1. 1
Gaspare Mura
January 2013
The Invisible
WoundsA policy brief
Target Audience: Policy Makers, Family of Veterans, Veterans.

2. 2
fbh
he purpose of this paper is to analyse the VA (the US Department of Veteran Affairs) mental
health policy in the USA in a context of conflicts and economic crisis. Mental problems are the
main cause of suicide among veteran communities and the origin of associated social issues such
as problems with the law or unemployment. Two main aspects have been analysed; the financial
aspect (considering 23% of the entire US budget is allocated to defence) and the social aspect. It
has been argued that the social side is the key to improving the financial aspect through moves
such as improving the efficiency of treatment, seeking a more efficient use of existing facilities
and increasing the VA system capabilities by establishing partnerships with healthcare providers.
Moreover, there is the need to develop IT management in order to cut waiting times and share all
the information to allow a 360-degree access to veterans who seek care in the private sector, and
create new categories of healthcare professionals able to deal with the particular needs of the
veterans. To conclude, a change is required to try to honour and support the million of service
members who fought not for them but for their people, for their country.
T
Executive Summary

3. 3
In America, on any given
day 22 veterans put an
end to their own lives.
(Carter, 2013)
1
Introduction
The World is changing and the nature of War is changing, and
as a matter of fact we are living in a period of constant
conflicts. A new world has evolved since the 9/11 episodes
and with it, new wars. These are exhausting and endless wars
wherein tactics have changed, and young men and women
are sent into combat situations even before they figure out
their future. As a result, both causes and effects are
changing. However, these developments are different for
every country and are tailored to the culture of that nation. In
this paper, we will analyse and evaluate the mental health
policy of veterans in the USA; one of the countries most
affected by this problem.
For instance, in the UK, the Department of Health (2009)
affirms that there is no prevalence of mental disorders among
people who served in the army and furthermore the number
of suicides of soldiers and veterans are not greater than those
figures found in the civilian population. On the other hand,
overseas in the USA the VADM (Vice Admiral) Regina
Benjamin (U.S. Surgeon General and of the National Action
Alliance for Suicide Prevention, 2012, p.3) stated that
“Suicide among those who serve in our Armed Forces and
among our veterans has been a matter of national concern”.
In the USA, on any given day, 22 veterans put an end to their
own lives (Carter, 2013) and more than 69% are 50 years of
age or older (Kemp & Bossarte, 2012). They are Vietnam and
Gulf War veterans who are facing life transitions such as
retirement, becoming grandparents or aging. The other 31%
are young soldiers coming back and finding trouble dealing
with the reality of an economic crisis. Young women are also
affected, and never before has the presence of women been
so considerable in the army. They are returning from a
combat environment and coping with the consequences of
separation from children (Make the Connection, 2012) and
other parenting related challenges.
Defining the “real” problem
However, the high suicide rate is only the tip of the iceberg.
Underlying this are the `real´ problems. Mental disorders are
the main cause of suicides. In the literature, they are called
“invisible wounds” because they alter the psychological
sphere instead of the physical, and most of the time they are
not understood by the family or are unknown by healthcare
professionals (Tanielian et al., 2008). Mental problems are
PTSD (Post Traumatic Stress Disorder), depression and
anxiety. These are the principal cause of homelessness,
domestic violence, divorce or separation, child issues and
problems with the law (Mental Health Foundation, 2010).
According to Elspeth (2012) 10% of all those imprisoned in
In America, on any given
day, 22 veterans put an
end to their own lives.
(Carter, 2013)

