Transcript Military Culture & Treatment - 101

Military Culture & Treatment - 101
three hour workshop to overview the culture
of the military and its families, issues affecting
treatment, and sources of support
Peter McCall, Exec Dir
[email protected]
770-329-6156
1
Introduction and Ground Rules
• This is not a political forum
• Questions are encouraged for group discussion
• Be respectful of others
• If the discussions, material, or videos at any time
become too disturbing feel free to leave the room till
you feel comfortable enough to return
2
Sources of Materials
CareForTheTroops 2009/2010 Military Culture 101 Workshop
The Fraser Counseling Center Staff, Hinesville, GA
Dr Blaine Everson, Clinical Dir, Samaritan Counseling Center, Athens, GA
Major Chris Warner, Winn Army Community Hospital, Fort Stewart , GA
Spiritual Wounds of War material
•
Kent D. Drescher, Ph.D., National Center for PTSD – Menlo Park
•
LTC Peter E. Bauer, MS USAR, LMFT, currently at Ft Hood
•
Chaplain Bill Carr, D. Min., LMFT, VA Hospital, Atlanta, Ga
•
Alan Baroody, LMFT, Presbyterian Minister, Exec Dir Fraser Counseling Center
VA Website
2010 AAMFT Annual Conference Workshop 303
TriWest Healthcare Alliance “Help From Home” DVD
“Care For Returning Vets” presentation from the ELCA Bureau for Federal Chaplaincies
Other citations on charts and handouts
3
Presentation Goals
There are 5 goals of this presentation:
• Understand the basics of the
military culture and veteran issues
• 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
• Provide an understanding of resources available and how
CFTT can help
• Ultimately, build more credibility for working
with military families
4
Agenda
Topics
Part 1
Opening
Veteran Issues
Military Culture
Discussion
Break – 10 minutes
Part 2
The Veteran Experience
Deployment Cycle
Children
Military Couples
Discussion
Break – 10 minutes
Part 3
Trauma Continuum
Spiritual Wounds of War
Insurance
CareForTheTroops
Closing
Handout – A0 …..an Example
5
Opening Videos
These three movie trailers provide a
good backdrop to the Veterans Issues
we are about to discuss.
Please take notes as a discussion will
be conducted after the next section.
The run time is approximately 8
minutes.
6
Veteran Issues
•
Multiple deployments are common causing stress and family attachment issues.
–
–
As of Oct 2008, multiple deployment breakdown: 60% = 1x 36% >= 2x 4% >= 4x
“Typical Deployment Durations”
Army and Marine
1 year (Ex Aviation and Spec Forces 4-6 months)
Navy
6-9 months
Air Force
~6 months
•
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
•
Other mental health, marriage, and family problems often occur with or leading up to PTSD
requiring attention so they don’t get worse
•
In 2009, 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)
–
43% of Service Members have children
–
Average number of children per military family is 1.97 (AAMFT 2010 Annual Conference)
–
42% rise in children’s visits in 2009 over 2004 per Tricare
–
84% of Regular Military Service Members’ children attend public school, not DoD base schools
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Veteran Issues (cont.)
•
Suicide, alcoholism, drug abuse, domestic abuse and violent crimes rates are rising. In 2010:
military suicides exceeded civilian suicides.
–
–
–
–
–
–
–
•
Army and Marine have higher suicide rates than Navy and Air Force
More are occurring Stateside and many go unreported for insurance reasons and are post-discharge
Female suicide rate triples when deployed (recent NIMH study), though still lower than male rate
In GA, per the CDC from 2006-2008, 500 suicides of people identified as current or former military . This
represents 19.4% of all suicides during those years. The Age breakdown is as follows:
20-29
8.4%
50-59
21.2%
30-39
10.8%
60-69
31.8%
40-49
16.3%
70+
55.8%
18 vet suicides out of 30 attempts per day; 5 are already being treated by the VA. Women try more with
less success than men …Army Times 04/2010
Illicit drug use in the military was 5% in 2005, but now nonmedical use of prescription drugs is the most
common form of drug abuse. SPICE is becoming very common.
