Healing the Invisible Wounds of Our Warriors: A Holistic, Evidence-Based Approach to Treating Combat Veterans

Since 2001, about two million US troops have been deployed to Afghanistan and Iraq alone (US Department of Veterans Affairs, 2010). They have and are still returning with the “invisible wounds of war.” Sadly, among veterans and veteran families, we see higher rates of addiction, depression, suicide, interpersonal violence, and child abuse statistics that highlight the critical and difficult transition back to civilian life. With so much at stake, it is important to address these issues early on and in a holistic approach.

In 2005, we both received phone calls from those in the military community looking for help. Dr. Fewsmith received a phone call from a concerned mother of a United States marine. She reported that her son had returned from serving overseas in Iraq, and that he was having an extremely hard time. She asked if the doctor could help. I, Jill Boultinghouse, also received a call, but mine was from a wife of a sniper looking for help for her husband, who was abusing alcohol and did not come back from deployment “the same.” Both of us, Dr. Fewsmith and Jill Boultinghouse, are mental health professionals with private practices in Orange County, California, as well as cofounders of Pacific Solstice Drug and Alcohol Treatment Center in California, and humbly replied that we neither had never served in the United States Armed Forces, nor did we have any specific training in dealing with this population, so we were probably not the right clinicians to assist. We did, however, promise to immediately find them the right resources and referrals. 

It soon became clear that help was not readily available. There was no clinic or counseling center in Orange County, California where active military, veterans, and their family members could receive the mental health services they earned, deserved, and needed. Finding a therapist who was affordable was unattainable. It was the first time we realized our nation was at war and these service members were not being cared for. Years passed and we saw more and more members of the military culture struggling with alcoholism, substance abuse, anxiety, posttraumatic stress disorder (PTSD), depression, and traumatic brain injury (TBI). We took many on a pro bono basis.

Our frustration peaked in 2012 when we decided that southern California’s military community deserved a place that could see hundreds of clients per year versus the small number of pro bono clients we could take on ourselves. By 2013, Strength in Support (SIS) was established as an independent 501(c)(3). SIS started run on solely volunteer efforts by us and a small group of passionate people, including veterans, military family members, other therapists, and business people serving Orange County veterans and families through our first clinic in Laguna Hills. SIS grew quickly due to years of military funding not meeting the needs of simultaneous wars over the previous decade, and with the shortfall significantly impacting availability, wait times, and advocacy for veterans’ services. There was a significant need for an alternative to provide rapid, personalized, and accessible services for veterans. SIS was developed with responsive programming to fill the gap in services and eliminate as many barriers as possible for veterans and their families to get behavioral health services.

Since we were trained as family systems therapists in both our private practices and Pacific Solstice Addiction Treatment Center, we unanimously agreed that all of the mental health services we offered to our veterans and active servicemen and women also had to be offered to the family members as well. Not only was this in the interest of the veterans, but we firmly believed that the entire extended family had served as well. Most of our veterans have told us that it is actually easier to be deployed overseas and serve in harm’s way than it is to stay home in both anxiety and fear, visualizing it every night. We observed profound symptomology in all of the family members, not just the veterans.

A marine client at SIS once told us that he would have signed up to deploy again, but his wife threatened divorce. He had two young sons who had been primarily raised by his wife while he was on several deployments in the first eight years of his children’s lives. When he returned home and had thoughts of returning overseas, understandably her resentment grew. She felt betrayed, abandoned, isolated, and alone. These feelings caused stress on the whole family, including the two boys. His PTSD also started to show signs once he was home and separated from the military. Nightmares, hypersensitivity, and alcohol abuse accompanied his PTSD, and the whole family needed help healing from this marine’s military service, deployments, and the after-effects.

We also agreed that there must be no prerequisites for our clients to receive our services. We will provide services for any veteran, no matter his or her discharge status. We do not care whether or not they actually saw battle. We do not care how long they served, what branch of service they were in or in what decade or conflict. They have all earned, and deeply deserve, our respect and our support.

We had a female client who had not been able to serve her full two years as a marine to be eligible for Veterans Administration (VA) benefits due to a psychological breakdown after a military sexual assault. She was discharged and was still having traumatic flashbacks of her assault. She was having difficulty transitioning to a productive and fulfilling civilian life. She worked as Lyft driver and was attending college, but was struggling in classes and work due to her PTSD. She had no extra funds to pay for her counseling and needed a specialist who not only understood her PTSD, but also the significance of it stemming from military sexual trauma (MST), as well as her difficulties going from military culture to civilian culture. Due to her specific issues and lack of VA benefits, finding a counseling center was difficult for the academic counselor at her college. However, she was referred to SIS, where she was able to attend weekly sessions with a trained EMDR therapist and finally get the intensive support and therapy she needed.