4. 4
2
the USA are Veterans.
Other disorders include; military sexual trauma, substance
abuse, bipolar disorder and schizophrenia (U.S. Department
of Veteran Affairs, 2013).
This current national concern is explained by Carter (2013)
who claims there is a peak in veterans’ mental healthcare
needs 10 – 20 years after the end of a war. We saw this
phenomenon after Vietnam, and it is going repeat itself after
the 9/11 and global terrorism war including OEF (Operation
Enduring Freedom) and OIF (Operation Iraqi Freedom). The
U.S. government has not been deaf to this call. In fact, on
31st August 2012 President Obama signed an executive order
directing the VA and other departments to improve mental
health care services for the veteran community (Cloud et al.,
2013). These are the reasons why current policy is examined
here, and recommendations are given for improving the
service, whilst acknowledging that a great deal has been
done, and the U.S. context is complicated and unique.
Current Picture – Policy Context
Since September 2011, 20% of all the 2.6 million soldiers
deployed in OIF and OEF, may have experienced symptoms
of PTSD or mental problems. Now, on any given day in the
USA, 7-8 million people have PTSD episodes, and in 2010
38,000 veterans lost their lives by committing suicide (Cloud
et al., 2013). Until now, more than half of the 900,000 Iraq
and Afghanistan VA patients have been diagnosed with PTSD
(Carter, 2013). During operation OIF and OEF more than
15,000 service members reported an injury in combat and
60% of all the soldiers wounded by explosive devices
reported TBI (Traumatic Brain Injury). TBI may cause mental
issues such as anger problems, sight difficulties and lack of
judgment and control (GAO, 2005). What is most worthy of
note is that in 2012, VA cared for approximately 6 million
patients, which represents almost one quarter of the entire
veteran community, including 83.6 million out-patient visits
and 703,500 in-patient admissions, and most of them have
been treated for mental health problems (Carter, 2013).
These are the figures the VA has to deal with, and despite
more than 150 trusts in the territory, 800 community clinics
and thousands of clinicians they are not sufficient to satisfy
the demand for mental health care (Carter, 2013).
Until now, more than
half of the 900,000
Iraq and Afghanistan
VA patients have been
diagnosed with PTSD.
(Carter, 2013)

5. 5
Frauds Issue
We are living in an economic
crisis, the benefits from the
state could be seen as a life
saver. However, cases of
fraud have not been rare and
from 1999 to 2004, the
number of veterans receiving
benefits for PTSD increased
by 79,5% (Frueh et al.,
2007). In their study, Frueh
et al (2007) found that it
could be a potential fraud
cost to the U.S. government
of $19.8 billion. From 1999
to 2004, the claims for PTSD
payments increased by 148%
and 94% of service members
applying for VA benefits
related to mental problems
were for PTSD. In reality,
only half of them are really
seeking psychiatric care
during the applications. Many
veterans’ clinicians do not
believe their patients
anymore; indeed they
suspect they are pretending
to be suffering from the
disease only to obtain
disability payment. This led
to suggestions to exclude
compensation for Veterans in
clinical research, and change
policies that are encouraging
chronically ill patient roles
(Frueh et al., 2007).
3
Costs and Savings
This is an extract from the Executive order signed by the
President of the United States of America, Barack Obama:
“Since September 11, 2011, more than two million service
members have been deployed to Iraq or Afghanistan. Long
deployments and intense combat conditions require optimal
support for the emotional and mental health needs of our
service members and their families. The need for mental
health services will only increase in the coming years as the
Nation deals with the effects of more than a decade of
conflict” (Cloud et al., 2013, p.47). The Veterans community
amounts today to 22 million (Carter, 2013); they could be an
independent state when we consider that the population of
the Netherlands is roughly 16 million (CBS.nl, 2014).
Furthermore, the number of veterans with mental illness or
substance disorder is expected to increase as the military
operations in the Middle East come to an end and soldiers are
returning to civilian life. We have already witnessed this trend
between 2004 and 2008 and as a matter of fact the numbers
of ill veterans soared by 38.5% (Watkins et al., 2011).
Accordingly, to ensure the best care for veterans, the
government this year will spend $7 billion (Carter, 2013),
defence itself including VA healthcare represents 24%(see
Figure 1) of the entire US federal budget spending
(Christopher, 2013); and in particular one third of the entire
VA medical costs is allocated to VA mental health care
(Watkins et al., 2011). Lastly, there are hidden costs of
frauds (see the box) that do not directly affect the defence
budget, but affect the U.S. Government`s spending, and on
the other hand prevent the full process of recovery of the
service members.
Figure 1: U.S. Federal Budget. (Christopher, 2013)
Social outcome becomes Income
Most of the analyses and research conducted have simply
focused on direct medical costs and the short-term costs such
as cost of delivery, structures, benefits and HR
remunerations. They do not focus on the more long-term
costs such as loss of productivity, homelessness, jurisdictional
problems, and suicides (see Figure 2). In research (Tanielian
et al., 2008), it has been assessed that the cost of PTSD and
other mental problems for two years for a veteran, ranges
from between $5,900 and $25,760 per person, that applied to

