why veterans are different | No Duff Learning Centre

Why Veterans are different

No Duff Learning Centre

Tho’ much is taken, much abides;

This page is long and a bit dry. If you are looking for a lighter look at veterans skip to the next page.

What is a veteran?

No Duff recently commisioned a New Zealand artist to create some signature art work with a veterans theme. As part of the process the artist needed to understand veterans to know how best to portray them. After talking with the public and veterans the artist realised there are a couple of problems. The public sees veterans as old men at the bar and standing on street corners shaking the tin on Poppy Day. The public doesnt realise things have changed since grandads day. The bigger problem though is the young veterans - they dont see themselves as veterans. This is a generation of veterans that is at real risk of being lost - because they dont see themselves as veterans, because the old guard have actively excluded them and because the public simply doesnt know they exist.

This neglect is a natural consequence of the very successful spin on modern operations. Peace keeping suggests a benign environment - no threat because its peace keeping. That makes it politically acceptable at home. It also means no one has any idea of what it was really like.

In the New Zealand context a Veteran has come to be defined as a military person whom has undertaken qualifying operational service as defined in our Veterans Support act. Dependant upon the period examined this may account for as little as 10% of those whom served, whilst at other times it may have been over 80%. What that means in reality is that anywhere up to 90% of those whom have served in a given period do not have VANZ eligibility.

The term veteran is used more widely in other countries, encompassing both domestic and operational service. It is a recognition that the rigours of military training and domestic service can have similar consequences to those resulting from operational service. The effect of watching your mate get shot doesn’t change with geography. Carrying a pack in Tekapo hurts just as much as it does in Afghanistan. Carrying 60kg loads is just as damaging in Waiouru as it is in Timor. It should be noted that military service, whether domestic or operational, is exempt the majority of New Zealand employment protections.

There are a number of elements which together could be argued to define a veteran. These are the nature of military service and the social contract that defines the commitment to service, the psychological conditioning inherent in service training, and finally the exposures and risk encountered in military service.

When you sign on the dotted line and attest, what you are commiting to is a promise to do what is required even if that means you loose your life. There are few other situations where that is the stark reality of your job.

When you enter service you cease to be a member of the civilian public - you give up many of the rights and protections that the public take for granted. Your job is 24/7/365 until you leave or die. You are subject to military law - which is a very different beast to civilian law.

Your conditions of service - your employment contract - can be changed at no notice and in any way that the Government or Defence Force feels is required. You have no say in those changes. The conditions are at the Commanders discretion - even if its in the conditions of service the Commander can elect to do something else - its up to your Boss what you do and what you get in return.

There are no hours of work - you go home when the job is done. My first trip away I did the 3 months pre deployment training, deployed for what we thought would be 6 months - however my replacement fell over at the last minute. I was extended until there was a replacement - which turned out to be 2 months later. 11 months away from my family. It wasnt the only time it happened.

There is no military pension - you have kiwi saver like everyone else.

There is VANZ if you get broken and you qualify and you can prove that its attributable - which means a benefit, it does not mean being made right again. If it happens on training at home you have ACC - which lacks an understanding of the veteran and what they need.

When you deploy it changes you - not always for the better. My wife commented that she could tell what kind of a trip I had by how much I didnt say when I came home. Veterans whom have had bad trips often have a similar story of how great a toll it took on their families.

What is a veteran - its someone whom promised everything and often received little in return.

That is why No Duff does not differentiate between how long you served or where you served. Its that commitment - the willingness to put everything on the line, knowing what price you are willing to pay defines a veteran.

The modern veteran

Following the US defeat in Vietnam most western nations changed the way in which service personnel were both selected and trained. This has proven to be highly successful in producing much more effective and Professional service members, but this has also come at a cost.

Training was changed in an attempt to both increase the proportion of troops whom will ‘shoot to kill’, whilst at the same time seeking to reduce the likelihood of rogue incidents such as the Mie Lie massacre. It placed a heavy emphasis on group identity and upon the ethos and values of service, in essence creating a rigid honour culture. An honour culture values adherence to the group values and reputation of the group above the dignity needs of the individual.

