The Unique Challenges Veteran Rehab Programs Rise To

Author: Mona Bapat, PhD, HSPP

Adjusting to civilian life after active duty can potentially come with mental health concerns such as post-traumatic stress disorder (PTSD) and alcohol use disorder (AUD). Veteran rehab programs are crucial to helping veterans recover from mental health symptoms and addiction.

Scope of Alcohol Addiction Among Veterans

A 2017 national survey found that 57% of veterans drink alcohol. This is higher than the 51% of the general population who regularly drink. A higher percentage of veterans also drink heavily compared to non-veterans.¹

Treatment for veteran drug addiction is needed to help individuals achieve recovery. There are also additional problems unique to veterans that need to be addressed. For instance, mental health concerns such as post-traumatic stress disorder (PTSD) and suicidal thoughts often occur in addition to alcohol use disorder (AUD).²

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Challenges for Veterans with Alcohol Addiction

Alcohol addiction and trauma are only part of the clinical picture in veteran rehab programs.

Trauma and Mental Health

One study that used a nationally representative sample of U.S. veterans found that of those with a diagnosis of alcohol use disorder (AUD), about 20% also met the criteria for post-traumatic stress disorder (PTSD). Veterans with both AUD and PTSD were also much more likely to have major depression and generalized anxiety disorder.²

PTSD can result from experiencing or witnessing a near-death experience, serious injury, or sexual violence. Veterans can be personally exposed to such tragedies or witness them happen to civilians, fellow service members, soldiers in combat. Other experiences that can cause PTSD in veterans include being a prisoner of war or sustaining torture.³

PTSD can include flashbacks, nightmares, or recurring upsetting memories. It can also cause veterans, compared to non-veterans, to be even more sensitive and reactive to common stressors such as unexpected loud noises.³

One component of PTSD that can occur for veterans is survivor guilt. This means that they feel remorse for coming out of combat alive when one or more of their fellow service members was killed. This can leave them struggling with why they survived while others did not. Thus, processing grief and meaning-of-life concerns can often be a part of therapy, not just symptom reduction.

Interpersonal Violence

As a result of PTSD, conflict with others can be serious for veterans. Heightened reactivity can cause a short temper and lead to verbal and physical aggression that may escalate physically.³

One research review found that more than 27% of men reported being physically violent toward their partners and 91% reported being psychologically abusive toward their partners.⁴

As a result, when domestic violence is present, part of the therapy work involves assuring the safety of the veteran’s partner and employing therapies designed specifically to break the cycle of abusive behaviors.

Isolation

Isolation is another factor that can exacerbate alcohol misuse among veterans. Mentally they can still be in the war zone and thus can feel alienated from civilians who have not been exposed to the traumas they have.

Veterans may feel isolated from their own friends and family who struggle to fully understand or appreciate their experiences. Of 199 veterans who served in Iraq or Afghanistan, 75% reported family problems such as their own house no longer feeling like home and having emotional distance from their children.⁵ Drinking is often connected to physical and emotional isolation.

Self-Endangerment

Self-harm, intentionally risky behavior, and suicidal ideation are more common among veterans than the general population. Increased reactivity to stressors can lead to impulsive and reckless self-endangering behavior such as dangerous driving or excessive drug or alcohol use.³

In 2018, there was an average of 17.6 veteran suicide deaths per day. Of these, 11.1 veterans did not use Veterans Health Administration services.⁶ This underscores the importance of veterans having access to treatment.

Veterans who have PTSD and AUD are more likely to have suicidal ideation and to have attempted suicide compared to veterans with a single disorder.² Trauma, survivor’s guilt, and isolation are a few things that could lead to suicidal ideation. Moreover, these straits could be in addition to any pre-existing mental health conditions that veterans might have before military service.

The first priority of therapy when suicidal thoughts are present is to ensure patient safety. After managing life-threatening symptoms or behaviors, therapy can then focus on symptoms or behaviors that threaten other parts of an individual’s life, such as their relationships or feeling of self-actualization.

