Transcript Military and Trauma Counseling: Treating the Mind, Body, and Spirit of Active Duty and Veterans Mark A.

Military and Trauma Counseling: Treating the Mind,
Body, and Spirit of Active Duty and Veterans
Mark A. Stebnicki, Ph.D., LPC, DCMHS, CRC, CCM
Professor- Coordinator of Military and Trauma Counseling Certificate
Dept. of Addictions & Rehabilitation – East Carolina University
[email protected]
Military and Trauma Counseling Network
http://www.ecu.edu/cs-dhs/rehb/omtc.cfm
Military and Trauma Counseling on
Facebook
https://www.facebook.com/ECUMTCN
Military Statistics NC
* North Carolina has deployed 50,886 troops to
OIF/OEF since 9/11.
* There are more than 750,000
veterans living in North Carolina.
* There are 150,000 Active
Duty North Carolina residents
* 35% of NC population comprise Military
* Bases: Fort Bragg; Camp Lejeune; Camp Geyger,
New River Air Station, Cherry Point, Seymour Johnson
Dept. of Veterans Affairs, 2012
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MTC Certificate Program: Military Culture
Courage
Commitment
Loyalty
Integrity
•DOD “Military and Associated Terms”
https://blackboard.ecu.edu/bbcswebdav/pid-6462558-dt-content-rid17376600_1/courses/REHB6375601201380/Dictionary%20of%20Military%20terms.pdf
• Officer Rank Insignia
http://www.defense.gov/about/insignias/officers.aspx
• Enlisted Rank Insignia
• Military Unit Size
http://www.defense.gov/about/insignias/enlisted.aspx
https://blackboard.ecu.edu/bbcswebdav/pid-6462569-dt-content-rid-17376721_1/courses/REHB6375601201380/Military%20Unit%20Size.pdf
Military Code of Conduct [punitive articles, NJP]
•http://www.dtic.mil/whs/directives/corres/pdf/130021p.pdf
The Psychological Cost of War: Personal
Testimonials of Trauma and Resiliency
•“I was only getting 2 hrs of sleep…”
• “Your head is always on a swivel…”
• “We were stuck at an FOB for 3 months of intense
fighting…command would fly-in for a morale-boost they’d stay
for an hour-then leave…”
• “My Master Gunny Sergeant told me to do (xyz)…I said are
you kidding me?”
• “I’ve seen my best buddy get burned alive”
• “%#@&*$# ragheads- you just don’t know who’s going to
take you out...”
The New Military:
Not Your Fathers Military
• Combat Training & Combat as an occupation:
-
Demands of killing
Avoidance of being killed
Caring for the wounded
Witnessing death and injury
Frequent geographic relocation
Separation from family and other support systems
Being available 24/7/365
Challenges of OIF and OEF
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No clearly defined “front line” or Rear or FOB
Highly ambiguous environment
Complex and changing missions
Long deployments
– Repeated deployments
– Environment is very harsh
Operation Enduring Freedom (2001), Operation
Iraqi Freedom (2003), Operation New Dawn (2010)
• 50,000-100K + wounded
• 6,825 + fatalities
-Blast wounds / TBI (13-24%)
- Soft tissue/orthopedic injuries
- Amputations
- Burns
- Hearing loss
- SCI
Exposure: OEF (AFG, 2001)
OIF (2003) OND (2010)
•Mortar
•Rocket
•Artillery Fire
•Small Arms Fire
•Multiple High-Intensity blast
•Roadside bombs
•IEDs
•Sniper Attack
MIL MH vs Community MH
The Occupational MH Model of PTSD
(Adler & Castro, 2013)
• Community MH models based on
-the unexpected
-freezing, shutting down
-person as the victim
• Military acquired PTSD
-adaptive and survive
-adaptive (not maladaptive) response
-aggressive (not stress)!!