In the New Zealand context the identification with the group is especially true. The adoption of the Maori tribal culture within the military has both positive and negative aspects. The esprit de Corps is intensely strong, hugely protective whilst accepted within the ‘tribe’. However, once the individual leaves, whether voluntarily or being banished from the tribe, it becomes even more dislocating than may occur in other militaries. The only other group with such a strong unit identity may be the US marine Corps and it should be noted that their self harm rate in service is lower than the US military, however the post service rate is significantly higher.

The conditioning in service usually begins at recruit training, most often at 18 years old. At this age the individual does not have a fully formed self identity, the moral development is still underway and the need for group acceptance is high. The conditioning is aimed to reinforce the group identity, reduce the individual identity, and in the most simplistic sense reduce the threshold for the application of violence. This could be argued to be a fundamental change in the development of that individual. It can be argued that this change explains the differences between military personnel and civilians which extends beyond the obvious uniform and haircut.

The longer an individual spends in service, the greater the conditioning that takes place. The ‘band of brothers’ effect is even more true of the effect of high intensity environments such as operational deployments, high tempo units and high risk training. The sense of belonging and purpose becomes an encompassing part of the service persons identity, which explains why leaving is so dislocating - the term in the military administration is separation from service. In a real sense it is just like the separation in a marriage - with the grief and pain that accompanies that.

Stop and think about this for a moment - we condition an individual to withstand hardship and pain, to put the mission before themselves and to apply overwhelming violence when it is required. The military does not train the individual to be a whole and healthy person, it spends a great deal of effort and time to train them to be a controllable killer.

The individual whom leaves service does not therefore suddenly transition from being military to civilian. For many they enter a twilight zone, being neither military nor civilian. They loose their sense of belonging to the tribe, however do not typically have a self identity or sense of purpose to replace that with. They lose the sense of purpose and consequently struggle for a sense of meaning in a life where the job is not all encompassing. They often have a low frustration tolerance, a fear of loosing their shit because they know what will happen, what they were trained for.

A veteran may therefore be considered a service person whom is not in service at this time, someone whom is neither active military nor civilian, someone separated from their tribe. In the context of No Duff, a veteran is someone whom has done one day of service .

Veterans Mental Health

Mental Injury in service

The transition from the military into civilian life is hard. Many of the things that a military person comes to take for granted in service are missing. Things however become much more difficult when the person leaves service with an injury - particularly if they have a mental injury.

There are 4 main types of mental injury in service personnel;

minor traumatic brain injury (mTBI),
post traumatic stress syndromes (PTSD and ASD, adjustment disorders),
burnout,
and moral injury.

It is relatively uncommon in the modern cohort to see individuals with a single diagnosis, which is in contrast to civilian presentations. The nature of both the physical and psychological environment make mTBI and the other presentations common comorbidities. The NZDF does not actively screen for mTBI, in fact it does not have baseline function screening to compare to if it did.

The rates of mental injury for the recent conflicts are reported as varying between 12% and 24% of deployed troops. Whilst the total number of contemporary veterans in New Zealand is unknown, this suggests that since Bosnia there are between 4000 and 8000 mentally injured service persons in New Zealand.

Traumatic stress syndromes

When the individual’s psychological distress following exposure to a traumatic event persists, and is severe enough to interfere with important areas of psychosocial functioning, it can no longer be considered a normal response to the traumatic exposure. The possible problems post a traumatic event are Acute stress disorder (ASD), Adjustment disorder (AD) and post traumatic stress disorder (PTSD). Unfortunately everyone thinks about PTSD but that is actually the least common presentation in modern New Zealand Veterans.