We also made a rather costly decision to not bill insurance. A large number of our clients work in either the defense industry or law enforcement after their discharge from the military, and are understandably extremely concerned about any record of their treatment being available. This is a huge obstacle for this population seeking mental health services. It is in this way our clients can receive help without fear of it impacting their professional lives.

A US veteran who is also now a police officer and his wife were struggling in their marriage. His multigenerational military background and her multigenerational civilian background caused a lot of parenting conflict. They were on the brink of divorce because each of them could not understand the other’s perspective. The husband was very concerned about privacy and confidentiality due to his employment in the police department. For over a year he refused to go to counseling with her out of fear his employer would find out. He did not want his employer ever knowing he was in counseling for fear it would jeopardize his reputation. Fortunately, he was willing to attend family counseling sessions at SIS because we never bill insurance and his counseling sessions were never shared. He and his wife were seen for over twenty sessions with complete confidentiality.

In the early days of providing service to the military community, referrals were not only easy to acquire, but the demands could be met. However, once we started to collaboratively work with other referral agencies, we ran into an unexpected problem: how to get the soldiers and veterans into treatment. It was one thing when they were being directly referred by other family members, but it was an entirely different experience when we started offering it on a larger scale. We knew the need was there. We read the statistics.

Locally, a study from the USC Center for Innovation and Research on Veterans and Military Families (USC CIR) found that in Orange County, 24 percent of post-9/11 veterans have indicated they need help transitioning from military to civilian life (Castro, Kintzle, & Hassan, 2015). In contrast to what military service members experience upon joining the military, there is a lack of preparation for civilian life after their discharge—no “unbasic training” as some study participants put it. Consequently, many leave the service without a job, without identified permanent housing, and with significant unmet physical and psychological health issues.

Among the mental health needs identified during this critical transition period, substance abuse, depression, and PTSD are of most immediate concern after return (Chua, Rumage, Santos, & Helmer, 2013). Initial alcohol and drug problems were reported by a significant number of Orange County veterans, which they identified as impairing their transition. This included one in three (34.3 percent) post-9/11 veterans who screened positive on the alcohol use disorders identification test (Castro et al., 2015). In Los Angeles County, 24.9 percent of post-9/11 veterans screened positive on the alcohol use disorders identification test.

As many of us know, recent wars have seen large numbers of veterans returning from combat having experienced potentially traumatic events. The Mental Health Advisory Team for Iraq and Afghanistan report that in 2007 78.4 percent of combat veterans had received incoming artillery, rocket or mortar fire, and 72.1 percent knew someone seriously injured or killed (US Department of Defense, 2008). Exposure to these kinds of trauma puts veterans at high risk for conditions such as depression and PTSD, diagnoses which present further challenges. In Orange County, 46 percent of post-9/11 veterans screened positive for depression and 44 percent screened positive for PTSD (Castro et al., 2015). Furthermore, a quarter of Orange County veterans screened positive for mild traumatic brain injury (TBI), and studies have shown that service members who have suffered from TBIs are at higher risk of attempting suicide, inflicting self-harm, and harming other service and family members. The Department of Veterans Affairs Mental Health Services Suicide Prevention Program estimated that in 2014 the rate of suicide among veterans equaled twenty suicides each day (US Department of Veterans Affairs, 2016).

In addition, although national attention has focused on post-9/11 veterans, these types of challenges are not limited to veterans of our most recent wars. Overall, it is estimated that 11 to 20 percent of Iraq/Afghanistan veterans, 12 percent of Gulf War veterans, and 30 percent of Vietnam veterans have experienced PTSD (US Department of Veterans Affairs, 2012).

Lastly, although female service members account for only 14.6 percent of active duty military (US Department of Veterans Affairs, 2010), they can face particular mental health challenges. Sexual assaults are a major contributing cause to PTSD in female service members and veterans. As a result of military-related sexual trauma, many female veterans struggle transitioning back into civilian life, with some ending up homeless (Castro, Kintzle, Schuyler, Lucas, & Warner, 2015). In Orange County, 61.5 percent of female veterans reported being sexually harassed while in the military and 31.2 percent reported being sexually assaulted (Castro et al., 2015).

