Vietnam and Iraq: lessons to be learned about mental health and war

Physical injury and death in war is expected. But we also now know the stories of large numbers of veterans suffering major psychological trauma.

These involve Post Traumatic Stress Disorder (PTSD), anxiety, depression, alcohol and drug problems and sometimes suicide. Former soldiers, whether they fought in Vietnam or Iraq, are dealing with some common but distinct experiences.

All wars are horrible but each is different in its own way. Those who were in Vietnam, for example, often fought at close range with a resourceful enemy who could not be easily distinguished from civilians. Massacres occurred.

Those who fought in Iraq and Afghanistan were affected by the ever-present dangers of Improvised Explosive Devices (IEDs) and suicide bombers while on patrol during their period on deployment.

The failure to properly treat Vietnam veterans, should remind us of our obligation to help returning soldiers to get the support they need.

The war weary

The experience of soldiers in wars in Afghanistan and Iraq contrasts to those involved in the Vietnam War. First, deaths and physical injuries for our forces in Vietnam were much higher than in Iraq and Afghanistan. Second, levels of PTSD and other mental illnesses associated with the Vietnam War were also very high.

A full 29% of all veterans who ever served in Vietnam have had PTSD that is accepted for compensation by the Department of Veterans Affairs (DVA). Over 8% had alcohol dependence or abuse, 5.5% had anxiety and 3.6% had depression that was accepted for compensation. Some of the veterans, of course, had all four conditions. But surprisingly, levels of suicide for veterans, when compared to the rest of the population do not appear elevated or if so, only to a small extent.

These high levels of mental health issues immediately pose the question: what was it about the Vietnam War that was so disturbing.

Films like Apocalypse Now and The Deer Hunter vividly represent the profound personal crisis of many of the soldiers involved. The nature of the combat meant the soldiers were killing in close range.

But another key issue was that after Vietnam, we became much more aware of the psychological impact of war than previously. This awareness has led to changes in attitude and a greater understanding of veterans’ mental health.

Post-traumatic stress

The PTSD syndrome was “discovered” in the aftermath of the Vietnam War. PTSD is characterised by re-experiencing the original traumas through flashbacks or nightmares, avoidance of stimuli associated with the trauma, and increased arousal - such as difficulty falling or staying asleep, anger, and hypervigilance.

To be accepted as a disability, symptoms must last more than one month and cause significant impairment in functioning. PTSD, of course, is not new - think of “shell shock” and “combat fatigue” as other words to describe the condition from earlier twentieth century wars.

In Vietnam, these high levels of mental disorders are linked with a massive absence of services. They were also substantially affected by the public response to their service involvement.

Vietnam veterans came home to no fanfare, to indifference and sometimes open hostility. It wasn’t until the Vietnam Veterans “Welcome Home” March of 1987 that public sentiment started to change but by then it was too late. A half generation of young men were psychologically scarred not only in the medical sense described above, but also through a loss of direction in life and embitterment.

Here to help

It is too early to know if Iraq and Afghanistan veterans will experience the same level of mental disorders. Early indications are that this is unlikely in Australia. Mental health services for both serving members of the Australia Defence Force (ADF) and retired veterans are much improved. Attitudes to veterans by the public are also more sympathetic.

Nevertheless, present problems are real and concerning enough, remembering that PTSD can present some decades after exposure to the wartime trauma.

More worryingly, there has been an increase in suicide rates in United States soldiers in Iraq or Afghanistan. This has not been observed to date in Australian soldiers but could still occur.

As noted, services are much improved. These include the post-deployment psychological screening programs and the All-hours Support Line for ADF members.

For veterans there is for example, the Veterans and Veterans Families Counselling Service (VVCS).

Room for improvement

However, treatment services can be further improved. In 2008, I conducted two ministerial reviews - Mental Health care in the Australian Defence Forces (ADF) and a study of suicide in veterans for the Department of Veterans’ Affairs (DVA).

It was clear that the ADF mental health workforce needed to be considerably expanded and better trained. It was also clear that the model of a multidisciplinary care team of psychologists, psychiatrists, mental health nurses and social workers, that is commonplace in civilian practice, did not exist in the ADF.

Psychologists were engaged in a wide variety of roles, more in human resources and training and less in clinical psychology relevant to mental health problems and illnesses. For DVA services, recommendations were for a review of services for the treatment of PTSD.

A wide variety of mental health promotion programs also exist in the ADF and operate through DVA. For ADF personnel, there are for example, the Suicide Prevention Program and the Alcohol Tobacco and Other Drugs Program. For veterans, there are for example, the At Ease Mental Health and the Right Mix alcohol websites.

Best practice

Programs though need further development to achieve best practice including in suicide prevention. Both the ADF and DVA acted on the recommendations of the reviews and allocated $90 million to support their implementation. Upgrades and improvements to treatment services and mental health promotion programs are now in train but have not as yet been fully implemented.

Until they are fully implemented, members of the ADF and veterans will continue to face challenges to receive best services. Even when they are fully implemented, some problems are likely to continue.

For example, senior staff readily appreciate that military culture does not, by its nature deal well with mental health problems that can easily be stigmatised as weakness. New programs are likely to be only partially effective in changing these attitudes.

In defending and protecting Australian society, members of the ADF undertake activities that other Australians want but do not wish to do themselves. That these activities frequently have the consequences described above is a constant reminder that ADF members and veterans have every right to expect the best possible services and programs that can be provided.

Last week marked the 50th anniversary of Australian forces arriving in Vietnam. The Conversation will be looking at the war’s legacy throughout a number of articles over the next week.

Part 1: Forgetting the ‘American War’: Vietnam’s friendship with its former enemy

Part 3: Stabilising Iran: lessons from Vietnam and the rapprochement with China

David Dunt received funding from the Ministries of Defence and Veterans Affairs in 2009 in 2008-9 in completing two Ministerial reviews for the Australian Government - A review of mental health services in the Australian Defence Forces through transition to discharge and An independent study of suicide in the Ex-Service Community.