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Samaritan Village Veterans Programs: Chemical Dependence Treatment for Veterans in a Therapeutic Community

Carol Davidson

ABSTRACT: Veterans are a special population that will benefit from chemical dependence treatment in an environment that addresses both the inherent strengths and clinical challenges associated with their military service history. Samaritan Village has a network of services that includes two residential therapeutic community pro- grams for veterans. Both programs serve male veterans who have problems such as substance abuse, homelessness, health, mental health, vocational, family, and criminal justice system issues. The programmatic culture is enhanced by veterans-specific services including an emphasis on veterans’ pride and camaraderie, and co-located treatment for Post Traumatic Stress Disorder (PTSD). Combat trauma frequently results in PTSD, and the incidence of substance abuse among traumatized veterans is signi- ficant. Therapy groups promote recovery by providing support for the processing of unexpressed memories, cognitive reframing of experience, the development of affect regulation skills, member- ship in a recovery-based support network, and the ability to build toward a future life that has meaning and purpose. As American veterans return home from Operation Enduring Freedom and Operation Iraqi Freedom, the need for enhanced awareness of their needs will be crucial within the field of human services providers.

Background

The aftermath of America’s long involvement in Vietnam brought an unprecedented level of professional, academic, and socio-cultural attention to the psychological ravages of war and the readjustment problems encountered by returning combat veterans. While the mental health community endeavored to explicate the essential features of a previously unspecified disorder associated with battlefield trauma, veterans gradually began enrolling in chemical dependence treatment services within the network of existing programs.

Carol Davidson LCSW, CASAC is at Samaritan Village, , USA. E-mail: [email protected] therapeutic communities, 29, 1, spring 2008 © The Author(s) Carol Davidson 97

In 1996, Samaritan Village acquired funding from the New York State Office of Alcoholism and Substance Abuse Services to open a residential therapeutic community for 48 male veterans in . Samaritan Village has a history that encompasses more than four decades of service to the greater New York metropolitan area, and an abiding commitment to the therapeutic community tradition in which the organization is rooted. The scope and breadth of treatment modalities currently integrated within the agency’s roster of programs includes both residential and outpatient facilities that address chemical dependence, co-occurring disorders, homelessness, vocational deficits, health issues, interpersonal and family dynamics, criminal justice mandates, and the myriad life challenges associated with recovery. In 2006, in recognition of ten years’ success of the Samaritan Village Veterans Program, and in anticipation of the needs of veterans returning from Operation Enduring Freedom and Operation Iraqi Freedom, funding was awarded to open a second veterans’ facility; subsequently, The Ed Thompson Veterans’ Center began operations in Richmond Hill, NY. The therapeutic community represents a microcosm of society in which deeply personal issues such as addiction, poverty, racism, sexual abuse, domestic violence, and HIV/AIDS emerged both as a focus of treatment for the individual client and as a reflection of the trends and challenges that existed within the external culture. At Samaritan Village, Vietnam veterans who sought treatment of their chemical dependence problems in the 1980s were met by clinical teams who had expertise in addictions treatment, but little specific knowledge about combat trauma, Post Traumatic Stress Disorder, health issues associated with Agent Orange exposure and/or other war-related injuries and illnesses, or the vast bureaucracy associated with military discharge codes and related entitlements. Combat veterans were often secretive, detached, irritable, preoccupied, and sometimes explosive. The therapeutic community environment provided both structure and nurture, but it was clear that the population posed specific challenges for which there was a paucity of knowledge to draw upon. Change develops organically within the therapeutic community, and the origins of expertise in veterans’ services began to emerge from within the extended family of the organization. Ed Thompson, a clinical staff team member at a residential facility, was a Korean War veteran. Combat veterans began to seek him out as a confidant and a role model. Over time, Thompson developed a ‘veterans’ club’, a specialized therapy group, and a linkage system for veterans in the other Samaritan Village facilities. Subsequent clinical experience, independent study, consultation with the professional community, and input from the client population contributed to a growing body of knowledge and techniques for treating veterans’ issues within a therapeutic community milieu.

