Military Culture & Treatment - 101

AAPC – SE Region Kanuga ConferenceDate 10/24/2009

workshop to overview the culture of military families, effective

treatments, and sources of support

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Peter McCallpetemccall1@gmail.com

770-329-6156

Presentation Goals

There are 3 goals of this presentation:• Review the CareForTheTroops organization and

understand the issues that drove the plan for the non-profit organization CareForTheTroops

• Review at a high-level some of the “military culture” issues that may help in counseling military family members

• Review the problems and issues faced by veterans and their families and clinical treatment issues for those who are serving and have served during periods of conflict.

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MILITARY OATH OF ENLISTMENTrecited by all Service Members at their swearing in ceremony

I, (NAME) DO SOLEMNLY SWEAR…THATI WILL SUPPORT AND DEFEND THE CONSTITUTION OF THE UNITED STATES… AGAINST ALL ENEMIES, FOREIGN AND DOMESTIC;… THAT I WILL BEAR TRUE FAITH AND ALLEGIANCE TO THE SAME;… AND THAT I WILL OBEY THE ORDERS OF THE PRESIDENT OF THE UNITED STATES… AND THE ORDERS OF THE OFFICERS APPOINTED OVER ME,… ACCORDING TO REGULATIONS AND THE UNIFORM CODE OF MILITARY JUSTICE,… SO HELP ME GOD.

NOTE: 3 dots … = represents a repetition break

Speaking these words has far more emotional power than these words on paper could ever convey. Anyone who has done this for real knows, in that moment, that they are agreeing to defend a principle with their very lives. It is a moment they never forget.

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CareForTheTroops, Inc.

Who Are We – ‘Big Picture’•CareForTheTroops is working to help the military and their extended family members receive mental health services and support from within the civilian elements of our society in the State of Georgia.

• CareForTheTroops is attempting to equip the civilian support services of society e.g. pastoral counselors and congregation leadership teams, with the capacities to be helpful.

• We are working toward “building a better net” to catch those that need help before they fall too far and reach moments of desperation.

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Organization

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Current Board of Directors:

President Rev Robert Certain, Rector, Episcopal Church of St Peter and St Paul (USAF)Exec Director Peter McCall (USArmy)Member Bill Harrison, Partner, Mozley, Finlayson & Loggins LLP (USAF)Member William Matson, Exec Director, Pathways Community Network, Atlanta, GAMember Alan Baroody, Exec Director, Fraser Counseling Center, Hinesville, GAMember Joseph Krygiel, CEO of Catholic Charities, Archdiocese of Atlanta (US Navy)

Current Partners:

The Georgia Association for Marriage and Family Therapy (GAMFT)The EMDR Network of Clinicians in GeorgiaPathways Community Network, IncFraser Counseling Center, Hinesville, Georgia (nearby Fort Stewart)Episcopal Diocese of Atlanta Presbytery of Atlanta and the Presbyterian Women of AtlantaCatholic Charities and the Archdiocese of Atlanta

501c3 status has already been approved by the IRS

Causes for Concern

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1. Multiple deployments are common causing stress and family attachment issues

2. An April ‘08 Rand Study reported 37% have either PTSD, TBI, or significant Mental Stress (5% all 3). Some estimate >50% return with some form of mental distress

3. Suicide, alcoholism, domestic abuse and violent crimes rates are rising. Suicide is 33% higher in ‘07 over ’06, 50% higher in ‘08, and almost equal to ‘08 by May of ’09

4. Military Sexual Trauma (MST) is running at 16%-23%

5. In 2008, military children and teens sought outpatient mental health care 2 million times, a 20% increase from ‘08 and double from the start of the Iraq war (‘03)

6. DoD and VA facilities are stretched … the Aug 2009 VA claims backlog is 900,000

7. Many more Reservists & Guard than previous wars (54% as of mid ‘08) and they and families are more distant from DoD and VA support facilities

8. Other mental health, marriage, and family problems often occur with or leading up to PTSD requiring attention so they don’t get worse