Occupational MH Model of PTSD
• Community MH model:
-Person experiences full range of symptoms
-Many times critical event is experienced by self
• Military acquired PTSD:
-Person most always experiences critical event in small
and large groups of others in their unit
-full range of symptoms may occur to a lesser degree of
intensity during combat training exercises
-symptoms (i.e., hypervigilence) is adaptive-esp. in
combat
Suicide Ideation & Threats
• Number of suicide completions in MIL- 2012 (N=349) have surpassed
those who died in combat the previsous year (N=295)
• Suicide on increase from 10.3%-16.1% (Marines); 19.3% (Army) per
100k (2001-2008)
• Suicide Methods: 49% Firearms (non-Mil issue); 21% Hanging; 19%
Other; 11% Firearms (Mil issue)
• Suicide is the 8th leading cause of death among adults in U.S.; the 2nd
leading cause of death in adolescents…#1 cause of death (2012) with
military and vet population.
• Suicide (inward directed anger & depression) often coexists with
homicide (outwardly directed)
• Suicide behavior include assessing risk factors of age, medical/physical
conditions, psychiatric conditions, intellectual and emotional conflicts
Traditional Suicide Assessment:
Community MH vs Military Culture
If the person answers “yes” to any of the following they are considered
high risk:
• Does the person communicate an intent? [MIL- emotional detachment]
• Have they devised a specific detailed plan ? [MIL- access to weapons]
• Person has no friends, family, or support system? [MIL- departure leads
to isolation, disconnect from “battle-buddies” little structure in life,
decreased meaning and purpose, typically unemployment]
• Is there a concrete life stressor (death of spouse, girl/boy friend, family,
friends, pet, facing legal issues such as incarceration, has a medical
physical condition, or life-threatening illness, mental health condition)
[MIL IS family death surrounds our Family]
• Has person had past attempts?
• Is the person a male?
• Is the individual on an anti-anxiety or anti-depressant?
Exposure to Combat
• 56% of all active duty reported combat exposure (High= 23%;
Mod= 21%; Low= 12%)
• Personnel exposed to high level combat were identified as
heavy drinkers (10%) and use of prescription drugs (34%)
• Personnel exposed to high level combat with TBI reported
binge drinking (39%); 45% prescription overuse
• Personnel exposed to high level combat with TBI reported
depression (23%); anxiety (43%); suicide ideation (10%); selfinflicted injury (13%); high risk taking (18%); high levels of
anger (18%); low affect (16%); and suicide attempts (2%)
•
http://www.murray.senate.gov/public/_cache/files/889efd07-2475-40ee-b3b0-508947957a0f/final-2011-hrb-active-dutysurvey-report.pdf
Characteristics of OEF, OIF, OND
• At least 19% (30-60%?) of active duty men/women
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•
returning from Iraq - Afghanistan will be dx:PTSD.
26-39% of all military met positive screen for PTSS
(gen. pop= 12%).
Strong “r” between being shot at, handling dead
bodies, knowing someone who was killed, or
killing the enemy and developing PTSD.
Characteristics of OEF, OIF, OND
• 32% + screen for depression; 25% + alcohol abuse; 33% met
•
•
•
•
criteria for addiction.
Only 38%-45% report receiving help for mental
health services within a year.
25% come home with a medical health problem & co-morbid
physical injuries (TBI, SCI, blast wounds, soft tissue
orthopedic injuries, burns, hearing loss,
amputations) doubles the risk for mental health problems.
Women comprise 14% of deployed forces, more than ever
before- creating multiple traumas.
Multiple deployment (Marines avg. 7 mos; Army 12 mos; 15)
Research: PTSD (PSS) is a Significant Predictor of Current
and Future Medical & Psychosocial Adjustment
Men & Women (post deployment), have more frequent
number of visits to their healthcare provider than those w/o PSS.
• Increased onset of cardiovascular, gastrointestinal, dermatological, and
musculoskeletal conditions.
• Increased onset of cardiovascular, gastrointestinal, endocrine, vision, hearing,
dermatological, and musculoskeletal, and chronic pain conditions.
