological effects of combat and terrorism. Join us online August 6-8 for APA 2020 Virtual. Learn more about your ad choices. Visit megaphone.fm/adchoices

Hello and welcome to Speaking of Psychology, a bi-weekly podcast from the American Psychological Association that explores the connections between psychological science and everyday life. I'm your host, Caitlin Luna. In this episode, we're going to talk about Veterans Mental Health. Having just marked Veterans Day earlier this month, it's a good time to discuss the mental health challenges that many veterans deal with, some of the latest psychological research into their care, and the complexities of modern warfare and its effect on veterans. I'm joined today by Dr. Rajiv Ramchand, a fellow at the Bob Woodrow Foundation, who researches the prevalence, prevention, and treatment of mental health and substance use disorders in veterans and other populations, and Terry Tenelian, a senior behavioral scientist at Rand Corporation,

who researches military and veterans health policy, military suicide, and the psychological effects of combat and terrorism. Thank you both so much for joining us today. Thank you for having us. Yes, thank you. So first I want to start on. off by talking about what are some of the most pressing mental health issues that veterans face today? I can get us started, sure. So, you know, we need to recognize there are about 19 million veterans living

in the United States today, and it's a very diverse population. It's becoming increasingly diverse, as we see more and more women who've served in uniform. And according to national data, we know that about 20% of veterans have a mental health problem. And this can include a range of conditions, such as post-traumatic stress disorder, but also depression, bipolar disorder, and substance use problems. We see that the rates of these conditions do vary by gender and age, particularly associated with the era of service of those veterans. So our veterans are facing a wide array of mental health challenges. Do you want to ask anything, Rijee? Sure.

I would just echo what Terry was saying that a lot of times we think of when we talk about veterans, the most recent, cadre of veterans, what we would refer to as the post-9-11 veterans. But as Terry mentioned, especially as we have veterans from the first Gulf War, Vietnam, Korea, aging, I think that we're going to see this bulk, as we are in American society at large, of mental health challenges associated with aging and the veteran population. We'll see that continue. And I think that it's just important for us to keep an eye on those older veterans. I want to zero in a bit more on a post-traumatic stress disorder. Are certain people more prone to having that happen to them when they return from more? So I can take that one. We have seen the most significant predictor of post-traumatic

stress disorder across studies and across samples is exposure to combat. So when people deploy, they have a variety of different experiences that depends on where they're stationed, the security climate of the region, the more intense combat exposure is consistently linked to suicide. Anything kind of above and beyond that might be a little bit here and there, but I'll turn it over to Terry to add more color if she wants. Sure. Well, we know that there are certain characteristics that are associated with those who may experience more combat related traumas and exposures based upon the service that they served in as well as the time period that they were deployed. But as Rajiv said, it really,

the most significant predictor is the number of combat traumas and individual experiences while they're deployed. And that may be irrespective of the time that they are in theater of the number of deployments they've had, but the number of experience that they've had during any one given deployment. What treatment options are available for veterans with post-traumatic stress disorder? So there are a number of treatments that are available, but we also know that research suggests that there are some particular treatments that have been proven to be very efficacious in reducing the symptoms of post-traumatic stress disorder. The guidelines that DOD and the Department of Veterans Affairs have released kind of highlight some of these evidence-based therapies and recommend that veterans be offered one of them as a first-line treatment option. These often focus on trying to process and confront the trauma that is the source of the problems for veterans. There are three in particular that are recommended for treating PTSD, prolonged exposure, trauma-focused cognitive processing therapy, and EMDR, which is another form of trauma-focused psychotherapy.

That's EMDR has gotten a lot of publicity lately. Can you explain a little more about what that is and how that would help a veteran? I can try. I am not a clinician, and we know that the evidence that has been generated for EMDR has shown that it's worked well in civilian populations, but we do not have as much data on how efficiation it is for veterans. but it is an approach that tries to help individuals process and make sense of their trauma by calling the trauma to mind while they pay attention to a back and forth movement or sound, such as a finger moving back and forth. So again, I'm not a clinician, but I know that this is a treatment that is being utilized, and we're hopeful that we'll see more data on how effective it is for treating veterans with PTSD. And Terry, can you explain more about what exposure therapy is?