24.8% reported binge drinking >1x per week in the past 30 days vs 17.4% for same-age civilians
Military Sexual Trauma (MST) is running at 16%-23%
–
–
–
–
–
Includes harassment and assault
Almost as significant among males as among females (Newsweek, April 2011)
Mostly enlister personnel under 25 yrs old (DOD 2010 Annual Report)
Single strongest predictor of PTSD in women - as combat is for men (Natelson, 8/05/10).
80% of assault victims fail to report the offense. (Natelson, 8/05/10)
Handout – A1 A2
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Veteran Issues (cont.)
•
DoD and VA facilities are stretched … the Aug 2009 VA claims backlog was 900,000; the April
2010 backlog was improved to 605,000
–
–
April 2010 back up to 756,000
450,00 claims are taking over 125 days (USA Today, Apr 2011)
•
The U.S. Bureau of Labor Statistics reports the unemployment rate among post 9/11 veterans as
15.2% in January 2011, well above the 9.6 percent rate for non-veterans.
•
The VA said in Dec 2010 that more than 9,000 OIF/OEF vets were homeless (UPI); women are the
fastest growing segment of this population.
•
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. This may be one of the most significant
affecting the future mental health impact on our communities and our society
–
–
–
•
Current numbers are in the 48% range
By design, approximately 33% should be Guard and Reserve
A large number of civilian contractors are also part of the deployed forces
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. Investing in proper treatment would
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actually save $2 billion within two years.
Fraser Center Experience
www.frasercenter.com
THE FRASER CENTER SETTING:
1.
2.
Clients include Veterans, Active Duty Soldiers, and Military Dependents
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.
2.
3.
4.
5.
The children of military families are often the first to be brought in for therapy – secondary trauma.
“Is daddy going to die?”
The length, number, and frequency of deployments decreases family resiliency upon redeployment (returning home from a deployment).
The number of engagements “outside the wire” increases the likelihood of Combat Stress
Symptoms (transient, acute, & PTSD).
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.”
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.
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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.
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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.
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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.
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Interview Videos
Here are three clips from the Alive Day and Brothers at War
movies. They represent interviews that further reinforce the
issues the soldiers have to deal with before and after
deployments.
Again, please take notes as a discussion will be conducted
following these clips. Run time approximately 18 minutes.
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10 Minute Break After a “Light” Clip
The Snow Car !
15
The next few charts cover the Military Culture
and organizational background to help you
better understand the client, where he/she was
positioned, and to
better interpret the
information and
stories they might tell
during their therapy
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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
• Material Products – weapons systems
Culture is associated with a social system
and unique to a given system.
Handout – B1
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Military Culture
Branches of the Military
Georgia’s Military presence is dominated by Marine and Army units, though Air Force
and Navy are well represented too.
Georgia’s National Guard also has a large number of transportation units subject to IEDs
on roads and highways. It was ill-prepared when first deployed in 2003.
Georgia is 6th largest National Guard State. With the current base closing plan, GA will
be one of the 5 largest military states along with TX, CA, NC, VA
NOTE: Coast Guard is now under Homeland Security
Handout – B2
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Military Culture
Military Branch Structures - Example: U.S. Army
Core Values
84%%
2%
14%
84%
2%
14%
Services – Army, Navy, Marines, AF, CG
Components - Active, Guard, Reserve
Handout – B3
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Military Culture
Language - Glossary of Military Terms / Acronyms
OEF
OIF
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.
Operation Iraqi Freedom - also known as the Iraq War; began on 3/20/2003.
Operation New Dawn – post OIF operations
Army
Navy
Marine
Air Force
Soldier
Sailor
Marine
Airmen
USAR
USANG
United States Army Reserve (Federal)
United States Army National Guard (State)
E1-E9; O1-O10
SPC
First SGT
Gunnie
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
A Marine First Sergeant
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
Handout – C1 C2 C3 C4 C5
www.rivervet.com/oif_glossary.htm
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Military Culture
Key ‘Descriptors’
•
•
•
•
•
•
Structured
Standardized
Authoritarian
Esprit de Corps
Focused on Mission
Disciplined
•
•
•
•
•
•
Service Before Self
Political
Mobile
Family Secondary
Technical
Education
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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
22
Military Culture
Regular/Active Duty vs Reserve/Guard Units
Regular / Active
• 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.
