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Surviving War: Challenges and Achievements of Military Service & Beyond Brittany Hall-Clark, Ph.D., Kizzy McNeal-Griffin, Donald Seamster, and Kelvin Shepherd February 26-27, 2015 Overview • Introduction of Panelists • Challenges Faced By Service Members and Veterans • African Americans in Military • Deployment Cycle • Transition to civilian life • Frequently experienced stressors • Behavioral health issues • Panelist Presentations • Adaptive coping mechanisms • Utilizing behavioral health resources Introductions • • • • Brittany N. Hall-Clark Kizzy McNeal-Griffin Donald Seamster Kelvin Shepherd African Americans in Military • Representation in active duty US military population • 17% of active duty Army (Maxfield, 2010) • Military segregation preceded desegregation in rest of country • Officially ended in 1948 in Korean War • History of discrimination stateside and while deployed • • • • Contrast in segregation between integration in Army and segregation stateside Segregated units often more assigned to services jobs German prisoners allowed in Officer club Could not arrest White Soldiers, even if MP • PTSD 3rd most common problem for VA patients of color • Race-related trauma • Similarity to enemy, relating to enemy, race/related assaults, racial/ethnic dissociation Effects of Combat on African Americans • National Vietnam Veterans Readjustment Study (NVVRS; Kulka et al., 1990) • African Americans • Higher PTSD prevalence • Mixed findings about differential rates of PTSD and symptom expression (Breslau, Aguilar-Gaxiola, Kendler, Su, Williams, & Kessler, 2006) • • • • • Marital relationships Violent behavior Happiness Life satisfaction Demographic: education, criminal involvement, unemployment • When adjusted, difference decreased by 10% • SES, previous exposure to trauma, & higher levels of combat (37% African American vs. 23% White) • Perception within AA community (Harris & Jones, 2007) • African Americans: less likely to be married, less likely to receive compensation, reported more substance use, less likely to commit suicide • Currently 60% of African Americans married (Maxfield, 2010) • Less likely to be divorced (Army Demographics, 2010) Stressors • • • • • • • • Repeated, extensive trauma over a long period of time Multiple deployments Environment of constant danger Multiple types of trauma (e.g., life-threatening, horror, “moral injury”, traumatic loss) Culture of denying personal difficulties Culture and training to have increased sense of personal responsibility Hypervigilance trained in military Discrimination, racism, and prejudice African Americans & Mental Health Treatment • African Americans (Kulka et al., 1990) • More likely to seek help for inpatient substance problems • Greater need for basic resources, finances, employment, legal assistance • Less likely to seek help in outpatient psychiatric services and psychotropic meds • Racial/ethnic differences in usage of non-VA services • Consistent with civilian literature (Snowden & Cheung, 1990) • Barriers: Stigma, resources, cultural mistrust • Significantly shorter duration of involvement and fewer individual sessions • • More likely to terminate within 2 months Clinician observations: less committed to therapy, reported less consistent attendance, less time on insight-oriented therapy, deconditioning negative affects, and discussing war trauma, more time on substance abuse • • Partially explained by less time in treatment Substance use associated with 1 month less in treatment • Differences in service use and outcome may reflect receptiveness • Zayfert (2008): differences may not be great in PTSD symptomatology but greater engagement needed for people of color • Lester et al. (2010) found higher drop out for Af. Am. in CPT, associated with more efficient use of treatment • Homogeneity of psychology as field (APA, 2005) • White -70.9% • Ethnic/racial minority -5.8% • Other/unknown – 23.3% Phases of Deployment Cycle • Pre-Deployment Phase (6-8 weeks prior to deployment) • Prepping for separation (logistically & emotionally) • Training • Deployment Phase (during deployment) • Reunion Phase (1-6 weeks prior to reunion) • Preparing for reunion • Post-Deployment Phase (1-6 weeks post reunion) • Reestablishing intimacy, renegotiating relationships, redefining roles Military Deployment Guide, FEB 