Program overview

The veterans’ programs are long-term, residential therapeutic communities for the treatment of chemical dependence. The criterion for admission is a primary

98 therapeutic communities, 29, 1, spring 2008 problem of alcoholism/substance abuse and a willingness to participate fully in the therapeutic community modality. Samaritan Village has chosen to define the term ‘veteran’ as simply indicating prior military service. Unlike the official government Veterans Administration system, military discharge codes are not used to determine admissions eligibility. This distinction has proved to be crucial in providing a treatment option for veterans who are not eligible for VA services. Prospective residents are admitted through a central intake facility where they participate in orientation activities and initial evaluations for health, mental health, vocational and other biopsychosocial issues which may be a focus of treatment. Diagnostic tools, including the ‘Life Events Checklist’ and the ‘Clinician Administered PTSD Scale for DSM-IV’, are utilized within the assess- ment process. Co-occurring disorders, including PTSD, and other mental health issues are identified and incorporated into a preliminary treatment plan. The intensive case management and enhanced mental health services available within the veterans’ programs allows for the inclusion of prospective clients whose multi-dimensional problems might traditionally have disqualified them from the therapeutic community setting. Upon transfer to one of the veterans’ programs, residents remain at that site for the duration of their residential treatment stay, including Re-Entry. The typical length of stay is about one year. Residents achieve eligibility for completion by successfully achieving a series of individualized, sequential treatment goals and developing a viable plan for independent living and Continuing Care. Veterans who are employable may attend vocational training while in treatment, and will ‘transition out’ to the workplace in fields ranging from food services to building maintenance, driving, security, human services, or other skilled jobs. A smaller percentage of the population resume civil service, technical, or professional careers. Both veterans’ programs are currently designed to treat male residents exclusively. (The special needs of female veterans will be best served in a stand- alone facility, which is a matter for future consideration due to the significant role of women in combat at this time.) Client demographics reflect a population that is generally middle-aged, with multiple prior treatment episodes and/or incarcerations. More than half of our residents have a co-occurring mental health diagnosis, including both combat and non-combat-related PTSD as well as a range of affective, personality, and psychotic disorders. Most of the residents have lengthy substance abuse histories, with heroin, crack cocaine, and alcohol as primary drugs of abuse. Common health problems within the population include diabetes, Hepatitis C, and hypertension. Veterans are referred through the criminal justice system, the VA, the Homeless Shelter system, and other providers. Most have a history of homelessness. The programs are designed to include all of the essential therapeutic community elements, including job functions, groups, seminars, and the core concepts of personal accountability, mutual self-help, and the values of ‘right living’. The clinical programs are enhanced by on-site mental health services, trauma and PTSD groups, an emphasis on veterans’ pride, and a rich linkage

Carol Davidson 99 system to the external veterans’ community. Clients typically remain in residential treatment for about one year as they advance through progressive phases of treatment by achieving therapeutic goals and objectives. The programs include a Re-Entry phase in which residents complete vocational training, obtain external employment, develop a community-based support network, and prepare for independent living. The criteria for successful completion of treatment include: the ability to demonstrate a strong foundation of recovery skills; the acquisition of suitable housing; the development of a community-based recovery support network; and a stable source of personal income (employment and/or pension/disability). Following completion of residential treatment, veterans participate in both a Continuing Care program within the Samaritan Village network of services and in regularly scheduled alumni activities at the veterans’ programs.