• 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
Handout – D1
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
• Need to make use of family or local
supports (church, etc.) though FRG’s
are very helpful
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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 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
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The next few charts cover the Veteran
Experiences and Stressors that are related to
the OEF and OIF veteran and to other
veterans and
their families to
help you better
understand your
client and their
presenting story
and issues.
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The Veteran Experience
•
•
•
•
•
•
•
Fear of Death
Killing
Survivor Guilt
Unreality
Strong Bonds
About Face
Unfinished Business
•
•
•
•
•
•
•
Seared Memory
Multiple Losses
Teamwork
Survival Mindset
Cautious of People
Soul Searching
Lack of Understanding
The Veteran Experience
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
Nation-building activities and interactions
with local leaders
27
The Veteran Experience
Profile of Differences by Era
Vietnam
OIF / OEF
•
military cohorts
• relatively homogenous
• enlisted and drafted
• fewer Reservists/Guard
• fewer civilian contractors
•
•
•
•
•
•
average age 18-22
not married
no children
no career developed
adolescents— early stages of
development
one tour (12-13 mos) were typical
communications via phone, mail
wounded/killed ratio 3:1
•
•
•
•
•
•
•
•
•
•
•
not homogenous---heterogeneous
• Active duty
• Reservists/Guard• joined for variety of reasons
• likely did not expect to be deployed
• Large number of civilian contractors
wide age range: 18-60+
married
parenting/grand-parenting job/career
financial responsibilities (e.g. mortgage, family)
multiple deployments with unknown duration
are typical
instant communication
more indirect combat e.g. IEDs and suicide
bombers, constant threat
wounded/killed ratio 15:1
Korea and World War II ???
28
The Veteran Experience
Demographics
Enlisted
Officer
Mean Age
27 Yrs; 80% under 35
34 Yrs
Female Population
14.8%
16%
Racial Minorities
32.9%
18.3%
Married Men
Women
50.9%
43.0%
71.4%
50.9%
Dual Service Families
13.6%
11.2%
Divorce vs non-Military
Higher (53% vs 49%)
Higher
Female rate is 2x Men’s
From 2010 AAMFT Annual Conference Workshop #303
Handout – D2 D3
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The Veteran Experience
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 – E1
30
Video – Signs of Stress
Scenes from these movies depict the stress points that occur
between couples upon re-deployment . These are also intended
to set up the following charts that cover the deployment life
cycle and key points on the cycle’s timeline.
Again, please take notes as a discussion will be conducted
following these clips. Run time approximately 10 minutes.
31
Deployment Cycle
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.
32
Deployment Cycle
• Pre-deployment - Period of training and
equipping prior to deployment (30-90 days).
• Deployment - Combat and Humanitarian
missions anywhere in the world (3-18
months).
• Redeployment - Return from operations to
home base (30 days). (For Reserve and National Guard
components this includes demobilization and return to civilian
life).
The Military Deployment Cycle
… or The Military Family Life Cycle
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
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Military Family Life Cycle
(…Career 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.
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Deployment Cycle
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
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Interviewed Guard Couple
Due to time limitations,
it is likely that we will
skip this during the
allotted time. If time
and logistics permit
after the allotted time, I
will be happy to stay
for those that care to
listen.
Interviews from TriWest’s “Help From Home” DVD
Again, please take notes as a discussion will be conducted
following these clips. Run time approximately 17 minutes.
http://www.youtube.com/results?suggested_categories=27&search_query=triwest+help+from+home%2C+channel
37
Children
Mental Health Overview
•
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 — many 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
38
Children
What Impacts Are Seen
•
•
•
•
•
•
•
Disruption of Routines
Boundary Issues & Parental Roles
Fear for Safety of Military Parent
Mimicry of Parental Responses
Sleep Disturbances and Phobias
Increase in Number of Physical Ailments
Secondary and Vicarious Traumatization
Children
Developmental Issues
• Toddlers (3-5) - Separation Anxiety,
Self-Comforting Behavior, Regression,
Refusal to Eating and Sleep
• Elementary (5-10) - Anxiety, Withdrawal,
Regression, Fear, Uncontrolled Acting
Out, Behavioral Contagion
• Middle School (10-13) + Fighting, Isolation Behavior,
Emotional Contagion, Difficulties with Concentration
• Teenagers (13-18) + Rule Testing, Substance Use,
Assaults, Use of External Systems for Support
Children
Items to Remember
• Children have individual reactions
• Children take their emotional and
behavioral cues from parents
• Children are generally egocentric and see
themselves as responsible for everything
• Children may need an invitation to talk
• Children need people to listen to them and their
stories
Children
Reserve and National Guard Family Concerns
• Families are not as experienced with deployment and
extended absences
• Family members are less familiar with military
support agencies
• Live in local communities with less
access to military support systems
• Face integration back into civilian job
or may need job assistance.