Acute Stress Disorder

After an individual has been exposed to a traumatic event, they may experience significant distress and/or impairment in social, occupational or other important areas of functioning. When this lasts longer than two days, a diagnosis of acute stress disorder may be considered, I.e. the symptoms duration must be at least 2 days from the time of the event. ASD is conceptualised as an acute stress response that does not require specific symptom clusters to be present. Rather, the person requires a certain number from a broad list of dissociative, re-experiencing, avoidance, and arousal symptoms. Think of mini short lived PTSD and you get the idea.

PTSD

When an ASD goes on for some period of time we are talking about PTSD. The key differences between ASD and PTSD is the duration of symptoms; ASD can be diagnosed between two days and one month following the traumatic event whilst PTSD can only be diagnosed at least one month following the traumatic event.

The core concept of PTSD, like ASD, is the inability to cope with overwhelming stress which may be followed by a distinctive pattern of symptoms. The concept does not presume that this is the only possible psychiatric outcome. It may be conceptualised as a permanent up regulation of the fight, freeze or flight response. In civilians this is most likely to present as a fear based anxiety condition (the freeze/flight response), however in military personnel whom are trained to run towards the danger the response will most likely be one of dysregulation of the fight/flight response. Hyper arousal, anger and violence become much more common in the military PTSD presentation.

It should be kept in mind that PTSD is a relatively new diagnostic concept, coming into use to explain the poor outcomes post the Vietnam conflict. PTSD has proven to be a very useful and valid diagnostic concept after 25 years of clinical use. Although there have been minor revisions in successive editions of the Diagnostic and Statistical Manual (DSM) to the diagnostic criteria, the core concept has withstood the test of time.

The PTSD concept made it possible to predict how affected people react to traumatic reminders, differentiate them from non-affected people or those with depression or other anxiety disorders, and hence develop unique therapeutic approaches (e.g. CBT & medication targeting specific symptoms) that could not have been envisioned without the PTSD model. However it could now be argued to be too successful - its overshadowing the more common and in many cases more difficult mental injury presentations.

PTSD can be conceptualised as a Disorder of Reactivity, its alteration of function is best revealed by uncontrolled responses to psychological or pharmacological stressors. Contrast this to depression where there is a shift in the basal state and alterations are best revealed by measurement of baseline activity. What the hell does that actually mean?

The way we explain it to veterans is the following.

We all have a guard dog - a small part of the brain called the amygdala. Its job is to keep watch and help you survive. A normal civilian has the family pet, a small fluffy barky dog that does as its told. When the person suffers an event that passes their coping threshold the amygdala kicks in - it learns just like training a dog. It works on pattern recognition. Looks like, smeels like, sounds like - these senses are direct wired with fast circuits into the amygdala.

The part of the brain that lets us think, monkey brain is a relatively recent upgrade. It works like a committee - holds a meeting, takes a vote then decides what to do. The senses are wired with slow circuits into monkey brain.

So when you next hit something stressful that looks, smells or sounds like your initial post threshold event the gurd dog has pattern matched and reacted before monkey brain is even aware that it exists. In the civilian the response would be to freeze in fear or run away. In the veteran the response is to fight - because that is what they were conditioned to do.

The military person whom is repeatedly exposed will develop stronger and stronger responses - the amygdala actually grows in size. The guard dog that was the family pet turns into a 600lb Rottweiler with an attitude.

So when I get sent to a counsellor whom tells me to think positive thoughts when I am triggered, count to 10 and walk away I know they are talking shit. When I am triggered the guard dog has savaged the threat before monkey brain knows it exists.

Beyond the exagerated threat response, untreated PTSD often results in the development of depression. It should be kept in mind that untreated mental injury in military personnel often progresses to a final common pathway - essentially all of the cases look the same. This makes it extremely diagnostically difficult when intervening late in the disease process. This is a reflection of the fact that military people, either through common personality or training, adopt similar adaptation and coping strategies. Late presentation makes achieveing the diagnosis difficult and the likelihood is it wont fit neatly into one of the DSM labels - which means it wont get accepted by VANZ.

