You’ve heard about them in the news, maybe seen them in an airport or sat next to one of them on a flight. You maybe a family member, neighbor, co-worker or friend with one of them. Who are they? They are our nation’s warriors, the men and women in our Armed Forces, individuals who make extraordinary sacrifices for our national interests.

Many of us do not think about them as often as we probably should because they usually stay under our radar, quietly doing their jobs efficiently and expertly. After they are discharged from the military, some of them will need help adjusting to civilian life—and yes, some of them will suffer posttraumatic reactions that will require mental health care.

Posttraumatic stress disorder (PTSD) is, arguably, the most commonly recognized form of emotional problem following military stress. The disorder, formally recognized in the Diagnostic and Statistical Manual of Mental Disorders (DSM) since 1980, is characterized by a constellation of anxiety-based symptoms that include:

• trauma-related nightmares
• recurrent thoughts
• “flashbacks,”
• sleep-disturbance
• anger management difficulties
• avoidance of feelings and activities
• social isolation
• hypervigilance
• exaggerated startle response to loud noises or sudden movements

The disorder is also associated with interpersonal difficulties, including problems with intimacy, marital and family relationships and workplace relationships. PTSD as we define it is a serious psychiatric disorder that can have dramatic and devastating consequences.

What Can We Do?

Don’t stigmatize or judge:  Be compassionate; understand that some people returning from war may have emotional difficulties or problems readjusting to life as a civilian. In addition to PTSD, other emotional problems such as depression, anxiety, substance abuse and marital problems may also be troubling for some. In fact, depression and interpersonal difficulties are probably more common than PTSD after deployment. The Department of Defense and the Department of Veterans Affairs offer a range of mental health services and benefits to help our warriors overcome these problems. There are also other private and community services available. If you know a veteran or a member of our Armed Forces who may be struggling to adapt to civilian life after overseas deployment, encourage them to seek professional counsel—because PTSD and depression are treatable conditions!

Don’t assume or stereotype:  It’s also wise not to make assumptions or rely on stereotypes about how an individual will or should respond to life post-deployment. Remember, the large majority of veterans adapt quite well to life after their combat service is over. Furthermore, of those veterans who do appear to be having difficulties, very few of them will fit the stereotype depicted so often in Hollywood movies. In his fine book Stolen Valor, B.G. “Jug” Burkett, himself a Vietnam veteran, reviewed the actual data related to many of the most common myths of the “dysfunctional Vietnam veteran” of stereotype and found that they were just that—myths.

Consider these lessons from a previous era:  In his book Band of Brothers, about E Company of the 506th Regiment of the 101st Airborne, a highly decorated combat unit that fought in the Normandy Invasion, Operation Market Garden and Bastogne and took nearly 150% casualties over the last year of World War II, historian Stephen Ambrose wrote of their post-war lives:

They accepted a hand-up in the G. I. Bill, but they never took a handout. They made their own way.  A few of them became rich, a few became powerful, almost all of them built their houses and did their jobs and raised their families and lived good lives, taking full advantage of the freedom they had helped to preserve….

There are many ways to support the men and women who have served overseas in our nation’s Armed Forces. I urge each of us to stop and think about what we can do personally for the returning veteran in our families, our churches and synagogues, our schools, and our neighborhoods. When you encounter one of them, perhaps the most important thing you can do is to welcome them home—and thank them for their service!

From Hollywood movies and media reports dating back to the late 1970s, you may have formed the impression that posttraumatic stress disorder (PTSD) is rampant among men and women who have been deployed to war zones.

Remember Bruce Dern’s character in Coming Home?  Or characters in The Deer Hunter, Rambo: First Blood, or more recently Jarhead and In the Valley of Elah? All of us can probably conjure up an image of the archetypal dysfunctional combat veteran: emotionally volatile, paranoid, socially isolated, angry, violent, drug-dependent and plagued by vivid flashbacks to brutal combat experiences.

Yet, how true to life is this image? It may come as a surprise to you, but this question is harder to answer than you might think.

