Excerpts from an entry in the Journal of Social work Education found at Unique challenges of war in Iraq and Afghanistan by Marilyn Flynn, Anthony Hassan THE EVIDENCE IS IRREFUTABLE. The wars in Iraq and Afghanistan, which formally began more than 7 years ago, differ in significant respects from previous confrontations. The number and types of injuries, the frequency of deployments, the nature of our military force, the consequences for family life and children, and the conduct of the war itself have combined to create a crisis for our society. The number of surviving service members with permanent disabling injuries surpasses that of any previous modern conflict. In World War II the survival rate for those suffering physical wounds was 2:1; it is now 8:1 (Tanielian & Jaycox, 2008). The invisible wounds of war are even more prevalent. Of the 1.7 million persons sent to battle since 2003, RAND Corporation estimates that more than 500,000 will develop combat stress disorders ranging from severe anxiety to depression. Untreated, these reactions may last a lifetime (Tanielian & Jaycox, 2008). The devastating effects of frequent redeployment--a hallmark of this war--are now well-documented. The practice of redeployment has been restricted by Congress for National Guard and Reservists, but not active duty troops. Some war fighters can respond to repeated combat exposure with bravery and resilience; for others, this is not the case.

Service members subjected to prior trauma, such as family violence in their own lives, are more susceptible, especially if they return to violent lower income neighborhoods following separation from the service. Hispanics, women, persons over 40, and reservists are also nearly twice as likely to experience posttraumatic stress disorder (PTSD) and major depression (Castaneda et al., 2008; Schell & Marshall, 2008). Estimates suggest that as many as one third of all women service members have been exposed to military sexual trauma in addition to the normal rigors of service. Beyond frequent redeployments, once at war service members have no "front" from which to retreat and recoup. In the streets, hills, and countryside informal explosive devices and snipers are concealed everywhere. The sounds of war are sometimes incessant, creating a lasting form of hypervigilance. Service members have no "step-down" time when they leave the Middle East. In as little as 18 hours, they may move abruptly from combat conditions to home community. The transition can be exceptionally difficult. Not surprisingly, families and children are profoundly affected. When a returning veteran cannot sleep, turns day into night, reacts with unpredictable irritability, fails to maintain employment, and is unable to concentrate, each of his or her family members is thrown out of normal balance.

Children react by performing poorly at school, developing strained family and peer relations, displaying bullying behavior, or becoming depressed. Parental combat deployment has a cumulative effect on children that remains even after the deployed parent returns home (Chandra et al., 2010; Hall, 2008; Lester et al., 2010). The lack of social and institutional understanding of secondary PTSD compounds the pain of this experience, especially in public schools and other institutions in the vicinity of military bases. The problem of combat stress is an old one extending back perhaps to warfare in ancient Greece and Rome. Veterans of the Civil War had "soldier's heart," a crushed state of mind that led to withdrawal and dispiritedness; soldiers from World War I were thought to be "shell shocked;" World War II combatants suffered from "combat neurosis." Interventions have included punishment, shaming, and a variety of largely untested treatment methods. Unfortunately, treatment methods in community mental health centers, veteran's centers, Veterans Health Administration hospitals, schools, public health clinics, and other venues may not reflect state-of-the-art knowledge (Tanielian & Jaycox, 2008). The National Institute of Mental Health estimates that the present state of practice in mental health at these facilities lags about two decades behind the treatment models supported by recent clinical trials (Brekke et al., 2007). Anecdotal evidence based on interviews with military medical commanders and mental health providers suggests that some interventions in the military have not changed since World War II.

Efforts to introduce new approaches to PTSD have often been met with resistance from older staff in established military and community mental health clinic settings. As a consequence, when service members rejoin their communities they encounter a civilian environment ill- prepared to accommodate them appropriately with mental health and health care, employment readjustment support, or other needed services (Burnam, Meredith, Tanielian, & Jaycox, 2009; Department of Defense Task Force on Mental Health, 2007; Tanielian & Jaycox, 2008). In many parts of the country, community mental health care providers for veterans have insufficient capacity and frequently fall short of recommended standards for care (Burnam et al., 2009; Castaneda et al., 2008; Department of Defense Task Force on Mental Health, 2007; Erbes, Curry, & Leskela,