Sure. Well, prolonged exposure therapy is a protocol-based treatment approach that teaches an individual to gain control of their trauma by facing the negative feelings. And it often involves talking about the trauma with a therapist and doing some of the things that you once avoided. So you're increasingly exposed to things that you've avoided and try to gain control over the situations and your responses to them. And so when members of the military are discharged,

are they given information about the resources that are available to them through Veterans Affairs, through other resources? I can start with this, and then maybe Rajiv can add, it's important to reflect that the past 18 years have seen some pretty dramatic changes in how the Department of Defense kind of exposes and encourages service members to gain access

to behavioral health care. And so over time, they've really changed the types of support that were available to troops in theater. But they've also introduced a number of programs that have helped raise awareness about the resources and treatment options that are available when the troops come home, but also as they transition out of the military. There's been an increased effort to make service members more aware of the services that are available, available to them from the Department of Veterans Affairs and the options that they can pursue through the Veterans Health Administration. We've also seen a proliferation of support programs and treatment facilities in the non-governmental sector that have been funded largely in the

philanthropic sector to create additional centers of excellence or clinics that offer outpatient or even intensive outpatient services to treat veterans' with mental health problems. Yeah, and I would just say, you know, to add upon Tari's, that that transition period, we know, is a really important period to engage veterans, to make sure that they're aware of their benefits, their eligibility, what's available. But it also assumes that, you know, they're going, they're becoming veterans and they're going through a transition status and they'll know everything and they'll retain everything.

And it's a lot of information to process. And, you know, it's a different time. they're leaving one career and going to a completely different culture and a different career. And I think that it's just incumbent upon us as a society to keep reminding veterans what's available because even their needs for treatment might evolve over time. They might not need it at that immediate time or they might think they might not need it. But six months down the road, a year down the road, two years down the road, they might decide that then it's time for treatment. And we need to make sure that they know at those various junctures that treatment options are available for them.

Yeah, that's a really critical point. I think that there's so much focus on the military to civilian transition. And we think that there's this one-time opportunity to educate service members about the options that will be available. But not only is it an overwhelming time, but they may find and recognize a need for it five, 10 years. later. And so we need to make sure that we're continually doing education and outreach to inform veterans and their family members about the services that they may be eligible for and that could benefit them. Terry, can you talk about some of the notable differences in mental health among veterans of different generations? We talked before about the differences between Vietnam veterans

to Desert Storm veterans to Veterans of the Wars in Iraq and Afghanistan. Can you elaborate on that a bit more? Sure. We know that the rates of post-traumatic stress disorder in terms of the point and time estimates of prevalence among these cohorts of veterans do vary, but it's important to keep in mind that the context for how these men and women deployed are also very different. Vietnam-era veterans, you know, served in the era of the draft. And so, you know, the all-volunteer force is a much different context. At the same time, our understanding of post-traumatic stress disorder has really evolved. And we've learned what we know currently today about identifying and diagnosing PTSD as well as treating it really on the backs of the Vietnam-era veterans. And so while

we can think about the rates of prevalence and even lifetime prevalence of PTSD. It's important to take into consideration some of those differences and nuances. Studies have shown that roughly between 11 and 20 percent of post-9-11 veterans experience PTSD at any given point in time. For Gulf War illness or Gulf War I veterans, that's about 12 percent. But again, that population hasn't been systematically assessed as much as we've done with the Vietnam era population where we see, you know, a point in time prevalence of about 15% for post-traumatic stress disorder and 30% for lifetime prevalence of PTSD. And so changes and differences in how we screen for and diagnose PTSD certainly contribute to those differences. but also our awareness and understanding of how to treat them offer hope for each of these veterans in terms of potential opportunities for recovery.

And I would just add to that that I think when we're talking about these different generations of veterans, we have to think about their cultural attitudes. And I don't want to claim that stigma is no longer an issue, but certainly the younger generation of veterans has been having more open discussions about mental health. There's been more of a push, a contemporaneous push, to encourage those in need to seek treatment. And that wasn't the case necessarily among people

who were returning from other wars. And so thinking of the cultural differences, I think, about what they think about mental health treatment, we might need different strategies to target some of the older veterans who may have been experiencing and really suffering from PTSD symptoms for really long periods of time, but still could benefit from treatment regardless of the duration from when it occurred. Yeah, absolutely. I mean, if you think about the context of support that these veterans faced upon returning home and the difference is there, not just in over.

overcoming some of the barriers to seek treatment and kind of recognize that they have challenges, but how they were embraced by, you know, their neighbors when they returned home and how that can contribute to shame and willingness to raise your hand and get help, I think is also important to consider. Absolutely. It's very important to note that veterans who came back from World War II were received very differently from Vietnam veterans. And do you think that the reception of veterans today is better than it was for Vietnam era veterans? You know, it was a very charged political climate when

Vietnam vets were returning. But at the same time, there was more of an integration of military personnel with the civilian society. So more civilians who are non-veterans, new veterans, and they were kind of more integrated. As we've gotten rid of the draft and this new generation of veterans, there's been a lot of support and outpouring of, as Terry was talking about earlier, non-governmental organizations that are conducting outreach and researching and welcoming veterans back. But at the same time, we're at a point in our history with the biggest separation between non-veterans and veterans. There are many non-veterans in civilian society who've never met a veteran who veterans are not in their social circle.

