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Mitigating the Risk of Late-Life Mental Health Problems for Veterans: Contributions of the Life Course Perspective to Emergency Management
Published online by Cambridge University Press: 15 August 2013
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References
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Older adults may be at risk in an emergency or a disaster depending on the nature of the event and how the event intersects with their specific vulnerabilities, needs, and capacities.1-Reference Wells3 Emergency management includes preparedness, response, recovery, and mitigation.Reference Haddow and Bullock4 Numerous international efforts have called attention to the need for research, education, and policy development on older adults’ distinct issues in all phases of emergency management.1, Reference Hutton5-8 There is urgency to this issue. Internationally, the number of emergencies and disasters is on the rise.8
Our focus is on aging veterans. Older veterans have distinct vulnerabilities and capacities that are not well understood or well integrated within emergency management practices. We use the life course perspectiveReference Elder, Johnson and Crosnoe9 to frame a discussion of veterans’ mental health and aging issues. We then consider the implications of this discussion for the field of emergency management.
Veterans
War veterans constitute a substantial proportion of the world's population.Reference Garfield10-Reference Bowling and Sherman13 As of 2006, an estimated 234 000 of Canada's World War II and Korean war service veterans were still alive.11 In the United States, as of July 1999, 23.6 million people were classified as veterans.Reference Zeber, Copeland and Grazier12 Since September 11, 2001, more than 1.3 million American service members have been deployed.Reference Bowling and Sherman13 Combat experience has been called the “hidden variable” in the aging of the current cohort of older American men.Reference Spiro A, Schnurr and Aldwin14 A powerful body of literature chronicles the circumstances that can lead to mental health problems for ex-combatants.Reference Bonwick and Morris15-Reference Dallaire19
Life Course Perspective
The life course perspective emerged as a reaction to the tendency in the field of gerontology to study older adults as a distinct category, separate from the continuity of their personal biographies.Reference Marshall and Mueller20 We apply the 5 principles of the life course perspectiveReference Elder, Johnson and Crosnoe9 to veterans’ mental health and aging issues.
Principle 1: Lifespan Development
Lives are represented by trajectories (relatively stable patterns) and transitions (changes). Particularly critical transitions are referred to as turning points and may alter the current behavioral trajectory. Generally speaking, people with personal, social, and economic advantages tend to accumulate more advantages during their lives, but disadvantages also tend to accumulate.
For many people, military service represents an important transition with lifetime consequences.Reference Sampson and Laub21 While most people do well when they leave the armed services,Reference Litz22 the transition from a combatant role to a civilian identity can be associated with significant psychological distress.Reference Bowling and Sherman13, Reference Boscarino23 Greater lifetime exposure to trauma has been associated with less favorable self-rated health, more acute and chronic health problems in old age, and more functional difficulties.Reference Schnurr, Spiro A, Vielhauer, Findler and Hamblen24, Reference Krause, Shaw and Cairney25 Research with Vietnam veterans with posttraumatic stress disorder (PTSD) indicates that repeated exposure to trauma is associated with the depletion of the very resources (eg, functional social support) that are needed for resilience.Reference King, King, Foy, Keane and Fairbank18 The persistence of mental health problems in a minority of veterans who served in the British armed forces in the 1990s has been related to factors such as an increased risk of social exclusion.Reference Iversen, Nikolaou and Greenberg26 These findings support the cumulative advantage and disadvantage concept articulated in principle 1.
Principle 2: Agency
People construct their own life course through the choices and actions they take within the opportunities and constraints of history and social circumstances. There is an increasing tendency to reminisce about one's life course with age, which is largely positive and aids in emotional regulation.Reference Cappeliez, Guindon and Robitaille27 However, reminiscence can be detrimentalReference Cappeliez and O'Rourke28 and may have a mediating role in the emergence of late-onset stress in previously asymptomatic combat veterans.Reference Davison, Pless and Gugliucci29
Principle 3: Time and Place
The life course is shaped by the historical times and places people and cohorts experience during their lifetime. Societal support for and acknowledgment of veterans’ contributions influence psychological outcomes.Reference Copp30-Reference Hautamäki and Coleman33 For example, among American veterans of World War II, the Korean War, and the Vietnam War, significant age and cohort effects were observed, reflecting in part differences in public support for the different wars.Reference Fontana and Rosenheck34 Similar conclusions have been reached in an analysis of the reintegration of veterans in Kosovo.Reference Barakat and Ozerdem35
Principle 4: Timing
When and in what order events occur in a person's life have an impact on the life course. There are cultural expectations about when some events should occur. While there is increasing acceptance of a need for mental health services for still-serving and recently returned soldiers,Reference Lamberg36 the idea that exposure to trauma can cause distress decades after a war has ended is poorly recognized and poorly understood.Reference Andrews, Brewin, Philpott and Stewart37 The concept of “late-onset stress symptomatology” has been proposed to capture the phenomenon of aging combat veterans who functioned well during midlife but have begun to experience trauma-related symptomatology as they approach retirement age.Reference Davison, Pless and Gugliucci29, Reference King, King, Vickers, Davison and Spiro A38