Interviewed Teenagers
Interviews from TriWest’s “Help From Home” DVD
Again, please take notes as a discussion will be conducted
following these clips. Run time approximately 12 minutes.
http://www.youtube.com/results?suggested_categories=27&search_query=triwest+help+from+home%2C+channel
43
Military Couples
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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Military Couples
Assessment and Treatment Issues
• Dangerousness to self / others
• Suicide / Homicide
• Domestic violence
• Child abuse
• Individual issues
• PTSD, TBI
• Medication abuse
• Alcohol and drug use
2010 AAMFT Annual Conference Workshop #303
45
Military Couples
Stressors Specific to the Couple Relationship
• Level of Commitment and Maturity
• Deployment Cycle / Adaptability
• Roles / Power issues
• Sexual Issues
• Infidelity
• Disabilities / Chronic illness
• Financial Issues
• Parenting
Additional for Reserve/Guard Families
• “Citizen Soldier”
• Mobilization and Deployment
• Separation from School, Jobs, etc
• Demobilization
2010 AAMFT Annual Conference Workshop #303
46
Interviewed Spouses
Interviews from TriWest’s “Help From Home” DVD
Again, please take notes as a discussion will be conducted
following these clips. Run time approximately 18 minutes.
http://www.youtube.com/results?suggested_categories=27&search_query=triwest+help+from+home%2C+channel
47
10 Minute Break After a “Light” Clip
The Evil Eye !
48
The next few charts cover Trauma, PTSD, TBI
and the Spiritual Wounds of War that are
related to the OEF
and OIF veteran.
49
The Trauma Continuum
“The past is never dead.
It is not even past.”
…William Faulkner
“Not everyone has PTSD.
It is not the only diagnosis.”
…me
ASR
COSR
PTSD
50
Trauma 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”
51
Trauma Continuum
Human Stress Response
52
Trauma Continuum
General Responses to Trauma
BEHAVIORAL
COGNITIVE
EMOTIONAL
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
Impulsiveness
Sleep disturbance
Hypervigilance
Need to do certain things
over and over
Doing strange or risky things
Self-medication
Eating problems
1000 yard stare
Keeping to yourself
Agitation
Always having to have things
a certain way
Over working
•
•
•
•
•
•
•
•
Distortions of orientation
Presence of cause & effect
thinking
Difficulty concentrating
Delusions (e.g., paranoia,
grandeur)
Obsessions
Violent/ homicidal/ suicidal
thoughts
Dissociation
Disabling guilt
Psychogenic amnesia
Helpless/ hopelessness
•
•
•
•
•
•
•
Anxiety
Feeling depressed
Irritability or rage
Unusual fears, and phobic
avoidance
Panic attacks
Feeling unsafe
Feeling disconnected from
the world
Regressive emotions in
adults
Feeling unlikable
Impatience
Unable to trust anyone
Trauma Continuum
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
Don’t Forget “Inter-Generational” PTSD
54
Trauma Continuum
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
55
Trauma Continuum
TBI: Traumatic Brain Injury
•
Signature Injury of OIF/OEF
•
Explosions account for 3 of 4 combat-related injuries
•
VA reports 61,285 OIF/OEF vets had preliminary
screen, 11,804 were positive (20%)
•
Improvements in war zone medical treatment has
decreased fatalities but may have impacted rise
in TBI
•
Prevalence is possibly still underestimated
•
Soldiers are returning home with “poly-trauma”
•
TBI may hinder or cause “good therapy” to be ineffective. A TBI
assessment may be appropriate.