So that's why I think it's an interesting question because you have these two kind of dynamics happening concurrently. Yeah, absolutely. And Rajiv, earlier when we spoke, you mentioned how with PTSD, you know, not every single veteran has post-traumatic stress disorder when they come back from when they finish their military service. but that a person cannot essentially, you said, leave the service without being changed in some way or the other. Can you explain that a little bit more? Well, I mean, I think it's just kind of developmentally in human nature that we all go through experiences and, you know, they change us.

They kind of influence us. And, you know, I think that we've been focusing, you know, on PTSD and some of the, you know, negative mental health consequences, if you will, or some of the mental health challenges. But for many people, they've learned, you know, many veterans have been able to use and develop skills that they otherwise wouldn't have. They've become leaders. They've developed really great leadership qualities that haven't been as well documented. So I think there's many ways to take your question. But right now, you know, I'm really thinking about, especially as Veterans Day, is upon us really kind of all the things that they've learned and all the ways that they've

potentially grown from their experience. And I think that we need to recognize, you know, that veterans have really unique contributions that they can offer to society that we really need to capitalize on. Absolutely. Yeah, absolutely. I mean, I think if you recognize their dedication to public service and, you know, their willingness to raise their hand and defend our nation and contribute to society by, you know, putting their own lives on the line, you know, that servant leadership is a key quality that comes through and needs to be valued and recognized as much as we need to pay attention to those who struggle. We need to recognize the value and contribution that all of our veterans make. Let's move on to an area of large

concern in our country today, and that's suicide among veterans. According to a government estimate, I found, there's 17 veterans who die by suicide every single day. And male veterans were 1.5 more times more likely to die by suicide than people who did not serve. And female veterans fared even worse as they were 2.2 times more likely to die by suicide than those who didn't serve. Clearly, this shows there's more that needs to be done to reduce these numbers. Can you explain what treatment works for veterans contemplating suicide and what gaps you see. Why don't we start with you, Terry? Well, these are great questions. And I think we have to understand, you know, a little bit about the risk and challenges that veterans face and providing access to high quality mental health

services as a key component of a comprehensive suicide prevention approach. And, you know, while we are always striving to understand the risk factors and the protective factors, you know, we do know that access and delivery of high quality mental health services is a very important and effective means of reducing suicidal behavior and suicidal risk for veterans. And so ensuring that we reduce the barriers to care and promote the use of these evidence-based therapies that I talked about will be critically important for making sure that we can reduce risk of suicide for veterans. At the same time that we know another effective means of reducing suicide is means restriction

and making the environment safer. And for veterans, this means really focusing in and discussing firearm safety and thinking through policies that can help address. access to firearms and storage of firearms for veterans who may be at risk of suicide. And those really are two big important areas that require attention if we're going to move the needle on suicide. But there are others as well. And I'd love to hear Rajiv provide some thoughts as this is an area that I know that he's been studying as well. Yeah. So what Terry said is absolutely correct. In terms of your question about what are the treatment options and what are the gaps is something that I think about a lot.

We know that 50% of those who die by suicide are in treatment in the general population. They're already in mental health treatment. So Terry's point about delivery of evidence-based and high-quality treatment is really important. And to my knowledge, you could call it three to four treatments that have been empirically tested to reduce suicide. attempts and suicidality. And those are dialectical behavioral therapy, cognitive behavioral therapy, a specific version for suicide that Greg Brown developed safety planning. And there's elements of safety plan that both Greg Brown and Barbara Stanley, as well as Craig Bryan, have thought about and published on, as well as David Job's collaborative assessment for the manage of suicidality

or CAMs. So those are four really high quality. kind of treatments and, you know, the safety planning, some people consider a treatment. But those are really kind of the strongest evidence to date. And I think one of the challenges is getting these treatments out to providers in the community so that they are equipped when somebody comes in and they assess them for suicide, which they should, you know, routinely be doing, that the providers are equipped to then treat the person's suicidality directly. And that's what these treatments offer. So that's just so critical.

But then, you know, there's a lot of other things as well, you know, besides treatment. And what Terry was talking about in terms of safer environments and firearm storage policies and things of that nature are absolutely critical as well. And, you know, just touching on what we were talking about earlier, you know, when we think about veteran suicide, we have to remember that a lot of the suicide, the suicide, you know, among the veterans, there's around 6,000, over 6,000 veterans who died in 2017. The bulk of those, the bulk of those were over the age of 50. You know, they're middle age.