Combat, trauma, and PTSD

Military service is almost universally considered a responsibility of citizenship and a rite of passage with profound archetypal resonance. The personal evolution from civilian to recruit, from soldier to warrior, and finally, to veteran, is a developmental process which is marked by significant tasks, tests, and milestones that impact on one’s self-esteem, status and, potentially, one’s survival. Preparation for combat involves the acquisition of a complex range of skills and, even more importantly, a psychological reconditioning that is designed to equip the warrior with the willingness and the capacity to violate the innate human prohibition against killing. Combat training requires soldiers to override the ‘gut level [understanding] that all humanity is inextricably interdependent and that to harm any part is to harm the whole’ (Grossman 1995). Combat soldiers are motivated by patriotism, harnessed aggression, the quest for valor, fidelity to a highly valued sense of mission and purpose and a fundamental ‘warrior ethos’ that engenders deep bonds of brotherhood among combat troops. Soldiers may be conditioned to dehumanize the enemy that they will face in combat, but they are profoundly influenced by both human nature and circumstance to develop a culture of unmatched loyalty and camaraderie among themselves. Warriors ‘are retrained to … believe that loyalty to the group matters above one’s own life ... they are indoctrinated with the group’s higher purposes they are now meant to serve’ (Tick 2005). Combat service is an inherently traumatic life experience, which involves profound risk of both physical and psychological harm. Soldiers are subjected to extreme conditions of stress and deprivation that may include prolonged exposure to atrocious weather conditions, inhospitable terrain, lack of sleep, inadequate nutrition and unrelenting anxiety that is punctuated by intermittent, cataclysmic events. When access to effective communication, equipment, or leadership is compromised, or when allegiance to the stated mission is diminished, morale can become dangerously undermined and psychological stressors can reach critical mass.

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Combat soldiers live with a pervasive awareness of their own human vulnerability and mortality. The potential for grave bodily injury or death represents an inescapable undercurrent of fear and dread that is seldom acknowledged or articulated. The trauma of repeated exposure to death, dead bodies, body parts and gruesome scenes of war, is further distinguished by circumstance, proximity, and perceived justification. Releasing bombs from a plane, for example, is different from killing someone with a knife in hand-to- hand combat and the psychological impact will differ accordingly. Grossman (1995) describes the spectrum of ‘empathic and physical proximity of the victim and the resultant difficulty and trauma of the kill’ according to a continuum of distance, weaponry and physical contact, from ‘long range … mid-range … close range … edged-weapons range … hand-to-hand combat range … and sexual range.’ The soldier’s ability to withstand the trauma of war is affected by a variety of factors. Individuals with a prior history of trauma are predisposed to developing PTSD, as are those with pre-existing mental health or substance abuse problems. Although a combat zone does not lend itself towards emotional processing opportunities, soldiers who are able to mourn their fallen comrades, sustain peer relationships over time and participate in thorough psychological debriefing are less likely to develop debilitating psychological scars. Deliberate attention to ‘unit cohesion … the cultural valuation of grief … honoring the enemy … and acknowledging psychiatric casualties’ (Grossman 1995) in the war zone may serve to reduce the incidence of combat-related PTSD. Character may be forged in the heat of combat, it may be revealed, or it may be irrevocably damaged. The ‘warrior ethos’ serves to define and distinguish the tasks of a warrior as founded in honor and governed by ethical parameters. Outside those parameters may lie intractable guilt, shame and disgrace, whether or not rightly deserved. The burden of a survivor’s guilt, for example, is often too heavy to be borne when soldiers perceive that a comrade was killed in their stead, as occurs when random quirks of fate cause soldiers to switch places in formation right before hostile engagement. Likewise, the failure to recover the body of a fallen comrade may forever represent an unconscionable abandonment of a cherished buddy. Renowned veterans’ expert and author Robert Jay Lifton (1973, 1985, 1992, 2005) describes a ‘diffuse sense of death guilt’ that consists of ‘self-condemnation, self-contempt, and self-disgust,’ rooted in an unconscious sense that ‘his survival was made possible by others’ deaths.’ The killing of innocents, under any circumstances, is a source of relentless psychospiritual torment. Soldiers at the breaking point, in the gray zone of morality that characterizes combat, sometimes lose their last grasp on reason and commit acts of indiscriminate brutality and revenge, in a ‘blood-crazed, berserk state,’ that creates ‘ruinous … psychological and physiological injury’ (Shay 1994). These veterans may suffer so profound a breach of personal integrity that a lifetime of self-punishment and destruction ensues. Post Traumatic Stress Disorder, formerly called ‘shell shock’, ‘soldier’s heart’, ‘battle fatigue’, or ‘nostalgia’ (Tick 2005), was officially added to the 3rd

