Keywords

FormalPara Vignette

Tom is a 27 year old male who served for 4 years in the Marine Corps before being honorably discharged upon completion of his enlistment. During his time in the Marines he twice deployed to Iraq where he served in the Anbar province. His deployments were marked with significant combat exposure and a number of Marines from his platoon were killed or severely wounded.

Tom himself sustained minor injuries from an improvised explosive device but was able to continue to perform his duties and complete his tour of duty and subsequent term of enlistment without follow on medical care requirements. Tom received a Purple Heart due to his combat injury. While he was screened on multiple occasions for potential mental health issues and did meet once with a military mental health professional. He chose not to report the intrusive memories he had of his deployment, the negative changes in his mood, or the changes in his physical and emotional reactions because he felt that asking for help would make him look weak in the eyes of his fellow Marines.

Upon completion of his service, Tom returned to his hometown in Montana where he was able to find work in a gun shop. Since his departure from military service he has had minimal contact with members of his former unit and he does not talk with his family about his military experiences as he feels they do not understand since he is the only one in his family to serve. The nearest VA clinic is over 2 h away and Tom has not sought any support or services through the VA. Outside of work, Tom is not engaging in any activities and while he previously enjoyed running and hiking, he has not been actively doing either activity.

Until the last 2 weeks, Tom was attending work without problem but recently he has become more isolative and has noted a worsening in his symptoms which have been present since the time of his service. After discussing with his primary care physician, he is referred to a local mental health clinic where he is diagnosed with posttraumatic stress disorder and treatment is started.

Introduction

Tom’s case is very representative of a large portion of veterans from the Global War on Terror. Many of them completed their service, left the military, and are now integrating back into our communities. They carry with them the burdens of the trauma and exposure that they experienced. As outlined in greater detail in the stigma chapter, both the Department of Defense and Veterans Affairs health systems have enacted numerous programs to reduce stigma and barriers to care. However, stigma towards seeking mental health care remains and can serve as a barrier to seeking help. As military personnel transition back to civilian service, some will go on to attend college using their GI Bill benefits while others seek employment. As outlined in the transition chapter of this book, the quality and experience of that transition can have significant impact on veterans such as Tom.

Additionally, while veterans like Tom are eligible for care through the VA’s health system, it is not uncommon that eligible veterans may not take advantage of available resources, especially if they are receiving health care benefits/insurance coverage through other employer provided programs or there are not nearby VA health system resources. Providers who care for military service members and veterans should be familiar with what Military Health System and VA services exist as they may be resources they can tap their patients into. Additionally, as providers and mental health teams develop their treatment plans, it is important to not only consider the medications and therapies required to treat these conditions but also the tailored social support resources and networks that may be available for this population.

Multiple studies in veteran populations have shown the positive impact of social support on posttraumatic stress disorder, depression, and suicidal ideations [1,2,3,4,5]. However, the concept of social support is not well defined and varies between family, friends, significant others, and co-workers. Additionally, these studies all focused specifically on mental health outcomes but not other factors such as financial support/need or other challenges. There are numerous resources available for military and veteran personnel designed to increase access to care, provide assistance for specific situations, and to enhance their social connectedness.

This chapter aims to provide some awareness of both the general medical services available to this population through the Departments of Defense and Veterans Affairs, as well as, emphasize military and veteran specific community resources and how they can be integrated into treatment plans for this specific patient population. The resources identified and listed within this chapter (Fig. 7.1) are not meant to be an all-encompassing list nor a recommendation or endorsement of any specific program but rather they are highlighted to increase awareness that such programs exist and to encourage mental health providers to become aware of what programs may be available within their area.

Fig. 7.1
An illustration of the 8 key websites for veteran medical and mental health resources. The overview concept of a website includes the military and V A health system, specific information, and D O D resources.