9. Rand Study estimates that PTSD and depression among service members will cost the nation up to $6.2 billion in the two years after deployment. The study concludes that investing in proper treatment would actually save $2 billion within two years

Mission of CareForTheTroops.org• Work to improve the ability of the civilian mental health infrastructure in the

State of Georgia, then nationally, to work with military family members

• Facilitate connecting military families to providers of spiritual and psychological services familiar with the military culture and trauma

• Focus on addressing combat stress recovery as well as other spiritual and mental health related problems impacting the marriages and families of military veterans

• Educate and train clinicians, congregation and community leaders, extended family, and civilian groups about the military culture and trauma associated with military deployments in order to better assess and treat mental health symptoms, and provide more effective referrals and care

• Provide opportunities for additional trauma treatment training to clinicians

• Operate in an interfaith, non-political manner, focusing on the humanitarian interest that benefits the veterans and their extended family members

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Approach

Person in need of support

Spouse

Siblings Grandparents

Parents

Children

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MilitaryMember

CareForTheTroops Operations OverviewRAND study says over 33% of returning military have some

form of mental distress

ISSUEISSUE CFTT will improve the overall mental health infrastructure to better support military families

RESPONSERESPONSE

54% of those deployed are R/NG. GA is 6th

largest R/NG

Improve support even in remote areas of the

state

ISSUEISSUE

RESPONSERESPONSE

How can families know where trained support is available

CFTT website lists therapists trained in the military culture

ISSUEISSUE

RESPONSERESPONSE

How to help referral sources know better when

& where to refer

CFTT website shows info usable by

therapists & referrals

ISSUEISSUE

RESPONSERESPONSE

How can CFTT assure that word of mouth spread all

over the GA

Use congregations to create a grassroots info

distribution channel

ISSUEISSUE

RESPONSERESPONSE

How do we expect to overcome the stigma of mental health help

Target info for friends & family “surrounding” the

military member

ISSUEISSUE

RESPONSERESPONSE

Private Sector MH providers have limited

military experience

CFTT will provide training opportunities, including

remote areas

ISSUEISSUE

RESPONSERESPONSE

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The next set of charts provide a simulation of using the www.CareForTheTroops.org website with pastoral counselors in mind

This is the top of the Home Page

This is the bottom of the Home Page

Highlights,New ItemsAnd Reports

Back to the top of the Home Page

Home Page

The drop-down menu for Mental Health Professional is opened up.

In this case, selecting the Enroll with CFTT page

Note the other options available

Top of the Enrollment Page

The info asked is completely voluntary. We do not ask you to volunteer time and any financial info is left between you and the client.

We are looking for people with background, training, and experience.

Home Page

The menu for Congregation Leaders is opened up.

In this case, selecting the About Congregation Programs page

Top of the About Congregation Programs Page

Click on the picture and this presentation is available

Moving down the same page gets you to the Guide Book info we have introduced in this presentation. It also shows the TOC and the Intro Letter in the document

Clicking on the picture of the book will let you download it.

Military Ministry Programs

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Table of Contents Part 1 – Step by Step Implementation Worksheet ......................................................................... 4

I. Congregational Leaders/Lay Leaders – ................................................................................ 5 II. Lead Congregations ............................................................................................................. 8 III. Additional Notes. ............................................................................................................ 10

Renewal Letter Example ....................................................................................................... 12 Letter from Congregation Leadership to Congregation, Example 1 ..................................... 13 Letter from Congregation Leadership to Congregation, Example 2 ..................................... 14 Letter to a Congregation Member in the Military or Related To One, Example .................. 15 Example of Article in Congregation Newsletter or Email to the Congregation .................... 16

Part 2 – Congregation Program Templates .................................................................................. 18 Program 1: Prayer List Identification - Spiritual Support and Care .......................................... 20