Carol Davidson 101 edition of the American Psychiatric Association Diagnostics and Statistical Manual in 1980. The current diagnostic criteria include: exposure to a major trauma, which engenders feelings of fear, horror, and helplessness; the presence of symptoms from each of three specific clusters; and a significant impairment in functioning over time. PTSD is differentiated from Acute Stress Disorder in that symptoms persist for more than a month following the traumatic event. PTSD may surface or resurface at any time in the lifespan of an individual, as evidenced by the number of Vietnam and other war veterans whose symptoms have begun reoccurring in response to the stimulation of current wartime news coverage. ‘Re-experiencing’ symptoms include intrusive thoughts, preoccupation with traumatic memories, nightmares, and flashbacks, intense psychological distress and physiological reactivity at exposure to internal or external cues. ‘Avoidance’ symptoms include efforts to avoid thoughts, feelings, conversations, places, activities, or people that are associated with the traumatic event, inability to recall aspects of the trauma, diminished interest in significant activities, detachment, restricted affect, emotional numbing and a foreshortened sense of future. ‘Increased Arousal’ symptoms include increased physiological reactivity in response to memory triggers, insomnia, irritability, difficulty concentrating, hypervigilance, and exaggerated startle response. Trauma activates a threat-response pattern in the brain and central nervous system. ‘The basis for a biological understanding of PTSD …,’ requires a recognition that the human system has reconditioned itself to ‘respond to danger when no credible danger exists’ (Cash 2006). Alterations occur in ‘neuro-anatomical structures and systems, neuro-transmitter systems, neuro- physiology, functional brain systems, neuro-psychological functions, and endocrine and hormonal functioning’ (Cash 2006), impact learning, memory, and emotional regulation. Empirical evidence, including brain imaging technology, has demonstrated that trauma produces measurable, long-term effects on biological functions. The incidence of PTSD among combat veterans has been estimated at anywhere from 10% to 39%. ‘In today’s theatres of war, where troops are dealing with extended and multiple deployments … ever-changing mission goals, and guerrilla warfare conditions where enemies and civilians blend together, it has been estimated that cases of PTSD may be higher than in past conflicts’ (Meagher 2007). The correlation between PTSD and substance abuse is well documented. The ‘odds of someone with PTSD also having a co-morbid Substance Abuse or Dependency Disorder is anywhere from 2.5 times to 8.5 times higher than if he or she did not have PTSD’ (Cash 2006). Drug and alcohol use serves both to sedate hyperarousal symptoms and to provide intense stimulation to overcome numbing symptoms. Combat soldiers may have access to drugs and/or alcohol while deployed, providing ‘distraction … from an especially bad experience …’ and establishing a belief that, ‘when you’re under stress, you need to use substances to cope’ (Armstrong, Best & Domenici 2006). Veterans may use drugs to simulate the adrenalin rush of battle, or simply to induce a dreamless sleep. The progression of addictive

102 therapeutic communities, 29, 1, spring 2008 disease impairs emotional development so that coping skills are gradually eroded, thus reinforcing dependence on substances of abuse. Veterans for America (2007) recently published a study that described alcohol and substance abuse as common among ‘recognized symptoms of PTSD,’ with ‘fourteen percent of … veterans from Operation Enduring Freedom and Operation Iraqi Freedom who sought treatment from the Department of Veterans Affairs between 2002 and December of 2006,’ receiving a diagnosis of non-dependent use of drugs.