Treatment Needs of Veterans

There are multiple treatment needs of veterans who deal with alcohol use disorder (AUD). A combination of a few different services could increase the chances of a successful recovery.⁷

Medication and Therapy

Veterans tend to deal with more severe symptoms when they have alcohol addiction plus post-traumatic stress disorder (PTSD) or other mental health issues such as depression, anxiety, or bipolar disorder. Medication may help address these symptoms to that therapy work can start addressing the underlying causes.⁷

Experts recommend that medication for alcohol use disorder be available to all patients who have AUD, with or without co-occurring disorders. However, one study of U.S. Veterans Affairs patients found that only about 9% of veterans with a dual diagnosis took medication for AUD, whereas about 75% of the patients took medication for their second disorder. The researchers conclude that barriers to getting AUD medication need to be identified and addressed.⁷

Experts also recommend psychotherapy and medication be used together to treat alcohol addiction in veterans. Providers typically use two main types of evidence-based therapies to treat AUD:⁸

• Motivational enhancement therapy involves helping the individual gain more motivation to reduce or stop their use. Therapists help the patient work through the conflict between the part of them that wants to continue drinking and the part that does not.
• Cognitive-behavioral therapy examines how thoughts, feelings, and behaviors all influence each other. The therapy works to change unhelpful thoughts to more productive ones. This can, in turn, help the individual to feel more positive and engage in healthier behaviors.

In addition, AUD treatment often includes integrating couples or family therapy because they can help facilitate communication and mutual understanding between veterans and their loved ones.⁹

Housing

Homelessness is, unfortunately, a reality for many veterans. On a single night in January 2020, approximately 37,252 veterans were homeless.¹⁰ The priority for these veterans is finding shelters or transitional housing and food. Only when their basic needs are met can they fully engage with mental health treatment, including addiction treatment.

Some transitional housing programs offer counseling, basic life skills such as money management, and connecting veterans with educational opportunities.¹¹

Outreach

Many veterans who struggle with alcohol addiction or mental health conditions do not have easy access to care. One such case is of veterans who live in rural areas. They have significantly lower access to mental health and addiction treatment when compared to veterans who live in urban areas.¹² Therefore, there is a greater need for clinics and providers in rural parts of the country. Telehealth is one a way to reach these veterans.¹³

Another group that needs outreach is female veterans who experienced sexual assault by a fellow service member, often a male superior officer. They may not feel comfortable going to a VA center that mostly men attend. In such a case, telehealth could be considered as well.^14,15

In short, a comprehensive treatment program is often needed to help veterans adjust to civilian life, work through trauma and other mental health concerns, and work on addiction recovery. An ideal treatment team includes a prescribing doctor, a mental health professional, a medical doctor, and a care manager to coordinate care and essential needs.

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Multicultural Competency in Treating Veterans

When treating veterans for alcohol use disorder (AUD) or other mental health concerns, it is important to consider their demographic characteristics. Veterans of different backgrounds experience mental health concerns and treatment in different ways.

It is imperative for clinician training and continuing education programs to address competency related to different demographic factors.

Racial Disparities

In outpatient settings, research has found that clinicians tend to more frequently diagnose Black veterans with psychotic disorders like schizophrenia and white veterans with affective disorders such as depression or bipolar disorders.¹⁶

Preliminary studies also suggest that Black veterans may benefit more by working with clinicians who are culturally competent in treating black patients. One vital aspect of cultural competency in working with Black veterans includes awareness of and empathy for systemic racism, discrimination, and harassment, which may include open, blatant racism experienced during active duty.¹⁶

Gender and Sexual Trauma

Sexual trauma is associated with the highest risk for the development of post-traumatic stress disorder (PTSD). Both men and women in the military can be exposed to sexual violence, with women being 3 times as likely. The Veterans Health Administration (VHA) has adopted the term military sexual trauma (MST) to refer to sexual violence experienced while serving.¹⁷