Examples of Day of Worship Bulletin and/or Newsletter Article ......................................... 21 Example 1 of Prayer List used by St. Peter and St. Paul Episcopal Church ........................... 22 Example 2 of Military Deployed List used by St. Peter and St. Paul Episcopal Church ........ 23 Example 3 of Returned Home List used by St. Peter and St. Paul Episcopal Church ........... 24

Program 2: Dedicating An Existing Program To The Military Serving Overseas ....................... 28 Program 3: Care Packages to Deployed Service Members ....................................................... 29

Newspaper Article Where the Care Package Idea was originally described ........................ 33 Program 4: Assistance and Practical Help to Those Inside the Congregation .......................... 34 Program 5: Assistance and practical help to those outside the Parish .................................... 35 Program 6: Writing Our Way Home .......................................................................................... 36

Part 3 - Veteran Friendly Congregations and Lead Congregations ............................................... 40 Veteran Friendly Congregation Designation Program .............................................................. 41 Lead Congregations .................................................................................................................. 43 Lead Congregation vs Veteran Friendly Congregation Responsibilities ................................... 44

Part 4 – Other Program Suggestions, But Not Documented ........................................................ 45

Back to the top of the Home Page

A key piece of the web site is the Resource Library with the 4 selections shown. This material is updated periodically. The reference material is weekly.

Home Page

Another key section is the gathered in the “Stuff” You Should Know Section.

Our goal here is to provide plenty of info on these topics and also refer you to the top 3-5 sites on these topics.

Home Page

Finally, an important aspect of our mission is to connect you to others that can help.

The Find a Therapist menu item discusses how one might choose a therapist and then allows you to search many ways.

This shows the first 4 search results for Fulton County in the database.

This is intended for use by congregation sources, clinicians, and people in need searching for a therapist who wants to work with military families.

Training is key.

This shows the training events we are aware of. Both from CFTT and from other organizations.

Please visit it periodically and also let us know of training you hear about to share with others.

Back to the top of the Home Page

EMDR TRAININGWeekend 1 (Part I)

January 15-17, 2010Athens, Georgia

Weekend 2 (Part II) - TBA

The EMDR HAP (Humanitarian Assistance Program) Training organization (www.emdrhap.org ) will conduct Weekend 1 (Part I) training Friday through Sunday, Jan 15th to 17th in Athens, Georgia. The training facilities used in Athens are at Milledge Avenue Baptist Church, 598 South Milledge Avenue, Athens, GA 30605.Weekend 2 (Part II) training will be scheduled 3-6 months later with details TBA.This training is jointly sponsored by the The Samaritan Counseling Center of Northeast Georgia (www.samaritannega.org ), GAMFT-The Georgia Association for Marriage and Family Therapy (www.gamft.org ), and The CareForTheTroops, Inc. non-profit organization (www.CareForTheTroops.org ).

AUDIENCE: This training is for licensed (and some licensable) counselors working in a non-profit environment. Specific details are available at the following web location: www.emdrhap.org/training/ .COST: $350 for each weekend. Lodging and meals are the responsibility of the participant.SCHOLARSHIPS: A limited number are available to cover the full HAP Fee for Weekend 2 (Part II) for those that meet the criteria below. So please apply early if one is needed.

ENROLLMENT: TRAINING: Enroll for the HAP Part I training is done on-line through the HAP website: www.emdrhap.org/training/toregister/listEvents.php. Look for this events’ description on the web page.SCHOLARSHIPS: Apply for the CareForTheTroops scholarship at www.careforthetroops.org/emdrevent.php . Download the Application Document, complete and email or mail it to the address shown on the document.

Additional information about this weekend such as schedule, lodging, restaurants, etc. can be found at the following web location: www.CareForTheTroops.org/emdrevent.php .

HAP Participant Requirements

EMDR PART I AND PART II are available for licensed mental health clinicians at the masters degree level or above, or for masters level clinicians on a licensure track, with permission of their licensed clinical supervisor. In keeping with its mission, HAP normally trains only clinicians working 30 or more hours per week in community based, non-profit settings. Exceptions have been made for private practice clinicians who have made a substantial commitment to pro bono service in the community.