It is important to note;

Misdiagnosis is common as the presentations are late,
Misunderstandings are common, paranoia is a prominent
presenting feature of the condition,
PTSD has become a great reason not to consider the other mental injury diagnoses due to its over representation in the media and political dialogue (for instance Moral injury is not a SOP condition with veterans affairs NZ),
PTSD is Serious but treatable when it is present, however it is a high resource requirement condition,
Military PTSD is qualitatively different to civilian PTSD and has different treatments, different risk profiles and a different prognosis
PTSD typically does NOT present alone in military veterans, it is associated with higher rates of major depressive disorder, anxiety disorder, bipolar disorder, borderline personality, and schizophrenia. These conditions are all screened for and are exclusions to service.
Traumas do not always lead to PTSD - 80% of service persons will eventually have post traumatic growth, only 20% will have longterm post traumatic loss of function,
ASD and PTSD are characterised by four types of symptoms: re-experiencing symptoms such as intrusive memories or dreams; avoidance symptoms such as avoiding thoughts, feelings, and places associated with the traumatic event; numbing symptoms such as feeling detached from others; and increased arousal symptoms such as poor sleep, irritability/aggression and hypervigilance.

Risk taking behaviour in Post traumatic stress syndromes

So with a post traumatic stress disorder I am a cranky individual with an attitude who tends to avoid people so that I dont accidently savage them, but wait there is more. The baseline for what is dangerous shifts because you have experienced dangerous things, but there is an even more important effect. There is an emotional contraction, a numbing which pervades life. In order to feel something, anything, the experiences become more extreme. Risk taking taking behaviour in Veterans with ASD and PTSD may considered a marker of disease severity. Reckless and self-destructive behaviours are common among Veterans exposed to trauma. Risk taking behaviours may also perpetuate PTSD symptoms by increasing exposure to new adverse events. It is important to note that the risk taking is usually not restricted to a single domain, for instance only gambling, rather its a generalised problem such as gambling with drugs/alcohol and dangerous driving.

Moral injury

So the veteran with a mental injury may be a cranky individual with an attitude who tends to avoid people so that they dont get accidentally savaged and takes stupid risks, but wait - there is more. The thing that held this all in check was that rigid moral framework that got beaten into the recruit. What happens when that gets broken?

Like post traumatic stress syndromes, moral injury describes extreme and unprecedented life experience including the harmful aftermath of exposure to such events. Events are considered morally injurious if they "transgress deeply held moral beliefs and expectations". Thus, the key precondition for moral injury is an act of transgression, which shatters moral and ethical expectations that are rooted in religious or spiritual beliefs, or culture-based, organisational, and group-based rules about fairness, the value of life, and so forth.

In the context of modern service, the rigid honour based culture and group identity creates a brittle moral framework. As long as both the individual and the organisation can operate within the declared norms there is no problem - it is hugely protective. However, once either steps outside of the norms the impact can be significant as the brittle framework shatters. The reality of modern conflict with no front line, enemies whom do not wear uniforms, the involvement of children, complex rules of engagement, and unclear political objectives to mention just a few of the difficulties means that adherence to an ideal is essentially untenable for the individual or the organisation.

In the context of military service, moral injuries may stem from direct participation in acts of combat, such as killing or harming others, or indirect acts, such as witnessing death or dying, failing to prevent immoral acts of others, or giving or receiving orders that are perceived as gross moral violations. The act may have been carried out by an individual or a group, through a decision made individually or as a response to orders given by leaders.

What this means is we create a set of ideals in the training and culture that neither the service person nor the organisation can live up to on the battlefield, and when either breaks the code it creates a moral injury. The sense of right and wrong becomes damaged. It is a much more fundamental and pervasive injury than the modern conception of PTSD. It should be noted that in Jonathon Shay’s original conception of PTSD the moral injury component was included, whilst in the modern DSM it has been removed.