Principles of treatment

The therapeutic community is in many ways an ideal treatment setting for veterans. Following WWI, a therapeutic community model evolved out of necessity in overcrowded British psychiatric hospitals. Core consistencies between military life and the modern TC model include the value for ‘pride in quality’, structure and discipline in daily functions, allegiance to a code of conduct and an emphasis on interpersonal loyalties, support, and mutual self- help. In a combat setting, the soldier’s survival will very literally depend upon his ability to make intuitive decisions that reflect his warrior training. Our veterans understand that lasting recovery will likewise depend upon their ability to consistently use the skills of recovery that they learn in treatment. The core principles of treatment form a continuum of personal healing and development that include processing, affect regulation, connecting, and future-building. Processing refers both to story-telling and to spontaneous expression of genuine emotion. This may represent the most difficult and high risk challenge for the combat veteran in treatment and requires the most sophisticated level of skill for the clinical staff. Combat veterans are secret-keepers. They hold secrets that may involve national security issues or covert operations, secrets that reflect shameful behaviors or failures and secrets that they may even be keeping from themselves through repression or dissociation. Processing is equivalent to exposure therapy and may occur in the context of individual or group therapy sessions. Combat veterans need a very high level of trust and a strong sense of safety in order to be able to process their experiences and feel their emotions. Avoidance is a hallmark of PTSD and cathartic therapies hold the potential for re-traumatizing the participant and activating the cycle of hyperarousal and subsequent numbing. The risk of flight, self-harm and/or relapse is significant. As a healing process, however, sharing allows residents to, ‘begin with the individual stories, but weave and interweave them until we embrace the collective story and find each participant’s place in history … and what meaning we may discover from it’ (Tick 2005). Healing can occur in a therapeutic context where the veteran is embraced within the supportive network of his fellow combat veterans, particularly in a residential setting. The trusted comrades who bear witness to the veteran’s story in group at 3pm will rally around him if he wakes from a nightmare at 3am. The community provides a therapeutic container that is large enough and strong enough to

Carol Davidson 103 hold the horror, grief, shame, rage, confusion, and despair that the individual may release into its collective consciousness. The veteran who is beginning to formulate and disclose the narrative of his fragmented and distorted memory has powerful positive role-models to relate to and to draw inspiration from. In the culture of the veterans program, senior residents and alumni play an important role in the extended family, and are often called upon to mentor a resident who may identify with a particular theatre of operations or specialized units. A US Army Ranger who served in Somalia, for example, will form an immediate bond with a program alumnus who enters the building wearing a Special Forces beret and insignia. Staff will provide invaluable professional skills to guide the process, but the community as method is epitomized in the bonds of brotherhood that combat veterans share. Processing allows the veteran to release repressed emotions, begin to form a narrative of his experience, and re-evaluate the meanings he has ascribed to it. With the help of his peers, he can begin to reframe self-defeating belief systems. Often, his willingness to offer unconditional love and respect to his fellow veterans in recovery is the foundation upon which he can begin to come to terms with himself. Affect regulation refers to the development of coping skills. The TC provides a structure in which behavioral norms are established and re-enforced. The veteran participates in an ongoing feedback loop where he both gives and receives responses about the impact of attitude, demeanor, and behavior. Skills such as anger management, the ability to restrain impulses and the appropriate use of support networks are taught and practiced on a daily basis. Residents develop increased self-awareness, the ability to identify emotions and to generate behavioral choices that produce desired results. Psychotropic medications may serve as an important element of a comprehensive treatment plan and the availability of on-site mental health services allows for a seamless co-ordination of care. PTSD symptoms such as insomnia, hypervigilance, lack of concentration, or extreme irritability can be effectively managed through the combination of psychopharmacology and therapy. Connecting represents coming home. In ancient cultures, warriors traveled long distances over time before rejoining their families and communities. They had a naturally-occurring opportunity to debrief their combat experience and to develop an identity as a veteran. Rituals for cleansing, healing and re-entering the civilian world further helped them to adjust. In America, we have welcomed our veterans home with great fanfare after some wars, but we have either ignored or alienated them after others. A combat veteran who is entering a substance abuse treatment program may be many years removed from his wartime experience, but may just be starting a process that will enable him to take his rightful place in society. At our veterans programs, it is our custom to literally greet each new resident with the words, ‘welcome home’. It is not uncommon to see tears come to a man’s eyes when he hears those words. Veterans who begin to talk about wartime experiences will frequently relate that they have never given voice to

