Transcript cftt_Military_Culture_101_FINAL

Military Culture & Treatment - 101
GAMFT Chapter Workshop
three hour workshop to overview the
culture of military families, effective
treatments, and sources of support
Blaine Everson
[email protected]
706-369-7911
Alan Baroody
[email protected]
912-369-7777
Peter McCall
[email protected]
770-329-6156
1
Presentation Goals
There are 5 goals of this presentation:
• Better understand the basics of the
military culture to build credibility
while working with military families
• Review key issues that can impact
the mental health of a military family
• Review the recommended treatments for military trauma,
what triggers to look for, and commonly encountered issues
• Review where clinical support material can be found via CFTT
• Learn what the GAMFT initiative is with the
CareForTheTroops.org organization
2
Agenda
Topic
Duration Comments
Intro and Opening
10
Presenters, Goals and Agenda
Oath of Enlistment
CareForTheTroops.org
20
Overview Mission / Role of Clinicians
Show Key Website Components for Clinicians
Review Enrollment and Marketing Assistance
En’visioning’ the Issues
40
Brothers at War Trailer
Audience Discussion
Fraser Center Perspective
Military Culture
35
Jargon and Organization
Deployment/Family Life Cycles
Stressors
Clinical Treatment Info
45
Demographics
PTSD-Signs and Treatments
Family Therapy Approaches
Case Study
Insurance Considerations
15
Insurance Overview @Fraser Ctr.
Q&A and Closing
15
On-Going Discussion
Handout – A0 …..an Example
3
MILITARY OATH OF ENLISTMENT
recited by all Service Members at their swearing in ceremony
I, (NAME)… NOTE: the 3 dots … = it’s a break point, repeat after me.
DO SOLEMNLY SWEAR…
THAT I 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.
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.
Handout – A1
4
Agenda
Topic
Duration Comments
Intro and Opening
10
Presenters, Goals and Agenda
Oath of Enlistment
CareForTheTroops.org
20
Overview Mission / Role of Clinicians
Show Key Website Components for Clinicians
Review Enrollment and Marketing Assistance
En’visioning’ the Issues
40
Brothers at War Trailer
Audience Discussion
Fraser Center Perspective
Military Culture
35
Jargon and Organization
Deployment/Family Life Cycles
Stressors
Clinical Treatment Info
45
Demographics
PTSD-Signs and Treatments
Family Therapy Approaches
Case Study
Insurance Considerations
15
Insurance Overview @Fraser Ctr.
Q&A and Closing
15
On-Going Discussion
5
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. clinicians, 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.
6
Organization
501c3 status has already been approved by the IRS
Current Board of Directors:
President
Exec Director
Member
Member
Member
Member
Rev Robert Certain, Rector, Episcopal Church of St Peter and St Paul (USAF)
Peter McCall (USArmy)
Bill Harrison, Partner, Mozley, Finlayson & Loggins LLP (USAF)
William Matson, Exec Director, Pathways Community Network, Atlanta, GA
Alan Baroody, Exec Director, Fraser Counseling Center, Hinesville, GA
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 Georgia
Pathways Community Network, Inc
Fraser Counseling Center, Hinesville, Georgia
Catholic Archdiocese of Atlanta
Cooperative Baptist Fellowship (CBF) of Georgia
Episcopal Diocese of Atlanta
Presbytery of Greater Atlanta/Presbyterian Women
7
Causes for Concern
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 (‘08) 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
8
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
9
Approach
Military
Member
Person in
need of
support
Spouse
Siblings
Children
Parents
Grandparents
10
The next set of charts provide a simulation
of using the www.CareForTheTroops.org
website with clinicians in mind
11
This is 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
This focus is
on the Top
Menu
In particular
this shows the
“Mental
Health
Professional”
options.
The Menu
that drops
down shows
the tasks
most often
used by the
Mental Health
Professionals.
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.
Moving down
the same
page.
Info about
your office ,
license,
language, and
education.
Moving
further down
the same
page.
