Identity and veteran health: Considerations of context, culture, and change

Abstract

Veterans often have poor physical, psychological, and social health outcomes compared with civilians, including elevated rates of substance abuse, self-harm, and suicidality. These outcomes are exacerbated by the reluctance of military personnel and veterans to engage with healthcare services, and a lack of consensus about optimal rehabilitation and transition strategies. In addition, the extent to which these outcomes and behaviours relate to identity is not clear. This investigation aimed to explore the extent to which identity and agency (collectively comprising ‘sense of self’) impacted the health and health behaviours of serving soldiers undergoing rehabilitation and transition. To achieve this, a qualitative thematic and contextual approach, positioned between non-relativist social constructivism and critical realism, was employed. Thirteen Australian high-risk combat soldiers undergoing rehabilitation took part in two semi-structured recorded interviews. These yielded approximately 50 hours of primary interview data, which were then transcribed, coded and analysed using psychodynamic object relations theory. This theory was developed by scholars such as Donald Winnicott and Ronald Fairbairn, who shared several features: they were veterans, held qualifications in medicine and psychoanalysis, and many had personal histories of early separation from their family. These experiences attuned them to primary group relationships (wherein mutual dependence is necessary for collective survival). As such, many of the concepts embedded with object relations theory had particular relevance to the experiences of current participants. Analysis yielded four data-driven papers that provide insight into the development, defense, loss, and redevelopment of participants’ identity, and the extent to which these influenced health and health behaviours. The first paper critically examines identity developed in combat and highlights the mechanisms that undermine such identity. The second documents the meaning soldiers attach to health and how these impact on health behaviours including primary healthcare utilisation. The third explores the extent to which identity loss related to participants’ negative health behaviours, including self-harm and suicidal ideation. The final chapter highlights the utility of exploring values in military and veteran populations and, in doing so, provides insight into the process of individuation and separation evident as some participants came to terms with their loss. Overall, the speech of participants, their reported behaviours, coping mechanisms, and relating styles, paralleled those most typically associated with adolescence. Although strong primary relationships were critical to mission success, extremely adaptive in context, and thereby highly valued, it appeared that when particular behaviours and perceptions of self and others were no longer available, a crisis of identity ensued. This crisis triggered negative emotional and behavioural consequences in all participants, and for some it also brought about a degree of maturity previously unknown to them. Findings and analysis have theoretical, policy, and clinical implications. They suggest that rehabilitation and transition may be usefully understood as a stage of separation and individuation, which points to the need for psychologically-framed primary healthcare services that build upon soldiers’ perceptions of health, articulation of need, and what they value, especially by way of interventions that address issues of identity and agency.