Mental Health: Global Challenges Journal
https://www.sciendo.com/journal/MHGCJ
ISSN 2612-2138
From treatment to social reintegration: principles of
medical and psychological support of veterans (on
example of the Russian-Ukrainian war)
Mykhaylo M. Pustovoyt, Ivan R. Romash, Iryna B. Romash, Myhailo I. Vynnyk, Kateryna V. Dzivak,
Ihor I. Syniuk, Bohdan M. Matushevskyi
Ivano-Frankivsk National Medical University. Ivano-Frankivsk. Ukraine.
Abstract
Introduction: Analyzing numerical data from different countries around the world
that have
experience of participating in wars and resolving their consequences, it is important to consider
the wide range of war effects on all spheres of society. This influence is discussed in the context
of economic, political, state-building, demographic, and other spheres. Special attention is
given to analyzing the consequences of this impact on individuals
returning from war. These
consequences are diverse and include physical and psychological problems, job loss, social
exclusion, and other challenges that require an integrated approach to effectively address
them.
Purpose: To analyze the main principles of medical and psychological rehabilitation of combat
veterans, having conducted a comprehensive analysis of their links and constituent elements,
and to consider possible ways of their implementation.
Methodology: We conducted a systematic search in the main electronic medical databases
such as: PubMed, Scopus, Web of Science and Google Scholar until January 2024. We used
theoretical methods such as systematic, bibliosemantic and retrospective, comparative analysis
and generalization of the publication da
ta of the conducted studies that considered links,
components, principles and possible ways of their implementation in the field of medical and
psychological rehabilitation of combat veterans. Relevant studies were identified by key words:
war or combat veterans, rehabilitation, reintegration, psychoeducation, hub.
Results: The research revealed complex challenges in the system of medical and psychological
rehabilitation of military veterans, including post-traumatic stress disorder, physical injuries, social
isolation and limited resources. The analysis identified key principles important to the planning
and implementation of rehabilitation programs, including individualization, comprehensiveness,
accessibility, and integration. The results highlighted the importance of a systems approach and
collaboration between various parties concerned for the effective implementation of the
veterans’ rehabilitation system. The study suggests specific ways of the identified principles
implementation. Un
derstanding the modality of the medical and psychological rehabilitation
system is a key aspect in improving the quality of rehabilitation and providing adequate support
to veterans. In order to achieve these goals, a hierarchy of therapeutic goals was created
determining the modalities of the medical and psychological rehabilitation system.
Conclusion: Effective medical and psychological rehabilitation for combat veterans should be
based on the systematic organization of care, recognizing the importance of each component
in ensuring coordination, efficiency and quality of services. Establishing clear therapeutic goals
forms the basis for comprehensive psychological support, contributing to veterans’ self-esteem,
mental health, and social integration, ultimately enhancing their overall well-being and quality
of life.
6
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Mental Health: Global Challenges Journal
https://www.sciendo.com/journal/MHGCJ
ISSN 2612-2138
Keywords
Mental health, combat veterans, mental trauma, medical and psychological rehabilitation,
reintegration, psychoeducation, hub.
Address for correspondence:
Ivan R. Romash, Associate professor of The Department of Psychiatry, Narcology
and Medical Psychology, Ivano-Frankivsk national medical university, Ivano-
Frankivsk. Ukraine , E-mail: iromashr@gmail.com
This work is licensed under a Creative Commons Attribution-Non-Commercial 4.0 International
License (CC BY-NC 4.0).
©Copyright: Pustovoyt, Romash, Romash, Vynnyk, Dzivak, Syniuk, Matushevskyi, 2024
Publisher: Sciendo (De Gruyter)
DOI : https://doi.org/10.56508/mhgcj.v7i1.196
Submitted for publication: 21
January 2024
Revised: 20 May 2024
Accepted for publication: 30
May 2024
Introduction
Analyzing numerical data from different
countries of the world that have experience of
participating in wars and resolving their
consequences, it is important to take into
account the wide range of war effects on all
spheres of society. This influence is discussed in
the context of economic, political, state-building,
demographic, and other spheres. Special
attention is paid to the analysis of the
consequences of this impact on individuals
returning from war. These consequences are
diverse and include physical and psychological
problems, job loss, social exclusion, and other
challenges that require an integrated approach
to effectively address them (Shvets et al., 2021;
Vus, Esterlis, 2022).