104 therapeutic communities, 29, 1, spring 2008 these memories before and sometimes have not even told their friends that they ever served in the military. They rarely display medals or share stories about acts of bravery, commendations, or achievements. Few have ever marched in a parade or visited a memorial. Our veterans are those who have been isolated, disconnected and self-destructive. They may see themselves as ‘outcasts or loners [who] think that civilians can’t possibly understand what [they] have gone through’ (Armstrong, Best & Domenici 2006). Our mission includes the challenge of helping them to connect to the greater whole of the community. Initially, they learn to connect to their fellow veterans within the TC environment. Gradually, they begin to participate in veterans’ and recovery- based groups in the external community and, eventually, they find their place among their families, friends, and neighbors as productive, contributing members of society. Repeated exposure to killing and death results in a kind of spiritual death that creates a foreshortened sense of the future. Some of the uncounted casualties of combat include the loss of spontaneity, joy, creativity, and dreams. Many veterans will verbalize the perception that, in a very real way, they died in the war. They may be riddled with survivor’s guilt that makes them feel unworthy of life, or they may be so preoccupied with intrusive memories that they cannot orient to the present. The progression of addictive disease becomes an ongoing game of ‘Russian Roulette’ in which life is devalued and the future holds no promise. The veterans’ programs assist residents with constructing a vision of the future that is based on new values, priorities, goals and a clearly-defined mission statement about the meaning and purpose of their lives. This process may begin with planning for something as concrete as tomorrow’s seminar, next week’s phase move, or next month’s holiday observance. As they engage in the life of the TC, with its many clinical, cultural, social, and recreational activities, they also engage at a deeper level in building a notion of a future in recovery. For many veterans, their membership in the program community becomes a defining element of their lives, and their position as a valued and respected role model for newcomers engenders a satisfying sense of direction and purpose for the future.

Services, enhancements, and strategies

The atmosphere and ambiance in the veterans’ programs is designed to celebrate the collective identity of the veterans and promote a valued culture within the treatment environment. The ubiquitous therapeutic community rituals, such as the morning recitation of the Samaritan Village Philosophy, the assignment of a Big Brother to a new resident and the use of program slogans and TC vernacular co-exist within a culture that also includes a daily flag-raising ceremony, the use of military slang and a good-natured rivalry between veterans of different service branches. Holidays such as POW/MIA Remembrance Day, Memorial Day and Veterans Day are observed with special reverence. In Manhattan, our program residents serve as the primary source of manpower for

Carol Davidson 105 the Untied War Veterans Council in producing the Veterans Day Parade. For many veterans in early recovery, it is an unparalleled opportunity to participate in community service, to develop real-world skills, to bond with several generations of fellow veterans and to experience the thanks of a grateful nation for their service. The program has cultivated connections in the external community that have enabled our veterans to support and participate in activities such as the ‘Wounded Warrior Project’, ‘Thanks for Serving’, ‘Stories of Service’, ‘D-Day 40th Anniversary Celebration’, and other service-related events. The daily clinical schedule includes a range of conventional TC services, including Morning Meetings, Caseload Groups, Encounter Groups, and psycho- educational seminars. Our specialized activities include a ‘Veterans Pride’ group that is designed to celebrate the veterans’ identity and highlight achievements associated with military service. The ‘Veterans Issues’ group is an open-ended therapy group that addresses combat trauma through a combination of exposure therapy, intense peer support and cognitive reframing. Eye Movement Desensitization and Reprocessing (EMDR) therapy is available on a very limited basis. Art therapy groups are conducted twice a week and the program hosts an annual public showing of veterans’ art. Cultural diversity is highly valued within the program culture, and a variety of holiday, social, and recreational events occur throughout the year. The foremost annual event, however, is a pilgrimage to , DC to pay tribute to our fallen warriors at Arlington National Cemetery, The Tomb of the Unknowns, The WWII Memorial, The Korean War Memorial and The Vietnam Memorial. Many weeks of clinical preparation occur in advance of the journey, and extensive processing continues after our return. For our Vietnam veterans in particular, the visit to ‘The Wall’ of Vietnam War KIA/MIA names may represent the pinnacle of their clinical experience, as program staff, alumni and residents stand together as the embodiment of a healing community to grieve the dead and to honor their sacrifice. The staffing pattern for the veterans’ programs is both specialized and enriched. All TC cultures depend upon alumni to ‘carry the culture’ to the next generation and the Veterans Program staff includes several alumni who serve as indispensable role models. All of our staff must exemplify the professional standards established by the agency and must also demonstrate the capacity to earn the trust and respect of the veterans’ population while managing the potentially damaging counter-transference issues of vicarious traumatization and/or ‘trauma addiction’.

