Working with Veterans and Working with Veterans and Their Families: Their Families:

Post-Traumatic Stress Disorder Post-Traumatic Stress Disorder (PTSD), Other Key Issues, and (PTSD), Other Key Issues, and

Clinical DilemmasClinical Dilemmas

James Munroe Ed.D.James Munroe Ed.D.

Boston VA Healthcare SystemBoston VA Healthcare System

May 19, 2007May 19, 2007

A Unique SituationA Unique Situation

We know a lot more than in the pastWe know a lot more than in the past It is an ongoing warIt is an ongoing war Discharged, active and reserve VeteransDischarged, active and reserve Veterans Males and FemalesMales and Females Possible redeploymentPossible redeployment A work in progressA work in progress We are learning a lot moreWe are learning a lot more

DoD RosterDoD RosterNovember 2006November 2006

(Since 2002)(Since 2002) 631,174 OEF/OIF separated from active duty631,174 OEF/OIF separated from active duty 46% Former Active Duty46% Former Active Duty 54% Reserve and National Guard54% Reserve and National Guard 205,097 sought VA health care (32%)205,097 sought VA health care (32%) 4.0% of 5.3 million vets receiving care4.0% of 5.3 million vets receiving care 36% Received possible Mental Health Dx36% Received possible Mental Health Dx

Frequency of Possible Mental Frequency of Possible Mental Disorders Among OIF/OEF Disorders Among OIF/OEF

VeteransVeterans PTSD 33,754PTSD 33,754 Non-Dependent use of drugs 28,732Non-Dependent use of drugs 28,732 Depressive Disorders 23,462Depressive Disorders 23,462 Neurotic Disorders 18,294Neurotic Disorders 18,294 Affective Psychoses 12,386Affective Psychoses 12,386 Alcohol Dependence 5,413Alcohol Dependence 5,413 Acute Reaction to Stress 2,273Acute Reaction to Stress 2,273

Scope of the ProblemScope of the Problem(Returning Screens and Follow Up)(Returning Screens and Follow Up)

26% with mental health disorders 26% with mental health disorders 23% to 40% sought VA mental health care23% to 40% sought VA mental health care Concern about stigmatization as barrier to Concern about stigmatization as barrier to

treatment (Kang et al. 2005)treatment (Kang et al. 2005)

Stigma is the greatest in those with the most Stigma is the greatest in those with the most need for care (Hoge et al. 2004).need for care (Hoge et al. 2004).

77% to 60% are in the community77% to 60% are in the community

Barriers to TreatmentBarriers to Treatment

Stigma of Mental HealthStigma of Mental Health Damage to CareerDamage to Career Perception of WeaknessPerception of Weakness Eagerness to go HomeEagerness to go Home Access to ServicesAccess to Services Mental Health MentalityMental Health Mentality PTSD FocusPTSD Focus VA ReputationVA Reputation

Overcoming BarriersOvercoming Barriers

Point of ContactPoint of Contact Center for Returning VeteransCenter for Returning Veterans Extended HoursExtended Hours Community Access (CBOCs)Community Access (CBOCs) Primary Care ConnectionsPrimary Care Connections Public Health MentalityPublic Health Mentality

OutreachOutreach

Returning UnitsReturning Units Family MeetingsFamily Meetings Educational MaterialsEducational Materials Professional and Community PresentationsProfessional and Community Presentations PDHRAsPDHRAs

VHA CRV staffVHA CRV staff Vet Center staffVet Center staff VBA Benefits counselorsVBA Benefits counselors Eligibility and sign upEligibility and sign up

DSM IV Criteria for PTSDDSM IV Criteria for PTSD Experienced Event(s)Experienced Event(s)

Death, threat to physical integrityDeath, threat to physical integrity Fear, helplessness, horrorFear, helplessness, horror

Re-ExperiencingRe-Experiencing Intrusive memories, dreams, flashbacksIntrusive memories, dreams, flashbacks

Avoidance and NumbingAvoidance and Numbing Reminders, triggersReminders, triggers Detachment, restricted emotionsDetachment, restricted emotions

ArousalArousal Irritability, sleep disturbanceIrritability, sleep disturbance Concentration loss, hypervigilant, startle responseConcentration loss, hypervigilant, startle response

Transitioning War Zone SkillsTransitioning War Zone Skills(8 Skills)(8 Skills)

SafetySafety Trust and the EnemyTrust and the Enemy Mission OrientationMission Orientation Decision MakingDecision Making

Response TacticsResponse Tactics Predictability and Predictability and

IntelligenceIntelligence Emotional ControlEmotional Control TalkingTalking

SafetySafety

Living in a war zone requires being constantly Living in a war zone requires being constantly alert for survival.alert for survival.

Situations at home that resemble war dangers Situations at home that resemble war dangers may trigger survival habits.may trigger survival habits.

Trust and the EnemyTrust and the Enemy

When the enemy is among the population, When the enemy is among the population, soldiers quickly learn not to trust people.soldiers quickly learn not to trust people.

Someone who is being friendly or helpful at Someone who is being friendly or helpful at home may be seen as being manipulative. home may be seen as being manipulative.

MissionMission OrientationOrientation

Once a mission is assigned all other non-related Once a mission is assigned all other non-related tasks are unimportant. tasks are unimportant.

The same focus of concentration can be problematic The same focus of concentration can be problematic with multiple goals and tasks. with multiple goals and tasks.