The aftermath of moral injuries may result in highly aversive and haunting states of inner conflict and turmoil. Emotional responses may include:

Shame, which stems from global self-attributions (for example "I am an evil terrible person; I am unforgivable; what kind of a monster would do that?")
Guilt, particularly survivor guilt in the military context,
Anxiety about possible consequences
Anger about betrayal-based moral injuries

Behavioural manifestations of moral injury may include:

Anomie (for example alienation, purposelessness, and/or social instability caused by a breakdown in standards and values)
Withdrawal and self-condemnation (“ I am a bad person”)
Self-harming (for example suicidal ideation or attempts, which is actually much more common in moral injury than in PTSD)
Self-handicapping behaviours (for example alcohol or drug use, self-sabotaging relationships, etc. “a bad person does not deserve to be happy”)

Moral injury has also been shown to result in the re-experiencing, emotional numbing, aggression and avoidance symptoms of PTSD. In addition to grave suffering, these manifestations of moral injury may lead to under- or unemployment, and failed or harmed relationships with loved ones and friends. Moral injury appears to have a worse long term prognosis than PTSD and is associated with higher rates of self harm. It is of particular concern as it commonly occurs in conjunction with PTSD and other forms of mental injury.

Moral injury is a transmissible problem - impacting partners and children as well as others around them. Research from both Kings College in the UK and from the Dutch longitudinal study is showing that for those with traumatic stress injuries and moral injury the rate of psychological injury in spouses is 80% and in the children is 60%. This creates a feedback loop within the family that is extremely destructive.

During the Afghanistan conflict period the NZDF undertook “imping and comping”, or to quote one senior Commander “trimming the dead wood”. Service persons whom were medically down graded were released from service based upon their medical gradings. Letters were sent to those “imped” informing them of the lack of commitment to service, for example for being unable to pass fitness testing even when medically excused. Many of those personnel were long serving members of the Services whom were retained due to their corporate knowledge. This had two devastating effects - it broke the trust based social contract that is service and it destroyed the service persons trust in the military medical service. Beyond this it also gutted the organisation - the dead wood was where the organisational knowledge and culture was held. It was a moral injury on a grand scale. Organisations, like the individuals which make them up, may be morally injured.

Following “imping and comping” service personnel lost trust in the NZDF and hence those with problems were extremely reluctant to declare them whilst in service - particularly with a major conflict underway. The net effect was the window of best opportunity to help those whom we break in operational service was lost. The effect of this continues to this day.

Burnout

The hidden trauma which continues unrecognised is burnout. Burnout may be considered a mental injury. There is increasing evidence in the medical and psychological literature that burnout produces many of the problems that are seen with other forms of mental injury. Like moral injury, it is a transmissible condition. It spreads through a unit as key elements fail. Just like moral injury then, burnout may be considered a condition which affects both individuals and organisations.

The NZDF is an extremely small force - it is not even brigade sized. That means to do what we do each person often double or triple hats. Positions appear on the org chart but have no one in them - but the work still needs to be done or our brothers and sisters at the front end suffer - so very long hours become the norm. From Bosnia onwards the NZDF has been involving in an increasing number of missions, whilst at the same time modernising most platforms and still having to undertake training. In some years the numbers of exercises and missions approached 150, which for a force of 9500 involved in overseas operations was an extremely high tempo.

The extremely high tempo of the last 25 years is on the background of the usual military career cycle. The military structure is based upon redundancy, its a 3 into 1 game. For example for every 3 captains there is one majors slot. Promotion assessment is every 2 to 3 years. Fail to promote and its harder next time. Fail twice and you are likely to get a service not required letter or a posting to the most shit job in the world. Its a survival game on a treadmill - every few years you are on the chopping block.

There was a significant rise in the number of unaccompanied postings during this period. When a service person is posted they have 2 choices - do the posting or get out. Tradionally that meant up rooting the whole family and moving - at the Defence forces cost. But families were not coping so well with the frequent postings, and the numbers of SNCO and Officers whom undertook unaccompanied posting rose. An unaccompanied posting is at the service persons expense. You pay for the privilege of being sent somewhere your family doesnt want to go. The concession that was sometimes made was (at the Commanders discretion) an equivalent surface fare travel warrant up twice each month. What thats means is the bus fare home every two weeks.

