January 01, 2014

What You Can Do for Your Country: Cross-Generational Support for Today’s PTSD Veterans

Readers of Experience are quite familiar with stories relating to the passing of wisdom from one generation to the next. But seldom is the need for sharing the generational wisdom of counselors as great as it is for Iraq and Afghanistan veterans who are experiencing the harsh consequences of post-traumatic stress disorder (PTSD).

We, the authors of this article, are each proud to be veterans of the Army’s Vietnam era. One of us is an aging veterans’ advocate and law professor; the other is an active volunteer peer counselor, a decorated Ranger, and now an advisor to fellow PTSD veterans of the younger generation. We appreciate the reader’s willingness to consider ways in which you, the senior lawyer with or without military experience, can fill a real need in our nation today.

We are energetic midwesterners in our mid-sixties, successful in our endeavors beyond our military service, but with a profound sense of duty toward younger veterans. In our generation, few could even spell PTSD, and the staff of the Veterans Administration (VA) focused greatly on the visible, physical wounds of World War II, Korea, and a wave of incoming survivors of the Mekong, Central Highlands, DMZ, and other jungle battlegrounds in Southeast Asia. Military medicine has come a long way.

Today, PTSD seems to be a well- studied affliction of younger veterans, but the ranks of helpers are thin. Would this be a good use of your volunteer time? Have you teared up at “the Wall,” the long, low monument along Washington’s Mall that remembers our dead companions? Our sense of duty to those comrades compels us to recruit some of you who are elders and counselors. We who are older veterans carry the credibility needed to do “listening therapy,” to describe and disarm the phenomenon of PTSD among recent war veterans before it leads to aberrant behavior and violent hostilities. Perhaps you could march with us into this role.

What Is PTSD?

Psychologists recognize that the minds of some persons react to the severity of sudden wounds and attacks, horrific forms of trauma, with a post-traumatic lingering response that remains. A history of PTSD can be found in the extensive psychological literature, and, for reasons of space, we will truncate the list of factors leading to a diagnosis with a summary of one ex-Ranger’s experiences: alienation, distaste for authority, a short-fuse reaction to threats and challenges, anger, and isolation. Such feelings get in the way of adjusting back to civilian life.

Generations ago, “shell shock” and vague diagnoses of combat fatigue were passed off as explanations for why U.S. Marines from Guadalcanal, soldiers from the Marne, and sailors from ships sunk in battle did not “come home the way they left home” for their wars. Military medicine’s refusal to accept PTSD as a cause of “slacking” and the bureaucratic insistence on physical injuries as a prerequisite for compensation benefits combined to further alienate the walking-wounded warriors. Our post-Civil War system for aiding those with visibly disabling physical injuries took a century to deal adequately with psychological trauma. However, the mid-twentieth century acceptance of the official PTSD diagnosis and its manifestations still lagged far behind the reality of frustration and alienation. The response from the VA still resembled a platoon sergeant’s orders: “Shake it off, toughen up, man up, get over it!” Civilian post-discharge struggles with manifestations of PTSD led some veterans into prisons or mental hospital lockups.

We praise the work of civilian and VA psychologists who steered the slow turn of the bureaucracy toward acceptance of the need to proactively reach out to aid the new generation’s psychologically wounded warriors. The changes in support of PTSD survivors that were belatedly applied to veterans of Khe Sanh, Laos, Tet, and other campaigns of 1963–1975 have progressed further with helping the veterans of Kandahar, Fallujah, and Tora Bora today. There is still much to do in brain and behavioral research, but progress is underway and we applaud it. There are positive measures that are mitigating the past burdens of surviving an ambush or an IED, living every day with fatal uncertainties, and then, as a new civilian, crying for help to a bureaucracy at a VA that had been dysfunctional. Our ETS (departing) physical exam was a joke; our medical records rarely showed the marks of prolonged anxiety and fear of sudden attack that today’s more empathic, listening VA will document.