CareForTheTroops(CFTT) Scholarship Criteria

It is the intent of CFTT to incent attendance of both EMDR Training Weekends (Part I and Part II) in order to increase the number of fully qualified EMDR Therapists to treat trauma in Georgia. Participants must:1.Practice in Georgia2.Attend and successfully complete both Part I and Part II EMDR training by HAP3.Enroll in the CareForTheTroops Therapist Database at the completion of Weekend 1 and stay enrolled at least 2 years. More Info about this is available at www.careforthetroops.org/clinician_cftt_enroll.php4.Be willing to work with military clients and their extended family members5.Pay the HAP Training Fee for Part I. CareForTheTroops will pay the HAP Training Fee for Part II which means you must attend a Part II by HAP6.Attend and complete Part II within 12 months of completing Part I7.Be responsible for all other costs, fees, and expenses associated with the training weekends.

Chapter WorkshopsMilitary Culture 101-Clinical Treatment Issues

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Chapter Chair / Contact Person Co-Presenter Date Time Location

Coastal Kathryn Klock-Powell Alan Nov 6th 10am-1pm Hinesville

Middle Bruce Conn Alan Nov13th 10:30-1:30 Macon

Northeast David Fowler/Dennis Cain Blaine Nov 20th 11am-2pm Athens

South Jeff Bickers Blaine Nov 21st 9am noon Valdosta

Southwest Elaine Gurly/Lori Ann Landry Blaine Dec 4th 11am-3pm Albany

East John Hill/Sid Gates Blaine Dec 11th 3pm-6pm Augusta

Metro Atl Licia Freeman Alan Jan 15th 11am-2pm Decatur

Northwest Joan Robinson Blaine Jan 22nd TBD Woodstock

West none TBD Columbus

NOTE: Check with your local GAMFT Chapter and also with the www.CareForTheTroops.org web site for changes and updates.

Final Comments Ref CareForTheTroops

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Help For You• Use the web site as a resource • Information and reference material• Training• Referrals• Use you involvement with CFTT to help market your practice

and or help your congregations

Help for Us• Enroll in the CFTT database if you qualify• Publicize CFTT to community and congregations• Would you consider being a Trainer using material similar to

what you see today?

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The next charts information about the military culture

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Military Culture

Sociologists define culture as …

• Language - nomenclature; acronyms, abbr.

• Beliefs – defenders of Democracy• Value Systems – leave no one behind• Norms & Rules – formal & informal conduct

Culture is associated with a social system and unique to a given system.

Language Barriers for CiviliansGlossary of Military Terms and Acronyms

Military Cultural Competence

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OEF Operation Enduring Freedom – it is a multinational military operation aimed at dismantling terrorist groups, mostly in Afghanistan. It officially commenced on Oct. 7, 2001 in response to the September 11th terrorist attacks.

OIF Operation Iraqi Freedom - also known as the Iraq War; began on 3/20/2003.

USAR United States Army ReserveUSANG United States Army National Guard

E1-E9; O1-O10 Enlisted Ranks; Officer RanksSPC Specialist, rank of E4, often referred to a “Spec 4”First SGT First Sergeant, rank of E7, lead enlisted person in a company. It and SSG,

Staff Sergeant are key leadership ranks with lots of job pressuresNCO Non-Commissioned Officer, ranks E6 through E9

IEDs Improvised Explosive DevicesSandbox Iraq and AfghanistanDown Range Deployed to anyplace where there is shooting.Outside the Wire Leave the safety of the “enclosed” military base (FOB)Taking the Pack Off Leaving mentally and physically from combatTop Cover Making sure the boss looks good

www.rivervet.com/oif_glossary.htm

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Military CultureBelief and Value Systems; Norms and Rules

• Beliefs:Defenders of Democracy

Trust in the leadership

Role clarity

Distrust of civilians

• Value Systems: Leave no one behind“The Group” practically becomes a ‘family system’Top Cover-defend and support the bossViolence :many have a history of violence which often plays a role

• Norms & Rules: Formal and informal conductStigma of mental health and PTSDCover of the boss (Top Cover) Back-logging trauma

Reserve and National Guard Units vs Regular Army

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• Units are small & based in local communities.

