What’s so special about military veterans?

Abstract

The mental health of military veterans has been, and continues to be, a topic of heated political and journalistic debate. There is a well-documented impact of conflict upon the mental health of service personnel, and most nations have aimed to provide effective care for individuals who have fought for their country. However, as the three thematic papers in this issue demonstrate, the realities of service-related mental health are rather more complex than they initially appear.

The mental health of military veterans has been, and continues to be, a topic of heated political and journalistic debate. Because of the well-documented impact of conflict upon the mental health of service personnel (Hunt et al, 2014), most nations have, for wholly understandable reasons, aimed to provide effective care for individuals who have fought for their country. Thus the argument for nations providing services for the mental health of war veterans, whether arising out of gratitude or of moral duty, seems to be simple common sense.

However, as the three thematic papers in this issue demonstrate, the realities of service-related mental health are rather more complex than they initially appear. First, it seems that although one might expect the main burden of operational stress injuries to occur during or soon after deployment, while individuals are still serving, it appears that mental health problems may in fact be more common once personnel have left service, months or years later.

Secondly, most of the authors note that the link between deployment and poor mental health is less clear than might be expected. There is now considerable evidence that soldiers who have served on peacekeeping (rather than combat) operations also experience traumatic stress-related disorders (Greenberg et al, 2008) and indeed that a significant proportion (about half) of post-traumatic stress disorder (PTSD) in the military is not related to deployment (Jones et al, 2013).

Thirdly, while not discussed in detail in the thematic papers in this issue, there is considerable evidence that pre-enlistment factors such as childhood adversity and sociodemographic factors significantly affect the risk of developing mental health problems during or after service. For instance, a UK study of post-deployment violence showed that pre-enlistment violent offending was the most influential risk factor (adjusted hazard ratio 3.85), whereas deployment itself was not an independent risk factor (MacManus et al, 2013).

Fourthly, while the debate about veterans’ mental health often appears to centre on how to increase the scope, efficiency or availability of mental health services for veterans, there is considerable evidence that most veterans who suffer with mental health problems do not in fact seek any help at all for them. This lack of help-seeking seems to result both from a lack of recognition of the existence of mental health problems and from fears or concerns about the consequences of seeking help, which may be practical (e.g. regarding the impact of receiving treatment for a mental health problem on career prospects) or perceptual (e.g. regarding self-perception as a resilient person or the perceptions of others). Research has shown that these concerns are not in any way unique to the military and a reluctance to seek help seems just as common within the general population as among those who have served in the military.

Lastly, there seems to be a general consensus among researchers that the process of transition out of the military may contribute in some way to the development of mental health problems. The reasons for this are less obvious but clearly transition out of the military is not directly a deployment issue; indeed, transition is about leaving the liability to be sent to a hostile area behind and settling into the somewhat safer civilian world.

The above five points are important because they all suggest veterans’ mental health problems are not particularly related to either deployment or the traumatic experiences that service personnel may experience while deployed. Instead, they suggest a much more diverse, and complex, explanation for the apparent excess of mental health problems that veterans experience. The word ‘apparent’ is appropriate here because while there is some, although inconclusive, evidence that the prevalence of mental health disorders is raised in veterans compared with those still serving and the general (never-served) population, few (if any) studies have compared veterans with people who have worked in similarly hierarchical professions. If high-quality evidence were available about veterans from other hierarchical organisations that rely heavily on teams ‘pulling together’ in often uncertain and challenging environments (e.g. fire or police workers), it might emerge that these veterans too would have similar risks of post-service mental health difficulties. It might also be useful to examine how social factors (e.g. relationships with family and friends) influence post-employment mental health outcomes, given that we know that the quality and availability of social networks are of the utmost importance to mental health. For instance, a UK study showed that military veterans who continue to rely on service-related social networks (e.g. mixing with individuals who are still serving) fare much less well than those who form sustaining civilian networks (Hatch et al, 2013). It may be that veterans are not especially experienced in forming supportive bonds unless they are in the face of intense adversity, which, thankfully, while commonplace in the military, is not so in the wider community. If this were found to be true, then further work would be needed to know whether this social deficit was a result of pre-service factors or of military service itself.

So, on one hand it appears that, contrary to the popular public perception of the ‘damaged war hero’, veterans’ mental health problems are not, in the main, particularly related to combat experiences. Instead, other factors, such as pre-enlistment vulnerabilities, difficulties in forming or using post-service social networks and a lack of appropriate help-seeking behaviours (not in any way solely a veterans’ issue, however), seem important determinants of post-service mental health. On the other hand, there is an abundance of data showing that personnel exposed to traumatic events (e.g. combat troops, those taken hostage, the physically injured) do suffer more mental health problems than other military personnel. Indeed, some of the US data on this topic suggest that almost one-third of US combat troops suffer from PTSD (Thomas et al, 2010). Additionally, particularly relevant to the US context, the issue of deployment-related mild traumatic brain injury (mTBI) appears inextricably linked to mental health disorders, with studies showing that a substantial proportion of personnel who report symptoms of mTBI also suffer with deployment-related mental health difficulties.

While on the face of it these two broad findings seem at odds with each other, in reality they only seem so because of the rather misplaced public view of what service life is about. The innumerable films and books about military life have propagated a misplaced belief that all military personnel frequently face overwhelming enemy forces and encounter tragedy or horror or some other ‘story-worthy’ challenge. Rarely do ‘military stories’ depict well-planned, successful missions, the mundaneness of life in main operating bases, the consistent challenges of being away from family for months on end or, indeed, the sense of humour, satisfaction, learning and personal ‘growth’ which deployment can generate. For instance, there is a growing, although not yet mature, literature on post-traumatic growth which suggests that even the most challenging of experiences can have positive outcomes (Dekel et al, 2011). To what extent deployment itself might lead to growth is still unclear, however.

Military service is not ‘inevitably’ bad for an individual’s mental health. While some service personnel will undoubtedly suffer operational stress injuries, in the longer term others, even those who have experienced the most traumatic of deployment incidents, may experience improved, rather than degraded, resilience. When considering the mental health of veterans as a whole, given the diversity of the experience of military service, it is not at all surprising that some groups of military personnel are at higher risk of developing mental health disorders and other groups at considerably lower risk. Given the often challenging pre-service backgrounds of people who join the military, perhaps politicians and journalists should applaud the military for the overall highly reasonable state of mental health of their active-service forces. How much the apparent deterioration in mental state of individuals as they transition to veteran status is a return to their more vulnerable pre-enlistment state or a function of their military experiences is not yet clear. What is clear, however, is that it is certainly not all about deployment.