The influx of combat injured service members needing care from war efforts in Afghanistan/Iraq who are entering the Department of Defense (DoD) and Veterans Health Administration (VA) health care systems, continues to tax existing resources (
1). In all, fewer than 10 percent of Americans wounded in 2010 in Afghanistan/Iraq, died from their wounds ( 2). This is an extraordinary survival rate and it has created a cohort of thousands of returning service members challenged to deal with and overcome their war-related disabling conditions. This high level of need for the care and rehabilitation of the military injured/disabled results from advances in medical care, a highly efficient system of evacuation from the battlefield, and advances in body armor ( 3). Many of our troops are being rescued from near death injuries, missing multiple limbs, suffering brain damage and with wounds and disabling conditions that will be exceptionally difficult to overcome as the injured/disabled try to resume work, social and family ties. The loss of well-being and the trauma of these disabling conditions have created an increased need for behavioral health practitioners and others to be particularly sensitive to the acceptance process of rehabilitation for these injured service members.
There has been remarkable progress in medical care for the wounded in current warfare. For the systems of care for our soldiers, this means that more service members return home with grave injuries that can transform their lives, many with injuries that require extensive level of care and needing treatment for many years after their initial injury (
4). As of February 2104, more than 51895 service members have been wounded in action in Afghanistan/Iraq ( 5). It is estimated that for every military personnel killed, there are at least 16 wounded ( 6). Approximately 20% of the wounded service members are treated and return to active duty within 72 hours; 80% are not able to return to duty and are sent to the United States for intensive and often protracted medical care. The most common cause of injury is blasts from IEDs (improvised explosive devices) which have numerous effects on the body including fractures, amputations, vision and hearing loss, burns, and traumatic brain injury ( 7). Casualty reports from the DoD ( 5) note that 1621 service members suffered major or partial limb amputations from 2001 to 2012. Upon wounding, typically the service member is sent to medical facilities in Germany and as soon as feasible, returned to the United States for care in a (DoD) facility or one of several poly-trauma centers in the United States ( 8).
Long-term rehabilitation of injured service members, those unable to return to active duty, is geared to restoring patients to their highest level of functioning. Rehabilitation takes place in a wide array of inpatient and outpatient government facilities. While many service members who receive rehabilitation services will return to active duty, others who are more seriously injured will likely be discharged from their military obligations and return to civilian life as Veterans, cared for in the VA health care system. Many Veterans with major disabilities and limitations could require life-long medical surveillance and rehabilitation (
9). In addition, a potential complicating factor in many cases, it is estimated that 75-90% of those injured in war will develop symptoms of post-traumatic stress disorder ( 10). Due to the large influx of military wounded from the current conflicts, rehabilitation therapies and counseling efforts will continue to be needed and have been bolstered over the last many years ( 6). 1.1. Acceptance of Disability for the Wounded Service Member
A wounded service member tends to have a unique situation as he/she transitions from active military service to civilian life (
11). Service members wounded in war face numerous hurdles and their transition, depending on the circumstances of their injury. Emotionally, they may feel unworthy, guilty, as though they have let others down; they may feel diminished and have a compromised sense of self due to physical limitations; there may be personality changes due to pain and pain medications; oftentimes the soldier’s routine is reduced to medical and hospital appointments. All of this is a far cry from active duty responsibilities. In many instances, there is the over riding concern that the service members will not be accepted as they are with the additional concerns of life style change and financial concerns ( 12). The process of injury acceptance poses many challenges as the service members attempts to integrate into their life and establish a new post-deployment life. Some of the challenges are unique to the military experience and complicated by the military culture.
The study described in this article sought to enhance understanding of the factors-demographic and war-related-that contribute to acceptance to disabling injury for those who have served in Afghanistan/Iraq. It was anticipated that knowledge of these factors would offer health care and behavioral health care providers a broader understanding of the rehabilitation and acceptance experience.
1.2. Becoming Disabled
Becoming a person with a disabling condition can create a profound change in the lives of the individual and those close to him or her. Many reactions can be anticipated on the part of disabled person and those close to his/her including high levels of stress, loss and grief, physical and sensory changes, changes in body image and functionality, stigma, unpredictability about the future, as well as numerous quality of life issues (
13). For those injured in wartime, these challenges frequently occur with the additional ‘job’ of integrating the wartime experiences as the disabled person transitions to civilian life ( 14). 1.3. Models of Disability
While there are numerous ways to view disability and the ideology of disability care and rehabilitation, two models dominate the discussion of disabling conditions: the social model and the medical model.