Some initial studies show that survivors of sexual assault in the military are often pressured to remain silent about the assault, have their reports ignored, or are blamed for the assault. Among these individuals, there are greater reports of depression and substance misuse. These survivors are also more likely to have various medical conditions such as gynecological, gastrointestinal, and cardiovascular problems.¹⁷

The VHA has a universal screening program for MST. Those who screen positive can receive treatment for MST-related issues at no charge.¹⁷

The prevalence of PTSD is greater for female veterans compared to civilian women, but research on treating this particular population is limited.¹⁸ Researchers recommend two main therapies for treating PTSD:^{19, 20}

• Present-centered therapy (PCT )is a research-supported therapy. The focus of PCT is on developing coping strategies to deal with current life stressors that are directly or indirectly related to the trauma.
• Prolonged exposure (PE) therapy teaches and supports patients in slowly approaching trauma-related feelings, memories, and situations. The idea behind PE is that the patient’s avoidance of fears only reinforces them. Therefore, PE helps to reduce PTSD symptoms by supporting individuals in facing their fears.

Experts recommend PE very highly for treating PTSD.²⁰ One study found that female veterans who received PE experienced a larger reduction in PTSD symptoms when compared to the women who received PCT. Those who received PE were also more likely to achieve PTSD remission.¹⁸

Transgender Veterans

Veterans who identify as transgender have a higher risk of severe mental health symptoms compared to veterans who identify with the gender they were assigned at birth (i.e., cisgender veterans). One study of over 5,000 transgender VHA patients found that there were more severe cases of depression, suicidality, serious mental illnesses, and PTSD compared to other veterans.²¹

The study also found that transgender veterans were also more likely to have been homeless, to have experienced sexual trauma while on active duty, and to have been incarcerated.²¹

One essential part of working with transgender veterans is to address hazing, harassment, and abuse they may have experienced due to their gender identity. Additionally, transgender individuals often deal with estrangement from family members, which may leave a veteran without the support of their biological family or their “military family.”

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Military Culture

The veteran and active duty military population has its own distinct culture that is important for therapists and addiction treatment providers to understand. It includes:²²

• A warrior mindset
• High expectations for discipline and performance
• Making the mission a priority over personal interests

If a therapist has a lack of understanding and appreciation for what it is like for a patient to be part of that culture, they can be of significant disservice to the person.

Researchers have found that:²²

1. The more competent their therapist is regarding military culture, the more effective a client perceives them to be.
2. The more culturally competent the therapist is, the more likely the patient is to complete treatment.
3. A lack of knowledge and awareness of the patient’s cultural identities can lead to stereotyping veterans and their experiences.
4. Lack of awareness on part of the therapist can put the patient in the position of educating the therapist about their cultures. In addition to being alienating, this can lead to misdiagnosis and inadequate treatment.

In sum, veteran addiction treatment needs to be comprehensive and done by culturally competent providers. While there are challenges associated with treating veterans for alcohol and other mental health disorders, treatment is available and effective.

A 2013 survey of about 10,000 veterans found that over 80% of respondents agreed that mental health treatment was helpful in their lives.²³

If you are concerned about your alcohol use or that of a loved one following military service, help is available. Please call 800-948-8417 Calls are forwarded to paid advertisers 24/7 to speak with one of our alcohol addiction treatment specialists.