The war in Ukraine actualized the problems of
treatment, medical and psychological
rehabilitation of combat veterans. Special
attention needs to be paid to the organization of
an effective system of support for veterans of the
Russian-Ukrainian war (Lashko et al., 2023). Full
mobilization of the efforts of state bodies,
doctors, psychologists, and volunteers is
necessary to solve them. It will probably not do
without the support of foreign partners, first of all
their practical experience (Matiashova, Tsagkaris,
Essar, Romash, Vus, 2022).
Despite this, the current legislation still lacks a
clear definition of who exactly is considered a
war veteran. Unfortunately, the lack of a clear
legal definition of the term war veterandoes not
allow for the formation of a single
understandable state approach to this category
of citizens. According to the Law of Ukraine dated
22.10.1993 No. 3551-XII, On the status of war
veterans, guarantees of their social protection
(Current version 16.01.2024.), war veterans are
individuals who participated in the defense of the
Motherland or hostilities on the territory of other of
states. War veterans also include: combatants,
people with disabilities as a result of war, war
participants. In general, according to the
specified law with numerous point changes in its
provisions, this word unites 54 categories of
citizens who have the status of a war veteran and
are covered under state benefits and
guarantees. (25 of them are individuals
belonging to combatants; 16 are individuals
belonging to people with disabilities due to war;
13 are indivduals belonging to war participants).
Ukrainian veterans are a diverse group of
people with different life paths that have
preceded the war. They include people who led
a peaceful civilian life before becoming
participants in hostilities, as well as those who
were professional soldiers. They come from
different socio-economic strata, represented by
different age categories: from youth to early
retirement age (Friedrich, Lutkefend, 2021).
Unfortunately, Ukrainian society has various ideas
about who a veteran is. The term veteranis still
often associated with the older generation,
fighters of past wars, especially World War II. In our
opinion, it is necessary to work on a general
public perception that would correspond to
modern reality, because the target audience
and the average portrait of a veteran and his or
her needs has fundamentally changed. And the
reality is such that more than 39% of members of
the armed forces belong to the category of
youth (aged 18 to 35) according to statistics in
2023 (Kirillova, Znovyak, Kazanska, Tkalyc, 2023;
Kirillova et.al.,2023). The vast majority of people
who will return from the war are people in their
both professional and physical development.
They have certain experience and competencies
acquired during military service. It is very
important not only to integrate them successfully
into civilian life but also to use rationally their
knowledge and skills in various fields.
A survey conducted in January 2023 by the
Ukrainian Veterans Foundation of the Ministry of
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Mental Health: Global Challenges Journal
https://www.sciendo.com/journal/MHGCJ
ISSN 2612-2138
Veterans Affairs in partnership with the
sociological group Rating on the topic Needs
of Veterans” as a part of the comprehensive
study Portrait of a Veteranshowed that only 7%
of respondents stated the need for psychological
support at this time. However, 20% of the
respondents expressed a desire for psychological
help when asked about their future needs. As for
the results of the study of the veteranssatisfaction
level regarding the service sector, the lowest
indicators fell on the level of medical care,
48.9% of respondents expressed their
dissatisfaction.
As part of the program, in the autumn of
2022, the Ministry of Veterans Affairs proposed to
improve the state regulation of the psychological
assistance provision to veterans and to adopt the
Resolution of the Cabinet of Ministers of Ukraine
On some issues of providing free psychological
assistance to individuals who are being
discharged or discharged from military service
from among war veterans, individuals who have
special services to the Motherland, family
members of such individuals and family
members of deceased war veterans and family
members of deceased Defenders of Ukraine”.
Purpose
The aim was to analyze the main principles of
medical and psychological rehabilitation of
combat veterans, having conducted a
comprehensive analysis of their parts and
constituent elements, and to consider possible
ways of their implementation.
Methodology
We conducted a systematic search in the
main electronic medical databases such as
PubMed, Scopus, Web of Science and Google
Scholar until January 2024 and used the followign
theoretical methods: systematic, bibliosemantic
and retrospective, comparative analysis and
generalization of the publication data of the
conducted studies that studied links,
components, principles and possible ways of their
implementation in the field of medical and
psychological rehabilitation of combat veterans.