• Part-time soldiers, often working with local police, fire, and EMS.

• Families may be left in a town with little or no support services.

• Mostly support units in Georgia (transport, MP, etc)

• Likely to work within local communities

• Can’t relocate easily when activated

• Lack of military related health services - PCP not Tricare approved

• Make use of family or local supports (church, etc.)

• Units are based at major military installations.

• Full-time soldiers who expect to be deployed .

• Families are left at their post where a variety of support is in place both on-post & in communities.

• Are part of a larger fighting force including 1/5 combat units.

• Live on-post or nearby; other family support

• Less need to relocate when deployed• Access to a variety of health, welfare,

& educational services• Support groups in-place through

soldier’s unit

Reserve / Guard Regular

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The next few charts provide some background of this war that might help you

better understand your client or congregation member and their presenting

story and issues

Why is this war different?

• Volunteer vs. draft• Multiple deployments • Type of suicide bombings• Never any safety, no real recovery time• Use of civilians as shields and decoys by the enemy• Deliberately targeting our moral code• COMMUNICATION! Internet, cell phones, etc.• IEDs, RPGs (TBI, hearing loss, neuro-chemical effects)• Advancement in medical treatments

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OIF/OEF - Statistics

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As of 12/1/2008

• 1.7M troops deployed

• 4207 US Military killed in Iraq (excludes civilians)

• 627 US Military killed in Afghanistan (excludes civilians)

• 65,000+ US Military wounded

• 54% deployed are Reserve / Guard (4/08)

• 1% of US population is directly touched by military service; more if you consider civilian contractors

• Deployed as of 09/2009:~ 130K troops in Iraq~ 160K civilian contractors in Iraq~ 65K troops in Afghanistan (more are being sought as of Oct 2009)

OIF/OEF - Profile

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• All-Volunteer military

• Many did not expect deployment(reminder: GA is 6th largest NG state)

• Multiple deployments is the norm

• 2008 Rand Study indicates:

• 53% of those that need treatment sought Mental Health treatment in ‘08

• 16-23% have experienced MSTMST = Military Sexual Trauma

• 2yr post-deployment cost $6.2B

• OIF vs OEF – VA indicates a OIF vet is 2x likely to seek help than a OEF vet

• As of 04/08, 120K mental health dx’s, 50% were diagnosed w PTSD

• “Homecoming Concept” = alienation, detachment, isolation, avoidance, boredom

• 15 wounded for every 1 fatality (Vietnam was 3 for 1)

• VA predicts that it will treat 263,000 OIF/OEF vets in 2008 and 330,000 in 2009

• Current backlog of veterans is 400,000 (as of 2008)

• Claims backlog is over 900,000 (as of Aug 2009)

• Heaviest of that backlog is mental health (Ex: Virginia VA community mental health services has a waiting list of 5,700 as of early 2008)

• 550,000 school age children of active duty Service Members (Reg/Res/NG)

• 52,000 children of Reserve and National Guard Service Members affected

• 84% of Regular Military Service Members’ children attend public school, not DoD base schools

• Georgia has over 750K veterans

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OIF/OEF - More Statistics

According to a new American Journal of Public Health study on veterans' mental health diagnoses

– Of the 289,328 veterans who entered VA care in 2008, nearly 37% had mental health problems, including post traumatic stress disorder (about 22%) and depression (roughly 17%). (ref: http://www.ajph.org/cgi/content/abstract/AJPH.2008.150284v1 )

– "Weekend warriors" over 30 years old in the national guard and reserves who left stable family, work and community environments for combat zones were especially susceptible to mental health problems.