2011 Continuum of Adjustment Readjustment Combat Stress PTSD Normal Adjustment Issues • Adjusting to civilian culture: using different set of skills • Distinct from military culture • Several different branches (Army, Navy/Marines/ Coast Guard, Air Force) • Key differences from military/theater • • • • Hierarchy vs. equality Life & death vs. day-to-day tasks Constant danger vs. relatively safe Regimented schedule vs. relatively unstructured • Adjusting to family • Family roles have shifted • Family has gotten used to functioning without SM so requires readjustment (discipline, chores, free time) • Lost time • Missed birthdays, holidays, developmental milestones • Personality changes • May feel like different people “You’re not the person I married.” • Mixed emotions • Joy for reunion, anger/guilt about separation, children unsure how to respond Adjustment-Related Symptoms • Tension among family members • Power struggles • Children testing limits • May not feel as close & connected • Miscommunication • Disagreements • Frustration about change/differences • Stress • Tend to improve over time Commonly Experience Mental Health Issues for Service Members & Veterans • Signs additional help needed: • Significant distress • Impairment of functioning • Problems not improving or getting worse over time • Combat stress/PTSD • • • • Range of symptoms Easily startled, always on guard Avoidance of triggers, people, family isolation Upsetting intrusive thoughts/memories/nightmares • Depression • • • • Loss of interest or enjoyment Loss of energy/restlessness Insomnia/hypersomnia Decreased/increased appetite • Suicidality/Homicidality • Thoughts of harming oneself + intent + plan • Substance Abuse/Self-medication • Alcohol/drugs • Reckless behavior Transition from Active Duty to Veteran • ACAP: Army Career & Alumni program • Transition program • Preseparation counseling • Phases (physicals) • Series of briefings • Benefits • Services available at VA • Classes • Resumé assistance • Transition assistance • SMs often ready/excited to get home and back to family Transition to Civilian Life • • • • Adjusting to civilian world Less frequent contact with military support system Adapting MOS to civilian employment Toll of service on body • Physical • Emotional/Mental • Disability ratings Cultural Strengths in African American Military Personnel • Spirituality • Role of church • Positive racial/ethnic identity • Belonging • Affirmation • Pride • Community orientation • Extended kinship • Flexibility in family roles • Many SMs say families are biggest source of motivation Questions for Panelists • What where the biggest challenges of your military career? • What were the most difficult parts in your transition from Service Member to Veteran? • What are 3 things you wish you had known earlier? • What helped you cope during difficult times during your military career? Transition to civilian life? • What recommendations do you have for family members, community members, and mental health professionals desiring to help Service Members and Veterans? • What barriers do you see for Service Members and Veterans • What would you tell Service Members and Veterans that are struggling with mental health issues? Utilizing Behavioral Health Resources • Peer Specialists • VA Services • Therapy Barriers to Help-Seeking • Stigma • General • Koenen et al. (2003) • Beliefs • • • • • 28.7% said can handle on own 18% afraid of what people think 13% afraid to take meds 9% don’t think have disorder 6% treatment won’t help • Resources(insurance, can’t afford, access) • 40% of those with PTSD did not know where to get help • Military • Downsizing • Gender • Racial/ethnic • Cultural mistrust (Terrell & Terrell, 1981) • Racial socialization • Distrust of therapists (Whaley, 1998) Overcoming Barriers • Strive for cultural competence • Providing psychoeducation • Biopsychosocial models • Medical analogy • Partnering with community • Education about when to seek professional help • Clergy Treatment of PTSD • Extensive research on treatment in civilian populations • Rape/Motor vehicle accidents • Physical/Sexual assault • 50-80% treated lose diagnosis • Some research on treatment of combat-related PTSD in veterans • VA patients treated long after discharge from active duty • Co-morbid disorders • PTSD disability • 20-30% treated to point of loss of diagnosis