Relevant studies were identified by key words: war
veterans, rehabilitation, reintegration,
psychoeducation, hub. All types of articles,
including original studies, systematic reviews, and
meta-analyses were reviewed. Studies with
reported conflicts of interest and results presented
in the popular media rather than peer-reviewed
journals were excluded.
Results
The analysis of recent research and
publications
Various approaches to the definition of the
war veteranconcept and determination of the
support level provided to them exist in the world.
Some countries designate war veterans solely as
those who participated in hostilities, wars, or
armed conflicts. Conversely, in other nations,
veterans encompass anyone who served in the
armed forces, irrespective of combat
involvement. For instance, in Great Britain, an
armed forces veteran is defined as an individual
who served at least one day in the Armed Forces:
regular or reserve, or engaged in official military
operations (Kokun, Agaev, Pishko, Lozinska,
Ostapchuk, 2017).The United States distinguishes
between two categories: armed forces veterans
and military veterans. The former refers to
individuals who served for a minimum of 180
days and received an official discharge, while
the latter pertains to those who participated in
actual combat operations. The level of
assistance and benefits they receive varies
based on individual needs. Meanwhile, Israel
operates a unique system of mass conscription,
where nearly every citizen, with few exceptions, is
mandated to serve in the army. Consequently,
the term veteran does not encompass
individuals who simply served in the armed forces
or were engaged in hostilities in the usual sense.
When discussing veterans, focus is typically on
those who sustained injuries or serious illnesses
during military service and require support
(Esmanova, 2023).
Israel, renowned for its extensive experience in
military operations, boasts an impressive
psychological support system for members of the
armed forces, veterans, and their families. This
system, comprising five key units, serves as a
model for many countries. It encompasses
diagnosis, profilisation, and career guidance;
military mental support services; assistance for the
demobilized; aid for civilian populations; and
support for families of victims. Rehabilitation
program for reintegration is of particular note. It
includes measures aimed at preparing relatives
of the members of the armed forces for their
returning home, develops rehabilitation
programs, establishes or sustains anonymous
help centers, and provides maintenance to the
members of the armed forces with diverse
needs. Ukraine can use this experience to
enhance its own assistance system for military
personnel and veterans (Shvets et al., 2021).
Departments of Community Mental Health
(DCMH) are an integral part of the system of
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ISSN 2612-2138
mental health support in the armed forces of
Great Britain. They include consultant psychiatrists,
mental health nurses, mental health social
workers and, where appropriate, clinical
psychologists. The main purpose of these
departments is to support members of the armed
forces and refer them to inpatient treatment if
necessary. The Veterans Health Alliance is also
worth noting among other features of support for
veterans in the health care system in Britain. It
consists of 49 hospitals and ambulances in
England, Scotland and Wales. About 100
accredited people work at it.
In the USA, there is a practice of implementing
a state program called Whole Health (WH), which
was initiated by the Department of Veterans
Affairs (VA) in health care facilities. WH is defined
as an approach to health care that empowers
and equips people to take charge of their health
and well-being in order to live a high-quality life.
The WH principles are based on a commitment
to move towards quality, person-centred health
care that is “personalized, proactive, and
managed personally by a patient(Kligler, Hyde,
Gantt, Bokhour, 2022). As part of this program,
veterans are initially referred to a medical coach
who performs a so-called health inventory a
comprehensive assessment of physical and
mental health parameters. Veterans make a
personal health care plan based on the received
data and are accompanied by a special team.
This plan is made up according to the principles
of SMART (specific, measurable, action-oriented,
realistic and time-bound goals) time goals) and
based on the personal life values of each
individual veteran. At the next stage, the
participants will be offered an individually
selected training program and comprehensive
support (by type of coaching) in order to achieve
the planned goals (Taylor et. al., 2023).
Another distinctive feature of this model is the
active involvement of veterans in health
programs based on complementary and
integrative health (CIH), in particular: yoga,
meditation, acupuncture. By the way, recently
the amount of evidence for their effectiveness
has increased significantly, especially in pain
management, so some of them are
recommended in national guidelines.
Principles of the system of medical and
psychological rehabilitation
The term medical and psychological
rehabilitationhas recently gained popularity and
spread. The concept of rehabilitationappeared
in 1844 in the international practice. It was used
to denote measures aimed not only at treatment
but also at restoring body functions in order to
improve the quality of life. After the First World
War, medical, recreational and social
rehabilitation services became available to
military veterans due to the efforts of the Red
Cross charity. In the modern world, the issues of
rehabilitation of this category of people have
become an important aspect of social policy.