A recent (July, 2009) US government accountability office report found that nearly 20% of women veterans suffer from PTSD (ref: http://www.gao.gov/new.items/d09899t.pdf )

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OIF/OEF – and some more Statistics

OEF / OIF Experience - Summary

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1. Indirect threats – not so much direct assaults and attacks• IEDs, car bombs• RPG, snipers• Suicide bombings

2. Powerlessness• threat is indiscriminate• not dependent upon skill or mastery• relationship between loss of control and PTSD

3. This generation’s war• 1st Internet War (Vietnam was the TV War)• Blogs, email, cell phone (cameras) 24 hr new sites• New versions of the “Dear John/Jane” letter• Home trouble as a leading stressor (financial, intimate partner)• Reservists/Guard: repeated, unpredictable separations from family/job

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The next several charts will cover life within the military family and clinical

treatment considerations

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SoldierDeployment

Separation Stress –

Depression & Anxiety

Family Adjustment w/o Soldier in Home – Out-of-

Ordinary Behaviors

Pre-reunion Stress – anxiety and worry

about behavior away

Reunion and homecoming –

joy and anticipation

Revitalize Relationships and

“honeymoon”

Family readjusts - Consequences

for behavior

Pre-deployment Conflict & PreviousStressor pile-up

Pre-deployment Stress – anxiety

and concern

The Military Deployment Cycle … orThe Military Family Life Cycle

Military Family At-Risk Factors

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1. Frequent Relocation 3.3 years average

2. Previous Deployments 87%

3. Longer Separations 7.3 month average

4. Larger Families 42% ≥ 3 children

5. Younger Mothers 26.5 median age

6. Blended Families 31% step-parents

7. Education 21% w/o HS diploma

8. Working Outside Home 44%

9. Median Income < $30,000 (34%)

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Separation

• Resulting from deployments, relocation, or training – range from a few to many months – disrupts life cycle transitions.

• Emotional ambiguity stemming from physical loss, but expect maintenance of closeness.

• Child & family ties/problems within the larger community.

• Heightening difficulties are the threat of death or injury of service member.

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Reunification

• Stressful because of adjustment required – family functioning may have been enhanced in absentia.

• Presence of service member alters household rule, role, time, & routine structure.

• Expect to return to normal functioning after long term separation ~ what is normal?

• Reckoning for misdeeds during service member’s absence (school failure, affairs, etc.)

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Relocation

• Families in the military (U.S. Army in particular) relocate every three to five years.

• Inconsistency of services b/w the installations (schools @ Ft. Hood vs. Ft. Stewart).

• Requires readjustment for family members who may lag behind service member both physically & emotionally

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Deployment Related Stressors for Spouses STRESSOR POSITIVE RESPONSE

Feeling Lonely 90.0% (271)

Having Problems Communicating with my Spouse 61.2% (184)

Experiencing the Death of a Close Friend or Relative 33.2% (100)

Managing and Maintaining Family/Personal Finances 47.2% (142)

Personal/Family Health Issues 43.2% (130)

Being Pregnant during the Deployment 26.9% (81)

Raising a Young Child while my Spouse is not Present 63.2% (190)

Childcare 39.9% (120)

Managing and Maintaining the Upkeep of my Home 49.1% (148)

Having Reliable Transportation 19.9% (60)

Caring/Raising/Disciplining Children with my Spouse Absent 56.5% (170)

Balancing between Work and Family Obligations/Responsibilities 53.4% (159)

The Safety of my Deployed Spouse 96.4% (290)

Warner CH, Appenzeller GN, Warner CM, Grieger T. “Psychological Effects of Deployments on Military Families” Psychiatric Annals 2009; 14: 56-62.

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…a closing thought on the Military Culture

“The capacity of Soldiers for absorbing punishment and enduring privations is

almost inexhaustible so long as they believe they believe they are getting a square dealthey are getting a square deal, that their

commanders are looking out for them, and that their own accomplishments are

understood and appreciated.”