They're not the post-9-11 veterans. So we have to focus on that post-9-11 group, absolutely. But we also have to keep in mind how are we reaching this older generation, or this other era of veterans and make sure that we're still keeping them in focus and offering them high-quality care and approaches that work for them. It's really fascinating that you mentioned that the older population, you're seeing rates of suicide be as high as they are. And that goes along with our very first question about,

you're saying that aging in the veteran population is an issue of what most importance today. I mean, suicide in the general population, you know, a lot of times we focus on the rates. And I should notice, I should note that there is this, the rates are higher among post- 9-11 veterans than non-veterans, but the numbers of veterans are much higher in that pre-9-11 group, if you will.

So it's this kind of balance between higher risk and rates relative to kind of where the burden of mortality is. And that's a balance that from a public health approach, we have to target all of these populations and we have to think about both of those groups. But in the United States, generally the burden of suicide is also in kind of this. middle-aged men group and older men. And I think that that's a area that we really need to talk more about. And why are female veterans more vulnerable? I mean, their suicide rate was higher than those of male veterans. You know, I'm not sure if the suicide rate is higher

among female veterans and male veterans. The risk is greater. So when you look at females, veterans have a greater risk relative to non-veterans than male veterans do to male veterans. non-veterans. But I have to look carefully at the numbers to see how the rates compare. But that said, the point is well taken. And this gets back to something Terry said earlier about, you know, about kind of the diversity and the increasing, you know, population of veteran who are women. I, you know, some of the strongest evidence to date is that a lot of, that military sexual, having experienced military sexual trauma or screened positive for military sexual trauma increases risk for subsequent suicide. So addressing military suicide is going to, or military

sexual trauma is going to, in my opinion, can potentially directly impact the suicide rates down the roads of veterans and especially women veterans. At the same time, you know, for the women who've already experienced military sexual trauma, we have to ensure that they are provided, again, this high quality evidence-based care. And for women veterans, I think cultural competency becomes so much more important. And I know Terry's done a lot of work on that among providers and cultural competency. So maybe she could speak to that. Sure. I just want to note, you know, we know even in the civilian sector that women who experience interpersonal violence and domestic violence may also be at greater risk for suicide. And so interventions and approaches designed to decrease sexual violence,

a sexual harassment, you know, can really also serve to decrease later risk for suicide. So those efforts are really critically important. But, you know, the role of cultural competence often comes up when we talk about ensuring access to high quality services and mental health, in particular for veterans. And it's this notion that the provider has a cultural awareness or sensitivity to the unique experiences that veterans may have faced, that they not only can speak the language and understand some of the terms or some of the kind of cultural issues that veterans faced while they're in the military that can really serve to help develop a better therapeutic rapport between the provider and the veterans so that they can successfully engage.

in an evidence-based therapy. And so there's been a lot of effort to try to increase cultural competence among veterans, or excuse me, among providers to veterans, particularly in mental health, so that they can not only speak the language, but understand and develop that sensitivity and empathy with some of the experiences that they have faced. And for women who have experienced sexual harassment or sexual assault, Even actually for some men, you know, while the rate of exposure to military sexual harassment and trauma may be lower for men, there are more men in the military. So the number of men who've experienced military sexual trauma is also high.

And knowing to ask about these experiences is critically important to try to understand how that may be related to their current mental health conditions or problems, but also related to their risk for suicidal behavior. And with that cultural competency, I know it's very important in the minority populations to have mental health providers who have a deep understanding of their clients. And in this case, having a military background, I'm assuming it's probably would be very beneficial or at least a deep understanding of that. Are there enough psychologists today who you think have those backgrounds and understanding, you know, those these psychologists out there, are there enough who are working with veterans? Well, that's a great question. And, you know, I think it's important to disentangle, you know, whether it's just about having a military background or whether cultural competence can be gained by being exposed to and work. with the population. And so anybody who has worked even as a civilian with the military population or in the Department of Veterans Affairs we have found will score higher on criteria, you know,

evaluating military cultural competence among the provider community. And there's been focused efforts, particularly for mental health, to increase cultural competency in mental health therapists more so than non-mental health therapists. But there's still not a lot of data to indicate that that cultural competency of the provider is tied to clinical outcomes. And so the theory is that it's about this cultural competency contributing to an enhanced therapeutic rapport, which is essential for treatment engagement and retention and adherence. And to treatment. And so the emphasis on, you know, training providers is important, but it's not just that a psychologist

