Brittany Hall-Clark, Ph.D. University of Texas Health Science Center at San Antonio

Mobile Crisis Outreach Training

July 31, 2014

Acknowledgements STRONG STAR

Multi-disciplinary PTSD Research Consortium UTHSCSA Jeremy Joseph, PhD

LCDR Allah Sharrieff Carl R. Darnall Army Medical Center

Ms. Sonceri Hutch Military spouse

Importance Calls for increased collaboration between community, mental health providers,

VA, and clergy (Straits-Troster et al., 2011; Weaver, Koenig, & Ochberg, 1996) Vets more likely to present to primary care, faith-based, MHP in own

community than DoD or VA Increased interaction between first responders & SMs/veterans (Rahilly, Tuttle,

& Gitelson, 2011) San Antonio is Military City USA

Consistent military presence for nearly 300 years Home to several military installations

Fort Sam Houston DoD largest medical center at Joint Base San Antonio

Camp Bullis Camp Stanley Brooks City-Base Lackland Air Force Base Randolph Air Force Base

Top military friendly city in US out of 381 cities(2011)

Who’s in the audience? Social Workers (LMSW or LCSW) Case Managers/Care Coordinators Licensed Professional Counselors (LPCs) LVNs & RNs Licensed Professional of the Healing Arts (LPHAs) Qualified Mental Health Professionals (QMHPs) Physician Assistants Law Enforcement Service Members Military Family Members

When might you encounter Service Members/Veterans? Client/patient care Crisis management Accidents Traffic stops Intoxication

Military Personnel in the US Active duty constitute about 1% of overall US population (US Census, 2010) Over 2,000,000 military personnel have deployed since 2001

Significant risk for psychological health problems (Institute of Medicine, 2012) OEF/OIF/OND veterans at heightened risk for deployment-related emotional and

behavioral difficulties compared with civilian populations (Hoge et al, 2004) Posttraumatic stress disorder (PTSD) Depression Anxiety Substance use 2007 DoD Task Force on Mental Health report of psychological symptoms after

returning from deployment 38% of Soldiers 31% of Marines 49% of National Guard

20.3% of active duty Soldiers and 42.4% of the reserve component required further mental health assessment or treatment (Milliken, Auchterlonie, & Hoge , 2007)

Prevalence rates of PTSD and depression ranged between 23 and 31% (Thomas et al., 2010)

Demographics of US Military Today’s Armed Forces quite diverse (Cozza, Benedek,

Bradley, Grieger, Nam, & Waldrep, 2004) Racial/ethnic minorities

24% of Air Force 40% of Army

16% women Over 50% married Over 95% graduated from high school or completed

GED

Overview Introduction to Military Culture

Branches of Services Rank Structures Military Values Phases of Deployment Cycle

Adjustment issues for military families When Service Members, Veterans, and Military Families Need Help

Common mental health issues affecting Service Members, Veterans, and military families

Evidence-based treatments Resources for helping Service Members, Veterans, and military families

Culturally Sensitive Interactions with Military Populations Intersectional identities (Military, racial/ethnic, and spiritual) Cultural strengths and stressors

Questions and Answers

Awareness Exercise You are asked to speak with Mike, age 27, White,

male, after he has been in a car accident Looking around constantly Uncomfortable when you come near him

Questions What impressions do you have?

Guarded Anxious Stigma Concerned about being in trouble

What possible symptoms did you observe? Re-experiencing Hypervigilance Disturbed sleep/fatigue Anxiety Irritability

What could lead to miscommunication? Acronyms and jargon Not addressing SM’s concerns

What important questions were not asked? Military experience What “feeling funny” means? Substance use Risk assessment

Helpful terminology Family Advocacy Program (FAP) Military Occupational Specialty (MOS)

91B: Wheeled Vehicle Mechanic National Training Center (NTC) in Ft. Irwin Non-Commissioned Officer (NCO) Improved Explosive Device (IED) Physical Training (PT) http://militaryacronyms.net/

How Many Branches of Uniform Service?

