The battle within: Treating PTSD in military veterans | USA


More than 20 million US military veterans are currently living in the US. After years of serving their country and waging war overseas, many of them struggle with post-traumatic stress disorder (PTSD), homelessness and addiction.

Peter Collins has been a licensed independent clinical social worker since 1988. In the past 10 years, he has worked with over 6,000 veterans and their families in a programme called Military and Veteran Services.

In the following account, he describes the symptoms of PTSD and provides an insight into how the US government deals with the veterans’ battle within.

I know one veteran who walked into a shopping mall, and when he saw a woman wearing a burqa, he immediately grabbed his kid and ran out of the mall. He felt threatened based on his experiences in combat – not knowing who were his friends or enemies and expecting both, men and women, to do ‘terroristic’ things. That’s an example of avoidance, which is one of the four major symptoms of PTSD.

The PTSD diagnosis didn’t exist until the Vietnam War.

PTSD has been called many things throughout history. In the Civil War, it was called, “soldier’s heart”, and in World War II and World War I it was called “shell shock” or “battle fatigue”.

Once the Vietnam war started to get rolling, the PTSD diagnosis was formalised, which was a real benefit, because then treatment protocols were figured out and more people were getting an accurate diagnosis.

Flashbacks, hypervigilance and avoidance   

The four symptoms of PTSD start with re-experiencing, which happens in many different forms, including having nightmares or flashbacks.

Flashbacks can take over to the point where you feel like you’re in the middle of the trauma right at that moment. Intensive thoughts and feelings are also part of re-experiencing and can take you away from anything that you’re doing or that you’re trying to concentrate on.

The second symptom is what we call hypervigilance. This is the sense that one is constantly on guard for any potential threat. Usually, the threats around them are amplified, so things that wouldn’t cause a person without PTSD to be triggered feel much larger to the veteran with PTSD.

Avoidance, the third symptom, is the need to avoid things that remind them of the trauma. That can be sights and sounds; it can be smells, it can be crowds of people. They also avoid conflict and crowds. Avoidance is a big part of the picture.

Finally, there are negative emotions and cognition. Depressive feelings and guilt.

Sometimes there’s a moral injury where battle buddies may have been killed by friendly fire, and so it is emotions that affect the way that they think. There are some cognitive distortions that they have, thinking that perhaps loved ones can’t be trusted, not trusting systems, particularly systems like the VA [Department of Veteran Affairs].

Hypervigilance… is the sense that one is constantly on guard for any potential threat. Usually, the threats around them are amplified, so things that wouldn’t cause a person without PTSD to be triggered feel much larger to the veteran with PTSD.

Peter Collins

In the last 10 years, I have worked specifically with service members and their families in a programme called Military and Veteran Services.

Service members and veterans are referred to us with a PTSD diagnosis in place. Others come in, and it’s a fairly simple matter to take a look at the four major symptoms of PTSD and see if somebody endorses them, and for how long.

We provide some basic tools for them to better cope with their symptoms, while exploring the options for treatment. 

We deal with a lot of post-9/11 veterans, many of whom have been deployed multiple times because that conflict required multiple deployments.

We’ve seen many veterans who were in the National Guard, who prior to 9/11 would drill once a month and go to an annual training for about a week. They would be on call for disasters in cities, like floods and those kinds of things.

But all of a sudden 9/11 happened and the same people that had never been to war and really didn’t get the full training to go to war went on multiple deployments into war, which they didn’t expect and neither did their families.

‘They weren’t allowed to wear uniforms when they came home’

We also deal with a lot of Vietnam veterans, who are kind of a special group. Many of them never got treatment. They were not welcomed home from their service, because of the state of the country and their country’s feelings about the war in Vietnam.

They weren’t allowed to wear their uniforms when they came home, because they would be spit on, and cussed at and called baby killers. The VA was not set up to handle that many veterans, many of whom had PTSD.

There were long waiting lists; they didn’t feel welcomed there, so many of them just continued to suffer with their PTSD for long periods of time. They developed problems with alcohol, split up with their families or lost their homes.

There’s a goal to end homelessness, but many Vietnam veterans are living off the grid. They live in the woods, and they don’t interact with society.

The creation of veteran centres where they can stay and get group therapy works well for veterans who don’t feel comfortable going to VA. If they are combat veterans, they can go to a vet centre, which is really small buildings in the community.

Many Vietnam veterans are living off the grid. They live in the woods, and they don’t interact with society.

Peter Collins

‘McDonaldisation of mental healthcare’

The McDonaldisation of mental healthcare is a problem. It takes huge research studies and a lot of money to create an evidence-based treatment, but yoga can be very useful, and that’s not on the list.

So, if you go to any VA in the country, you’re going to probably get cognitive processing therapy or cognitive behavioural treatment because those are the evidence-based practices that they use. It’s like if you go to any McDonald’s, a cheeseburger is going to be the same.

I have a problem with that because many other things could be useful in the treatment of someone struggling with PTSD. Alternatives such as gradual exposure, prolonged exposure, yoga, anxiety-reducing kinds of things like teaching breathing techniques, mindfulness.

The evidence-based treatments are just not right for everybody. Some veterans may not have the intellectual capacity or the emotional capacity, or might be offered treatment in a location that they don’t feel comfortable in, but yet, if you go to the VA, that’s what you’re going to get.

I would say the US government is not doing enough to help veterans. Just with the post-9/11 population, only about 60 percent of veterans are working with the VA.

Sometimes the waiting lists are extremely long, and when somebody is in crisis mode, trying to get treatment and to come in is difficult. And then they find out they can’t be seen for six weeks or eight weeks. There’s a high turnover rate at the VA, and I’ve heard many stories of veterans who start working with somebody on their PTSD and then their therapist leaves, and they’re assigned to a new therapist.

That can be very damaging to the relationship. There can be an interruption in treatment, and for many, it can just be a trust thing that they can’t recover from.

‘They are not in a position of asking for help’

The other thing is, if you got to any VA in the country at about four o’clock, many staff are fleeing to their cars. Treatment is only offered Monday to Friday from about 9am to 4pm.

For service members and veterans who have PTSD or other mental health problems who maybe employed, it’s almost impossible to receive treatment at the VA.

Veterans, particularly combat veterans, are not in a position of asking for help. It runs counter to the way they see themselves.

They see themselves as strong and resilient and as people that do things and provide services to other people.

Many of the veterans have told me, despite the fact that they are suffering, that they’re not sure whether they should work with us because somebody else – another veteran – probably needs us more than they do.

I think that there’s room for a lot of growth at the VA, in the community and the veteran centres. 

I guarantee you that our military right now is developing strategies as well as mobilising and recruiting soldiers, because of the various hot spots around the world.

There are people in America that don’t know that we’re still in Afghanistan, that we’re still In Iraq, and we’re still in many other countries across the world. The Korea situation is obviously hot and marching towards a potential war.

One of the best things that could happen is for there not to be another war, but when we look at politics around the world, the conflicts that still exist, the conflicts that look like they’re about ready to start, I don’t see that happening.

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