•
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
56
Trauma Continuum
VA Opinion of PTSD Interventions
• Cognitive Therapy (CT)
• Exposure Therapy (ET)
• Stress Inoculation Training
(SIT)
• Eye Movement
Desensitization &
Reprocessing (EMDR)
• Generally individually
oriented and systemically
focused – “One size does
not fit all”
Handout – F3
From VA website, 2010
57
The Spiritual Wounds of War
The following Spiritual Wounds of War charts are based on the work
originally developed by the following individuals:
•
•
•
Kent D. Drescher, Ph.D., National Center for PTSD – Menlo Park
LTC Peter E. Bauer, MS USAR, LMFT, currently at Ft Hood
Chaplain Bill Carr, D. Min., LMFT, VA Hospital, Atlanta, Ga
58
The Spiritual Wounds of War
“The soldier’s heart, the soldier’s spirit, and the
soldier’s soul are everything. Unless the
soldier’s soul sustains him, he cannot be relied
on and will fail himself, his commander, and his
country in the end.
. . . General George C. Marshall
59
The Spiritual Wounds of War
Why Discuss Spiritual Issues?
• A growing body of evidence indicates that trauma exposure
and spirituality interact
• Trauma affects spirituality in both positive and negative ways
(more detailed charts follow)
• Spirituality may affect recovery from trauma
• Prayer is one area where research has shown to have a
positive affect on wellbeing
• Spirituality is an important component of resiliency
• When spirituality is lost and despair increases to a
significant level there is greater risk for:
•
•
•
•
•
•
Substance Abuse and Dependence
Marital and Family Conflict
Estrangement and Isolation from friend and family
Estrangement and Isolation from Faith Communities and God
Greater potential for physical violence against self/others
Greater potential for Suicidal or Homicidal ideation
GOALS
1. A renewed sense of
self
2. Reintegration back
into the family
system (and faith
family)
3. Normalizing life
within the culture
from which they
came
60
The Spiritual Wounds of War
Evidence for a relationship between trauma &
spirituality – both positive and negative
Positive Affects
• Increased resiliency
• Increased spirituality
Negative Affects
• Loss of faith while in the war zone
• Difficulty reconciling faith with the war zone experiences
I abandoned my religious
faith during the war.
Difficulty reconciling beliefs with
traumatic warzone events
Agree
Agree
Neutral
Neutral
Disagree
Disagree
0%
20%
40%
60%
80%
100%
0%
20%
40%
60%
Citation: Study of veterans in residential post-traumatic stress disorder (PTSD)
treatment in a Veterans Affairs facility
80%
100%
61
The Spiritual Wounds of War
Veterans’ Spiritual Coping Skills
•
•
•
•
•
•
•
•
•
I was preserved for another purpose
Prayer and the prayers of others
Pursued a deeper spirituality
I had a sense of God’s protection
I went to chapel
I met a chaplain
I started thinking for myself
I expanded my faith
I talked to other veterans
62
The Spiritual Wounds of War
Veteran Quotes of Spiritual Injuries
•
•
•
•
•
•
•
•
•
•
•
“I was totally alone”
“I was not myself”
“I saw myself dead”
“I lost my innocence, sanity and faith”
“Time stopped”
“Did I die there?”
“I became mean and cold”
“I was afraid”
“I never talked about it”
“I reject religion”
“Nothing prepared me”
63
The Spiritual Wounds of War
The Insidious Nature of Trauma
Spirituality requires a balanced connection between mental,
physical, emotional, and relational wellbeing
Trauma’s emotional and cognitive distortions cause numbing
and impairs relationships with families and God/Higher Power
Pre-Trauma Spiritual Approach
Post-Trauma Inhibiters
Experiential – Feeling God’s presence
Numbing of emotions and relationship
disrupts one’s experience
Cognitive – Well thought out belief in
God/Higher Power
Disrupts ability to process logically and
grasp belief (esp. if TBI exists)
This results in making the renewal of spirituality very difficult
64
The Spiritual Wounds of War
Repairing Spiritual Injuries and Interventions
• The need for forgiveness of self and others
• Atonement for what one has done during combat
• Commitment to reparations regarding behavior, especially
violent behavior during combat
Interventions:
“Things to do vs Talk”
Introduction of rituals which enable a soldier and family transition from the
combat ready culture to the former culture of family, home, or social group
• Spiritual
• Body Movement
• Communal
Handout – G1
65
The next few charts cover Insurance issues
related to working with Military Families
66
Insurance
VA
The VA approved on Sept 28th, 2010 LPCs for
staffing procedures equivalent to MFTs and LCSWs
http://www1.va.gov/vapubs/viewPublication.asp?Pub_ID=507&FType=2
“…This revision establishes the Licensed Professional Mental Health
Counselor occupation under VA’s Title 38 Hybrid excepted service
employment system in accordance with the “Veterans Benefits,
Health Care, and Information Technology Act of 2006” (Public Law
109-461).”