Info about
your
insurance,
specialties,
and training
Text boxes
are there for
free-form
input ref
insurance
and
specialties
Moving to
the end of
the form.
Info about
your
experience,
unique
background.
This is also
where you
enter your ID
and
password.
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.
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.
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.
Training is key.
We have just
added OnLine
Training from
2 sources:
Alliant Univ.
The VA
Much of the
training is
free, a wide
selection of
courses, and
some is
eligible for
CEUs with a
nominal fee
attached.
EMDR TRAINING
Weekend 1 (Part I)
January 15-17, 2010
Athens, 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 Georgia
2. Attend and successfully complete both Part I and Part II EMDR training by HAP
3. 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.php
4. Be willing to work with military clients and their extended family members
5. 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 HAP
6. Attend and complete Part II within 12 months of completing Part I
7. Be responsible for all other costs, fees, and expenses associated with the training weekends.
Chapter Workshops
Military Culture 101-Clinical Treatment Issues
Chapter
Chair / Contact Person
Co-Presenter
Date
Coastal
Time
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
Jan 8th
1pm - 4pm
Metro Atl
Licia Freeman
Alan
Jan 15th
noon - 3:30 Decatur
Northwest
Joan Robinson
Blaine
Jan 22nd
11:30 - 3:30 Sandy Springs
East
John Hill/Sid Gates
Blaine
Feb 5th
8:30 - noon Augusta
West
none
TBD
NOTE: Check with your local GAMFT Chapter and also with the
www.CareForTheTroops.org web site for changes and updates.
Location
Albany
Columbus
25
Final Comments
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
Help for Us
• Enroll in the CFTT database
• Publicize CFTT to community and congregations
• Would you consider being a Trainer using material like you
see today?
26
Agenda
Topic
Duration Comments
Intro and Opening
10
Presenters, Goals and Agenda
Oath of Enlistment
CareForTheTroops.org
20
Overview Mission / Role of Clinicians
Show Key Website Components for Clinicians
Review Enrollment and Marketing Assistance
En’visioning’ the Issues
40
Brothers at War Trailer
Audience Discussion
Fraser Center Perspective
Military Culture
35
Jargon and Organization
Deployment/Family Life Cycles
Stressors
Clinical Treatment Info
45
Demographics
PTSD-Signs and Treatments
Family Therapy Approaches
Case Study
Insurance Considerations
15
Insurance Overview @Fraser Ctr.
Q&A and Closing
15
On-Going Discussion
27
Brothers At War Film Clip
http://www.brothersatwarmovie.com/
28
Fraser Center Experience
Film Clip Comments
THERAPEUTIC ISSUES OBSERVED IN THE CLIPS FROM “BROTHERS AT WAR”:
1. The adrenaline high, or adrenaline addiction – “It’s like the best!”
2. Personality changes. No one returns the same from combat or lengthy deployments.
3. Generalized and undifferentiated anger: short fuse, loss of patience, (increase in
domestic violence and child abuse). “Now when he gets mad, he just screams.”
4. Grief over absence during important life transitions (also, resentment by spouse at
soldiers absence). “When I come home I just want to hug her, but she may not let me
because she won’t know who I am.”
5. Intense bonding during deployment competes with and sometimes trumps marital
and family bonds. “My friends here are closer than any I’ve had.” “These guys take
you on as a brother.”
6. Survivor guilt and loss: “It hurts a lot to lose fellow soldiers.”
7. Family of origin issues: “I want to make my Dad proud.”
8. Fantasy verses reality. (living on dreams and through TV series)
9. Emotional numbing: “He used to be sensitive. Now, he shows no emotion and wants
me to be the same way.”