Cultural Differences Service branch

Missions Entrance

Air Force, Navy, & Marine tend to be highly educated Army more flexible: more GED holders & more waivers as OEF/OIF/OND

escalated Reserve status Enlisted vs Officer Deployment location Era

Draft or volunteer Peacetime or conflict

Values Rank Structures

Army Values Loyalty- Bear true faith and allegiance to the U.S. Constitution, the Army, your unit

and other Soldiers. Bearing true faith and allegiance is a matter of believing in and devoting yourself to something or someone. A loyal Soldier is one who supports the leadership and stands up for fellow Soldiers.

Duty- Fulfill your obligations. Doing your duty means more than carrying out your assigned tasks. Duty means being able to accomplish tasks as part of a team. The work of the U.S. Army is a complex combination of missions, tasks and responsibilities

Respect- Treat people as they should be treated. In the Soldier’s Code, we pledge to “treat others with dignity and respect while expecting others to do the same.

Selfless Service- Put the welfare of the nation, the Army and your subordinates before your own. Selfless service is larger than just one person. In serving your country, you are doing your duty loyally without thought of recognition or gain.

Honor- Live up to Army values. Integrity- Do what’s right, legally and morally. Integrity is a quality you develop by

adhering to moral principles. It requires that you do and say nothing that deceives others.

Personal Courage- Face fear, danger or adversity (physical or moral). Personal courage has long been associated with the Army. With physical courage, it is a matter of enduring physical duress and at times risking personal safety.

Phases of Deployment Cycle Pre-Deployment Phase (6-8 weeks prior to

deployment) Deployment Phase (during deployment) Reunion Phase (1-6 weeks prior to reunion) Post-Deployment Phase (1-6 weeks post

reunion) Military Deployment Guide, FEB 2011

PTSD DSM-5 Criteria

A: Traumatic event: actual/threatened death, serious injury, or sexual violence B: Re-experiencing

Upsetting intrusive thoughts/memories/nightmares/flashbacks C: Avoidance

Behavioral/Situational: triggers, people, family isolation Cognitive: Memories/thoughts Emotional: Feelings

D: Negative alterations in cognitions & mood Persistent & exaggerated beliefs about self, others, & world Distortions about cause or consequences of trauma Persistent negative emotional state Numbing Dissociative amnesia

E: Hyperarousal Easily startled, always on guard Hypervigilance Irritability/anger outbursts Sleep disturbance Reckless/self-destructive behavior Exaggerated startle Concentration problems

F: At least 1 month G: Significant distress or functional impairment

Prevalence in PTSD in Veterans Military

Vietnam 26% (Kulka et al., 1990)

OIF/OEF /OND Non-treatment seeking: 5-20% (Ramchand et al., 2010) 23% of tx-seeking (VA, 2008)

• Racial/ethnic minority • Higher rates for African American & Latino veterans (Kulka et al., 1990)

• Mediated (Frueh et al., 1998; Schwartz et al., 2005) • Trauma exposure • SES

• Gender inconsistently associated with PTSD (Ramchand et al., 2010) • NVVRS (Kulka et al., 1990)

• Male: 15% (current); 31% (lifetime) • Female: 8.5% (current); 27% (lifetime)

• Combat exposure is strongest predictor of PTSD

Getting Trained in Evidence-Based Treatments (EBTs) Mental health professionals at all levels can successfully administer

EBTs Importance of protocol adherence

VA roll-outs National workshops Websites Webinars Books

Manuals Importance of ongoing supervision & consultation

Other Common Mental Health Issues for Veterans Combat stress Depression

Loss of interest or enjoyment Loss of energy/restlessness Insomnia/hypersomnia Decreased/increased appetite Depression

Vietnam: 48% (Kessler et al., 1995) OIF/OEF: 6-24% (Grieger et al., 2006; LaPierre et al., 2007)

