Occupational Stress and Depression among Vietnam Veterans

An exploratory analysis was conducted to assess the effect of exposure to a distal source of extreme trauma on current levels of depression. The purpose of this study was to assess the nature of the relationships among: (1) exposure to the extreme stressor of combat in Vietnam; (2) persistently difficult life conditions; and (3) psychological distress. The impact of various stressors on current psychological distress is evaluated in light of the mediating influence of personal coping resources. Findings suggest that exposure to combat has neither a direct nor an indirect effect on current levels of depression. Exposure to combat was found to affect depression only as it interacts with work-related sources of chronic strain. INTRODUCTION AND PURPOSE Almost a decade has passed since United States armed forces withdrew from Vietnam, yet debate continues about the long-term impact of the war on the lives of the survivors. Relatively few battlefield psychiatric casualties were produced by the Vietnam War. However, once the war had ended, mental health * An earlier version of this paper was presented at the annual meeting of the Midwest Sociological Society in Chicago, April 20, 1984. The research was supported in part by the National Institutes on Drug Abuse, Grant DA-2046, Richard R. Clayton and Harwin L. Voss, Co-principle investigators. professionals began to report high rates of psychiatric symptoms among Vietnam veterans. This problem was also acknowledged by the government, as noted in a 1975 Veterans Administration internal memorandum indicating that: ". . . serious and prolonged readjustment difficulties seem to exist in one out of five Vietnam Veterans and to a lesser degree are experienced by all." (Boulanger et al., 1981) Labeled Post-Traumatic Stress Disorder (PTSD) in 1980 by the American Psychiatric Association, service in Vietnam became legitimized as a distal but powerful causal factor in producing a set of symptoms that includes: feeling jumpy and irritable; having nightmares and flashbacks; apathy; anxiety; depression; insomnia; fear of losing control; and experiencing general disphoria. A variety of related behavioral problems found to be associated with exposure to combat in Vietnam include confusion, anxiety, frustration, helplessness and social isolation (Worthington, 1978); drug dependence (Robins et al., 1974); substance abuse and (Nace et al., 1978); and manifest anxiety (Enzie et al., 1973). Since the war, there have been a number of research reports that address the psychological and social adjustment process of Vietnam veterans to reintegrate back into society (Boulanger, 1981). In a review of the literature on the long-term psychological consequences of combat exposure, Boulanger et al., (1981) indicate that many of these studies identify the amount and intensity of exposure to combat as potential causes of psychological distress (i.e., Helzer et al., 1978; Glass and Appel, 1969; De Fazio and Rustin, 1975; Strayer and Ellenhorn, 1975; Figley and Southerley, 1980). Boulanger further notes that the more precisely combat experience is measured, the more the long-term psychological consequences become apparent. In a number of other studies, no "significant" effects of combat exposure were found. However, Boulanger et al. (1981) argue that these results can be discounted for two reasons: (1) because they failed to precisely measure combat exposure or (2) biased samples were used (i.e., Borus, 1974; Buchbinder et al., 1979; Panzarella et al., 1978). Neither Buchbinder et al. nor Panzarella et al., distinguishes between combat and non-combat Vietnam veterans, however, although both reports suggest that military service in Vietnam was itself sufficient to produce stress reactions. These findings are subject to further criticism because in failing to control for combat exposure the analysts fail to provide support for the existence of a post-Vietnam stress syndrome associated with combat experience. Boulanger et al. (1981) also criticize the research of Nace et al., (1978) for only using an "approximate" measure of combat exposure thereby raising a question about the validity of the major finding: that the only psychological adjustment difference found to exist between combat and non-combat veterans of the Vietnam War was an increased incidence of depression. In addition to "psychosocial" responses to combat exposure, there is some evidence to suggest that military service in Vietnam had an effect on the educational and work careers of the veterans. These "social" consequences were the primary focus of a work entitled Legacies of Vietnam (U.S. Congress, 1981). The data show that veterans of the Vietnam era have attained less education and hold lower level jobs than do non-veterans. These differences appear to be even more marked among veterans who served in Vietnam since a large number of them have experienced serious work-related problems and have higher levels of unemployment. It is further reported that many of the occupational differentials observed between veterans and non-veterans are due to the greater likelihood of non-veterans having graduated from college. It is also reported in Legacies of Vietnam that occupational and educational disadvantages of veterans as compared to non-veterans are largely due to background characteristics. The most important of these pre-military characteristics is the level of education attained prior to entry into the military. Moreover, the most disadvantaged group appears to be veterans who were exposed to combat. In sum, these findings suggest that the effects of military service in Vietnam and exposure to combat on occupational attainment result primarily through its negative impact on post-service educational attainment. Kadushin et al.(1981) do not specifically consider the potential moderating effect of occupational and educational attainment on the relationship between long-term stress reactions and combat exposure. While some evidence is provided that status as a Vietnam veteran has a deleterious effect on such attainment and that exposure to combat increases the likelihood of post-traumatic stress symptoms, they fail to present their findings in a convincing integrative fashion. This is typical of research that attempts to assess the effect of exposure to traumatic situations. No attempt is made to sort out the potential statistical interactions, and no attempt is made to theoretically integrate the process by which stressful events impact on the subsequent life-course of the survivors. For example, Kadushin et al. (1981) indicate that psychological stress reactions were more intense and more likely to persist among men whose social position makes them least able to cope (i.e., minority members, the unemployed, the poor, and members of unstable families). In reporting these findings, however, the analysts fail to conceptually account for or empirically disentangle the effects of exposure to combat. In order to understand the relationship between the extreme stress of combat and subsequent levels of psychological distress, it is necessary to extend conceptually and analytically previous lines of inquiry. To understand the manner in which exposure to combat affects the psychological well-being of survivors, it is essential to consider the relationship in terms of predispositional characteristics as well as taking into consideration the potential consequences of exposure to combat. It is also essential that the relationship between combat exposure and subsequent psychological and social adjustment be examined within the more general context of the effects of stressors on distress. The purpose of this paper is to examine the consequences of Vietnam military service within the integrative framework suggested by Pearlin. This framework allows for consideration of the nature of the relationships among: (1) exposure to the extreme stressor of combat in Vietnam; (2) persistently difficult life conditions; and (3) psychological distress. The impact of various stressors will be assessed in light of the mediating influence of individual coping resources. CONCEPTUAL FRAMEWORK Pearlin et al. (1981) indicate that stress can result from either discrete events or the presence of continuous problems. The analysts also note that adverse consequences are primarily dependent on the "quality" of stressful life events as determined by their desirability (Gersten et al., 1977; Mueller 1979; Vinakur and Seltzer, 1975), the degree of control people have over their occurrence, and whether or not these life events are "scheduled" life-cycle transitions. Another important factor is the recognition that stressful events do not always have a direct effect on individuals, but may also operate through a wider context of "chronic" stressors. Arguing that stressful experiences and chronic stressors converge in the production of psychological distress, Pearlin and Liberman (1979) empirically demonstrated that life events may create new stressors or intensify pre-existing stressors thereby producing a stress-related response. Occupational strain and job dissatisfaction, for example, have been shown to have a deleterious impact on mental health (House et al., 1979; House, 1981; Kasl, 1974, 1978; Kornhauser, 1965; LaRocco et al., 1980), and are included among the category of stressors identified by Pearlin and Schooler (1978) as having the potential for arousing threat. These research findings suggest that role strains are important mechanisms linking stressful events to adverse reactions such as depression. Moreover, these