67
Insurance
TriCare
• Tricare has many plans: Prime, Select, Standard, etc.
http://www.tricare.mil/mybenefit/home/overview/Plans/LearnAboutPlansAndCosts?
• MFTs and LCSWs are eligible to conduct therapy with a
TriCare member without supervision
• LPCs need supervision by an M.D. (In Dec 2010, Congress
passed that new rules must be in place by June 20th 2011
which allow LPCs to be handled like MFTs and LCSWs.)
• 90-120 days application process
• Application in handout
• More confidential; less need to exchange info for decisions
• Preference is to use the spouses contract
• Provider Enrollment:
http://www.humana-military.com/south/provider/tools-resources/new-tricare-provider.asp
68
Insurance
Ceridian
• Ceridian is the EAP for the Military. They manage and run the
Military OneSource program under contract with the DOD
• 5 yr clinical experience required
• Fax the application
• 12 sessions (raised sessions allowed; lowered fees)
• Cannot renew to same clinician
• Must use Ceridian forms and notes
• Less confidential; requires more client info for decisions
• Good place for EMDR or other short term approach because of
limited sessions
• Easier access
• Provider Enrollment
https://www.ceridianprovidersolutions.com/Pages/CeridianWelcome.aspx
69
Insurance
What/When MH Coverage for Active
Duty/Reserves?
Active/Reserves
Active
Discharged
Retired
Service
Member
OnBase Behavioral Health
via Ceridian and Family Life
Counselors
Off Base if referred by a
Physician
90 day Transition Window only if the
Member elected Tricare to use a Tricare
approved 3rd Party
Tricare Eligible at a cost
Non-Combat
- At least 2 yrs active service
-- DD Form 214
-- Co-Payment may be required
-Combat
--5 yrs coverage of screened issues-Free
--After 5 yrs, claim must be filed
--After 5 yrs, co-payment may be req’d
Yes
Tricare is free -PPO or HMO
VA
No
Availability is Disability
Dependent
-Availability is Disability Dependent
Family
Member
Yes – similar to Service
Member; but can be used as
way for off base referral
using spouses Tricare
Tricare PPO – 80/20
Tricare HMO – 100%
No Generally
Tricare Eligible at a cost
Exceptions:
-- Vet Center (Combat vet only)
-- Caregiver babysitting / Respite)
70
Insurance
What/When MH Coverage for National Guard?
Guard
Active
Discharged
Retired
Service
Member
OnBase Behavioral Health via
Ceridian and Family Life
Counselors
Off Base if referred by Physician
180 day Transition Window with
Military OneSource
Tricare Eligible upon
retirement at a cost
Tricare for a fee available
Retire after 20 yrs; Age 60
Non-Combat
- At least 6 months on active service
-- DD Form 214
-- Claim & Co-Payment may be required
-Combat
--5 yrs coverage of screened issues-Free
--After 5 yrs, claim must be filed
--After 5 yrs, co-payment may be req’d
Yes
Tricare is free -PPO or HMO
VA
No
Availability is Disability
Dependent
-Availability is Disability Dependent
Family
Member
Yes – similar to Service Member
with M1S added as referral
access to off base
Tricare PPO – 80/20
Tricare HMO – 100%
More dependency on M1S
Includes extended family
members
No Generally
Tricare Eligible at a cost
Exceptions:
-- Vet Center (Combat vet only)
-- Caregiver (baby sitting / Respite)
71
The next few charts cover CareForTheTroops
and the information and support they provide
to therapists and other community
organizations.