• Mortality has declined due to advances in body armor and battlefield
medicine BUT 28% sustained TBI primarily closed head and blast wound TBI.
• Four variables were positively associated with re-entry: being an officer;
having a consistently clear understanding of the missions while in the service;
being a college graduate; and, for post-9/11 veterans but not for those of other
eras, attending religious services frequently.
Overall Problems in
Medical/Psychosocial Adjustment
• Multiple reconstructive surgeries require not just
•
•
•
one adjustment to disability- rather there are
multiple re-adjustments.
Reliance on medical equipment/tech
RFC leads to permanent disabling conditions TBI,
PTSD, SUDs, Chronic pain
Significant vocational/career impairments.
Veterans Vocational & Career Obstacles
• #1 Disability (Pew- 44% acquired MH/Phy)
• #2 Lack of Civilian job experience and transferable
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•
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skills to other occupations.
#3 Policies that hinder licensing, certifications, and
other skills that transfer to civ jobs.
Jobless rate all Vets about 7% (Nov 2013)
Unemployment NC Guard = 19% (Nov. ‘13)
Gulf War II vets have 28% unemployment
The Stigma of Counseling: Reducing
Barriers to MH Tx
(Mental Health Advisory Team, 2011)
• Service men/women report: “difficulty in getting time off for an
appt.” and “don’t know where to go for help”
• 29% reported embarrassment
• 38% reported mental health counseling would harm their career
• 42% reported their units would lose confidence in them
• 50% report they would be seen as weak
• Others could loose security clearance
• DoD Health-related Behavioral Survey.2011
http://www.murray.senate.gov/public/_cache/files/889efd07-2475-40ee-b3b0508947957a0f/final-2011-hrb-active-duty-survey-report.pdf
Intake Assessment
-What is your MOS? What is your RATE (for Navy)
-Where did you do your basic training?
-What advanced training do you have?
-Any experiences that you remember that caused negative or
disturbing memories?
-Have you talked to anyone about these experiences?
-Are you (were you married) during your service or when
deployed?
-Do you (have you ever used) the VA?
-Were you in a combat zone/combat space? FOB?
-Ever surrounded by the enemy? Blown up? Under fire?
-See death of any member of your unit or others you know?
PTSD & Other Measures
Personal Interview & Observations
CAPS
Life Events Checklist (LEC)
Primary Care PTSD Screen (PC-PTSD)
Combat Exposure Scale (CES)
BDI-II
ASI- 5th ed.
Spiritual and Religious Values
“We are all spiritual beings traveling through
time having a human experience”
“The most important question to humankind is
where we came from before we were born and
where we will be going to after we pass-on”
“Making sense of combat, death, catastrophic
injury is a spiritual question- not CBT Q”
Deployment Cycle
Treatment Options
Pre-deployment
Re-deployment
Reintegration
Post
Deployment
Deployment
Sustainment
Family Issues (or if the Army wanted men to have
a wife -they would issue one)
Primary caregiver may
neglect
own mental-physicalspiritual wellness
Family/spouse misinterprets
absence of spouse as (they
don’t love me-putting work
before family) and resents role
of single mother-father
Family/spouse experiences loss & grief of
deployed service member- communication may
not occur for weeks or months- deployed
location cannot be disclosed
Family structure and roles are significantly altered and routines
disrupted during deployment
https://blackboard.ecu.edu/bbcswebdav/pid-6462562-dt-content-rid17376703_1/courses/REHB6375601201380/Facts%20for%20Families%20in%20the%20Military.pdf
Sexual Assault in the Military
https://www.youtube.com/watch?v=Scsb5
uB1Z7Y [NBC Today Show- Rape in the
Military]
https://www.youtube.com/watch?v=Wl2BN
eLi5c0 [Deborah Slagboam- MST]
Modern Military Family
• 2 million + have served
• 47,000-70,000 LGBTs (RAND Corp.; UCLA School of Law)
• DADT Fact Sheet
https://blackboard.ecu.edu/bbcswebdav/pid-7621821-dt-content-rid-
32857248_1/courses/REHB6375601201530/Quick_Reference_Guide_Repeal_of_DADT_APPROVED.pdf
• 1.2 million children have at least one active duty parent
• 75% of these children experienced at least one parent
deployed
• 55% of troops are married
• 50% report negative affects on the psychological health of
partners and children
•Intimate partner (intense arguments, emotional/behavioral
dysregulation, physical/sexual violence) violence widespreadmuch attributed to PTSD, TBI, SIDs
LGB Military, Partners & Family
• As a group LGB military experiences health
•
•
disparities and poor health outcomes.
