Substance Use Disorders: Assessment and Treatment, 2nd Edition _ ___________________________________
mismatch between expectations that coming home would be a welcome return to “normal” and the reality that what used to feel “normal” felt alien because of changes in the veteran and changes at home. This situation led to a feeling of being disconnected from the very support systems on which the individual veteran needed to rely. This sense of being discon- nected can be further increased by unresponsiveness from the U.S. Department of Veterans Affairs (VA) or some community organizations, by a lack of structure in civilian life as compared with the military, and by a loss of a sense of purpose. Clinicians working with veterans need to understand that the transition for many individuals from military to civilian life will be chal- lenging and often unexpectedly painful. Having a mentor who has successfully made the transition from military to civilian life can be very helpful. Likewise, having a safe place that is respectful of military culture where the client can discuss, freely and openly, the unexpected difficulties of this adjustment can offer great relief. The following vignette demonstrates an initial meeting between a civilian therapist and a recently returned combat veteran: Therapist : Mr. Lanso, I understand that you returned from Afghani- stan recently. How long have you been back in the States? Client : It’s been about 3 months now. Therapist : How have things been going for you? Client : Not so good. Therapist : Can you tell me a little about it? Client : I just don’t fit in anymore. I feel scared all the time, I can’t sleep, and my memory is shot. I guess it’s all because of what hap- pened in Afghanistan. Therapist : Can you tell me about what happened to you in Afghani- stan? Client : An IED exploded under our personnel carrier. Two of my buddies, Todd and Oki, died right after the blast. My buddy Smitti, he died 3 weeks later. It was the burns that got him. The guys in the Humvee behind us, they pulled me out. But the fire was on my legs. Therapist : Is there anything else you remember? Client : I remember Todd and Oki screaming. And burning. Then I don’t remember anything until I came to in the field hospital. Therapist : Do you know what flashbacks are? Client : Yes. Therapist : Do you ever have them? Client : Yeah, all the time. Sometimes I still see my legs on fire. Some- times I see when I’m driving my car, a haji, about forty meters away, on a hill, watching with a video camera. And he’s smiling. Stuff like that happens every couple of days. Therapist : Flashbacks are extremely difficult to deal with. Do you ever have nightmares as well?
useful for group or individual therapy. It is an integrated form of treatment that addresses PTSD and SUDs simultaneously. However, it seems that, regardless of the type of treatment the clinician and client select, initiating treatment with a brief motivational feedback session would be beneficial. Such a session uses motivational interviewing techniques in a com- pressed format to help individuals overcome their ambivalence toward treatment and engage more easily. This technique was developed under the sponsorship of the Center for Sub- stance Abuse Treatment (CSAT) of the U.S. Department of Health and Human Services, using the name Screening, Brief Intervention, and Referral to Treatment (SBIRT; SAMHSA, 2020b). When conducting a motivational feedback session, the clinician takes information from an initial assessment and discusses this information with a client in a nonjudgmental fashion, helping the client explore his or her own motivation for possible change. This approach has proven quite effec- tive in facilitating entry into treatment by veterans who have both mental health and substance use disorders (Lozano et al., 2013). Much has already been said in a previous section about TBI. However, there is some indication that, among military personnel, having a TBI with loss of consciousness that lasts more than 20 minutes significantly increases the negative con- sequences of heavy drinking. This effect seems independent of other problems an individual might have, including PTSD (Adams et al., 2013). Although it makes sense to focus on veterans with specific problems such as PTSD, TBI, and physical disability, an issue for the vast majority of veterans is reintegration into civilian life. It has been known for some time that problems in rein- tegration can lead to other problems, such as homelessness, SUDs, and premature mortality. The issue was first raised after World War II as “home coming theory” (Schuetz, 1945), refer- ring simply to the concept that while deployed and in combat, the veteran has come to view his or her unit as a family and has shared many unique and powerful experiences with this military family. These are experiences the member of the military or the veteran does not share with his or her family and friends at home. Furthermore, the family at home has had many experiences while the veteran was away that are similarly unshared by the veteran. Both the veteran and the family and environments at home have changed during separation, and each will be in many ways unknown and unfamiliar to the other upon reunion. The differences between expectations and real- ity for the returning veteran and family and friends at home can result in a shock on both sides; navigating homecoming involves re-establishing connections despite these changes. Ahern and colleagues (2015) explored the phenomenon of homecoming with veterans of Iraq and Afghanistan. They found that, for many, “normal” had become alien. Veterans frequently talked about civilian life as “normal,” while it was clear that many aspects of civilian life no longer felt normal to them upon return from military service. The veterans felt a
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