or a mental health therapist has a military background, but that perhaps they've been exposed to and worked with the population and been trained about the experiences that the veteran community may have faced so that they're asking the right questions, listening and developing a good therapeutic relationship. And before we kind of move to another topic, Caitlin, I just wanted to highlight that for women veterans, we hear kind of time and time again in the research that the presumption that they're not veterans is really strong. So among in, you know, VA facilities when, you know, even non-clinical staff, when, you know,

the people checking them in, administrative support, you know, assumes that the woman is the veteran spouse, for example, can be very off-putting. And so I think that goes, you know, for community providers. I don't think, I don't know if we know to what extent community providers are making these assumptions or not. The research hasn't been done necessarily, but I think that that's really critical that, you know, the minute a woman veteran, or rather, I would rather say that cultural competency requires an understanding of the diversity of the veteran population and not making presumptions and just thinking through and allowing, you know, your implicit bias, recognizing your own potential implicit bias and correcting that.

Yeah, I imagine that's very important. You said if someone's assuming that the woman is not the veteran, that's, you know, that's already setting you up for, you know, maybe a fragmented relationship or, you know, bringing up a lot of different issues that wouldn't be helpful later on. So there's a lot, so you're saying basically there's a lot that needs to be done in this area, but that having a deep understanding of the military, at least, and having that knowledge is beneficial to the, to the client in the, in the relationship. Yeah. And my discussions, you know, Terry has really helped me think through this. You know, I used to think about high quality care, like evidence,

like you're juggling, like providers are juggling two things, high quality care and, cultural competency and juggling those two. And Terry's really kind of convinced me and helped me understand that a part of high quality care is not just the delivery of evidence-based care, but also being culturally competent. So they're not two separate things. They're all kind of this umbrella of high-quality care. Right. Do you think in general there's a lot of stigma about veterans seeking mental health services? Do you think that's lessen today? I mean, in general, in the population, mental health stigma has decreased, but in the veteran population, is it decreasing? Is it the same? So, you know, I like to unpack that term stigma and really kind of

focus on the, you know, the phrase kind of barriers to care and what we know are obstacles and barriers to help seeking and the receipt of high quality care. And while certainly the attitudes that an individual has about help seeking and how they might be perceived are important, there are other barriers and repercussions from help seeking that are also critical for the veteran population. And this really is the fear of a negative career repercussion, that they could somehow be harmed in their career progression or career to. trajectory by getting mental health care. It could somehow affect their security clearance. And those are more highly endorsed among the military and veteran population than are the traditional

thoughts that, you know, you would be seen as weak by getting mental health care. And those consequences can be very real for some individuals. So we need to kind of focus on, you know, interventions that can decrease those obstacles and not necessarily just call it all stigma. I think that there's been a greater awareness and efforts to promote veterans to seek care when they need help. And the rates of help seeking among those who've served in the Post-on-11 era is about, you know, 50% of those who've experienced a mental health problem will have sought care for that problem. We would like to see it become higher. But again, it's about decreasing some of those barriers and not just overcoming what we traditionally think of as the stigma

associated with mental health. That's so important. I love unpacking this term stigma. Two things. I do a lot of work on. So some people think, well, what does a security clearance matter if you're a veteran? You know, you're no longer in the military. It's not as important to have a security clearance. We have to look at the data and recognize that a lot of veterans are going into jobs that still require, you know, some of these clearances.

I think, you know, all the ones, all the veterans who are going into work for the intelligence community, for law enforcement, first responder community. I mean, it's full of veterans. And so these concerns about the impact, the career repercussions for seeking mental health care are the same, or, you know, just it's the same version of the same coin. The other one that we hear about that I haven't seen as much attention on is kind of the diversity of treatment options. So we hear a lot, we've heard a lot that some veterans are really concerned about the side effects of different pharmacotherapy treatments. And so I think really just educating veterans and part of our, you know, quote unquote, anti-stigma campaigns needs to be about what actually mental health treatment is and that there are options and that it should be patient-centered and patient-directed. And if you want pharmacotherapy, then there's a number of different options that you can.

try. And if you want, you know, psychotherapy, then there's, you know, really good high quality treatments. A lot of the ones that, you know, Terry already mentioned, like prolonged exposure or CPT, trauma-informed CPT. So I think that, you know, we really have to be, it's not just about, you know, getting people into care by telling them, you know, it's not a sign of weakness. While that's important, we have to be tackling these other angles, if you will, of stigma. Right. And the beliefs about the effectiveness of mental health care are really, important. And so, you know, we need to help veterans and others know that treatment can work and that there are effective therapies available and helping them to understand the options