GENERAL Dwight Eisenhower, 1944

Demographics - AGE

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Enlisted

Officers

Demographics - Young Adults in the Military

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• 46.6% of all service members are <= 25 yrs old• 53% of enlisted members are <= 25 yrs old• 24.8% reported binge drinking >1x per week in the

past 30 days vs 17.4% for same-age civilians• Higher smoking rates (40% vs. 35.4%) than same-age

civilians• Illicit drug use in the military was 5% in 2005, but

nonmedical use of painkillers is the most common form of drug abuse.

Source: Military Family Research Institute at Purdue University.(2005). 2005 demographics report. Arlington, VA: Office of the Deputy Under Secretary of Defense, Military Community and Family Policy. Retrieved January 7, 2009, from www.cfs.purdue.edu/mfri/pages/military/2005_Demographics_Report.pdf

Demographics – GENDER AND RANK

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Women represent approximately 15% of the military force.

Representation of women is slightly lower for Senior Enlisted and General Officers.

Demographics – MARITAL STATUS

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RED = Civilian

BLUE = Total DOD

Marital Status Divorce TrendsAC=Active Duty

RC=Reserves/Guard

Demographics – Suicide

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Two dominant factors:

1.Financial Stress

2.Concerns with Intimate Partners

The 2008 overall Army rate was 24/100K, a 33% increase

70% increase reported from 2005 to 2007

SIGNS / SYMPTOMS OF (COMBAT) PTSD

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• HYPER-AROUSAL: Fight/Flight/Freeze, Angry, poor sleep, argumentative, impatient, on alert, tense (hyper-vigilant), intense startle response, speeding tickets (once home) and other risky behavior.

• NUMBING/AVOIDANCE: Withdrawn, secretive, detached, controlling, removes all reminders, avoids similar situations, ends relationships with people associated with trauma, etc.

• RE-EXPERIENCING: Nightmares, flashbacks, intrusive thoughts

PTSD: Cues or Triggers

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• Think “full body”: memories are laid down in all sensory spheres (smell, sound, vibrations, colors, etc)

• Terrain: desert, urban

• Weather: heat wind, humidity

• Songs

• Smells

• Driving: signature trigger for OIF/OEF vets (assess driving safety !)

• Nature of war in Iraq and Afghanistan

• Need for high speeds, evasive maneuvers

• Importance of a driving assessment

• People: automatic response to persons who appear Middle Eastern, children

• Situational: mimic loss of control powerlessness (e.g. dentist chair, anesthesia, OB-GYN exam, endoscopy, etc)

PTSD: non-DSM

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What does PTSD feel like1. Sense of immediacy (“happening right now”)2. Re-experiencing of original memories and sensory impressions3. Involuntary4. Guilt

• Rational or irrational• Understanding atrocities• “Survivor Guilt”, also guilt for leaving, being intact

5. Grief• Multiple losses without time to grieve• Affective numbing, anger/revenge• Impact of pre-war losses, post-war losses• Deaths of loved ones during deployment

6. Other Feelings• Anger at Government• Mistrust of Authority• Desire to return to the war zone• Damage to spirituality

TBI: Traumatic Brain Injury

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• Signature Injury of OIF/OEF

• Prevalence hard to estimate

• Approximately 2100 Afghanistan troops diagnosed since 2001 as of 08/2007

• VA reports 61,285 OIF/OEF vets had preliminary screen, 11,804 were positive (20%)

• Prevalence has probably been underestimated so far

• Explosions account for 3 of 4 combat-related injuries

• Improvements in war zone medical treatment decreases fatalities but may impact rise in TBI

• Soldier return home with “poly-trauma”

• Symptoms: headaches, tinnitus, dizziness, balance problems, sleep problems, persistent fatigue, speech, hearing and vision impairment, sensitivity to light and sounds, heightened or lessened senses, impairments in attention and concentration, memory problems more like dementia than amnesia, poor impulse and anger control

MST: Military Sexual Trauma

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1. 2008 Rand Study reported 16% - 23% experienced MST

2. Reported MST were 1,700 in 2004 and 2,947 in 2006

3. VA indicates that 1 in 4 female veterans using the VA reported at least one MST

4. The VA Day Hospital Program estimates 3-5 female referrals have MST

5. Treatment Considerations• May be compounded by combat trauma• Frequently unreported

Trauma occurs in context of where the solder lives and works (comparable to incest)