10. The ramifications of “sacrificing for family” and the sacrifices made by families.
29
Fraser Center Experience
www.frasercenter.com
THE FRASER CENTER SETTING:
1. Clients include Veterans, Active Duty Soldiers, and Military Dependents
2. Clients primarily from FT Stewart (3rd Infantry Division) and Hunter Army Airfield
GENERAL OBSERVATIONS MADE BY FRASER CENTER THERAPISTS WHO WORK
WITH OIF/OEF VETERANS, ACTIVE DUTY SOLDIERS, AND MILITARY DEPENDENTS:
1. The children of military families are often the first to be brought in for therapy –
secondary trauma. “Is daddy going to die?”
2. The length, number, and frequency of deployments decreases family resiliency upon
re-deployment (returning home from a deployment).
3. The number of engagements “outside the wire” increases the likelihood of Combat
Stress Symptoms (transient, acute, & PTSD).
4. Over time, the constant threat of incoming mortar rounds and IED incidents increases
likelihood of CSS and PTSD for those who remain primarily in “green zones.”
5. The primary concerns of combat troops are: Mission First, staying safe, keeping their
buddies safe, getting home, and what is happening at home with their spouse and
families.
30
Fraser Center Experience
www.frasercenter.com
GENERAL OBSERVATIONS (continued…):
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
While deployed, soldiers also fight on the homefront via internet and cell phone with their
spouses. Homefront stressors may be higher than combat stressors.
Viewing internet pornography and internet sex chat is becoming a norm for deployment and
effects marriages upon return.
Many soldiers maintain their unit bonds following re-deployment to the detriment of their family
bonds.
Returning soldiers rarely talk with spouses about combat experiences.
There is a high rate of infidelity among soldiers and spouses during deployments. This is not
necessarily the “deal breaker” that it might be in civilian life.
Illegal/prescription drugs and alcohol are prevalent and are used as common coping mechanism
by soldiers (deployed and at home) and by their spouses.
While deployed, many soldiers are constantly sleep deprived and share each others medications
(i.e. ambient, provigil). Hooked on Energy Drinks.
The suicide rate of re-deployed) soldiers and spouses is on the increase.
Most soldiers know of at least one other soldier in their unit who “ate his gun” or was blown up by
an IED.
There is a high incidence of rape and sexual molestation of deployed female soldiers.
Soldiers and spouses express a great deal of anger toward perceived incompetency in the chain
of command, or in procedures, which have a direct negative impact upon their lives.
31
Fraser Center Experience
www.frasercenter.com
GENERAL OBSERVATIONS (continued…):
17. Home is no longer a safe place to live. Many now carry weapons when not on military
installations at home.
18. The vast majority of returning troops are filled with undifferentiated anger and a short fuse.
19. There is a statistically verifiable increase in domestic violence and child abuse among military
families. Child abuse increases as the stressors increase in the life of the non-deployed spouse.
20. A primary therapeutic issue is the soldier’s inability to re-connect emotionally with spouse and
children. (exacerbated by anger and lack of patience).
21. Chaplains are the mental and spiritual health “first responders” at home and in the combat arena.
22. Special attention needs to be given to National Guard and Reserve Chaplains. There is a high
incidence of their leaving the ministry.
23. Both spouse and soldier recognize that the soldier is “changed” by combat deployment.
24. Important family milestones and transitions have been missed.
25. Soldiers may pursue activities which replicate the adrenaline rush of combat and sometimes reenlist without spousal consultation in order to maintain the rush.
26. Spousal dissatisfaction and resentment: power control issues upon redeployment. “I didn’t sign
up for this.” The military spouse sacrifices education and career
27. With increased monetary incentives and a lowering of recruitment standards the quality of the
troops has been increasingly lowered: no GED necessary, accepting recruits with DSM-IV
diagnosable conditions and on meds, increase of gangs in the army.
32
Fraser Center Experience
www.frasercenter.com
GENERAL OBSERVATIONS (continued…):
28. Due to young age, immaturity, and low educational levels, many soldiers and spouses have poor
life skills: money management, parenting, communication, etc.
29. Some soldiers return to empty bank accounts and houses.
30. The military has greatly increased mental health support resources at home and abroad. The
Army recognizes that it is still not adequate.