and to evaluate which ones are going to be most successful will be critical in making them more informed consumers and perhaps more confident that when they seek out to reach help, that they will be offered something that has the promise of relieving their symptoms and promoting recovery. What about the caregivers of veterans? I'm talking about spouses or family members who likely take on the everyday responsibilities of working with their family member or loved one with the physical or mental health wounds. Do they have enough resources and support? In short, I would say no, that they don't have enough resources yet available. to them. Fortunately, Terry and I actually collaborated and worked on a project together on America's

military and veteran caregivers called Hidden Heroes, where we learned a lot about the population. And if we focus on that post-9-11 group of caregivers, we found that there's around 1.1 million American adults today who are caring for someone who served in post-9-11 era in the post-911 era, that around 64% of them are caring for someone for mental and behavioral health challenges, and that around 40% of those caregivers themselves meet criteria for depression. So I think we have to think about the resources that are available to them. But also, sometimes, you know, the resources exist, and it's ensuring caregivers know about those resources that are able to support them.

and letting them know that help exist. And then, you know, critically is then making sure that those resources and the availability of them fits with the caregiver's schedule. Their caregiving demands can be very difficult. They may be juggling caregiving as well as being a parent, as well as, you know, and being a worker. They may be employed. So they're carrying multiple hats. So nine to five treatments or support groups, you know, things that happen. from a 9 to 5 schedule may not work to their, you know, be conducive to them.

So if it's there, but they can't access it because of their other demands, then it doesn't do them much good. So we have to think if we want to support this group, how we can best kind of meet their needs wherever they are so that we can support them. But I actually think that the families of those people with mental illnesses themselves don't necessarily have adequate support. for caring for their loved ones. Terry, do you have anything to add?

Well, I would add, you know, that it's important to think about their eligibility and access to these services, as Rajeev mentioned, but many of them, you know, may fall outside of the traditional eligibility criteria for a lot of caregiver support programs or the services that are available to them because they are the parents, for example, of the veteran. And, you know, they may not qualify for some of the traditional caregiving support services or they are the friend or neighbor of the veteran that they are caring for. And so we often think about family caregivers as the spouse or a child. But we know that, you know, this is, again, a diverse group. It includes parents as well as friends and neighbors who are providing that support.

And so making sure that they also have access to those support resources because they too are vulnerable to the burdens and stress associated with caregiving. Yes, absolutely. Terry, we spoke earlier about the concept of moral injury, which I want to talk a little bit about here, which is basically when someone violates their moral code and they experience a lasting psychological impact. Can you talk more about moral injury of this concept and what it means for veterans? Sure. Certainly I'm not an expert in the study of moral injury, but it is an area where we're gaining a deeper understanding of the construct as well as seeing the development of some specific interventions that can try to address it. And it really does get at, you know, what you mentioned is, you know, a challenge to an individual's beliefs that may be culture-based or group-based or focused around religious or spiritual beliefs. and that a moral injury occurs when they've either committed an act of transgression or they've witnessed a transgressive act by another, whether purposefully or by mistake, and that this somehow causes this dilemma. And so as we're trying to understand the challenges that veterans face, you know, clinicians and researchers have identified, you know, moral

injury is a consequence of combat experience and war and seeing that, you know, this guilt and shame and other kind of phenomenology is associated with what they're calling moral injury. And it suggests really different types of interventions and approaches to help those individuals overcome some of those consequences so that they, you know, can live, again, more symptom-free and regain a quality of life. Yeah, I'm not an expert on it either, but I will say I'm very excited. I've seen a lot of research recently that is trying to develop protocols and evidence-based treatments for non-mental health professionals like chaplains or pastoral

counselors that are attempting to get at some of these other dimensions of moral injury. and I've seen new kind of policy initiatives that for mental health providers that recognize their patients or an individual's kind of spiritual health and then try to foster kind of collaboration between a chaplain and the mental health professional so that they're kind of giving consistent messages, that they're not conflicting without, you know, of course, without violating the patient's privacy, but that they're kind of coming up with ways to, work together so that they're addressing, you know, potentially the depressive symptoms as well as some of the guilt and shame associated with moral injury that Terry was just talking about. And in general, today's warfare, modern warfare is very complex. There are deployed members who serve overseas, of course, and they live in that reality every day. But there are others who are based in the U.S., but who are performing duties in a war zone. So, you know, for example, a drone operator could be here in the Washington, D.C. area, strike a town in Afghanistan.

some are thousands of miles away. And if, for example, if that, that strike kills people, including some civilians, then the operator goes home. You know, they go back to their, quote, normal life and they're not in that war environment every single day. I want to talk about what that juxtaposition does to someone's mental health. I mean, when they're basically living almost, I guess I almost think of it as like living two different lives in one day. How does that, you know, Terry, can you elaborate on that a bit more? Well, I can try again. You know, I don't know that we have enough data to really understand the nuances

associated with it. But if we think about the concept of deploying as a military unit in a combat theater, you know, the idea that you're there as a unit with a group, small team or a large team, you're focused on a particular mission. And you have, you know, not only individuals to kind of, you know, watch your six or guard your back and you're there for a specific mission, but you have people that you're experiencing it with, and so an opportunity to process. And you're also away from the stressors of home life or, you know, some of the distractions that they can introduce.