GLMA, 2006; MPFC, 2011 report only 45% LGB
“come-out” to physician; self-disclosure may create
negative reaction, fears of retribution, rank,
promotions, career.
There is an “invisibility and isolation that exists for
LGB serve members, partners, & family…moreso
for transgender service personnel…”
DADT 2010
• Don’t Ask, Don’t Tell Repeal Act, 2010 which took effect Sept.
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•
2011 allows LGB to serve- NOT transgender individuals.
Former Defense Secretary Chuck Hagel “every qualified
American should be allowed to serve”; AMPA, 2015 U.S.
Army reviewing policies on transgender; Defense Secretary
Ash Carter (Feb. 24, 2015) “transgender individuals should be
allowed to serve…” [supported by Pres. Obama]
Military IS hypermasculine, heterosexual environment where
women and minority groups have a much different experience.
The New TBI: The Signature Injury
of OEF-OIF-OND
Mild Traumatic BI
• Mild TBI- 85% of all TBIs BUT 52% of mTBI dx: PTSD!!!
• Altered state of consciousness-brief loss up to 30 minutes loss of
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•
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consciousness.
Glasgow rating of 13-15 or higher.
Person feels stunned & disoriented, has reduced concentration,
focus, loss of memory immediately before-after, learning new
tasks.
Many go untreated until “Postconsussion Syndrome” appearsheadache, vertigo, tinnitus, sleep disturbance, depression,
irritability, reduced attention span/memory.
After 3 mos post-injury 78% have persistent headaches; 59%
have memory problems; 34% unable to R-T-W.
Closed/Open vs Blast Injuries and
Battlefield Medicine
•
Initial shock wave from a high-intensity-explosive detonation or blast,
resulting from supersonic blast-wind or blast-wave of inhalations of dust,
smoke, carbon monoxide, other chemicals, burns from hot gasses or
secondary fires, and crushing injuries from structural collapse.
• Consequence: penetrating and thermal trauma, soft tissue, orthopedic injuries
due to person thrown against fixed objects, falling, vehicle crash, penetrating
injury from blast projectiles.
Classification of Blast Injuries:
• Primary: rapid changes in atmospheric pressure caused by blast wave.
• Secondary: objects accelerate by energy of explosion causing blunt or
penetrating ballistic trauma.
• Tertiary: injuries resulting from person’s body being thrown by expanding
gasses, high winds, penetrating injuries from blast projectiles and soft tissue,
orthopedic wounds.
Cognitive Consequences of BI
Memory
Judgment,
Reasoning
and Insight
Attention &
Concentration
Information
Processing
Concept
Formation
Self-awareness
Problem-solving
&
Decision-making
Personality
Changes
Apathy
Depression
Anger
Irritability
Personality
Affect
Loss of
Selfesteem
Nonconformance
to Social Norms
Impact that Stress & Traumatic Stress
Have on Emotions and Illness
Peripheral/ANS: Sympathetic-Parasympathetic
Nervous System
Pathways to Traumatic Memories
Activating
Event
Seeing, Hearing, Smelling,
Tasting, Touching,
Physical-sensory, Balance
Working
Memory
(Here & Now
or Past)
Object
Recognition
(Neural pathways-whatwhen-where-how-why?)