When on an unaccompanied posting in Barracks their is not much to do - drink or work. Those on such postings tended to work rediculously long hours.

It can be argued therefore that whilst individuals were suffering mental injury in deployment, in the period following Bosnia the organisation suffered large moral injury and burnout problems.

The service person whom burns out often destroys their own career in the process. Unfortunately that is not the only effect. Like moral injury, burnout is a transmissable problem. Units under extremely high tempo could be shown to have burnout transmitters - individuals whom burnt out and then became the transmitter for those around them. The organisational response was unfortunately to label the burnt out individuals as poor performers and exacerbate the problem. No one would say no or indicate they had a problem because their career would flat line.

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Leaving the tribe

Transition

Transition is a term often used to describe the process of leaving service and the release support. For those with short service there is essentially nothing - only the administrative process of severance. Short service is less than 6 years regardless of the number of operational tours. For those with more than 6 years there is a transition seminar, a short course run on how to prepare a CV, financial advice from financial firms, and similar life skills advice. It is held infrequently and usually massively over subscribed. Access is therefore limited.

For those with more long term service there is more assistance, however this is at the discretion of the unit Commander and Service leads. This is typically resettlement leave, which requires to be taken whilst still in service. In rare cases the leave provisions may be able to be paid out if the individual is unable to take the leave whilst in service. What transpires is a highly variable transition process which is entirely at the Commanders discretion in a system which is under resourced for the numbers leaving each year.

If an individual is being dishonourably discharged there is no support no matter the length of service.

With the removal of the administrative staff from the units, the only face to face contact individuals may have in the release process is a Commanders interview. What follows is then administrative emails, completing online forms and a release pack with a handbook. It has for most become a hands off affair. Transition support could therefore be considered a myth and a handbook for all but a privileged few.

Transition is a concept which needs to be revisited from an organisational and Governmental point of view. The time to turn a civilian into a soldier is of the order of at least 2 years. It represents a significant investment of money and resources. The investment to release a person is of the order of 3 days or less in the majority of cases. It is not possible to change the degree of psychological conditioning that has occurred in making a soldier in that time. Separation is therefore the accurate term and is the one used accurately in the administrative process internally in the NZDF.

This does allude to a much more fundamental issue in the care of service persons, particularly once injured or releasing. The Defence force has a difficult job to do. The Commander must accept that soldiers may be injured or killed in order to undertake combat operations effectively. Operations do not stop simply because someone is injured or killed. To have the Commander then responsible for both the success of the mission and the successful care and rehabilitation of the soldier is a conflict of interest which cannot be resolved - one requirement must give. In the military the mission is paramount - every soldier accepts that. The result is the help that soldiers need is often an afterthought at best.

What should be in place is an accountability which is independent of the Commander for the care of the injured and releasing soldier. In the UK ill and injured soldiers pass from the Command of their unit to the Command of medical Services until released back to duties with their unit or medically released from service. When releasing normally they pass to a depot unit whose job is to transition them out of service. In NZ they remain under their unit Command until released from service. It is a fundamental difference which massively impacts the care soldiers receive and the resources put to their seperation and transition.

In the UK the armed forces Covenant, a diversion program for veterans with police and justice, and the integration of care through the gateway project have seen a massive change in the outcomes for Uk veterans. Unfortunately in NZ care remains fragmented and confusing, there is no diversion program and no single point of entry for getting help. Whilst there is resistance to engagement in the contemporary cohort due to the trust issues, there are also significant barriers to care.

What happens when you leave - you become a veteran. But then what?

Veteran outcomes

Veterans typically present at changes in life circumstances or when they are too broken to do anything else. Peak psychological crisis presentations are typically following operational tours when in service, often resulting in medical or disciplinary discharges, at around 4 to 5 years post service following a period of steady decline, at retirement with the loss of a sense of purpose, and at end of life when making things right becomes important.