72
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
73
Organization
501c3 status has already been approved by the IRS
Current Board of Directors:
President
Exec Director
Member
Member
Member
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)
Dorie Griggs - Presbyterian Representative, Citadel Parent
Al Shauf - CBF (Cooperative Baptist Fellowship) Representative, Retired AF
Bud Onstad – Lutheran Representative, Retired Army Chaplain
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 and Diocese of Georgia
Lutheran ELCA Southeast Synod
Presbytery of Greater Atlanta/Presbyterian Women
74
Approach
Military
Member
Person in
need of
support
Spouse
Siblings
Children
Parents
Grandparents
75
Programs
A Comprehensive Web
Site Feeds and Supports
Our Programs
Clinicians / Therapists
Military Culture 101
Conference Workshops
EMDR Weekends 1 & 2
On-Line Training
Training Calendar
Information Resources
Articles / Reports / Presentations
Therapist Database
Congregations / Clergy
Information Workshops
Military Ministry Programs
-Veteran Friendly Congregation
-Lead Congregation
-Program Guidebook
Clergy/Lay Leader Training
- Signs of Trauma and Spiritual Wounds
- Referral Source Information
76
This is the top
of the Home
Page
Handout – H1
What are some next steps to consider?
1. Connect with Military OneSource
http://www.militaryonesource.com/MOS/ServiceProvidersGateway.aspx
2. Get on the Tricare Panel
see Handout J1
3. Enroll in the CFTT Database
http://www.careforthetroops.org/clinician_cftt_enroll.php
4. Go to additional training from CFTT or another organization.
Consider upcoming EMDR training and look for LPC District
workshops
5. Consider being a CFTT trainer to outreach to community
organizations, congregations, and other counselors
• to participate in the CFTT initiative
78
• to market your practice
The EMDR HAP (Humanitarian Assistance Program) Training organization (www.emdrhap.org ) will conduct Weekend I and Weekend II training on the
dates shown above. The training will be in Brunswick at Gateway Behavioral Health Services (http://www.gatewaybhs.org/home.htm), a Georgia
Community Service Board Association member organization, 600 Coastal Drive (Blue Building), Brunswick, GA 31520.
This training is jointly sponsored by the CareForTheTroops, Inc. organization (www.CareForTheTroops.org ), The Georgia Association of Community
Service Boards (www.GACSB.org), and GAMFT (www.GAMFTorg).(www.CareForTheTroops.org ).
AUDIENCE: This training is for licensed or licensable counselors working in a non-profit, government, prison, or hospice environment. Specific details are
available at: www.emdrhap.org/training/..
CEUs are being applied for:
LMFT, LPC, LCSW, and GPA
COST: $375 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 Weekend I training on-line through the HAP website: www.emdrhap.org/training/toregister/listEvents.php. Look for this event's
description on the web page under the SPONSOR NAME: CareForTheTroops and for the dates June 24th to June 26th. Enrollment information for Weekend II
will be provided to you on the last day of Weekend I.
SCHOLARSHIPS: Apply for the CareForTheTroops scholarship at www.careforthetroops.org/emdrevents_brunswick.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/emdrevents_brunswick.php .
HAP Participant Requirements
CareForTheTroops(CFTT) Scholarship Criteria
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 in community based non-profit, government,
prison, or hospice settings.
It is the intent of CFTT that enrollees attend 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. Attend the 2 hour Consultation Conference Calls conducted after Weekends I and II that are
scheduled by the HAP office.
4. 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
5. Be willing to work with military clients and their extended family members
6. 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
7. Attend and complete Part II within 12 months of completing Part I
8. Be responsible for all other costs, fees, and expenses associated with the training weekends.
This training is intended for therapists that work primarily in one of the
setting specified above. It is not intended for therapists who work in
private practice. You will be asked to get a HAP Participation
Agreement form signed by a supervisor attesting to that fact.
In Closing
Why it’s all worth learning
about how to work with
military families.
Run time is 4 minutes
Remember
www.JoiningForces.gov
80