There was more than one time we can recall when Dr. Fewsmith nearly got punched out for innocently suggesting to combat veterans that they might benefit from therapy. Combat veterans really are warriors—many would say US-trained soldiers or marines are the best warriors. The US military has spent millions of dollars since World War II perfecting the training of these warriors, though they spend very little money training warriors to be civilians again. Warriors do not have doubt, and do not accept weaknesses. Warriors do not ask for help, and they are certainly not crippled by feelings of guilt and shame. Good soldiers remains both functional and self-reliant through their own discipline, tenacity, and inner strength. A suggestion that their thoughts and feelings were intruding upon their efficacy was an inadvertent insult to the schema this community guides itself by. There certainly was little enthusiasm to have some therapist tell them they might benefit from some compassion, empathy, and mental health treatment. There also is an inevitable unconscious resistance to reopening and triggering of an unimaginable Pandora’s Box of traumatic feelings that resulted from their deployments. The only defense mechanism taught to them was to stay focused, stay strong, and never look back.

We also knew that the isolation many veterans feel after leaving their close band of brothers and sisters was exacerbating their transition to civilian life. We also knew that many veterans went into military service at eighteen years of age and the military told them what to do, when to do it, and how to do it. Unlike civilian life, the choices were very limited and life experiences outside the military were miniscule. Our veterans needed some education on how to be civilians. We knew we needed programs that would address behavioral health issues for those who are not yet willing or may never be willing to attend therapy. And of course, we needed behavioral health services that would never be able to be addressed within the four counseling walls. This is why SIS created our holistic, three-pillar programs, counseling being the first pillar.

The second pillar was a monthly series of events and workshops on everything from how to use VA benefits to how to invest in real estate, as well as recreational workshops like golf and Clippers games. We also borrowed from Pacific Solstice’s PHP holistic program and included workshops on yoga, returning to school, business etiquette, and managing money. We had different professionals who would graciously volunteer their time to come in and lead the workshops. These workshops broke down isolation, educated, filled in gaps in knowledge and experience, and got many veterans active again, both physically and socially. This became an indirect means of creating relationships with marines and soldiers who would not otherwise attend our facility.

We also created the third pillar to include a vet-to-vet mentorship program. Mentorship by veterans and family members helped transitioning veterans and their families deal with isolation, and offered practical help and encouragement getting through tough situations related to deployment and reentry. Drawing on personal experiences, volunteer mentors were able to provide individual and group support, sharing their knowledge and providing referrals to help fellow veterans and families find the resources they needed. Vet mentors provided face-to-face support as well as telephonic and electronic support. They also provided case management services for issues such as housing, VA benefits, and connecting veterans and their families to other programs and services they may not otherwise connect to.

We also discovered that asking for volunteers from our veterans for fundraising events was another way to build trust, camaraderie, a community, and more investment in the organization they now felt part of. This community has an extraordinary instinct for loyalty and service that we capitalized on for the purpose of making them feel part of an extended family. This also eventually led to more opportunities to offer traditional mental health treatment. A few of our past clients also volunteer to work as vet-to-vet mentors and lead workshops.

When working with clients in any of the three-pillar programs, we purposely do not take a stance of assuming that we have the professional answer or solution for all our clients upon first meeting with them. It is important to welcome a spontaneous exploration, and we believe our clients often have the best answer for themselves. Often, our job as counselors is to remove our own expectations and training, and just listen to what the intuition or wisdom of these clients has to teach us in regards to what works for them as individuals. Though we are agnostic as to what approach should be taken with each individual client, we remain passionately resolute that there is an appropriate treatment modality and intervention that will provide relief and healing for everybody.

Also essential to the treatment of this population is to accept, with humility, that we are not the best therapists, educators or mentors for every client, and we never could be. Our personalities, experiences, approaches, theoretical orientations, and creativity were a great fit for many clients, and absolutely terrible fits for others. It is imperative to openly explore this dynamic with clients, and when it is determined that we are not the right fit for them, to find the right professional, volunteer or partner program that is. Educating veterans about different collaborations with other programs and nonprofits, and letting them know the pros and cons of each program, is one way to ensure they receive the right treatment. This then empowers them to take responsibility for their own participation and experience, and allows ample room and permission for them to self-advocate for a different approach that they instinctually believe might be a right fit for them.

A young marine moved to southern California in 2015 and moved in with a fellow marine. Per his report, he “basically sat in a room alone,” until he was in such “deep trouble” that he was referred to Battle Buddies by a friend. Battle Buddies referred him to a vet center in Garden Grove, but since he was never deployed, he was not eligible for services. He was also referred to Families First in Santa Ana, and at the time was told that since he did not have a family, he was not eligible for services. Then he was referred to SIS by Battle Buddies and saw an SIS therapist for three hours at his first meeting. Then he saw the therapist two times per week to break down his isolation, stress, and other transitional issues. One year later, he was able to attend a SIS recreational workshop event, where his ties to the community strengthened and his journey of healing expanded.