The physical health related presentations historically increased in retirement. The data is now showing that early physical health presentations are increasingly common in the contemporary generation. There is evidence of hip and knee osteoarthritis onset in service personnel in their mid 20’s following the recent operational conflicts.The normal presentation in the civilian and historical veteran population is over 45. The reason for this is the extreme loads that were carried in recent operations. New Zealand soldiers in Timor and Aghanistan wore 18kg of body armour, 7kg in their webbing, 4.5kg in their rifle, and up 45kg in their packs (higher still in some trades). Whilst a civilian is limited to 25% of their body weight intermittently, the service person may be carrying their body weight for the day whilst undertaking all of the activity you would expect of a soldier.

The typical mental injury presentations fall into 3 main groups;

Those whom predominantly have an initial adjustment disorder, may perform poorly for 12 to 24 months and then develop post traumatic growth. In rough terms this is 80% of those exposed. They are military veterans with the usual quirks that that entails, however their service and transition has lead to a positive adaptation.
At risk. Those whom have any of the 4 mental injury diagnoses and progress through the same trajectory as those above. However, instead of reversing the trajectory through positively adapting at some point, the trajectory continues downwards. Increasingly maladaptive coping strategies compound the problem. In many cases they stabilise at a low level of function with chronic disability, often presenting as failed relationships, alcohol and drug problems, and histories of minor disciplinary and legal infractions. Increasing burdens of mental health develop over time, making late presentations increasingly difficult to diagnose and manage.
Crisis. In a small subset, often the most injured, the trajectory continues to spiral down. These cases present in crisis with significant histories of self harm or aggression, often with major criminal activity histories. These are the cases that unfortunately often progress to suicide. The rate of suicide in NZ veterans from an unpublished NZDF study is believed to be 15/100,000 per year, or in other words mid way between the the UK and US veteran suicide rates. These cases now represent 1 veteran in crisis case per week, with the rate appearing to increase as time elapses from the recent conflicts.

For about 20% - 1 in 5 veterans - the net effect of service and seperation is less positive. In No Duff we talk about the 1 in 5, its a way of getting the idea across to our support workers that we need to screen for those whom are struggling and the numbers involved.

1 in 5 have problems after they leave service.

of those, 1 in 5 will have those problems for life.

Of those with life long problems 1 in 5 will require significant levels of support,

and of those 1 in 5 will currently be a suicide or homicide risk.

On average, from an unpublished study, the rate of veteran and military suicide in NZ is about 15/100,000 per year - about one every 3 to 4 weeks. We think this is a significant underestimation. In New Zealand, deaths of veterans are not required to be notified to the coroner. The coroner must investigate all cases of suicide, however the cororner is not required to determine if they were a veteran. New Zealand is the only Western nation where that is the case.

The veteran whom requires help will fall into one of two main presentations - those requiring non urgent social or financial support for example and those who requiring urgent medical care. Within the medical care group there are significant access problems.

Most practices in New Zealand will have very few veterans enrolled - and even less will have those veterans identified as such. Non of the current electronic health record systems has a veterans identifier in the demographics (at primary care or secondary care level).

There are now very few providers in New Zealand with specialised military and veterans health expertise, in marked contrast to the situation for historical veterans. In the era up to the 1980’ every practice had many veterans. As the historical cohort have aged and passed away, that expertise has withered as a new generation of practitioners has come through without that experience. The lack of a readily identifiable referral resource sees Primary care providers default to the public system for help with veterans conditions. This results in delays to service and a lack of specialist opinions to facilitate decision making, both for care and eligibility with VANZ.

Few Gps take the time to invest in building expertise around what is now such a small fraction of their practice where a specialised option for care does not exist. They are therefore often of limited assistance to the veteran in identifying service related conditions or accessing services.

The current support model was designed around historical veterans. In that context physical presentations were more common and the ageing population saw few crisis presentations. The commonest presentations were conditions of ageing. The support system therefore evolved into a routine support and benefit system. Access was typically through the RSA. The contemporary veterans are less likely to be members of the RSA. They are more likely to seek support through the primary care providers, often the after urgent care clinics. This is particularly the case for veterans in crisis.