Those may not necessarily be present for individuals who are perhaps stateside, you know, and performing their support functions or, you know, combat rule. and then going home and having dinner to help with homework that night or, you know, take on some of the household responsibilities. And so, you know, having to make sense of those two different worlds can create challenges for some, but it also may help them mitigate and be able to, you know, pay attention to other things and not necessarily dwell on, you know, what they did during the day. And so it's unclear I think, you know, understanding some of the nuances and what its impact might be until we gain, you know, more data on those types of operators and the experiences that they have and what contributes to those that

do well and those that don't do so well. And some other work that we've done looking at the impact of deployment on military families, we know that communication with the spouse at home can be protective and, you know, helping to manage the expectations about how a service member maintains that relationship with their family while they're deployed can have a protective role in the impact long term. And so, you know, how does that family communication get supported when the, you know, the, you know, individual isn't deployed? to a combat zone, but is only, you know, going to their job and then home every day. Rejeeve, do you have anything to add on this topic? I just think it's so critical. I think that what Terry said is great.

And I just think it needs to be researched so much better. As I said earlier, I do a lot of work on law enforcement suicide. And when we were talking, you know, we just interviewed, we did a study recently where we interviewed over around 120 law enforcement agencies across the United States. And we were focused on the officers. But when we asked them, you know, who else in your, you know, who else who works for Hugh are you concerned about? And they would always say the dispatch operators.

And I kind of, maybe it's not similar. Maybe it is. But they're kind of on the phones who are getting called about this crisis and then dispatching someone. And oftentimes they don't see necessarily what happens as a result, but it's a high stress environment. And, you know, they too go home and, you know, to their homes and things of that nature and often aren't considered officers. But it's a very, I think there's a lot of jobs out there that are very stressful in ways that we haven't kind of assumed in the past.

And we need to, like, really open our aperture for lack of a better term and think about the different stressors that people are experiencing on a day-to-day basis. Right. And absolutely. And think about then what that suggests for different ways that we put in support resources for them, whether it be, facilitating, you know, additional resources or opportunities for interventions is really critical because it could be a totally different model that we need. Yeah, that's really fascinating about some of these jobs that maybe aren't like the front lines, but they're contributing to, you know, helping people, first responders, that sort of thing. And that just sounds like a really fascinating area of research, like, as you said, that needs to be explored more.

What about some of the other complexities you see in the way wars are fought today and those effects on veterans' mental health as compared to the past? So, I mean, that's a perfect setup because and what we were just talking about, I think when Terry and I at the beginning of the podcast we were talking about, you know, the combat exposure and its risk on, you know, subsequent PTSD, some people think of that as kind of, you know, in the military, you have a combat role. or a combat support rule. But those distinctions don't necessarily relate anymore to a person's combat exposure because you can be a truck driver in the heightened, you know, the heightened kind of security climate in Afghanistan. You're a truck driver.

You know, when IEDs are a huge threat, you know, you're essentially providing support, but you could be experiencing combat day to day. And so exactly where you're saying, you know, modern warfare and kind of we have to think about these exposures and then think about how we're measuring, you know, what people are doing and the risks that they're experiencing. And I think the IED kind of combat support role is a prime example of the ways that modern warfare is changing. And we have to kind of, again, throughout our assumptions of what exposure to combat and

where we're most likely to see that, what occupations were most likely to see that. Right. And just a follow on of that, not only, you know, the exposure to the these very threatening experiences and traumatic experiences for even combat support roles, but just the understanding of being exposed to a traumatic brain injury and what those consequences can mean, particularly from blast exposures. We're still learning more about the effects of blast exposure on the brain and some of the short and long-term consequences that may be experienced by veterans who have traumatic brain injury. I mean, I think, you know, the common lure that

this is just a concussion and the symptoms are going to reside may not necessarily hold true for some of our veterans who've had repeat exposures and repeat brain injuries and with the symptoms that can overlap with post-traumatic stress disorder or depression, really trying to disentangle and understand how do we provide appropriate effective treatment for things like headache and concentration difficulties. We can't just assume that it's all, you know, associated with experiencing post-traumatic stress disorder, but that some of it may be, you know, as a result of changes in the brain from the brain injury itself and that blast exposure. And so that's really changed the way that we need to be more diligent in how we assess

veterans who present with these symptoms and making sure that we're not just doing self-report of the symptoms, but also thinking about, you know, images or, you know, getting images of their brain and understanding what may be happening. That could also require independent or concurrent interventions. And during this podcast, we've covered some pretty heavy topic. So I want to end going on more of a high note here. But the first question I want to ask is, is the, can you both speak to the importance of finding meaning after military service? I'm sure that's a big transition that happens when people leave something like the military where you have this meaning and then you go into civilian life. And how important is it to find a new sort of meaning or, you know, as it changes as you leave service?