Resources

1. National Institutes of Health. (2019, October). Substance Use and Military Life DrugFacts.
2. Norman, S. B., Haller, M., Hamblen, J. L., Southwick, S. M., & Pietrzak, R. H. (2018). The burden of co-occurring alcohol use disorder and PTSD in U.S. Military veterans: Comorbidities, functioning, and suicidality. Psychology of Addictive Behaviors, 32(2), 224–229.
3. American Psychiatric Association. (2013). Trauma and stressor-related disorders. In Diagnostic and Statistical Manual of Mental Disorders 5, 490-491. American Psychiatric Publishing.
4. Trevillion, K., Williamson, E., Thandi, G., Borschmann, R., Oram, S., & Howard, L.M. (2015). A systematic review of mental disorders and perpetration of domestic violence among military populations. Social Psychiatry and Psychiatric Epidemiology, 50, 1329-1346.
5. Sayers, S. (2009). Family Problems Among Recently Returned Military Veterans Referred for a Mental Health Evaluation. The Journal of Clinical Psychiatry, 70(2), 163-170.
6. U.S. Department of Veterans Affairs. (2020). 2020 National Veteran Suicide Prevention Annual Report. Office of Mental Health and Suicide Prevention.
7. Rubinsky, A.D., Chen, C., Batki, S.L., Williams, E.C., & Harris, A.H.S. (2015). Comparative utilization of pharmacotherapy for alcohol use disorder and other psychiatric disorders among U.S. Veterans Health Administration patients with dual diagnoses. Journal of Psychiatric Research, 69, 150-157.
8. Dworkin, E.R., Bergman, H.E., Walton, T.O., Walker, D.D., & Kaysen, D.L. (2018). Co-Occurring post-traumatic stress disorder and alcohol use disorder in U.S. military and veteran Populations. Alcohol Research, 39(2), 161-169.
9. Makin-Byrd, K., Gifford, E., McCutcheon, S., & Glynn, S. (2011). Family and couples treatment for newly returning veterans. Professional Psychology: Research and Practice, 42(1), 47–55.
10. U.S. Department of Veterans Affairs. (2021). Veterans Health Administration (VHA) homeless programs office (HPO) fact sheet.
11. U.S. Department of Health and Human Services. (n.d.). Transitional living program fact sheet.
12. Edmonds, A.T., Bensley, K.M., Hawkins, E.J., & Williams, E.C. (2021). Geographic differences in receipt of addictions treatment in a national sample of patients with alcohol use disorders from the U.S. Veterans Health Administration. Substance Abuse, 42(4), 559-568.
13. deKleijn, M., Lagro-Janssen, A.L.M., Canelo, I., & Yano, E.M. (2015). Creating a roadmap for delivering gender-sensitive comprehensive care for women veterans. Medical Care, 53(4 Suppl 1), S156-S164.
14. U.S. Department of Health and Human Services. (2020, September). 2019 National survey on drug use and health: Veteran adults. Substance Abuse and Mental Health Services Administration.
15. Jaconis, M., Santa Ana, E.J., Killeen, T.K., Badour, C.L., & Back, S.E. (2017). Concurrent treatment of PTSD and alcohol use disorder via telehealth in a female Iraq veteran. The American Journal on Addictions, 26(2), 112-114.
16. Saha, S., Freeman, M., Toure, J., et al. (2007). Racial and ethnic disparities in the VA healthcare system: A systematic review.
17. Kimerling, R., Gima, K., Smith, M.W., Street, A., & Frayne, S. (2007). The Veterans Health Administration and military sexual trauma. American Journal of Public Health, 97(12), 2160-2166.
18. Schnurr, P.P, Friedman, M.J., Engel, C.C., Foa, E.B., Shea, M.T., Chow, B.K., Resick, P.A., Thurston, V., Orsillo, S.M., Haug, R., Turner, C., & Bernardy, N. (2007). Cognitive behavioral therapy for posttraumatic stress disorder in women. Journal of the American Medical Association, 297(8), 820-830.
19. U.S. Department of Veterans Affairs. (2020). Present-centered therapy for PTSD.
20. American Psychological Association. (2022). Prolonged exposure (PE).
21. Brown, G.R., & Jones, K.T. (2016). Mental health and medical health disparities in 5135 transgender veterans receiving healthcare in the Veterans Health Administration: A case-control study. LGBT Health, 3(2).
22. Taylor, J.J. (2019). The relationship between multicultural competence, experience, and case conceptualization among counselors working with veteran clients [Doctoral dissertation, University of Cincinnati]. OhioLINK.
23. U.S. Department of Veterans Affairs. (2014). VA mental health services: Public report.