From Somalia to Desert Storm to the recent war in Iraq, the U.S. military has made the safe return and post-combat reintegration of American troops a top priority--a recent example being the seven American soldiers who were rescued from captivity during Operation Iraqi Freedom.

The recovery mission didn't end when these POWs were rescued by U.S. military personnel. They received top-notch after-care from the Joint Personnel Recovery Agency (JPRA), a military program that assists the reintegration of all American prisoners of war and other detainees--whether military members or government-contract workers--from the minute they're recovered and for years to come.

From the beginning, psychologists help them manage the emotional aspects of repatriation facilitating the normal decompression of stressors encountered during captivity. Specially trained psychologists--with oversight provided by JPRA psychologists Col. Kenneth Rollins, PhD, and Gary Percival, PhD--help recovered personnel understand their psychological reactions to their experiences, recognize their strengths and support them in returning to their homes or station and managing other unique aspects of their experience.

What is JPRA?

The JPRA, created in 1999, is the umbrella term for all military, civil and political efforts to train, rescue and repatriate personnel--whether captured, missing or isolated--from hostile environments. The agency is housed in the Department of Defense, and all branches of the U.S. military are involved.

Once an American has been rescued or released from capture or detainment, JPRA members begin the work of repatriation. Psychologists, as part of the JPRA team, work to help minimize problems related to acute stress, family adjustment and media demands. The goal of repatriation is to enable these individuals to continue their work and personal lives effectively, say JPRA psychologists.

JPRA psychologists are trained in Survival, Evasion, Resistance and Escape (SERE)--the specialized interventions they provide are preventive in a sense. "It is much more along the lines of inoculation--providing folks with the information, skills and, most importantly, the confidence to survive the captive experience," says Sally Harvey, PhD, a SERE psychologist and chief psychologist of the European Regional Medical Command. The SERE psychologist is actively involved in the repatriation process from the time of recovery and typically travels to meet recovered personnel once they've been brought to a safe area--potentially outside the United States--in the first phase of repatriation.

During the next phase, at a transition site such as a regional hospital, the recovered personnel receive complete medical care as well as extensive debriefing and decompression. JPRA psychologists provide an unstructured, unsupervised environment to help "normalize" detainees' experience, says Lt. Col. Debra Dunivin, PhD, deputy chief and director of residency training at Walter Reed Army Medical Center and a newly trained SERE psychologist. They give a range of psychosocial interventions to those who need it, she says. According to official JPRA documents, the decompression is "perhaps the most critical and least understood essential element of the repatriation process." Finally, in the third phase of repatriation, returnees can connect with their families back on U.S. soil. Medical care continues as necessary and the SERE psychologist stays involved to monitor the repatriation process.

"For example, if it's a POW, there would be a SERE-trained psychologist who goes forward to where the person is and accompanies them back home, helps them understand the psychological reactions to such events, helps them through the process of returning to the states or to duty, and stays with them through any necessary medical care," says Dunivin.

"The psychologist is even involved in assisting with statements that might be made to the press. There's often a sudden interest in these folks, and we help them understand what the pitfalls of intense media attention might be," she adds.

And for at least one year after returning stateside, SERE psychologists continue to work with returnees as needed. After that, all POWs, hostages and detainees are eligible for free follow-up medical and psychological services at the Robert Mitchell Center for Repatriated POW Studies in Pensacola, Fla.--for the rest of their lives.

Follow-up care

In fact, much of the basis for psychological care of returnees is based on lessons learned from the Mitchell Center's work, which began with Vietnam POWs.

Since 1989, neuropsychologist Jeffrey Moore, PhD, has served as the only psychologist with the Department of Defense follow-up program at the Mitchell Center. Depending on the need of the repatriate, the program provides an annual physical and psychological evaluation that typically takes two or three days. Moore collaborates with cardiologists, neurologists, ophthalmologists and other health-care providers to care for repatriates.

"Sometimes the evaluation involves psychological testing," says Moore. "It always involves interviews and follow up."

"The main concern psychologically is the risk for long-term post-traumatic stress disorder [PTSD]," he says. And diagnostically, he adds, there can be issues such as torture-related head injuries or premature aging associated with malnutrition. "The average POW in Vietnam lost 25 to 30 percent of their body weight," he notes. Many of these POWs were in solitary confinement for four years. One POW, says Moore, was held in Vietnam for nine days short of nine years.

Along with the potential for serious psychological effects of capture or detainment, namely post-traumatic stress disorder, returnees can experience a whole host of other issues, such as reintegrating with family, once they're back. "Marriage is tough enough," says Moore, but captivity--especially the multiple years that many Vietnam veterans experienced--can exacerbate marital problems.

"I count on every year at least doing an interim history of how things have been going and a follow-up assessment [of all repatriates]," he says. "With the Vietnam group, the average age is 68 now. Retirement from second careers, sleep-related problems, memory concerns, and PTSD symptoms are all issues they might be dealing with."

In addition to seeing Vietnam POWs, Moore works with Desert Storm POWs and other hostages or detainees from military conflicts, such as prisoners from the Black Hawk helicopter incident in Somalia.

"The next group we'll see will be from Iraq," he says.