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Afghanistan

A helping hand for soldiers
Dr. Tracy Stecker

Tracy Stecker is studying the most effective ways to encourage veterans of the Iraq and Afghanistan conflicts who need mental-health support to seek it out.

"Their lives are just haunted, completely haunted," says Dr. Tracy Stecker, a clinical psychologist on the Dartmouth faculty. She’s referring to soldiers who come home from service in Afghanistan and Iraq with memories like this:

"A soldier calls in to say that he has been suffering with feelings of grief after watching two of his buddies die when an IED hit their Humvee. He was supposed to be in that vehicle on the convoy, but switched spots with [one] buddy. He didn't even realize an IED had hit the first vehicle in the convoy until he saw someone running over to them, on fire and screaming, 'Put me out! Put me out!' ... It took several minutes to realize it was his friend.

"Since his return..., he has had difficulty letting go of his friends. He stands in for them at family affairs and ruminates about that day. He has nightmares about explosions that kill people close to him but that he is able to walk away from. He has not asked for help because he thinks he is doing okay and he can't get time off from work to ask for help.

"During the intervention session, he processed through his beliefs about seeking help and decided that although he doesn't believe he has time, he does value the idea of closure. He would prefer not to carry the event with him at such an emotional level every day for the rest of his life. He worries that processing his grief will somehow dishonor the memory of his friends but [is] willing to talk to a professional about his grief."

Stecker, who is based in Dartmouth Medical School's Psychiatric Research Center, can recount a lot of stories like this—stories that make clear the impact of combat conditions on soldiers who have spent time in Afghanistan and Iraq.

Intervention

With funding from the National Institute of Mental Health, Stecker is leading a national research project that is testing the effectiveness of a cognitive-behavioral intervention on the likelihood that soldiers who need help will seek it. "My research focuses on getting people with either mental health problems or addiction problems into treatment," she says.

A recent preliminary study, involving Stecker and colleagues at DMS, the National Center for PTSD (post-traumatic stress disorder) at the Dartmouth-affiliated VA Medical Center in White River Junction, Vt., and other sites within the VA system, showed that veterans of the Iraq and Afghanistan wars often return home with a variety of co-occurring conditions—including pain (physical or emotional), PTSD, depression, and substance-use disorders.

"The people that I'm working with in my study have screened positive for PTSD but have never accessed treatment services," Stecker explains. "We're reaching them through advertisements in military venues, saying, 'If you're thinking about getting help, give us a call.' We're enrolling 300 veterans, and it's a randomized study, so 150 will get an intervention and 150 won't," she adds, although control participants do receive an initial assessment when they contact the team. "We're about halfway through the study at this point," Stecker says.

In the hour-long telephone intervention, veterans are assessed for PTSD and depression and are asked about their beliefs about treatment. "We follow all study participants one, three, and six months later to reassess their symptoms and to see if they've gotten any help," she says.

If they do make a decision to seek help, Stecker talks to them about treatment options and their preferences and then provides contact information for their local outreach coordinator. "The VA is great because they have someone at each site whose job it is to hook veterans in with the right services," she says. "We're finding that most who end up deciding to seek help don't want medicines, with the exception of something that will help them sleep. They'd rather receive therapy, as long as it's confidential and it's with somebody 'who's been there' and 'who would understand.'"

Intense pain
Soldier hugging woman

Nearly all soldiers who screen positive for PTSD—whether the condition is a result of chronic stress or of one catastrophic event—have suffered significant trauma during their combat experiences. "From their trauma, they're carrying this intense emotional pain that they can't let go of," she says. "They often suffer from nightmares, and they're unable to function well in their day-to-day lives. They're angry, they're prone to violence, and many are abusing substances; that makes for a very unhealthy if not dangerous mix."

Yet veterans can be highly resistant to accepting help. "Some of the common responses are: 'Well, that's for people who are worse than me,' or 'I would never want anybody else to know that I'm struggling,' or 'I'll get through this on my own,' " says Stecker. "Back when I started the project, a lot of them were saying things like 'I'm drinking right now and it seems to help me sleep and to calm me down.' Now they're starting to say that the drinking is not working and they're getting consequences from their addiction."

"Our goal with the cognitive-behavioral approach is to get them to see that the choices they make and the behaviors they engage in—in this case the decision to actually make that call to schedule an appointment to get help—is directly linked to what they think and how they feel about treatment," she adds. "If we can modify their beliefs through the intervention process, we think they'll be much more likely to seek treatment."

So far, the data is proving her right. "At this point, only 16 percent of the control participants have scheduled a treatment session, versus 39 percent of intervention participants," says Stecker. "But I think it's important for people to know that much more needs to be done. Most of the veterans who've been to war who are actually symptomatic or struggling aren't able to get to treatment on their own. It usually takes a court order, some catastrophic event in their life, or interventions like we've been doing. Hopefully, through my work and the work of others, we can find ways to help more veterans get into the services they need."

Humbled by heroes

To this end, Stecker is sharing what's she's learning from her research in a related but separate book project with Hazelden Publishing, a treatment agency in Minneapolis. "I'm documenting the stories of five people who have struggled with PTSD, and three of them are veterans," she says. "It's one of the best things I've ever done. A lot of people told me that because I'm a nonmilitary person and a woman that many of the veterans wouldn't talk to me, but I've found them to be totally open and honest."

"I feel humbled and privileged to have been let into their worlds, and that they've been willing to share so much about their lives and about how they're coping with their traumas," adds Stecker. "You know, it's a complete stereotype to say it—and before I worked with them I would not have truly understood what this meant—but these young men and women really are heroes."