Prevalence rates

In studies of U.S. military veterans, the prevalence of combat-related PTSD ranges from about two to 17 percent.  This is a wide range.  Here are some reasons why there’s such considerable variability in rates of prevalence:

• scientific and technical differences in sampling strategies;
• measurement strategies (e.g., use of structured psychiatric interviews versus self-report measures);
• inclusion and measurement of the Diagnostic and Statistical Manual’s “clinically significant impairment” criterion;
• latency of assessment and potential for recall bias;
• various features of the combat experience itself

Prevalence rates are also likely affected by issues related to a range of sociopolitical and cultural factors.  For example, PTSD rates in the U.S. military are often a bit higher than they are for other Western nations.  Media reports, societal expectations and even various system incentives (e.g., disability payments) or disincentives (e.g., stigma) can influence symptom reports and affect perceptions of combat and emotional problems.  The same is often true for many reported physical symptoms as well.

Is it possible to narrow the range of PTSD prevalence with any precision?  Despite a significant body of scientific literature on PTSD, a lack of clarity remains regarding the prevalence of the disorder among military personnel and veterans.  In 2007, a debate in Science demonstrated an interesting variety of perspectives that experts in the field hold. This debate followed Bruce Dohrenwend and colleagues’ excellent re–evaluation of PTSD prevalence among Vietnam veterans from data collected in the late 1980s by the National Vietnam Veterans Readjustment Survey. Data from this one study have been interpreted to indicate a 15.2%, 9.1% and 5.4% prevalence of PTSD among Vietnam veterans.

More recently, an article last year by David Dobbs in Scientific American and highlighted in numerous print, radio and television stories and blogs further reinforced the fact that PTSD prevalence remains hotly debated.  This is partly because the stakes are large: major decisions about VA funding, research allocations, veteran disability payments and even society’s perspective on war itself may hinge on the answer to this question.

My own interpretation of the scientific literature is that the best prevalence estimates are in the five to nine percent range.  This is undoubtedly a meaningful percentage, but it also means that, by any estimate, the vast majority of combat veterans DO NOT have PTSD.

What’s the bottom line?

Regardless of the “true” prevalence of combat-related PTSD, the disorder as we currently define it is present in a substantial number of veterans and is associated with severe impairment in daily functioning, the presence of other psychiatric disorders, other medical problems and reduced quality of life.  Thus, it represents a significant and costly illness to veterans, their families and our society as a whole.  Certainly we need more research to help us better understand the prevalence, course, phenomenology, protective factors, effective treatments and costs associated with combat-related PTSD.

The bottom line is that veterans with PTSD or any other difficulties readjusting to civilian life need and deserve compassion, understanding and the very best healthcare and mental health services that we as a society can provide.  We owe them that much, don’t you think?

A national expert on PTSD research, Dr. Frueh is the director of Clinical Research at The Menninger Clinic and a professor at the University of Hawaii at Hilo.

“We are the tools of our trade,” declared Laurie Pearlman and Kay Saakvitne in their book Trauma and the Therapist. Plainly, our capacity to provide mental health care rests on our own mental health. No doubt, we are in an emotionally hazardous occupation. Therapists who treat traumatized patients are subjected to vicarious trauma as they resonate emotionally with their patients’ psychological pain and imagine vividly scenes from their patients’ stories. Like their patients, therapists can experience intrusive memories and nightmares. Moreover, therapists may have a trauma history that resonates with that of their patients, whether it be in the context of combat trauma or childhood maltreatment. Ironically, the fundamental basis of therapists’ helpfulness, empathy and compassion places them at risk for vicarious trauma.

Are we mental health professionals who are at risk any less deterred by shame and stigma from obtaining the care we need than others in the community?

Perhaps. There is some evidence that therapists with a trauma history are more likely to seek treatment, and we should be encouraged that such therapists value personal therapy as being most helpful.

All we can do to maintain our mental health is practicing what we preach, and availing ourselves of personal therapy is one example. More generally, we advocate that our patients “process” traumatic experience by allowing themselves to think and talk about it while experiencing and expressing the associated emotional pain. Yet this “processing” is liable to evoke symptoms of posttraumatic stress disorder by evoking disruptive emotional memories.

Accordingly, we recommend that processing be balanced by containment, most importantly, in the form of trusting, secure attachment relationships coupled with the capacity to regulate emotional distress with coping skills such as relaxation, mindfulness, physical activity and self-soothing. Such containment also can be bolstered by knowledge about trauma and by structure in one’s life as evidenced in stable routines.

There is nothing more for us therapists than for our patients:  If we are to provide help, we too must have opportunities to talk about painful experience in the context of secure attachments (in personal therapy, supervision and other confiding relationships) as well as the skills to cope with our emotional distress and well-structured lives. We should have the benefit of expert knowledge; yet, as with much else, it’s easier said than done.