31. The military is going out of their way to encourage soldiers to seek out mental health treatment,
yet the stigma against seeking help continues to exist.
32. Spirituality is an important tool in the healing process as it is an important issue among those who
have been in combat. It may not be express in typical “religious” language.
33
Chris Warner’s Sources of Stress
Number of Contacts
300
250
200
150
100
50
0
1
2
3
4
Combat Exposure
5
Peer/Unit
6
7
8
9
10
11
--->> Number of Months
Home Front Stressors
Warner CH, Breitbach JE, Appenzeller GN, et.al. “Division Mental Health: It’s Role in the New Brigade Combat Team Structure Part I:
Pre-Deployment and Deployment” Journal of Military Medicine 2007; 172: 907-11.
34
Agenda
Topic
Duration Comments
Intro and Opening
10
Presenters, Goals and Agenda
Oath of Enlistment
CareForTheTroops.org
20
Overview Mission / Role of Clinicians
Show Key Website Components for Clinicians
Review Enrollment and Marketing Assistance
En’visioning’ the Issues
40
Brothers at War Trailer
Audience Discussion
Fraser Center Perspective
Military Culture
35
Jargon and Organization
Deployment/Family Life Cycles
Stressors
Clinical Treatment Info
45
Demographics
PTSD-Signs and Treatments
Family Therapy Approaches
Case Study
Insurance Considerations
15
Insurance Overview @Fraser Ctr.
Q&A and Closing
15
On-Going Discussion
35
Intake Scenario
Your New Client
• 20 year old male
• SPC in USANG, 4month Post-Deployment
from OIF
• Gunner from 1st BCT 3ID
• “on edge”, “pissed off”, difficulty Sleeping
• First SGT concerned over his irritability
• Anger towards leadership for decisions made
downrange
• Married with 2 children, <4 yrs old, one born
during his deployment
• Marital discord
• Wants to deploy again ASAP
36
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
• Material Products – weapons systems
Culture is associated with a social system
and unique to a given system.
Handout – A2
37
Language Barriers for Civilians
Glossary of Military Terms and Acronyms
Military Cultural Competence
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
USANG
United States Army Reserve
United States Army National Guard
E1-E9; O1-O10
SPC
First SGT
NCO
Enlisted Ranks; Officer Ranks
Specialist, rank of E4, often referred to a “Spec 4”
First Sergeant, rank of E7, lead enlisted person in a company. It and SSG,
Staff Sergeant are key leadership ranks with lots of job pressures
Non-Commissioned Officer, ranks E6 through E9
IEDs
FOB
Sandbox
Down Range
Outside the Wire
Taking the Pack Off
Top Cover
Improvised Explosive Devices
Forward Operating Base
Iraq and Afghanistan
Deployed to anyplace where there is shooting.
Leave the safety of the “enclosed” military base (FOB)
Leaving mentally and physically from combat
Making sure the boss looks good
www.rivervet.com/oif_glossary.htm
Handout – A3_1, A3_2, A3_3, A3_4
38
The next few charts cover organizational
background to help understand the client,
where he/she was positioned, and to
better interpret the information and stories
they might tell during their therapy
39
Branches of the Military
Georgia’s Military is dominated by Marine and Army units,
though Air Force and Navy are represented as well.
Georgia’s National Guard also has a large number of
transportation units subject to IEDs on roads and highways.
NOTE: Coast Guard is now under Homeland Security
Handout – A4
40
Military Branch Structures
Example: U.S. Army
Core Values
84%%
2%
14%
84%
2%
14%
Handout – B1, B2, B3
41
Military Culture
Belief 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 boss
Violence :many have a history of violence which often plays a role
•
Norms & Rules:
Formal and informal conduct
Stigma of mental health and PTSD
Cover of the boss (Top Cover)
Back-logging trauma
42
Reserve and National Guard Units
vs Regular Army
Reserve / Guard
• 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.)