Implications for the field

A new generation of combat veterans that is already well in excess of one million strong will be coming home to face a multitude of challenges in their transition to civilian life. They are a diverse group of men and women, including career military personnel, reserve unit ‘weekend warriors’ who never expected wartime deployment, skilled combat soldiers, and ‘support’ troops who unexpectedly became combat soldiers in the asymmetrical battlefields of Iraq.

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Over time, many will appear at the doors of human service agencies with mental health, adjustment, family and substance abuse problems. The Veterans Administration, by its own admission, will not be prepared to address all of their treatment needs. Professionals are already identifying that PTSD and Traumatic Brain Injury have emerged as the signature wounds of this war. A recent study by The Alliance to End Homelessness cites veterans as accounting for one in four of America’s homeless, with ‘veterans from Iraq and Afghanistan … trickling into shelters … seeking treatment’ (Associated Press 2007). Some experts predict that, ‘we’re going to have a tsunami of them eventually because the mental health toll from this war is enormous’ (Associated Press 2007). Therapeutic communities that treat chemical dependence and other life problems will be well placed to prepare for this population by developing competencies in trauma and PTSD. The Veterans for America report on ‘Trends in Treatment for America’s Wounded Warriors’ (2007) expresses concern that ‘the military is ill equipped to assist service members with undiagnosed service- connected mental health problems who are abusing alcohol and/or illegal substances.’ The therapeutic community represents a viable alternative setting for the ‘dual-track alcohol and Post Traumatic Stress Disorder treatment’ that is recommended. Considerations for further study and training include: a deeper understanding of the neurobiology of PTSD and its relationship to substance abuse; the use of flexibility and creative therapies within the TC setting; the special needs of female combat veterans; and the modifications that may be necessary when utilizing TC tools like confrontation and Learning Experiences when treating this population. At Samaritan Village Veterans programs, we are guided by a time-honored military tradition that commits to ‘leave no man behind’. It will require the talents, skills and commitment of the entire human services field to ensure that America’s combat veterans are welcomed all the way home from the ‘Global War on Terror’.

References

Armstrong, K., Best, S. & Domenici, P. (2006) Courage after fire: coping strategies for troops returning from Iraq and Afghanistan and their families. Berkeley, CA: Ulysses Press, p.25. Associated Press (2007) Study finds that veterans constitute a quarter of America’s homeless. Retrieved from the World Wide Web on 11-09-07: http://www.msnbc.com/id/21678030/ Cash, A. (2006) Wiley Concise Guides to Mental Health: post traumatic stress disorder. Hoboken, NJ: John Wiley & Sons, pp.83, 85, 123. Grossman, D. (1995) On killing: the psychological cost of learning to kill in war and society. New York, NY: Back Bay Books/Little Brown and Company, pp.38, 99–134,198–204. Lifton, R.J. (1973, 1985, 1992, 2005) Home from the war: learning from Vietnam veterans. New York, NY: Simon & Schuster, pp.106–107. Meagher, I. (2007) Moving a nation to care: post traumatic stress disorder and America’s returning troops. Brooklyn, NY: Ig Publishing, p. xxi.

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Shay, J. (1994) Achilles in Vietnam: combat trauma and the undoing of character. New York, NY: Touchstone/Simon & Schuster, pp.77–98. Tick, E. (2005) War and the soul: healing our nation’s veterans from post- traumatic stress disorder. Wheaton, IL: Quest Books/The Theosophical Publishing House, pp.54, 99, 218. Veterans for America (2007) Trends in treatment for America’s wounded warriors. Retrieved from the World Wide Web on 11-10-07: www.veteransforamerica.org, pp.11–12.