6. 6
Figure 2: Distribution of costs including
Suicide mortality (Tanielian et al., 2008)
The cost of PTSD and other
mental problems for two
years for a veteran, ranges
from between $5,900 and
$25,760 per person, that
applied to all people suffering
from these illnesses results in
an amount between $4 billion
and $6.2 billion.
(Tanielian et al., 2008)
4
all people suffering from these illnesses results in an amount
between $4 billion and $6.2 billion.
On the other hand, with the implementation of evidence-
based treatments in all cases it would be possible to save up
to $1.7 billion, and in two years this system could allow the
therapies to pay for themselves (Tanielian et al., 2008). In
reality this may be considered to be a visionary plan, because
a self-financed system is seen as a daydream; something
unachievable. Nonetheless, there is no immediate answer. A
solution would be changing the culture, starting to plan in the
longer term, lowering targets to achieve a better patient care
outcome which will result in a saving for VA.
VA Services and Organizations
In this paper it has been decided to focus on the support that
VA and organizations offer to service members with PTSD or
associated mental problems outside trusts. As one of the
main obstacles to veterans seeking care is the fear of being
stigmatized as ill, it is vitally important to establish a means
of approach outside the hospital that allows them to realise
the problem. Moreover, this approach allows them to retain
their anonymity and at the same time take the first step
towards recovery by admitting the problem. The support is
based on digital platforms as there are web-based
psychological healthcare tools, smartphone apps as well as
telephonic support. This is an important step for the whole
healthcare world, the beginning of a new era. The digital
services available to veterans has to be seen as setting an
example to all other fields. The use of low-cost devices such
as smartphones has two main advantages. Firstly, it ensures
that everyone has access to support both before and during
the therapy. Secondly, it overcomes the problems associated
with distance.
The first organization operating on the web is “Make the
Connection” and it has been proved through research
literature (Cloud et al., 2013) that the best way to help
Veterans is through sharing the experience with other service
members that have already overcome the problem. Through
different media, on the site, veterans can find support,
testimonies and advice from a fellow in the same situations or
others that have successfully dealt with mental challenges.
The second group is “Wounded Warrior Project”. In their
website their mission is written as, “to honour and empower
wounded warriors”, they serve veterans and wounded or
injured or ill following 9/11. Veterans seeking help can find
programs focused on Mind, Body, Economic Empowerment
and Engagement (Wounded Warrior Project, 2014). The last
association is “Military Kids Connect”. It is worthy of
consideration because it is the first application offering
support at all levels of the family of veterans in parenting

7. 7
5
problems (Cloud et al., 2013).
Then, in the event of experiencing suicidal feelings, a former
soldier or family can text, chat or call the VCL “Veteran Crisis
Line” and he or she will be put in contact immediately and
directly with a VA healthcare professional, the service is
active 24/7 and 365 days a year (Cloud et al., 2013). This
service has been improved recently with an executive order
directed at the Departments of Veteran Affairs, Defence, and
Health and Human Services. Reinforcing the capacity of VCL
in a program of suicide prevention by 50%(Cloud et al.,
2013)
Apps are the latest kind of help from the VA and, as today
mobile devices are part of daily life, software has been
developed to support treatment programs. These apps are
Breathe2relax, which advocate a diaphragmatic technique to
calm down in conditions of stress. PE coach and PTSD coach
have been developed jointly by the DoD and VA, and they
respectively offer treatment and help to self-assess in case of
PTSD episode, and put users in direct contact with support
resources (Cloud et al., 2013). However, apps and web tools
are only meant to be a complement to the therapy and they
cannot replace a professional mental health cure (Cloud et
al., 2013).
Today Issues, Tomorrow Solutions
Veterans own their destiny
Veterans are the main actors and influencers in the first
category of issues. First of all, the “average delay by a person
with PTSD in seeking care is 12 years” (Cloud et al.,2013,
p.8). Many of them do not seek help at all and only 40% of
veterans whose results prove positive in screening for mental
disorders visit a healthcare professional (Mental Health
Advisory Team IV, 2007 cited by American Psychological
Association, 2012); the number is even smaller, 30%, if we
talk in particular of PTSD cases (Tanielian et al., 2008).
Figure 3: 1-17 th Infantry
helps clear 120 kilomweters
to Shorabak (Mackie, B.,
2012)