Handout – C1
Regular
• 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 onpost & 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
43
soldier’s unit
The next few charts provide some
background of this war that might help you
better understand your client and their
presenting story and issues
44
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
45
OIF/OEF - Statistics
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)
46
OIF/OEF - Profile
• NG and Reserve 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 MST
MST = 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
Handout – C2
47
OIF/OEF - More Statistics
•
15 wounded for every 1 fatality
(Vietnam was3 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
Handout – C3
48
OIF/OEF – and some 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. 2008 American Journal of Public Health study
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 )
49
OEF / OIF Experience - Summary
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
50
The next several charts will cover life
within the military family and clinical
treatment considerations
51
The Military Deployment Cycle
… or The Military Family Life Cycle (Original View)
Pre-deployment
Conflict & Previous
Stressor pile-up
Family readjusts Consequences
for behavior
Revitalize
Relationships and
“honeymoon”
Pre-deployment
Stress – anxiety
and concern
Reunion and
homecoming –
joy and
anticipation
Soldier
Deployment
Separation
Stress –
Depression &
Anxiety
Family Adjustment w/o
Soldier in Home – Out-ofOrdinary Behaviors
Pre-reunion Stress
– anxiety and worry
about behavior
away
52
Military Family Life Cycle
(…Multiple Deployment View)
<May be 1st deployment for both partners>
-Courting
-Pregnant
Deploy
-Marriage
New
family
begins
in
absentia
<Missed 1st year of marriage>
Mid-tour
leave
Parental
adj &
young
children
Return
&
Reunion
Resume
normal
routines
<Divorce & remarriages w/ kids for previous relationships are common – complex stepfamily>
ETS or
Retire
Families
w/
teens &
possibly
steps
Relocation
Return
&
Reunion
Family
w/
school
agers
Redeploy
Transitions are often marked by crisis points in the family life cycle.
53
Military Family At-Risk Factors
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%)
Quality of Life Among U.S. Army Spouses During OIF, Dissertation, 2005, Dr. Blaine Everson
54
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.
55
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.)
Handout – D1
56
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
57
Deployment Related Stressors for Spouses
Length & Number of
Deployments
Children’s
Well-being
Family Finances
Waiting Spouse of
Service Member
Parenting Strains –
# & ages of kids
Fear of Injury or Death
Of Service Member
Relational Quality
w/ Deployed Spouse
Work/Life Balance
58
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.
59
Summary of Stressors
For Active Component Families
• Permanent Change of Station (PCS)
• Temporary Duty (TDY)
• Deployment
• Foreign Residence
• Risk of Injury or Death
• Behavioral Expectations
Additional for Reserve/Guard
Component Families
• “Citizen Soldier”
• Mobilization and Deployment
• Separation from School, Jobs, etc
• Demobilization
60
…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 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
61
Agenda
Topic
Duration Comments
Intro and Opening
10
Presenters, Goals and Agenda
Oath of Enlistment
CareForTheTroops.org
20
Overview Mission / Role of Clinicians
Show Key Website Components for Clinicians
Review Enrollment and Marketing Assistance
En’visioning’ the Issues
40
Brothers at War Trailer
Audience Discussion
Fraser Center Perspective
Military Culture
35
Jargon and Organization
Deployment/Family Life Cycles
Stressors
Clinical Treatment Info
45
Demographics
PTSD-Signs and Treatments
Family Therapy Approaches
Case Study
Insurance Considerations
15
Insurance Overview @Fraser Ctr.
Q&A and Closing
15
On-Going Discussion
62
Demographics - AGE
Enlisted
Officers
63
Demographics - Young Adults in the Military
• 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
Handout – D2
64
Demographics – GENDER AND RANK
Women represent
approximately 15%
of the military force.
Representation of
women is slightly
lower for Senior
Enlisted and
General Officers.
65
Demographics – MARITAL STATUS
Marital Status
Divorce Trends
AC=Active Duty
RC=Reserves/Guard
RED
= Civilian
BLUE = Total DOD
66
Demographics – Suicide
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 2008
Handout – E1
67
Psychological Injury Continuum:
ASR to COSR to PTSD
• ASR (acute stress reaction)
produces biological, psychological, and behavioral
changes. ASD means it has become
disruptive and destructive.
