Nathaniel A. Brown, MD

I could call it a case, but really, this is my story. In the spring of 2003, I entered Iraq with a rifle and a side-arm. By the fall of 2003, I was walking into a classroom. Instead of worrying about snipers and dust storms and explosives, I was worrying about writing essays on Russian novels. I felt more nervous and awkward in the room of teenage students than I did months earlier in a foreign land in the dust-choked throat of war. I just knew they could see that I didn’t belong with them. I could feel them looking at me with guarded suspicion-the quiet guy in the front row-they knew I didn’t belong. While they had been comfortably enjoying their youth, I had bled and fought with fear and mortality. I didn’t resent them, but I partly wished I had their innocence and ignorance.

I quietly walked the halls and obsessively took notes in my classes, desperate to feel comfortable in this new setting and life. But I knew it was only a matter of time before I was exposed as an impostor. Certainly someone would announce to everyone that I was faking it: “He’s not a real student. He’s not one of us.” I felt they would be able to peek underneath and see the thoughts and experiences that I drifted to so often. The thoughts became a heavy blanket of security and comfort from the exposure that I felt.

The same thoughts and experiences separated them from me. The feel of the grip of my M-4 in my hand, my thumb brushing the safety. The deep penetrating rhythmic pulse of 50-caliber machine guns bursting in harmony. The smell of dirt and diesel and weeks-old sweat. The vivid realism of my thoughts gave me fleeting moments of normalcy within the distant isolation I felt.

In time, I settled in. This was largely by discovering that I was not alone. We discovered each other with an indoctrinated familiarity. Maybe the clue was a glimpse of a nylon belt or a matte-black knife in a pocket. The small things that all of us had that linked us to the life we had left. It wasn’t long before we were doing our own group therapy over pints of beers and war stories. Our shared experiences and our shared identity meant we did not have to be alone. Eventually our group expanded and formalized. We began doing outreach at vet centers promoting education and welcoming new student veterans to the campus. We attempted to use our individual experiences with the uncertainties of transition to create an environment of acceptance and understanding.

Leaving the military is not an easy or simple process. Like any major transition, it brings the stress of adjustment to new roles, relationships, routines, and assumptions.

 According to Schlossberg, it is not the transition itself that is important but the degree of change. The roles, relationships, routines, and assumptions within combat are unlike anything that a service member finds outside of the military. The degree of change that a combat veteran experiences while transitioning to civilian life is profound. The potential psychological stress of coping with such a change exposes one to the risk of significant adverse effects to health and well-being. To effectively direct interventions and support, attention should be placed on the factors that contribute to the transition, or transitions, as well as the factors that contribute to the ability to successfully adapt to the transition.

Schlossberg has done extensive work on transition and adaptation to transition. She has offered a model for analyzing human adaptation to transition in her aptly named 

, “A Model for Analyzing Human Adaptation to Transition.”

 I believe that her model offers guidance and insight to the combat veteran transitioning to civilian life. Her model can help identify the variables that affect transition and adaptation and, thus, guide treatment to minimize the potential effects of any psychological stress.

She defines a transition as “an event or non-event that results in a change in assumptions about oneself and the world and thus requires a corresponding change in one’s behavior and relationships.” Adaptation to transition is defined as “a process during which an individual moves from being totally preoccupied with the transition to integrating the transition into his or her life.”

Schlossberg’s model, drawing from a large body of literature on adult development, lays out 3 major factors that influence adaptation to transition (

 The characteristics of the particular transition

 The characteristics of the pre-transition and post-transition environments

 The characteristics of the individual experiencing the transition

 that the “ease of adaptation to a transition depends on one’s perceived and/or actual balance of resources to deficits in terms of the transition itself, the pre-post environment, and the individual’s sense of competency, well-being, and health.”

The transition of the combat veteran to civilian life is part of a sequence of several other significant factors in the individual’s life. The first is from civilian life to the military. This transition is facilitated through various levels of training aimed at establishing new roles, expectations, values, and norms of the military. The second transition is the experience of combat itself. Many of the roles and expectations of combat are taught and trained for prior to the experience. However, once within the unpredictability of actual combat situations, numerous influences have the power to “change [one’s] assumptions about oneself and the world.”

 Each of these is significant in and of itself, but they also determine the ease with which a combat veteran will adapt to civilian life.

Schlossberg’s model lays out several characteristics that can be used to describe a transition: role change (gain or loss); affect (positive or negative); source (internal or external); timing (on-time or off-time); onset (gradual or sudden); duration (permanent, temporary, uncertain); and degree of stress. Each of these may apply in varying degrees of relative influence and will certainly differ in importance based on the specific role that a combat veteran transitions to in civilian life.

For example, how can a combat veteran who leaves the service at 24 and enrolls in college fulfill these various characteristics? He can view leaving the service as the loss of a previous role, but inversely he may have a positive affect about gaining the role as a student. He may also feel that age 24 is a socially “off-time” to be starting college.