The processes of aging that have been hypothesized to contribute to the emergence of trauma-related psychological symptoms in later adulthood include threats to personal control, more time for reflection and increased reminiscence, loss of usual coping strategies owing to age-related changes in habits and health, cumulative social network losses, changes in sleep patterns and sensory abilities, and cognitive changes (eg, decrease in attention-allocation resources that permit intrusion of trauma-related memories), as well as ageist stereotypingReference Snell and Padin-Rivera39, Reference Floyd, Rice and Black40; and consequences of misinterpreted symptomatology can be severe. For example, in a case series, it was observed that World War II combat veterans with dementia with PTSD symptoms did not receive help until a violent outburst occurred, despite the presence of clinical red flags such as recent preoccupation with previously unmentioned wartime experiences.Reference Johnston41
Principle 5: Linked Lives
Lives are lived interdependently, and sociohistorical influences are expressed through this network of shared relationships. Good social support from wives, families, and veteran's associations is protective for veterans.Reference Hunt and Robbins42 Successful group therapy with veterans has been attributed in part to the benefits of working with a same-age cohort, which allows for a shared historical lens and collective memories and emotions around war experiences.Reference Snell and Padin-Rivera39, Reference Lew, Vanderploeg and Moore43, Reference Frueh, Elhai, Hamner, Magruder, Sauvageot and Mintzer44
The importance of family and, especially, commitment to future generations can be central to psychological well-being for veterans.Reference Coleman and Podolskij45 This finding reflects the concept of generativity, which many veterans express through contributing to organizations and activities that aim to help younger generations develop leadership and other prosocial skills.46
Implications For Emergency Management
Emergency management includes a wide range of activities that aim to create a state of preparedness to deal with emergencies should they occur, enable response as needed when an emergency occurs, facilitate recovery in the short- to mid-term, and mitigate risk over the long term.Reference Haddow and Bullock4 In this section, we consider implications of aging veterans’ mental health issues, needs, and capacities for the field of emergency management.
Preparedness
One of the oft-repeated recommendations in the seniors and emergencies literature is to make use of the life experience of older adults as a resource for current emergency management.Reference Hutton5-8, Reference Gibson47, Reference Gibson and Hayunga48 Veterans and veteran organizations are resources that should be systematically included in emergency preparedness activities. At the same time, emergency responders need to understand how an emergency or disaster may trigger recall of past traumatic experiences, including war exposure.
Response
Age alone does not create vulnerability, but a constellation of age-related changes in health, mobility, cognition, family and social networks, economic resources, and status does.8 Similarly, veteran status alone does not create vulnerability, but a history of cumulative disadvantage does.
Recovery
An appreciation of military culture and the common and unique features of the war zone activities to which survivors of different conflicts have been exposed can reasonably be expected of mental health care providers who treat veterans routinely and providers who encounter them in the aftermath of an emergency or disaster. Both groups need to understand that the personal meaning of an emergency or a disaster will be colored by how it fits into the persons’ life story. For many veterans, this may include having sacrificed much in their youth in the hopes that the world would become a safer place.
Mitigation
Coping with war experience and aging is addressed in the handout “PTSD and Older Veterans” from the National Center for PTSD.49 However, there is little mention of coping with war exposure in the mainstream self-help literature on aging, despite the prevalence of veterans in the current cohort of older men and the evidence that war-related trauma can interact with the processes of aging to increase the risk of psychological distress. As a resilience-building intervention, health promotion materials directed to older adults should raise awareness of this issue and options for addressing it. A health promotion focus is critical to supplement the limited capacity for direct intervention that is available through primary and secondary care.Reference Hobfoll, Watson and Bell50
Within the formal health care system, relapse preventionReference Dugas, Radomsky and Brillon51, Reference Dobson and Ottenbreit52 should be a priority in the treatment of veterans, especially techniques that emphasize coping with potential trauma-related triggers,Reference Litz22 such as exposure to emergencies and disasters.
Conclusions
Veterans are a significant subgroup within the contemporary senior population. Veterans are a potential resource for emergency managers. They have skills and experience that could be a distinct asset for emergency preparedness activities. At the same time, public messaging about disasters should include the relationship between past trauma, including war experience, and potential negative reactions to contemporary emergencies and disasters. First responders and others involved in the immediate response to a crisis must recognize and address the distinct needs of vulnerable veterans. Health care providers who work with survivors must be sensitive to the implications of past war experience in disaster recovery efforts. There is a general need to implement health promotion strategies and clinical interventions that mitigate the challenges associated with the intersection between the processes of aging and war experience for veterans.
Author Disclosures
The authors report no conflicts of interest.
Published Online: December 6, 2010. doi:10.1001/dmp.2010.48