Today he is, in his own words, “doing great, works another other job, hanging with friends. But still needs to address some school issues.” This year he was working and volunteering at Battle Buddies when he heard SIS’s vet-to-vet mentor was leaving and a new position opened up. He had been a counseling client and had attended our recreational workshop events, so he decided to apply and transition from being a client to a SIS vet mentor. Now he can testify from a personal place to the efficacy of a holistic approach as he reaches out into the community. He is also able to refer vets to our partner agencies’ programs as well.

This past client and marine now working as an SIS vet mentor has connected with a brother in arms that was at one time homeless. He too is a marine, and comes from from Chicago. He attends community college and has a few classes left. He lives in Laguna and commutes to Long Beach. He had reported to his SIS vet mentor he was feeling “beat down,” so his SIS vet mentor referred him to the SIS counseling department. He has been participating in therapy weekly, talks to his SIS vet mentor every other day, and has been referred for food and housing to Veterans of America. He is doing well and is no longer isolating. He is finishing up school successfully and has the resources he needs to meet his goals.

Now we have two veterans who are healthier and happier. This holistic approach of providing services and utilizing more experienced veterans to pass on their wisdom and knowledge to less experienced veterans is working. The Orange County Community Foundation recently published on their website the mid-year report for the various veteran organizations in Orange County, California that are also utilizing a holistic approach both within their agencies and with interagency approaches as well (OCCF, 2017). Findings include that the more partners organizations utilize and network with, the more assistance they are able to provide to veterans. A holistic approach has provided organizations with a broad knowledge of resources available making them better equipped to connect those in need with those who are able to help.  

This open style and collaborative attitude is how we work with the veterans at Strength in Support. This posture of “us as expert” goes against the paradigm of faithfully accepting orders without question that is common to the military. We believe this encourages more autonomy and empowerment in veterans as they are making the transition to civilian life.

SIS’s growth is testament to the tremendous need in the veteran-serving community to move beyond simple case management to a holistic, evidence-based model for long-term healing for veterans. SIS structures its programs on three pillars: counseling, mentorship, and educational and recreational workshops, and individuals and families alike are encouraged to access all three service lines as needed. Counselors’ ultimate goal should be to ensure that all veterans and their families can transition smoothly back to civilian life with the dignity, respect, and support that they have earned. Incorporating a variety of staff—mental health clinicians, licensed marriage and family therapists, trainees, drug and alcohol counselors, and interns—and having them trained in military social work and veteran services is essential. 

It is a deeply rewarding and powerful clinical experience to work with veterans and their families. To have filled a need in our community and to serve those who served us is not only our patriotic duty, but also a chance to further understand addictions and trauma through the military culture lens.

Castro, C. A., Kintzle, S., Schuyler, A. C., Lucas, C. L., & Warner, C. H. (2015). Sexual assault in the military. Current Psychiatry Reports, 17(7), 54. 

Castro, C. A., Kintzle, S., Hassan, A., (2014). The state of the American veteran: The Los Angeles County veterans study. Retrieved from http://cir.usc.edu/wp-content/uploads/2013/10/USC010_CIRLAVetReport_FPpgs.pdf

Castro, C. A., Kintzle, S., Hassan, A., (2015). The state of the American veteran: The Orange County veterans study. Retrieved from http://cir.usc.edu/wp-content/uploads/2015/02/OC-Veterans-Study_USC-CIR_Feb-2015.pdf

Chua, F. B., Rumage, C., Santos, S. L., Helmer, D. A. (2013). Facilitating reintegration for veterans: Patient-centered, comprehensive care. Retrieved from https://www.warrelatedillness.va.gov/WARRELATEDILLNESS/research/articles/2013-ChuaF-facilitating-reintegration-for-veterans.pdf

Orange County Community Foundation (OCCF). (2017). Orange County veterans initiative: Mid-year program summary June 2017. Retrieved from https://donor.oc-cf.org/file/Veterans-Mid-Year-Program-Summary-2016-2017.pdf

US Department of Defense. (2008). Mental health advisory team (MHAT) V, operation Iraqi freedom 06–08: Iraq operation enduring freedom 8: Afghanistan. Retrieved from http://armymedicine.mil/Documents/MHAT-V-OIFandOEF-Redacted.pdf

US Department of Veterans Affairs. (2010). America’s wars. Retrieved from https://www.va.gov/opa/publications/factsheets/fs_americas_wars.pdf