Consciousness
(Cognitions, thoughts,
symbols, feelings,
emotions, purpose,
meaning)
Stress and Post Traumatic Stress
• Excessive, recurrent, and intense emotional arousal
of an unhealthy nature results in stress and disease;
• Repeated reactivation of our perceptual-cognitiveaffective response that is unhealthy in nature…;
• Stored unhealthy thoughts, perceptions, and
emotions, become a worn neural pathway which
leaves an imprint on our cognitive unconscious
and causes a mind-body interaction.
So Why Don’t All Those Exposed-Die
from Stress?
• We all differ as to the:
-pattern
- frequency
-exposure
-magnitude/intensity
-immune competence & resistance
…..of how we turn-on our own stress
response
Complex Grief Reaction
■ Preoccupation with the deceased.
■ Pain in the same area as the deceased.
■ Memories are upsetting.
■ Avoid reminders of the death.
■ Death is unacceptable.
■ Feeling life is empty.
■ Longing for the person.
■ Hear the voice of the person who died.
person died.
■ Drawn to places and things associated
with the deceased.
■ See the person who died.
■ Anger about the death.
■ Disbelief about the death.
■ Envious of others.
■ Lonely most of the time.
■ Bitter about the death.
■ Difficulty trusting others.
■ Difficulty caring about others.
■ Feeling stunned or dazed.
■ Feel it is unfair to live when this
The New PTSD-Typically
Complex PTSD
TBI
Depression
Suicide Ideation
SUD
Chronic Illness & Physical Disability
Sleep Disorders
The New PTSD: DSM V ClassificationTrauma and Stressor-Related Disorder
(Not under Anxiety Disorders in DSM-IV)
313.89 (F94.1): Reactive Attachment Disorder
313.89 (F94.2): Disinhibited Social Engagement
Disorder
309.81 (F43.10): PTSD
308.3 (F43.0): Acute Stress Disorder
309.81 PTSD: A Review of DSM-V
A. Exposure to actual or threatened death, serious injury, or sexual violence in
one or more of the following ways: (experiencing, witnessing, learning
about, experiencing repeated or extreme exposure to aversive details of
event(s)- NOT electronic media)
B. Presence of one or more of the following intrusion symptoms associated
with traumatic event(s)-beginning after the trauma (recurrent, involuntary,
intrusive distressing memoires, distressing dreams, dissociative reaction
which individual feels or acts as if the trauma were occurring (e.g.,
flashback), intense prolonged psychological distress of internal or external
cues that symbolize or resemble trauma event)
C. Persistent avoidance of stimuli associate with the traumatic event(s)
beginning after the traumatic event as evidenced by one or both:
(avoidance of distressing memories, thoughts, feelings closely associated
with trauma; avoidance of external [people, places, conversations,
activities, objects, situations)
309.81 PTSD: A Review of DSM-V
D. Negative alterations in cognitions and mood associated with
trauma, beginning or worsening after trauma has occurred as
evidenced by two or more (inability to remember important aspects
of trauma due to dissociative amnesia [not due to TBI,
alcohol/drugs] persistent and exaggerated negative beliefs of self and
others; distorted cognitions; negative emotional state; diminished
interest or participation; feelings of detachment or estrangement
from other; persistent inability to experience positive emotionshappiness, satisfaction, or loving feelings)
E. Marked alterations in arousal and reactivity associated with
traumatic event beginning or worsening after trauma as evidenced
by two or more (irritable behavior, recklessness or self-destructive behavior,
hypervigilance, exaggerated startle response, problems w/concentration, sleep disturbance)
309.81 PTSD: A Review of DSM-V
F. Duration of disturbance (Criteria B, C, D, E)
more than 1 month.
G. Disturbance causes clinically significant
distress or impairment in social, occupational, or
other important areas of functioning.