The social model sees the issue of disability as a socially created problem with an emphasis on the impact of society’s view on the disabled person. Disability is not an attribute of the person but more a complex collection of conditions, many of which are created by the social environment. As such, it behooves society to address the environmental conditions-the systemic barriers-that deter disabled persons from full participation in all areas of life. An example of this would be the necessity for all public buildings to have ramps in place for wheelchair access. In contrast, the medical model views disability as a condition of the person that requires sustained medical care. The emphasis on the person suggests that the disabled person must make adjustments and behavioral changes to enhance their life. Inherent in the medical model is the role of society as being responsible for caring for the disabled and developing medical approaches to reducing the impact of the disabling condition, i.e. improved prosthetic devices for the amputee. For this study, greater emphasis is placed on the medical model that sees the person’s adjustment and behavioral efforts, as important for their acceptance to their disabling condition (
15). 1.4. Acceptance of Disability
Acceptance of disability describes the process a person goes through in order to come to terms with his/her disabling condition. Dembo et al. (
16) and Wright ( 17) described acceptance of disability as a series of value changes wherein individuals will enlarge the scope of their personal values in such a way that the perceived losses from their disability do not negatively affect the value of their existing abilities. The individual’s acceptance of their disabling condition is associated with better adjustment of the disability. The perception of disability as a misfortune or value loss leads the person with a disability to underestimate their existing abilities resulting in personal devaluation. Many experience disabling conditions as those that ‘take away’ from the value of the self, potentially compromising self-esteem and resulting in levels, albeit not necessarily permanent, of depression and devaluation. Wright ( 17) refined the process of acceptance of disability in terms of four value areas that are experienced which include enlargement of scope of values, subordination of physique, containment of disability effects, and transformation from comparative values to asset values. Enlargement of the scope of values-Occurs when the person begins to recognize the importance of values other than those that have been lost by their disability. This occurs when a person can find meaning in events and abilities that they can accomplish rather than they cannot accomplish. They are enlarging their sphere and personal definition beyond the disability.
Subordination of physique-Physique includes physical perfection, beauty and ability, which many who are disabled consider lost to them. As a person begins to accept and adapt to their disability, the emphasis on physique is lessened and other attributes such as friendship, intelligence, work and creativity gain ascendance. Physique is subordinated to other qualities. Containment of Disability effects-Many disabled individuals considers their disability as their primary defining characteristic. Persons who do not spread their disability beyond their actual impairment are said to be able to contain the effects of their disabling condition. Containment is achieved if the disability is seen only as a possession and the person and disabling condition are seen as separate, or only one of many aspects of the individual. Transformation of Comparative Values to Value Assets- the value shift characteristic of transformation requires individuals to move beyond comparing their limitations and liabilities to emphasizing their assets and abilities. Asset value makes it possible to appreciate the positive in the person, moving beyond comparison to others (
18). These value shifts vary over time. 1.5. Study Instrument
For this study of Veterans with a disabling condition, the Revised Acceptance of Disability Scale (ADS-R) (
18) measured the value shifts leading to acceptance of Veterans cared for in the Warrior Transition Brigade of two major DoD facilities. The relationship between the acceptance of disability and demographic characteristics was assessed. It should be noted that this study is grounded in a medical model of rehabilitation, i.e. there is greater emphasis on the mind-set of the patient and his/her ability to adjust and adapt to their disabling condition. 1.6. Study Hypotheses
This study had the following hypotheses:
1) Participants will display a low level of acceptance of disability, as evidenced by a low score (32-64) on the ADS-R and will display low levels of acceptance in each of the value areas.
2) Participants’ degree of disability acceptance, as measured by scores on the four subscales of the ADS-R, will be a predictor of their level of acceptance to disability.
3) Participants’ age, number of deployments, and length of deployments (as per participants’ self-report), will negatively impact their level of acceptance to disability.
4) There will be differences in participants’ level of acceptance to disability, based on differences in gender, race, education level, family status and type of injury.