You know, I think there's a lot of focus on ensuring that service members as they transition, you know, maintain their sense of purpose and mission and commitment. And we know that by and large, you know, veterans are more engaged civically and in their communities than non-veterans. And so they are mission-driven, purpose, you know, driven individuals. And so helping veterans to understand that while their military mission may be done, there are many other, you know, missions and purposes that they fulfill. And, you know, whether it be finding meaningful employment or leadership within their communities or, you know, reconnecting with their families, we've seen a lot of affinity groups that focus on this post on 11 veteran population that are really oriented. around helping veterans get engaged and, you know, find those new opportunities once they are back home and integrated within their communities.

Rejeev, do you want to elaborate on that a bit more? Sure. I'll just, you know, I'll say that, you know, maybe it reflects, you know, my own kind of middle-agedness. But, you know, I think finding meaning is really hard. When you say, like, you know, having veterans find meaning, that can be, you know, somewhat existential and can be very challenging to do, and it's a lot to place on a veteran. So I kind of think, you know, as a veterans where we really need to focus is ensuring that non-veterans really, as we've been talking about, really recognize the value of veterans.

They're, you know, how civic, they raised their right hand and served and served, you know, very challenging kind of times and a very challenging climates with very different roles. and I think, you know, it's incumbent upon the non-veterans to actually increase their awareness and recognition of the contributions veterans have made. So I would love to kind of, and I think by doing that, you know, it's not all on the veteran to find meaning, that they'll find meaning. If we appreciate their service, then the meaning, I hope, will come from that. But I do think it's a critical role in something that as a society we really need to focus on.

And that's the beauty of veterans day. That's what it's all about. It's about us kind of non-veterans recognizing the role that veterans have played. Yeah, absolutely. That's a wonderful way to end that question. And overall, I just want to end this one other note too. Are you seeing improvements in the overall care of our veterans? We've talked a lot about where those gaps are.

But what are some of the areas you're really seeing are care of veterans going well? I see that I actually have seen that we are talking. I maybe, I don't know if this is true, but it used to be a question about access to mental health care stop. And I think that we are seeing increased awareness as not just access to mental health care, but access to high quality care. And I think a lot of organizations are trying to increase the capacity of our mental health care professionals to do. deliver really high quality evidence-based care. And that's really, I think that we still have a long way to go. Don't get me wrong, but I do think that there's been a lot of awareness about these issues, as well as in the mental health community about the necessity for delivering high-quality evidence-based

care. Yeah, absolutely. And I think, you know, we've seen certainly large investments from the federal government in dollars for both the Department of Defense and the Department of Veterans Affairs to expand their clinical services, but also to invest in research. And so that opportunity is affording us even more insights in becoming more precise with how we can not just diagnose in terms of improved diagnostics, but how we can think about even getting towards precision medicine for the treatment of post-traumatic stress disorder. So we can do a better job in the end of matching veterans to particular types of efficacious treatments, you know, based upon an increasing and burgeoning scientific base for understanding who's going to respond to which types of treatments

best. And so it's not just increased access to high quality care is, as Rajiv said, we've made important headway in that, but increasing the opportunity we have to match veterans to specific evidence-based treatments that we know will work for them. So I see hope on the horizon, on the horizon in that regard. And we need to keep funding research on mental health conditions. I mean, I just think it's an increasing awareness. We need more. evidence-based protocols. I think the ones that we have are great and let's, you know, keep it going with more. Thank you so much for joining us on this very important topic. I really appreciate your time and I think our listeners will really enjoy this episode. Thank you for having us. Yeah, thank you.

This is great. And before we go, I just want to let you know that we want to hear from you. You can email your comments and ideas to speaking of psychology at APA.org. That's speaking of psychology, all one word.org. And please give us a rating in iTunes. We'd really appreciate it. Speaking of Psychology is part of the APA podcast network, which includes APA journals dialogue about new psychological research and progress notes about the practice of psychology. You can find all of our podcasts on Apple, Stitcher, Spotify, or wherever you get your podcast. You can also go to our website, speakingof psychology.org to listen to more episodes. I'm Caitlin Luna with the American Psychological Association.