H. Disturbance is not attributable to the
physiological effects of a substance or another
medical condition.
Specify whether: 1. Depersonalization (detached)
or 2. Derealization (unreality)
Psychosocial Aspects of Suicide in
Military Life: DoD Suicide Outreach
http://www.suicideoutreach.org/Docs/Reports/DSPO_2012_Annual_Report_MARCH_2013_FINAL.pdf
• Major depression is the #1 cause of suicide
followed by PTSD and substance abuse disorders.
The grieving process is different for those in the
Military:
- Death surrounds us
- Prolonged intrusive images
- Survivor guilt, constant reminders of self-blame
Holistic Approach to Transition Services
From Active Duty to Civilian Life
• Dx: and treatment of mental health disorders.
• Psychosocial counseling.
• Family and/or relationship counseling.
•Vocational evaluation, career, Ed. assessment.
• Medical and healthcare services.
• Medical supply and assistive technology.
• Allied health services.
“The tragedy of life is not death;
itself but what dies inside of us
as we live”
-Norman Cousins
Post-Traumatic Growth:
A Journey into Healing
(Calhoun & Tedeschi)
1. Strength: a sense of self-efficacy, coping, resiliency, thriving.
2. New Possibilities: new meaning, purpose, positive future-oriented
attitude, with crisis comes opportunity.
3. Relationships: deeper appreciation of relationships with family, friends,
intimates
4. Appreciation of Life: sense that one has been given a second chance at
life which should not be wasted, less time at work more with family members, “don’t sweat
the small stuff”, overall- a significant shift in priorities.
5. Spirituality: a renewed sense of religious-spiritual strength, knowing God
through adversity, trauma-experiences may have been a gift to bring them closer to God.
The Resiliency Advantage
Dr. Al Siebert
1. Making conscious choices in life.
2. Power of Positive Thinking.
3. Take responsibility.
4. Internal locus of control.
5. Self motivate yourself.
6. Don’t fear trying-out new things.
7. Take control of your life.
8. Practice positive approaches to life.
Green Zone Training: Transitioning from
Base to Campus
Location recognized by veterans - service members as a Safe Place
.
Transition Difficulties
May have difficulty relating to classmates
(Campus Life, College Student Culture, Age-related differences, Marriage, Dep.)
May find loud noises to be disturbing
May be anxious with structure, assignments,
changes in the classroom
May have excessive absences
May have symptoms of trauma from military
experiences
Post-911 G.I. Bill/Montgomery Bill
Transition Strengths
• Veterans/ Servicemembers transitioning out of the military onto
college campuses bring a unique perspective
– Military training
– Life experience
– Established Identity
– A more worldly view
• Skills taught in the military help
students to be successful
– Leadership
– Motivation
– Time Management
– Work Ethic
– Stress Management
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Treatment Programs-Provider Resources
Defense Centers for Excellence for Psychological Health & BI http://www.dcoe.mil/blog/1310-30/Benefits_of_Mindfulness_Push-ups_for_the_Brain.aspx
Tricare Provider Handbook
https://blackboard.ecu.edu/bbcswebdav/pid-7503897-dt-content-rid31972644_1/courses/REHB6375601201530/REHB6375601201530_ImportedContent_201501
05024914/TriCare%20Provider%20Handbook.pdf
Military Deployment Guide
https://blackboard.ecu.edu/bbcswebdav/pid-7522387-dt-content-rid32000897_1/courses/REHB6375601201530/DeploymentGuide.pdf
Soldiers Resiliency Guide
https://blackboard.ecu.edu/bbcswebdav/pid-7503838-dt-content-rid31972449_1/courses/REHB6375601201530/REHB6375601201530_ImportedContent_201501
05024914/ARNG.Leaders%20Guide%20to%20Resilience.pdf
Real Warriors-Real Battles- Real Strength
http://www.realwarriors.net/taxonomy/term/13
Veterans Employment Toolkit
http://www.va.gov/vetsinworkplace/