In addition, some individuals leave the military suddenly and not as the result of their own choice, which may negatively contribute to the overall level of psychological distress. The characteristics and ultimate degree of stress are influenced by the individual’s perception of the transition as well as by individual personality type. An understanding of this may provide clues for potential areas of interest to improve coping with the transition.

Pre-transition and post-transition environments

The second factor that influences adaptation to transition is the relative difference between the pre-transition and the post-transition environments. This relates to multiple different domains, including interpersonal support systems, institutional support systems, and the physical settings of the pre- and post-transition environments.

When I started college, I felt disconnected to would-be peers until I found other veterans on campus with similar stories and experiences. In the military, individuals have relationships within their units that are based on shared experiences. When they transition out of the military, veterans often leave these relationships behind or have limited continued contact.

There are numerous different veteran groups around the country: some are national organizations, some are local and specific to regions. Some utilize recreation as a core, while others focus on volunteerism and continued “service”; other groups are simply social. All can help veterans forge a connection to others with similar experiences in order to have the interpersonal support that they may have had while on active duty. Recognition of this and referral to different groups may greatly improve the ability of combat veterans to successfully transition from active duty.

The third major factor that can affect adaptation to transition is the person’s characteristics. There are multiple individual characteristics that can contribute to adaptation, but a few are of great significance to the combat veteran. The first is psychosocial competence. A 

 for psychosocial competence was defined by Tyler

 that involves self-attitudes, world attitudes, and behavioral attitudes.

, and anxiety often afflict combat veterans. These disorders, perhaps especially PTSD, represent significant change in one’s view and attitudes about one’s self, the world, and subsequent behavioral attitudes. It is therefore not surprising that 

 conducted by the US Department of Veterans Affairs notes that those with PTSD have greater difficulty with reintegration, or transition, to civilian life than those without the disorder

 Successful identification and treatment of PTSD and other psychiatric disorders can positively contribute to the psychosocial competence of the individual and in turn improve capacity for adaptation to transition.

The individual’s state of overall health can also affect adaptation. Veterans as a group have poorer health and health behaviors than active duty or civilian populations, including higher rates of smoking, heavy alcohol use, and diabetes and lower levels of exercise.

Age and life stage also play an important role in the adaptation to transition. It is unlikely that chronological age is of great importance, but life stage is. It may be important to recognize that the average combat veteran may have very different experiences in terms of leadership and responsibility than a civilian of similar chronological age. In addition, there are differences in the nature of stresses experienced and a difference in the ratio of positive to negative experiences. All of these contribute to the relative life stage of the individual.

The final individual characteristic is the individual’s experience with past transitions. As stated, the combat veteran has already participated in significant past transitions. The effectiveness with which the individual may have navigated those transitions may give clues about future success with transitions and may point to psychological or personality qualities that determine success or difficulty.

By several metrics I could say that my adaptation to transition from a combat role was successful. I graduated Phi Beta Kappa from a well-regarded university, graduated from medical school, and will be starting my 4th year of psychiatry residency as a chief resident. However, I still feel the grip of that life with a rifle that I led years ago. It is something that I know will never leave me completely. That’s OK because the real change-the real success-is that I now feel comfortable and confident in my new role, with new relationships and expectations.

We all have different personalities and psychological perspectives that contribute to our ability to adapt to transition. Some of us may have had experiences or physical injury leading to a radical shift in views and assumptions about self and the world. We may be without the interpersonal supports and relationships that may have existed on active duty, which leaves us with a sense of isolation and disconnection. Our physical health may have declined. Perhaps we have struggled through every transition we have faced in the past. There are many different factors that contribute to the ability of the combat veteran to successfully adapt to the transition to civilian life. Successfully identifying those factors and addressing them can lead to improved adaptation and subsequent improvement in health and well-being.

Dr. Brown is currently a Fourth-Year Psychiatry Resident at the Naval Medical Center in San Diego, CA; he serves as the Chief Resident of the Consult/Liaison Service. The author reports no conflicts of interest concerning the subject matter of this article.

 Schlossberg NK. Transitions: theory and applications. International Perspectives on Career Development. Symposium conducted at a joint meeting of the International Association for Educational and Vocational Guidance and the National Career Development Association; June 2004; San Francisco, CA.

 Schlossberg NK. A model for analyzing human adaptation to transition. 

 Tyler FB. Individual psychosocial competence: a personality configuration. 

 Sayer NA, Noorbaloochi S, Frazier P, et al. Reintegration problems and treatment interests among Iraq and Afghanistan combat veterans receiving VA medical care. 

 Hoerster KD, Lehavot K, Simpson T, et al. Health and health behavior differences: US military, veteran, and civilian men. 

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Leaving the military is not an easy or simple process. Here is one psychiatrist's personal story.

Author | Nathaniel A. Brown, MD

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Combat Veterans: Adaptation to Transition