Flashbacks, depression, anxiety, sleeplessness, and substance abuse are commonly experienced by PTSD sufferers. I, Donald Black, have been known to explain that “I would like to recover my life and not spend my life in recovery.” I have benefited from psychological counseling, physical therapy, group therapy, chaplaincy counseling, and pain clinic assistance. As a veteran and as a peer counselor, I know how important such services are. And we “old guys” note that the Iraq and Afghanistan forces have endured multiple tours of combat duty that seem to exceed our “364 and a wakeup” attitudes toward departing the earlier war for calmer duty in Kentucky or Germany. Today, the war veteran of multiple tours in alien places returns hyper-vigilant toward strange or new situations, in some cases benefiting and in some cases rejecting the additional therapy options that may be offered. Ask yourself: if you were to switch places with these veterans, how would PTSD feel?

Slow Change to the System

There are many positive signs of institutional change. The Veterans Health Administration’s approach has softened, and veterans groups have urged Congress to fund and augment the capabilities of the military and veterans hospitals and outpatient clinics to support those who have experienced PTSD. A separate part of the VA system, the Veterans Benefits Administration’s regional offices dealing with compensation and pensions are somewhat more receptive to granting benefits for the PTSD claims than they had been in prior decades.

As the institution’s view softens, the budget strain on VA funding places more stress on the system as it strives to sustain its existing needs. There remains the real need to reach out to those who have not yet been served with counseling and support programs. In a tight budget climate, denying claims of nonphysical injury might seem to make sense as a restraint on spending. The original Tea Party members went to war as militiamen; the current group of at-home deficit hawks seems uncommitted to sustaining the needs of veterans. The irony is that their principles of personal responsibility would seem to require the larger society to accept responsibility. “You broke it, you buy it!” is a philosophy that can be applied to both individuals and groups. Because a past administration sent volunteers into combat for national security reasons—to make the Middle East a tolerant and democratic sphere, or to protect the oil market’s price stability (choose your preferred rationale)—the system that sent them must now deal with their legitimate needs. We can and we will deal with the intense harm caused by those volunteers’ confrontation of sudden and sharp threats to their survival.

Some members of Congress deserve praise; they awakened to the PTSD wave and funded new VA efforts to provide counseling, “talk therapy,” and medications. But one of the symptoms of PTSD is withdrawal into a mistrusting form of self-isolation. So we as a society must do more collectively to reach our veterans population and to engage them with listeners and problem solvers who come from their communities. In short, we need you!

Why Should I Take On Unpaying Clients?

Senior citizens of all backgrounds wave the same flags at Fourth of July parades alongside many other admirers of the Legion or VFW color guard marchers. But after the Main Street parade passes by, look further down that scruffy alley: why are those guys sitting in the homeless shelter or struggling with joblessness? I, James O’Reilly, am a former state police officer, and I recall dealing with some very disturbed contemporaries in the 1970s because there was then no place for them to get timely VA help. The criminal justice system has begun to adapt, and we applaud judges willing to take a docket of minor misdemeanors committed by troubled veterans and steer the offenders into alternative treatment and mandated counseling sessions and substance-abuse support programs.

That’s the point to remember: the “System” has improved, but not for all PTSD veterans. Some need help and can’t get counseling or legal assistance without guidance. Our legal profession understands how best to deal with barriers and bureaucrats. What can senior lawyers do for the alienated, skeptical PTSD survivor?

  1. Read up on PTSD, and you will be surprised at the reliable estimates for the deferred care “people costs” of our recent Middle Eastern adventures. “Mission Accomplished” banners fade, but needs persist. You know some of your legislators and they hear you, so talk about fiscal support that the VA needs in your state.
  2. Next, contact the National Veterans Legal Services Program (www.nvlsp.org) or the veterans coordinator at any large legal aid society. Listen to them talk about the needs of some of their veteran clients in your area. “Re-up,” or enlist again, to help meet these actual local needs. Understand more about the volume of veterans in your community that you could help reach a positive outcome.
  3. Take the VA-required legal representation training, get certified as a volunteer veterans representative, and study the appeals system. Volunteer to help the neediest local veterans by starting with homeless shelter directors and community agencies such as county veterans service commissions. You will soon leave your comfort zone. Accept help from groups like the Disabled American Veterans (DAV), but do not buy the usual platitudes; nonattorney veteran group organizers are long on following formulations and forms, but they lack a lawyer’s insight to push the system for personal attention to the special needs of the one individual veteran whom you will be helping at any particular moment.
  4. Apply some administrative law savvy to a process that seems so off-putting and cold to the PTSD veteran. It’s a long shot to ask you to combine understandings of the Privacy Act, Equal Access to Justice Act, Court of Appeals for Veterans Claims (CAVC), and ways of making effective requests for congressional help, all into one package for this, your most needy client. However, in your career, you probably have solved puzzles and mastered processes more arcane than the puzzling VA mousetraps. Left in the hands of certain old-line veterans groups, the vet’s case will bumble along. But you can do so much more than a mere lay service organization can do. Imagine the comparison: today veterans groups’ services are like the old-line industrial unions. No union member there would rock the boat, and all were waiting in the same line. But today, individual worker’s rights actions are the keys to change and success. The VA chokes on its paper files and refuses to act with expedition on most cases, while your client may be dying or in desperate need. Be the lawyer who shakes things up and gets results.
  5. Next, recognize that you’re one of a few attorneys in your town helping to appeal VA denials because lawyers at the VA benefits level do not get more than a token payment, and those who do move ahead and reach the rare appellate court decision don’t get paid what they are worth. Veterans’ benefits appeals have been virtually pro bono since 1866 laws capped the legal fee at $10 in the early stages. Later stages pay a pittance; no one gets rich.