8. 8
6
Veterans perceive mental illness as a stigma, they feel it is
embarrassing and dishonourable to be sick (SAMHSA, 2007
cited by American Psychological Association, 2012).
Furthermore, researchers have found an exclusive
characteristic of the military context to be a barrier to seeking
help. In the army, soldiers are bound under a secret law to
look out for their “buddies”, and this and the good of the unit
become the priority. Following this belief, veterans think that
they do not deserve the help. They believe there is a fellow
soldier who needs the support more than they do because he
or she has been in a combat environment or they have been
exposed to harder conditions. In respect of that, inside the
service, members felt a sense of shame for using resources
(Make the Connection, 2012).
To address this problem, the veterans’ awareness
must be increased. It is essential to communicate the
message that illness is not a shame. They must be aware that
therapies with proven effects exist and that there is support
preventing them from feeling alone. In this case, the media
plays an essential role. Already in the USA there are
campaigns like “Veterans Voices”, “Stand By them” or “Side
by Side” launched by PSA (Public Service Announcement).
Also, within the world of sport, the NFL for example supports
the cause, and Hollywood is helping to transmit the
information with shows like Homeland, Bones (Cloud et al.,
2013) or Army Wives.
Another obstacle is the struggle of service members to
collaborate with civilian healthcare professionals. Veterans
believe that they cannot understand their feelings, and they
do not comprehend the army culture (Mental Health
Foundation, 2010). “Military services involve entry and
participation in a unique culture, one with a particular value
set and cultural identity distinct from the civilian population”
(Cook et al., 2013, p.29). Although, it is true that mental and
health providers in communities have different backgrounds,
and many of them are inexperienced with army culture or war
related trauma and disorders (Burnam et al., 2009).
Overall, there is a lack of specified training on the mental
health specialty workforce (Cook et al., 2013). To make up
for this deficiency it is necessary to create new professionals,
clinical and social workers and psychologists with skills in
military and social work. It might be necessary to create a
new human capital pipeline from the base, following the
example of collaboration with the universities of Southern
California and South California (Carter, 2013).
Last, is the warrior mentality whereby a soldier feels himself
to be a killer machine. He feels proud to serve the country
and protect all his brothers, so when there are signs of
weakness they try to minimize them. Moreover, if and when
“Military services involve
entry and participation in a
unique culture, one with a
particular value set and
cultural identity distinct from
the civilian population”
(Cook et al., 2013, p.29)

9. 9
7
they accept the treatment, working in a group puts them in
an uncomfortable position, delaying the recovery and
contrasting the change (Cook et al., 2013).
VA - time to change
VA and clinicians have the power to change the second
category of issues: facilities, communications, prescription
drug misuse and efficiency of the treatment.
VA capacity has proven insufficient in satisfying the demand,
in spite of the efforts made by the DoD (Department of
Defence) and VA to improve the service by hiring 1058
mental health clinical providers, 1600 mental health
professionals and 100 peer specialists in January 2013 (Cloud
et al., 2013). After all, still “there is a large gap between the
need for mental health services and the use of those
services” (Tanielian et al., 2008, p.2).
The current model of VHA (Veteran Health Administration)
relies mostly on VA employees to deliver care and this makes
it the largest government workforce outside the DoD. There
are three alternative ways of addressing the problem of the
capacity of the VA healthcare system. First, hire more
clinicians. Second, expand the use of the existing facilities
(more hours, new types of care) or create new facilities
(Carter, 2013). In order for there to be a solution that can
satisfy all these needs, contracted work would be necessary.
Government bureaucracy involved in hiring process could be
avoided if the VA were empowered to hire contractors
directly, then it would provide the scalability that VA Human
resources needs, and in the long term costs would be lower.
Pilot projects, like that of CBOCs (Community-based
Outpatient Clinics), showed that this option produces a
similar or better patient satisfaction (Carter, 2013).
This paper considers three main issues under the term
communications. First, there is the need to develop new
Figure 4: ‘America’s Battalion’
Marines, sailors run to honour
fellow wounded warrior (Reece,
L., 2012)

10. 10
8
software to schedule the visits. The GAO (Government
Accountability Office) claims that waiting time is a serious
problem, and 91.3% of VA doctors recognize that the
responsibility of the delay in care for VA patients is
attributable to the process of scheduling appointments, and
for this reason there is a need to integrate this system at a
National level (Carter, 2013). After the creation of a
management system for booking, the second step would be
the sharing of this information. The DoD, VA and HHS
(Department of Health and Human Services) must necessarily
increase communication and coordination between them
(Jackonis et al., 2008).
The VA, moreover, should try to create a unique patient
database, where private sector and VA health providers
supply information. More than 20% of veterans seek mental
health care outside the VA (American Psychological
Association, 2012); 75% have private insurance coverage,
and current research shows that the veterans prefer the
private sector in terms of its economic efficiency and
convenience (Carter, 2013). The VA has been accused of
lacking transparency and it is recommended that they should
make all the data available to focus on working towards
improving the services it provides (Carter, 2013).
Prescription drug misuse. There are many returning veterans
who suffer chronic pain problems, and through treating this
problem they are more at risk of developing an addiction to
painkillers (Cook et al., 2013). Chronic pain and mental
health problems are factors that increase the problem of
substance disorder such as alcohol (Cloud et al., 2013), and
this problem is usually is masked by the label of social drinker
especially for young veterans (Cook et al., 2013).
Prescription drug misuse is a real concern also because it is
an obstacle to seeking help. Many veterans are afraid of the
side effects of treatment and are concerned that it can
influence their job or their career (Burnam et al., 2009). It is
true that unemployment among veterans outpaces the civilian
rate (American Psychological Association, 2012).
“Raw” PTSD
The latest kind of issue has taken a new form. The most
recent veterans are different from the previous ones. Iraq
and Afghanistan soldiers display PTSD symptoms which are
more acute and with a higher level of anger. This more acute
form is known as “RAW PTSD”. Some explanation has been
found in the fact that the new veterans are freshly
“wounded”, bad memories are new, and they are younger
when they come back (Cook et al., 2013). As a consequence
of that, there is the need to change therapies and the means
of delivering care. It is necessary to update all the types of
care and to start to approach the study of the new disease in
a different way.