Military Culture emphasizes cohesion• Males victims as well as female• Female perpetrators as well as male• Largely male population in the VA where female veterans go for help

PTSD Treatments

• Cognitive Therapy (CT)• Exposure Therapy (ET)• Stress Inoculation Training (SIT)• Eye Movement Desensitization

& Reprocessing (EMDR)

Generally individually oriented and systemically focused – “Onesize does not fit all”

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VA Opinion of PTSD Interventions

… A Extra Word About The Children

• Currently, there are about 230,000 American children and teenagers with an active duty mother or father at war. [Another 320,000 from Reserve/Guard families. 550K total] Nearly half of all troops deployed in support of the recent wars are parents — most of whom are on their second or subsequent deployments. (Aug ‘09)

• In 2008, military children and teens sought outpatient mental health care 2 million times, which was double the number at the start of the Iraq war (2003), according to an internal Pentagon document obtained by The Associated Press.

• An article published by the Associated Press (August 9, 2009) notes a Pentagon report indicating a 20 percent increase in the number of active duty dependent children hospitalized for mental health needs between 2007 and 2008.

• The document revealed there was also a spike in the number of service members' children hospitalized for mental health reasons.

• http://www.msnbc.msn.com/id/32585278/ns/health-kids_and_parenting/ http://cbs3.com/wireapnewspa/Camp.for.military.2.1147685.html

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Realizing the bridge is down…

“Home—the place many think is the safe haven to find relief from the stress of war—may initially be a letdown. When a loved one asks, ‘What was it like?’ and you look into eyes that have not seen what yours have, you suddenly realize that home is farther away than you ever imagined.”

Down Range: From Iraq and Back, by Cantrell & Dean, 2005

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Intake Scenario – Interpreting It

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Your New Client20 year old male 33% of Reserves are in the age range of 17-24

SPC in USANG, 4 month Post-deployment from OIF

SPC means rank is E4, not yet an NCOUSANG means Guard just back from Iraq(OIF)

Gunner from 1st BCT 3ID 1st BCT – First Brigade Combat Team; 3ID=3rd Infantry Division; he probably saw up-close, ground combat

“on edge”, “pissed off”, difficulty sleeping

These symptoms of Reunification stressors should be considered; As a Guard member, inquiry into transition back to his civilian life and prior pursuits as this is a common challenge for Guard members

First SGT concerned over his irritability First SGT- significant that his enlisted leader had concerns

Anger towards leadership for decisions made downrange

“Downrange” means in the combat area.

Married with 2 children, <4 yr old , 1 born during his deployment

Military at a younger age tend to have responsibilities equivalent to civilians of an older age. She went thru the birth alone; he went thru combat alone. Do they each appreciate it.

Marital discord Enlisted Males have lower divorce rates than enlisted females; but higher divorce rates than officers

Wants to deploy again ASAP Need to know why: closer bonding to the combat unit than to the family; need for risky behavior; grief over losses in combat, back loading of some trauma and wants to keep it suppressed.

Presentation Goals – What We Did

There were 3 goals of this presentation:• We Reviewed the CareForTheTroops organization

and the issues that drove the plan for the non-profit organization CareForTheTroops

• We Reviewed at a high-level some of the “military culture” issues that may help in counseling military family members

• We Reviewed the problems and issues faced by veterans and their families and treatment issues for those who are serving and have served during periods of conflict.

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In Closing…Consider These Next Steps

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• Look for more training opportunity to learn about treating the military. Visit www.CareForTheTroops.org

• If not yet trained in a trauma treatment technique, consider getting that training, e. g. EMDR (Jan 15-17 Weekend I in Athens)

• If you are willing to work with military families, and meet the qualifications, enroll in the CareForTheTroops database

• Consider being a trainer to outreach to community organizations, congregations, and other counselors

• to participate in the CFTT initiative• to market your practice