As noted, those most in need of support are most likely to have had a medical, disciplinary or unplanned exit from service. A red flag that is well validated in the literature for poor outcome is unplanned release within 6 months of returning from an operation, or a medical or disciplinary release following operational service. Those most in need of support are therefore the least likely to be able to access it and to have a trusting relationship with the NZDF (and therefore by extension VANZ) due to the manner of their release. With approximately 7500 veterans registered with VANZ, less than 5% are contemporary veterans (which means only 2% of contemporary veterans have registered with VANZ).

The rate of mental injury in veterans has increased with successive conflicts. For contemporary veterans the rate is estimated to be between 12% and 24%. The reasons for this are threefold, namely a change in the way service personnel are trained, a change in the nature of warfare, and lastly a change in society and the support for veterans.

The contemporary cohort is presenting with a higher complexity of social and illness factors when compared with historic veterans. This is occurring in the setting of a changed society which is less likely to provide community level support. The net result is contemporary veterans becoming more likely to present in crisis, both in the community and in the judicial system.

Typical problems

In order to gain support from VANZ for a Mental injury a veteran must meet 3 criteria - the diagnosis must be confirmed by a psychiatrist or other registered provider with expertise in the field using the DSM criteria, the condition must be service related as determined by the Statements of Principles, and the veteran must have operational service.

There is often a delay in the condition being recognised at the Primary care level. Neither electronic health record system in use in New Zealand has a field for veteran status, so even if a Gp remembers to ask the question it gets lost in the body of the medical record. Once a condition is suspected a psychiatrist is required to confirm the diagnosis, with the delays that inevitably result from the referral, request for funding and then supply of the report. Whilst VANZ can support the initial assessment prior to meeting all 3 criteria, funding the treatment requires the condition to be accepted to gain funding.

There may be a delay of months from initial Gp presentation to the condition being accepted. In many cases, due often to a late presentation, the condition does not meet the full DSM diagnostic criteria for acute PTSD which results in further delays. PTSD, like many conditions, changes over time as the person adapts to their condition. In particular the criteria E factors around hyperarousal may become blunted. The diagnostic criteria were set for early presentations, which is the exception generally for New Zealand veterans.

Having achieved a diagnosis of PTSD the SOP criteria for service attribution must then be met. In essence the SOP requirements are 4 weeks of operational service with symptom onset within 1 year following exposure to a traumatic experience, or operational service and exposure to a life threatening event with symptom onset within 1 year, or within 2 years for death of someone close, or where the individual is subject to repeated exposures. This provides a great deal of difficulty as service records are extremely poor and late presentation is the norm in New Zealand.

Claims are assessed against the claimed condition. If the claim is for PTSD and the criteria are not met, then the claim is declined. The responsibility is then on the veteran to appeal or claim for a different disorder.

In a group that is so heavily connected through social media, word quickly spreads of the difficulties in claiming and many opt to use alternatives, resulting in often maladaptive strategies being used.

The nett result is the average age of those for whom VANZ provides services is in their 80”s. Less than 5% of the VANZ caseload are contemporary veterans, accounting for less than 1% of those whom have served following Vietnam.

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Summary

Veterans are different. They are conditioned to be different. They dont engage with the established support services well and they have problems that the established services generally manage poorly.

New Zealand has the least visibility of its veterans outcomes in the western world.

It is the only Western country that does not have mandatory reporting of veteran deaths to the coroner.

There is no Veteran identifier in any electronic system in health - nor in the census.

There is no veterans pension, no veterans health support, and few manage to achieve significant support under scheme 2 of the veterans support act.

There is no veterans in patient care unit, no specialist veterans out patient health support or indeed any specialist service in NZ which specialises in veterans care.

There is no veterans ID, You hand your ID card inbefore you leave and if you are lucky you get a form letter for future job interviews.

The music video below is 5 finger death punch and the song is "thanks for asking". This a US metal band - military veterans playing tracks about veterans and their problems.

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