11. 11
9
Veterans’ Leverage
There is a strict connection between American politics and veterans, the connection
originated alongside the foundation of this country. In order of that, twenty-six of all forty-
four Presidents have served in the army, as it follows more than half of the Presidents were
veterans (U.S Department Veteran Affairs, 2011). The implementation of this policy is
mostly a matter of government, in fact, they would have the means to change the current
system and carry out the changes needed. In the first part of this brief paper it was
analysed that, through the development of care delivery, it would be possible to save up to
$1.7 billion a year, which would lead into creating general benefits for the US budget
spending. In addition to that, the policy can have implications on the political picture. In
the American society veterans inhabit respected positions earned due to their service in the
combat field. The citizens are eager to give their political preferences thinking of them as a
model of discipline, loyalty and honesty. According to that, 108 members of the 113th
congress were in the army or have served in the military (F.A.S. Federation American
Scientists, 2013). The significant numbers of veterans’ community can have an influence to
the entire political system shifting the equilibrium either to one or the other side. Simply
put, President Obama has won the last election with 62,611,250 popular votes (Politico
LLC, 2012), only the veterans’ society could represent one third of all voters for the
election of the future US President and change the destiny of the nation. Politicians cannot
afford to turn their back to veterans; the risk could be too high about lives, and more
importantly for them, about the power.
Conclusions
In conclusion, even if the American system is one of the best in the world (Make the
Connection, 2012), it is really difficult to cope with the needs of millions of Veterans. This
is one of the consequences of the GWOT (Global War of Terrorism); even if the combat
field is far away, in the USA the effects are being felt not only in the society. Furthermore,
the deployment in these years of crisis is seen as safe income, but too often young soldiers
consider just one side of this choice.
Clearly, through analysis it is possible to identify several efforts made by the VA and
Voluntary organizations to offer a vast range of services, but in respect of this point it
might be better to have a smaller quantity of services with more quality within them.
Moreover, the number of current facilities is not adequate, and most of the time these
facilities are located in urban centres excluding isolated suburban zones; a problem that
could be overcome through delegating services to contractors.
On the other hand, if the facilities are inadequate, the use of technology in healthcare for
veterans is worthy of note. Smartphone apps in healthcare could well be the future,
especially for patients like soldiers who are afraid of being recognized and judged. The
entire healthcare system could follow this example. The use of technology is the result of a
patient care centred system and many of these ideas have been suggested by non-profit
organizations that are around the VA. The efficiency of these organizations is well known,
and in a way Veterans are supporting and healing themselves following the order issued on
the combat field, “to look out for the fellow soldier”.
This paper has highlighted that there is the need to work on two sides of the current policy.
The conclusion to be drawn is that an effective means of improving the financial aspect
might well be best achieved by working on the social side. The aims are clearly to decrease
the suicide rate, improve the efficiency of therapy and adopt evidence-based treatments.

12. 12
0
As stated before, from the review it has emerged that VA departments offer a significant range
of services, but there is a lack of organization, coordination and development of evidence-
based treatments. There is the necessity to reduce waiting list times and there is the need to
share all data with the private sector for two reasons. First, in order to permit Veterans to seek
care in private trust. Secondly, in order to start focused research on the real results of the
current therapy. Furthermore, to improve the results of the therapy there is the need for
specialized healthcare professionals, starting partnerships with schools for the creation of MSc
studies or courses related to army subjects.
The final consideration here is that of Virtual Reality (VR) (Carter, 2013). Today it is possible
that service members could re-live certain situations and particular feelings through VR.
Studying therapies based on VR could be a successful strategy to adopt in order to fight these
veterans’ personal wars. In brief, VA mental health policy is a real concern that will affect the
USA for a long time. Acknowledging that today Vietnam Veterans are the most affected, this is
the main reason why it has to be a central theme both in the politics and within society in the
USA.

13. 1
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