Key website for veteran medical and mental health resources

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Department of Defense

The Military Health System provides medical care to 9.6 million military service members, family members, and military retirees. This care is provided through two systems. The first is the direct care delivered by the more than 50 military hospitals and 425 ambulatory health clinics at military installations around the world [6]. While these facilities have the primary responsibility to support active duty military service members and their families, they also support other beneficiaries that live within 50 miles of the facilities.

Most all of these facilities provide at a minimum outpatient mental health services and larger facilities will include sub-specialty mental health services, inpatient mental health capability, and in some cases, residential treatment facilities. Military treatment facilities will include a mix of active duty military and Department of Defense Civilian psychiatrists, psychologists, and licensed clinical social workers capable of treating both acute and chronic conditions with pharmacology and psychotherapeutic interventions. All installations will also have personnel specifically trained in substance abuse and family advocacy (military equivalent of child protective services). Select installations have specific centers affiliated with the National intrepid Center of Excellence to provide specialized treatment for those with both posttraumatic stress disorder and traumatic brain injury.

These military treatment facilities also support the various mental health screening initiatives that are conducted by the Department of Defense. This includes pre- and post-deployment health screenings that seek to identify potential exposures, medical ailments, and mental health issues that may be present at the time. In the terms of pre-deployment screening the emphasis is to ensure that injured and ill service members are not deploying or if they are deployable, have the necessary medical resources and capabilities [7]. Post-deployment efforts have increased in frequency and more recently all US military personnel now complete an annual screening separate from deployment called the periodic health assessment. These screens are focused on the early identification of depression, posttraumatic stress disorder, alcohol disorders, and risk factors for suicide and domestic violence and linking those service members for care [8]. Separately, the Military Health System introduced depression and posttraumatic stress disorder screening to each service member primary care encounter [8]. Unfortunately, these processes are limited by the willingness to self report and the lack of anonymity in the process leads to service member under-reporting [9].

Additionally, Military Health System beneficiaries have the ability to access civilian medical services around the world through the purchased care network using their selected TRICARE plan. Of note, National Guard and Reserve service members have limited health coverage under these programs unless on an activated status. This is covered in further detail in Chap. 6.

Beyond the Military Health System capabilities, there are several other mental health services that are available for military service members to help reduce barriers to seeking care. Some military installations offer Military Family Life Consultants which are mental health providers who are working throughout the military community to educate service members and their family members about potential mental health challenges and services available. These consultants are not permitted to enter into a therapeutic relationship but do have the ability to coordinate mental health care if needed. In contrast, the Military One Source program provides free, short-term, confidential, non-medial counseling for a wide range of issues including marital conflicts, stress management, and coping with grief and deployment transitions. Military One Source providers are not able to make a clinical diagnosis nor are they able to provide medication or specialized therapies. However, they can coordinate and transfer care to a TRICARE provider if necessary. Despite these limitations, both of these services are used frequently due to the confidential nature.

It is also important to understand community resources that are available to military service and family members through the Department of Defense. As highlighted in the military culture chapter, military installations are cities within themselves with their own churches, in some case schools, and community resources. Additionally, most all military installations have morale and welfare resources on the installations to encourage recreation (golf course, bowling alley, swimming pool, outdoor areas) and social gathering of individuals with like interests (gyms, auto skills shop, woodworking and art studios, etc.). As highlighted several times in this book, one group that can have a difficult and challenging transition within the military are the junior enlisted service members, those who are unmarried and recently entered the military. Most military installations have activity programs in place for single service members to encourage them to socialize, interact with each other, and take advantage of recreation and education activities within the area of their installation. For example installations in Texas might organize a trip to attend a rodeo or those in Florida might take a weekend trip to one of the many amusement parks in Orlando. These types of activities not only get the service members some time away from their duties but also the opportunity to establish social networks within their community.

In the case of Tom, he was screened for mental health concerns and educated about available services as part of his post-deployment health assessments and annually as part of his periodic health assessments. Additionally, he would have received periodic screenings for depression and posttraumatic stress disorder as part of his engagements with his military primary care providers. But, these processes all require that Tom would want to get help and self report his symptoms. In this case, Tom chose not to do that because of stigma concerns. The result was that Tom did not receive any treatment while in the Military Health System and was not considered for potential associated disability due to the condition or coordination of care with the VA health care system.