Other sources describe how the VA appeals process works: badly! The regional offices are swamped, the front-line decision makers are disincentivized, and the veterans service organizations play by the arcane rules of the bureaucracy in order to receive the benign charity of the VA. I, James O’Reilly, have been frustrated at the Board of Veterans’ Appeals quagmire and especially the CAVC’s refusal to summarily award benefits, even in the most deserving cases. I was invited to address the CAVC Annual Judicial Conference, where I compared the CAVC’s tedious output of remands, without ordering benefit awards, to a “hamster wheel” of institutionalized delays and frustrations. When I asked the administration’s judicial selection leader how those pro-government judges were selected for that court, I was told that Defense Department and VA general counsels supply the lists, unlike conventional nomination channels for appellate slots on other federal circuits.

In that response lies the core problem of reviewing VA errors: we see an inability to shake up the sclerotic system that has been institutionalized from the top down—even the ultimate appellate review body, the Federal Circuit, has eschewed veterans appeals as that court’s least favorite cases. Perhaps you could take on the challenge to change this, and break the logjams for your clients. Can you receive the flak of an angry bureaucracy and survive? Can you be paid nothing but professional pride for bravely questioning “the emperor’s new clothes”? But what would you get for this quixotic courage?

When It’s Just You and the Veteran

Distaste for authority and hostility to hierarchies mark the PTSD patterns of individual cases. When it is just you meeting with just one veteran, what steps should you take in counseling that younger veteran, to build on our experiences?

  1. Listen carefully and empathetically.
  2. Recognize that, when disability benefits are awarded to veterans between the ages of 25 and 35, the benefits awarded for PTSD may be the difference between a life adrift and a life rediscovered.
  3. Prepare for a system of sloppy records, replete with gaps and dead ends.
  4. Don’t be shocked if sexual assault was a cause of PTSD for this veteran, as she or he deals with a system hostile to civilian life’s norms of remedies for such harms.

What would success look like? Veterans health benefits will be available to your client now; these will include counseling, medication screening, and, in some cases, group home or “aid and attendance” benefits. If the client’s PTSD makes him or her especially troubled, obtaining unemployability status may be the right direction to take in order to pay for sustenance while he or she is getting help.

Picture the sharp crack of a bullet or the sudden road explosion of an IED; imagine how it would frighten and distract you. The event happens right now, but the undoing of PTSD will take years. During this period, offer a helpful listening ear, and expect to stay in touch. The veteran who bonds with you may use your continued help to retrain for jobs, re-anchor his or her life to its real potential, and reduce the unproductive fears that impair future success.

Your Next Steps

Put down this magazine and pick up the phone. Get in touch with well-recognized homeless shelter managers and behavioral healthcare providers who interact with veterans. Get in touch with legal services teams that can link you to the training required of lawyers dealing with the VA. One veteran at a time, please deliver them from evils, the evils that are internal, within their heads, and those that are external, within the bureaucracy they face. Stand tall, don’t leave a comrade wounded on the battlefield, and don’t ignore a plea for help. Find inside you the strength to help the PTSD vet overcome the mess he or she has encountered. Mahatma Gandhi never wore our jungle camo, but his words ring true: “Be the change you want to see in the world.”