Decision MakingDecision Making

In war, decisions must be made quickly and In war, decisions must be made quickly and clearly without discussion.clearly without discussion.

At home, decisions making is slow and At home, decisions making is slow and involves a lot of discussion.involves a lot of discussion.

Response TacticsResponse Tactics

Hesitating in responding may be dangerous or Hesitating in responding may be dangerous or even deadly, act first, think later. even deadly, act first, think later.

Life and death responses are rare at home, Life and death responses are rare at home, thinking first and acting later is important.thinking first and acting later is important.

Intelligence and PredictabilityIntelligence and Predictability

Information can be used by the enemy to Information can be used by the enemy to anticipate and stage attacks. anticipate and stage attacks.

Social chatter at home may seem frivolous or Social chatter at home may seem frivolous or even dangerous.even dangerous.

If the enemy can predict your location or If the enemy can predict your location or movements they can attack you. movements they can attack you.

Be unpredictable, show up late or early, take Be unpredictable, show up late or early, take round about routes.round about routes.

Emotional ControlEmotional Control

Soldiers learn to numb fear into an ability to react Soldiers learn to numb fear into an ability to react quickly and decisively. quickly and decisively.

The numbing to improve war zone skill, may get in The numbing to improve war zone skill, may get in the way at home.the way at home.

Anger enhances the ability to use force effectively in Anger enhances the ability to use force effectively in war. war.

Veterans may have strong defensive or aggressive Veterans may have strong defensive or aggressive reactions to home situations.reactions to home situations.

TalkingTalking

During the war, there may be little time to talk During the war, there may be little time to talk about powerful events.about powerful events.

Talking realistically at home may make people Talking realistically at home may make people leave quickly or change the subject.leave quickly or change the subject.

What needs to be talked about?What needs to be talked about?

Collateral DamageCollateral Damage

Beyond Effects on VeteransBeyond Effects on Veterans Beyond the Individual Diagnosis of PTSDBeyond the Individual Diagnosis of PTSD Veterans belong to familiesVeterans belong to families Effects on FamiliesEffects on Families Effects on ChildrenEffects on Children Effects do not require a diagnosisEffects do not require a diagnosis

Intergenerational TransmissionIntergenerational Transmission(Danieli, 1998)(Danieli, 1998)

Avoid separation, protect parentsAvoid separation, protect parents Dissociation and numbingDissociation and numbing Belief world is not safeBelief world is not safe Sense of forebodingSense of foreboding Emotional constrictionEmotional constriction Headaches, insomniaHeadaches, insomnia More psychiatric treatmentMore psychiatric treatment

Mechanisms of TransmissionMechanisms of Transmission

SilenceSilence Over-disclosureOver-disclosure IdentificationIdentification Re-enactmentRe-enactment

SilenceSilence

““IT” cannot be talked aboutIT” cannot be talked about Elephant in room is ignoredElephant in room is ignored Behaviors do not make senseBehaviors do not make sense Others create sense with few factsOthers create sense with few facts Distorted beliefsDistorted beliefs Walking on eggshellsWalking on eggshells May be generalizedMay be generalized

Over DisclosureOver Disclosure

Detailed descriptions of eventsDetailed descriptions of events Horrible material unprocessedHorrible material unprocessed Told at inappropriate timesTold at inappropriate times May show powerful emotionsMay show powerful emotions May show no emotionsMay show no emotions Sometimes used to teach or shockSometimes used to teach or shock May be used to stop questionsMay be used to stop questions

IdentificationIdentification

Traumatized parent too distantTraumatized parent too distant Responds to survival behaviorsResponds to survival behaviors Children learn to emulate behaviorsChildren learn to emulate behaviors Closeness through approvalCloseness through approval Children copy more behaviorsChildren copy more behaviors Children go to warChildren go to war

Re-EnactmentRe-Enactment

Acting out trauma themesActing out trauma themes Family induced to carry out rolesFamily induced to carry out roles Parallel emotions generatedParallel emotions generated Survival skill demonstratedSurvival skill demonstrated Family learns war zone skillsFamily learns war zone skills Peacetime skills diminishedPeacetime skills diminished

How Children May PresentHow Children May Present(8 Clues)(8 Clues)

Do children feel unsafe or fearful?Do children feel unsafe or fearful? Are they mistrustful or suspicious?Are they mistrustful or suspicious? Are they overly focused or withdrawn?Are they overly focused or withdrawn? Are decisions rigid or defiant?Are decisions rigid or defiant? Do they act first, think later?Do they act first, think later? Are they unpredictable or evasive?Are they unpredictable or evasive? Are they emotionally flat or angry?Are they emotionally flat or angry? Do they avoid talking?Do they avoid talking?

ResourcesResources Web site: istss.orgWeb site: istss.org Web site: ncptsd.orgWeb site: ncptsd.org Do you know the nearest VA?Do you know the nearest VA? Do you know the nearest Vet Center?Do you know the nearest Vet Center? What are your local resources?What are your local resources?

Point of Contact: Mel TapperPoint of Contact: Mel Tapper857-364-6780; 617-515-3961857-364-6780; 617-515-3961

Transitioning From the War Zone: Information for Transitioning From the War Zone: Information for Veterans and Those Who CareVeterans and Those Who Care

james.munroe@va.govjames.munroe@va.gov