Department of Veterans Affairs

Generally, veterans qualify for VA health care depending on income or disability rating. Further, these factors determine the cost of VA health care services. The VA is committed to providing free health care for conditions related to military service, or Veterans with catastrophic disabilities and disability ratings of at least 50%, as well as for those who cannot afford to pay for care. Additionally, the VA offers free health care related to readjustment counseling and mental health services, care and counseling related to military sexual trauma, exams to determine future risk of health problems linked to military service, care related to combat service for Veterans that served in a theater of combat operations after 11/11/1998, VA claims exams, care related to a VA-rated service-connected disability, and individual or group programs to help you quit smoking or lose weight [10].

In the absence of VA disability compensation or pension payments or special eligibility factors (like receiving the Medal of Honor, Purple Heart, or former Prisoner of War), the VA will ask for information about income as part of the health care enrollment process. It is required by law and is called an income assessment or financial assessment (formerly known as means test). Gross household income for the previous year is requested and if the information provided shows that the Veteran’s income is below current limits and qualifies for free VA health care, medications, or both, the VA is required by law to verify the information. This is done by confirming the information provided with the Internal Revenue Service (IRS) and the Social Security Administration (SSA). Veterans do not have to provide financial information if they agree to co-payments for care. However, without this information, the VA will not be able to consider eligibility for free medications or beneficiary travel.

With more than nine million enrolled veterans, the VA is home to one of the United States’ largest integrated health care systems providing care at nearly 1300 health care facilities around the United States include over 170 medical centers and more than 1100 outpatient clinics of varying capacity [10]. VA medical facilities provide a wide range of services including traditional hospital-based services, primary care, and most medical centers offer additional specialty services. Specific to mental health, the VA has an integrated system of care that offers inpatient, intensive outpatient, and comprehensive outpatient mental health services. To address the potential barrier to care of travel to the nearest VA clinic, VA mental health services have been in the forefront in the area of tele-mental health care.

The VA also offers mental health intensive case management for veterans with severe and persistent mental illness, opioid treatment programs, and collaborative addiction recovery services to help those veterans who are struggling with substance use disorders. For those who have significant polytrauma, the VA offers multiple polytrauma centers that focus in providing the highest quality of care for both those visible and invisible wounds of war. Additionally, there are countless other programs throughout the VA to support veterans with mental health disorders ranging from those specific to military sexual trauma, veterans who are victims of intimate partner violence, and those who are facing criminal justice issues related to their mental health disorder. If you have a veteran patient who may benefit from these services or you would like to learn more about the specific services offered, reach out to the social work services section of the local VA in your area.

The VA also offers some financial and support assistance that may be beneficial for patients including financial hardship assistance for those have accrued outstanding balances for co-payments related to VA care or medications and beneficiary travel support to potentially reimburse the veteran’s travel necessary to get to and from the appointment. Additionally, multiple specialized case management programs exist based on the specialized care or veteran group which can help connect the veteran to the necessary resources depending on their case complexity or needs. Lastly, the VA also offers a caregiver support program that provides resources, education, and supportive counseling to caregivers of Veterans. This program offers text support, self-care courses, telephone support line, peer-support mentoring, and resources for health and stress management.

Outside of the VA medical facilities, the VA has community based counseling centers called Vet Centers that provide a wide range of social and psychological services. The counselors and staff of these facilities, many who are veterans themselves, offer individual, group, marriage, and family counseling to support a successful transition to civilian life or after a traumatic event experienced in the military.

It is important to recognize that the Veteran Health Administration is only one portion of the benefits and resources that the VA provides to veterans. These benefits can include disability compensation, veteran’s pension programs, education programs, housing and home loan guarantees, job training, business loans, and cemetery services. A separate chapter in this book talks about disability benefits provided by both the military and VA.