They are based on the principles of respect for
human rights and equal opportunities. One of the
key aspects of the rehabilitation concept is the
transition from a purely medical direction to a
broader, social one. Rehabilitation is now defined
as a complex process that includes
psychological, social, cultural, and economic
support in addition to the treatment and
functioning restoration. This allows providing full
and comprehensive assistance to veterans in all
aspects of their lives (Sasina, Grebeniuk,.
Medvedok, 2023).
In 2006, according to the World Health
Organization (WHO), the concept of medical
and psychological rehabilitation started
meaning an active process, the goal of which is
to achieve the full restoration of functions
impared as a result of a disease or an injury, or
optimal realization of physical, mental and social
potential of a disabled person, the most
adequate integration of him or her in society
(Savenkova, 2013).
We consider the main principles of the
medical and psychological rehabilitation system
to be worth considering in more detail:
The principle of inclusiveness, individualization
and personalization is one of the fundamental
principles of ensuring veteransvarious needs in a
specific community and the specific needs of
individual groups of veterans. Each participant in
the conflict has his or her own physical,
psychological and social needs, which require an
individual approach in planning and providing
rehabilitation services. This principle implies taking
into account the unique needs of each veteran
in the rehabilitation process. It involves meeting
the needs of all veterans, regardless of their
place of residence, social status and severity of
their condition. The assistance provided should
be available 24 hours a day, due to to hotline
services and a system of providing on-site
medical and psychological assistance to
veterans at their place of residence, and should
be able to solve specific problems (for example,
both problems of addiction to psychoactive
substances and legal and social issues).
The principle of continuity, consistency and
duration is related to the first principle and
involves the creation of a system of assistance for
veterans, prevents illness perpetuation of the
veteransproblems, and also promotes the ability
to navigate the network of rehabilitation and
social services. This means that all rehabilitation
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services must be connected in a single network,
namely a system of services that could work in
cooperation and coordination without obstacles,
so that the veterans path from one service to
another is not complicated and burdensome. For
example, this principle includes the development
of an individual rehabilitation plan for a specific
veteran and management of the necessary
communication between the various services of
the rehabilitation system for their optimal
functioning. Medical and psychological
rehabilitation of veterans must be continuous and
last over a long period of time to ensure stable
and lasting results. The rehabilitation process may
require constant monitoring, correction and
support from specialists.
The principle of accessibility, equality and
justice implies that the services of the veterans’
rehabilitation system are always open to those
who need their services. This means that they
must be located close to where veterans live or
work, close to public transportation, and their
hours of operation must include evening
reception hours and weekends. In order to
achieve a similar result, rehabilitation services
must be placed evenly in the communities of
district centers and cities. Convenience in the
provision of services is achieved by the availability
of such services for people with physical
limitations, with limited hearing and vision. All
veterans should have equal access to qualitative
and competent rehabilitation services, regardless
of their social status, ethnicity or geographic
location.
The principle of working in multidisciplinary
teams is another principle of veteran-oriented
rehabilitation, which implies that specialists who
provide care and rehabilitation in the community
should be organized into appropriate teams.
Such teams consist of psychotherapists,
psychiatrists, psychologists, social workers,
occupational therapists, rehabilitation specialists,
nurses and, if necessary, other consultants. In
addition, some team members should be experts
in certain areas, such as housing, vocational
rehabilitation or legal aid. Thus, the system of
veterans medical and psychological
rehabilitation should be comprehensive and
integrated, covering not only medical and
psychological support, but also social,
professional one and rehabilitation in society.
According to the principle of cooperation,
partnership and responsibility, an effective
rehabilitation system is based on the cooperation
between different sectors, institutions and
organizations that have a common goal, namely
to provide the best support to veterans. This
principle provides for the responsibility of services
to veterans and is implemented in such a way
that veterans themselves take part in decision-
making and in the management of the
rehabilitation system services as members of the
public board or the Board of Observers.
Eventually, if they feel their influence on events
and processes, they will be more ready to
cooperate and take responsibility for their lives.
Involvement of participants and their families:
The participation of veterans and their families in
the rehabilitation process plays an important role
in achieving successful outcomes. After returning
from the battlefield, the ways of establishing
relationships and interaction in the family
undergo their own changes, in particular, they