• COSR(combat and operational stress)
is expected, common, and occurs throughout deployment to some
degree. Pretty much everyone comes home with some version of
combat and operational stress.
• PTSD(post traumatic stress disorder)
becomes classified if COSR symptoms are daily, interfere, and “last
longer than 1 month”
68
SIGNS / SYMPTOMS OF
(COMBAT) PTSD
• 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
69
PTSD: Cues or Triggers
•
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)
70
PTSD: non-DSM
What does PTSD feel like – What do you “hear” in therapy
1. Sense of immediacy (“happening right now”)
2. Re-experiencing of original memories and sensory impressions
3. Involuntary
4. 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
Handout – F1, F2
71
TBI: Traumatic Brain Injury
•
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
72
MST: Military Sexual Trauma
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
Handout – C2
73
PTSD Treatments
•
•
•
•
Cognitive Therapy (CT)
Exposure Therapy (ET)
Stress Inoculation Training (SIT)
Eye Movement Desensitization
& Reprocessing (EMDR)
VA Opinion of PTSD Interventions
Generally individually oriented
and systemically focused – “One
size does not fit all”
Handout – G1, H1
74
… 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
75
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
Handout – H2
76
Intake Scenario – Revisit and Review
Your New Client
20 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 NCO
USANG 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.
77
Agenda
Topic
Duration Comments
Intro and Opening
10
Presenters, Goals and Agenda
Oath of Enlistment
CareForTheTroops.org
20
Overview Mission / Role of Clinicians
Show Key Website Components for Clinicians
Review Enrollment and Marketing Assistance
En’visioning’ the Issues
40
Brothers at War Trailer
Audience Discussion
Fraser Center Perspective
Military Culture
35
Jargon and Organization
Deployment/Family Life Cycles
Stressors
Clinical Treatment Info
45
Demographics
PTSD-Signs and Treatments
Family Therapy Approaches
Case Study
Insurance Considerations
15
Insurance Overview @Fraser Ctr.
Q&A and Closing
15
On-Going Discussion
78
TriCare - Ceridian
TriCare
• MFTs are eligible for TriCare
• LPCs need supervision by an M.D.
• 90-120 days application process
• Application in handout
• More confidential; less need to exchange info for decisions
• Preference is to use the spouses contract
Ceridian
• 5 yr clinical experience required
• Fax the application
• 12 sessions (raised sessions allowed; lowered fees)
• Must use Ceridian forms and notes
• Less confidential; requires more client info for decisions
• Good place for EMDR because of limited sessions
• Easier access
Handout – I1, J1, J2, K1
79
Agenda
Topic
Duration Comments
Intro and Opening
10
Presenters, Goals and Agenda
Oath of Enlistment
CareForTheTroops.org
20
Overview Mission / Role of Clinicians
Show Key Website Components for Clinicians
Review Enrollment and Marketing Assistance
En’visioning’ the Issues
40
Brothers at War Trailer
Audience Discussion
Fraser Center Perspective
Military Culture
35
Jargon and Organization
Deployment/Family Life Cycles
Stressors
Clinical Treatment Info
45
Demographics
PTSD-Signs and Treatments
Family Therapy Approaches
Case Study
Insurance Considerations
15
Insurance Overview @Fraser Ctr.
Q&A and Closing
15
On-Going Discussion
80
What This Presentation WAS About
There were 5 goals of this presentation:
• Better understand the basics of the military culture to build
credibility while working with military families
• Review key issues that can impact the mental
health of a military family
• Review the recommended treatments for military trauma,
what triggers to look for, and commonly encountered issues
• Review where clinical support material can be found
• Learn what the GAMFT initiative is with the
CareForTheTroops.org organization
81
In Closing…Consider These Next Steps
• 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, 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
Handout – L1, M1
82