Suicidality/Homicidality Thoughts of harming oneself + intent + plan

Common Health Issues for Veterans Substance Abuse/Self-medication

Reckless behavior 30-50% of SUD have PTSD (Boden et al., 2012: Ouimette

et al, 2003) Kessler et al. (1995)

Men: 50% Women: 28%

Medical Insomnia TBI

When Professional Help is Needed Signs that additional help needed:

Significant distress Impairment of functioning

Professional Social Financial Self-care

Problems not improving or getting worse

Veteran Encounters with First Responders Often potentially traumatic situations Sirens, loud noises, lights, authority figures (Rahilly,

Tuttle, & Gitelson, 2011) May trigger re-experiencing symptoms

Barriers to Help-Seeking Stigma

General Koenen et al. (2003)

Beliefs 28.7% said can handle on own 18% afraid of what people think 13% afraid to take meds 9% don’t think have disorder 6% treatment won’t help

Resources(insurance, can’t afford, access)

40% of those with PTSD did not know where to get help Military

Downsizing Gender Racial/ethnic

Cultural mistrust (Terrell & Terrell, 1981) Racial socialization Distrust of therapists (Whaley, 1998)

Overcoming Barriers Strive for cultural competence Providing psychoeducation Biopsychosocial models

Medical analogy Partnering with community

Education about when to seek professional help Clergy

Cultural Considerations Identity

How does the SM view him/herself? Cultural identity ADDRESSING model (Hays, 2007) Intersection of identities

Acculturation Which cultures does the SM identify with? Bi/multicultural?

Consider important values and value conflicts Protect vs. Kill

Verbal and Nonverbal Communication May verbally agree to be polite

Worldview Locus of control Beliefs about health/illness

Consider role of privilege

Cultural Stressors Repeated, extensive trauma over a long period of time Multiple deployments Environment of constant danger Multiple types of trauma (e.g., life-threatening, horror, “moral

injury”, traumatic loss) Culture of denying personal difficulties Culture and training to have increased sense of personal

responsibility Hypervigilance trained in military

In civilian life can become safety behaviors Discrimination, racism, and prejudice

Intercultural & intracultural (skin color, hair type, body type) Acculturative stress Stereotypes

Cultural Strengths Unit cohesion

Vertical Horizontal

Community orientation Extended kinship

Flexibility in family roles Many SMs say families are biggest source of motivation

Religion/spirituality Church Scripture Emotional processing God’s will Forgiveness Spiritual figures as role models and examples Discussion with pastors/chaplains

Perspective Exposure of talking

Positive racial/ethnic identity Belonging Affirmation Pride

Cultural Competence: Assessment Ask preferred name Listen for culture and self-identification Ask about clients’ experience of culture

Culturally educated questions (Rodriguez & Walls, 2000) Consider environmental influences

Stressors Protective factors

Personal strengths from culture Environmental considerations

Seating Artwork

Measures

Cultural Competence: Diagnosis Be aware of cultural differences in symptom expression

Somatization Anger is more socially acceptable than other emotions in military

Be aware of value-laden diagnoses Psychosis

Overdiagnosed in African Americans (Whaley, 1997) Cultural Paranoia (Terrell & Terrell, 1981)

Personality Disorders Dependent Personality Disorder Schizotypal

Cultural Formulation in DSM-5 (Section III and Glossary of Cultural Concepts of Distress)

Cultural Competence Language fluency and educational level

Minimize jargon Look for cultural strengths as source of alternative/balanced

thoughts Not inferior, different

Consider incorporating family members into treatment Cultural factors and norms in relation to symptom expression

Depression Anger

Consult with respected healers/authority figures (e.g. pastors) Discuss culturally relevant values and beliefs

Cultural Competence Educate self about cultural groups that clients identify

with Accessible homework assignments

Behavioral activation SES Culturally congruent

Reading assignments Educational level, fluency

Validate experiences of oppression Challenge after more trust has developed

Do not challenge core cultural beliefs

Cultural Competence: Crisis Response Risk Assessment Crisis Response Plan

Identify triggers Self-soothing

Grounding Social support

Family Friends Church community Motorcycle clubs Military chaplains

Formal resources

Discussion Questions Do you feel more equipped to help active duty

personnel, veterans, and military families? What steps can you take to strive for cultural

competence in your clinical work? What are your take-aways from today’s presentation?