Of note, the majority of veterans leave the military under honorable conditions. However, a certain few may receive dishonorable or bad conduct discharges which may bar VA benefits. If you are caring for a veteran who has received one of these discharge statuses, there are two ways to try and qualify for VA benefits: a discharge upgrade or a VA character of discharge review.

While Tom did not seek care for his conditions while in the military and has not engaged the VA for support to date, he may still be eligible for both VA health care and disability benefits. As noted, he lives a significant distance from the nearest VA but this may be overcome through the use of tele-mental health capabilities or through financial support for beneficiary travel.

State and City Supported Benefits

Most states and some large cities have established veteran’s offices and provide unique benefits to their veteran residents. Some of these may be additional health care assistance either through state funded care or coordination with veteran support organizations in the area. Other resources may include counseling services, housing assistance, and food assistance. Homelessness in the veteran population is a significant issue and is addressed in greater detail in a chapter in this book as well as some of the services available in those situations.

States and cities also tend to offer educational, financial, and other benefits specific to veterans beyond health care. For example, Texas offers veterans who have received certain military awards and decorations specialized license plates that allow them to travel toll free on all state roads. Other states like Hawaii offer real estate tax exemption and discounted motor vehicle registration fees. While these types of benefits may be outside the scope of the treatment plan, it is important to encourage a veteran to get educated about their available benefits to help their situation.

Specific to health care, many states offer connections for those seeking mental health assistance to veteran support organizations who can arrange affordable or free mental health treatment. Additionally, most all states have one or more Veterans homes which provide independent living, assisted living, or nursing assistance to elderly veterans who either have low income or desire to spend their last years with their comrades.

As a resident of the State of Montana, Tom is encouraged to seek potential state resources. While there are no specific health resources available, he does learn about potential tuition and education assistance opportunities that would allow him to pursue some of his future goals. Additionally, he has now engaged with the VA and is undergoing evaluation for potential disability. This may make him eligible for state tax exemptions and reduced or no fee vehicle registration. These financial benefits may significantly reduce Tom’s financial stress.

Veteran Service and Community Organizations

When discussing veteran service organizations, it is important to recognize that this is a non-specific term that encompasses a large group of organizations. The Department of Defense provides a list on their defense.gov website of organizations based only on the criteria that they are designed to support military service members, their families, or veterans; are a non-profit organization; do not represent or endorse partisan, hateful, or anti-American positions; and have received favorable vetting by at least two charity evaluators. The Department of Veterans Affairs provides a list on their va.gov website of recognized organizations sorted by whether they are congressionally chartered and if they are officially recognized by the VA to prepare, present, and prosecute claims on veteran’s behalf.

Some organizations, such as large charitable entities like Salvation Army or national mental illness advocacy groups, have larger missions but have dedicated specific efforts targeting veterans or military personnel. In contrast, veteran service organizations generally have a primary mission focused on supporting the military and veteran population. Some of these organizations provide mental health counseling or will provide financial support for services. Many others provide referral services for mental health counseling. Before recommending any particular organization that does provide or coordinate care, ensure that you research what evidence based interventions they support or endorse. Other groups provide adjunct support such as retreats or service dogs. Some organizations are focused on specific groups either by injury, ethnicity, race, period of service, or rank of service. Many of these organizations also provide advocacy for their specific population through various avenues.

More importantly, these organizations can provide a mechanism for social networks and connectedness with individuals who have had shared experiences. Gold Star families are those who have lost a service member in combat. An organization specifically focused on supporting that group will not only create contacts between those who have recently lost loved ones but also a broader family of those who have experienced this loss from previous wars. One gold star wife whose spouse was killed in Afghanistan in 2012 noted that one of the most powerful and influential conversations she had was with a gold star wife whose husband was killed in the Korean War. She noted how that discussion more than any helped her find a direction for her life after the loss and helped her anticipate some of the challenges that lay ahead. These types of peer support connections can be very influential and supportive.