Resources Handouts

Local & national veteran organizations Websites Apps Military Culture resources

Veteran Crisis Line: 1-800-273-TALK

Please contact me at hallclark@uthscsa.edu for copies of presentation, questions, or feedback.

References APA Commission on Ethnic Minority Recruitment, Retention, and Training in Psychology Task Force

(CEMRRAT2) & Office of Ethnic Minority Affairs APA Public Interest Directorate. (2005) A Portrait of Success & Challenge: Progress Report: 1997-2005. American Psychological Association.

Breslau, J., Aguilar-Gaxiola, S., Kendler, K. S., Su, M., Williams, D., & Kessler, R. C. (2006). Specifying race-ethnic differences in risk for psychiatric disorder in a US national sample. Psychological Medicine. 36 57-68.

Dana, R. H. (1993). Multicultural Assessment Perspectives for professional psychology. Longwood Professional Books.

Foa, Keane, & Friedman (2000). Effective Treatments for PTSD. New York: Guilford. Maxfield, B. D. (2010). Blacks in the Army: Then and now. Office of Army Demographics. Retrieved from:

http://www.armyg1.army.mil/hr/docs/demographics/MRA_booklet_10-ARMY.pdf Military City USA San Antonio website. http://www.militarycityusa.com/index.htm Hays, P. (2007). Addressing Cultural Complexities in Practice: Assessment, Diagnosis, and Therapy, Second

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Treatment-Seeking in a National Screening Sample. Journal of Traumatic Stress, 16 (1), 5-16.

References (continued) Kulka, R.A., Schlenger, W.A., Fairbank, J.A., Hough, R.L., Jordan, B.K., Marmar, C.R.,... Cranston, A.S. (1990). Trauma

and the Vietnam War generation: Report of findings from the National Vietnam Veterans Readjustment Study. New York: Brunner/Mazel. 503-520.

Military Deployment Guide (2011). http://www.militaryonesource.mil/12038/Project%20Documents/MilitaryHOMEFRONT/Service%20Providers/Deployment/DeploymentGuide.pdf

Powers, R. (2013). Minimum Required ASVAB Scores and Education Level. http://usmilitary.about.com/cs/genjoin/a/asvabminimum.htm

Rodriguez, R. R., & Walls, N. E. (2000). Culturally educated questioning: Toward a skills-based approach in multicultural counselor training. Applied & Preventive Psychology, 9, 89-99.

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“San Antonio tops 'Military Friendly Cities' list; Texas lands 7 in Top 50.” http://www.kens5.com/story/news/local/2014/06/26/10458290/

Snowden, L. R., & Cheung, F. K. (1990). Use of inpatient mental health services by members of ethnic minority groups. American Psychologist, 45, 347-355.

Visit San Antonio website. http://visitsanantonio.com/english/Explore-San-Antonio/Attractions/Military Weaver, A., J., Koenig, H. G., & Ochberg, F. M. (1996). Posttraumatic stress, mental health professionals, and the

clergy: A need for collaboration, training, and research. Journal of Traumatic Stress, 9, (4), 847-856. Whaley, A. L. (1997). Ethnicity/race, paranoia, and psychiatric diagnoses: Clinician bias versus sociocultural

differences. Journal of Psychopathology and Behavioral Assessment, 19, 1-20.

Additional Discussion Questions What is the culture of your profession? How did your professional training add to or shape

your cultural identity? What are the unspoken rules about health or illness

you share with your co-workers? How does your job title change the way people think of

you? How would YOU react if someone came up to you and

said, “Hey, you don’t seem like your normal self, is everything ok?”