Additionally, some organizations may have a fairly sizeable local presence that helps promote this type of connectedness through activities such as running, hiking, etc. or through local gatherings. These organizations generally seek to have activities within the community such as supporting military and veteran holiday services or community service that also helps the members of their organization become more connected to their broader community, helping support their long term transition.

In the case of Tom, he is now back in his home town and has become increasingly isolated. Not many of the individuals that he grew up with chose to enter the military and he does not have a large veteran presence within his family. Yet, within his town there are two veteran service organizations that maintain activity halls and have frequent gatherings and a separate group that conducts weekly runs in honor of the fallen. He could be connected to these organizations that could promote him getting back into activities he previously enjoyed while also meeting other veterans from both his and prior generations who have shared experiences. It is important to note that there are no scientific studies that show what level of benefit that involvement with veteran service organizations provide, but as noted in the beginning of this chapter, there are clear benefits of increased social connectedness and support.

As previously noted, this section has predominantly focused on veteran service organizations. These are all organizations specifically dedicated to and focused on veterans. However, there remain many other organizations within communities that while may focus on larger national and community challenges, also provide services to veterans. For example, the United Way has a special program called Mission United which focuses on helping veterans and their families acclimate back into civilian life and the Salvation Army has efforts specifically targeting veteran homelessness. As stated previously, when supporting a military or veteran patient, it is important to be aware of what resources are specifically available in your area or have contacts who are adept at accessing and are knowledgeable about these resources.

Tom remained frustrated about the travel distance to the nearest VA and disengaged from his care with them. As part of his biopsychosocial treatment plan, he was recommended to engage with the Veteran Service Organizations that operated within his town. The first organization focused on addressing veterans who were suffering from mental health conditions. They were able to assist Tom in finding a nearby therapist that he felt comfortable with and understood veteran specific mental health issues. He remained engaged in treatment and was notably improving. A second group maintained a social gathering site in town and Tom was encouraged to visit. He attended two events and began to establish a friendship with a Vietnam veteran who himself had struggled with his own experiences and his return from military service. Based on Tom’s prior enjoyment of distance running, his provider recommended that he participate in weekly run that a veteran service organization hosted honoring the fallen service members. Tom began participating and found that he enjoyed the people that he met at the events and the fellowship from the event while also feeling like he was honoring and remembering his friends that he lost through his participation. He began developing friendships and relationships that he had not had since his departure from military service.

Future Direction

The Military Health System and Veterans Health Administration will continue to evolve and develop capabilities to care for our nation’s military personnel and veterans. However, due to stigma, barriers to care, and the broad dispersal of veterans throughout our nation, they will never be able to meet all of the needs of this population. States, cities, and Veteran Service Organizations will continue to be needed to support these individuals and their families who have sacrificed for our country.

As providers caring for this patient population develop their treatment plans, it is important to consider the aspects of social support and the resources that may be available within their community. Studies have shown positive impacts of social relationships, but the benefit of community provided social support is unclear. Future research should look to assess the impact of these organizations, clubs, and activities to more thoroughly address the full biopsychosocial needs of veterans.

Clinical Pearls

  • The Military Health System provides medical and mental health services for military service members, their families, and retirees through both their direct care system and an international network of providers who accept TRICARE.

  • To combat stigma concerns, Department of Defense provides non-medical, confidential counseling services to their beneficiaries to support transitions, grief, adjustments, and trauma.

  • The VA provides the largest integrated health system to meet the medical and mental health needs of America’s veterans. This is delivered through a large network of medical centers and health clinics throughout the United States.

  • Most states and select cities provide specific veteran benefits and services to aid in transition to civilian life and deal with the consequences of military deployments and combat exposure.

  • Multiple studies in veteran populations have shown the positive impact of social support on posttraumatic stress disorder, depression, and suicidal ideations.

  • There are a large number of Veteran Support Organizations that provide varying services and support. Some are focused towards specific veteran sub-groups while others are focused on specific types of injuries.

  • Depending on their aim, Veteran Support Organizations can provide medical, financial, and social support and should be considered for veterans in need.