Military Culture & Treatment GAMFT Chapter Workshop

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 Alan Baroody Peter McCall

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 Key Points: Review each bullet item with the audience The design point is a 101 Level workshop Future CFTT Presentations will be offered to discuss specific topics in greater detail There are several full day / multi-day workshops periodically offered by other organizations; urge the audience to take advantage of them

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 Ctr. Q&A and Closing On-Going Discussion Key Points: Point out the handout indicator in the bottom left corner. Explain that it refers to the packet of handouts and which item(s) in the packet relate to the presentation chart Time for Q&A has actually been built into each section of the agenda; not just at the very end. So please do ask questions as discussion will help everyone. Handouts: A0 Handout Listing – shows all the handouts and their indication ID, e.g. A0 Handout – A0 …..an Example

MILITARY OATH OF ENLISTMENT recited by all Service Members at their swearing in ceremony
I, (NAME)… 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. NOTE: the 3 dots … = it’s a break point, repeat after me. Key Points: Say Slowly … repeat after me … the 3 dots represent where there is a break in the repeat Very meaningful to most Imagine you are 18 to 21, and you are about to leave home; want to “part of something” and serve a purpose. Try to put yourself in their place Starts the bonding process of “the group” which we will discuss later and is an important element in understanding the trauma impact Today, almost all envision heading for he middle east and we have provided a map of that region in the handouts Handout: A1 Map of the Middle East Handout – A1

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 Ctr. Q&A and Closing On-Going Discussion Key Points: Point out the handout indicator in the bottom left corner. Explain that it refers to the packet of handouts and which item(s) in the packet relate to the presentation chart Time for Q&A has actually been built into each section of the agenda; not just at the very end. So please do ask questions as discussion will help everyone.

Who Are We – ‘Big Picture’
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. Key Points: If the civilians professionals and support services are going to be helpful, they have to understand more about the military culture. Working with the military is no different than other categories, they have nuances and a “culture” to understand to have a better chance at a more successful therapy experience.

Organization 501c3 status has already been approved by the IRS
Current Board of Directors: President Rev Robert Certain, Rector, Episcopal Church of St Peter and St Paul (USAF) Exec Director Peter McCall (USArmy) Member Bill Harrison, Partner, Mozley, Finlayson & Loggins LLP (USAF) Member William Matson, Exec Director, Pathways Community Network, Atlanta, GA Member Alan Baroody, Exec Director, Fraser Counseling Center, Hinesville, GA Member 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 Key Points: Quickly run through this chart We are an official 501c3 We have an established Board that will continue to grow We have key Partners. We are not a faith-based organization but we do aspire to leverage the faith-based networks

Causes for Concern Multiple deployments are common causing stress and family attachment issues 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 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 Military Sexual Trauma (MST) is running at 16%-23% 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) DoD and VA facilities are stretched … the Aug 2009 VA claims backlog is 900,000 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 Other mental health, marriage, and family problems often occur with or leading up to PTSD requiring attention so they don’t get worse 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 years Key Points: These are some of the many reasons we felt the need to establish this initiative These are reasons that we hope will give you pause to consider working with the military and participating in additional training We are going to go over some of these in more detail later, but for now I want you to see that there is a mounting problem and getting you equipped to help with the issues contained within this list is important

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 Key Points: We want to identify clinicians Help them get trained in the military culture AND in trauma treatment

Person in need of support
Approach Person in need of support Spouse Siblings Grandparents Parents Children Affected Systems Community Congregations Employers Extended Family Members Military Member Key Points: A “surround” approach Inform and train people who will surround the person that has a need Better way (than a direct approach) to get them to come to therapy GAMFT and Family Systems approach fits the need well Plus, GAMFT has a state organization and members are located in rural areas as well as urban areas We need also know if there are any GAMFT members who are willing to enroll on our database and who are willing to be trainers

The next set of charts provide a simulation of using the www
The next set of charts provide a simulation of using the website with clinicians in mind Key Points: Just a set up chart to alert the audience what to expect

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.

HANDOUT Moving down the same page.
Info about your office , license, language, and education. HANDOUT

HANDOUT 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 HANDOUT

HANDOUT Moving to the end of the form.
Info about your experience, unique background. This is also where you enter your ID and password. HANDOUT

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 ( ) 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 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 ( ), GAMFT-The Georgia Association for Marriage and Family Therapy ( ), and The CareForTheTroops, Inc. non-profit organization ( ). 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: . 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: Look for this events’ description on the web page. SCHOLARSHIPS: Apply for the CareForTheTroops scholarship at . Download the Application Document, complete and 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: . 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: Practice in Georgia Attend and successfully complete both Part I and Part II EMDR training by HAP 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 Be willing to work with military clients and their extended family members 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 Attend and complete Part II within 12 months of completing Part I Be responsible for all other costs, fees, and expenses associated with the training weekends.

Chapter Workshops Military Culture 101-Clinical Treatment Issues
Chair / Contact Person Co-Presenter Date Time Location Coastal Kathryn Klock-Powell Alan Nov 6th 10am-1pm Hinesville Middle Bruce Conn Nov13th 10:30-1:30 Macon Northeast David Fowler/Dennis Cain Blaine Nov 20th 11am - 2pm Athens South Jeff Bickers Nov 21st 9am - noon Valdosta Southwest Elaine Gurly/Lori Ann Landry Jan 8th 1pm - 4pm Albany Metro Atl Licia Freeman Jan 15th noon - 3:30 Decatur Northwest Joan Robinson Jan 22nd 11:30 - 3:30 Sandy Springs East John Hill/Sid Gates Feb 5th 8:30 - noon Augusta West none TBD Columbus NOTE: Check with your local GAMFT Chapter and also with the web site for changes and updates.

Final Comments Help For You Help for Us 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?

Brothers At War Film Clip http://www.brothersatwarmovie.com/
Key Points: Background: 3 brothers; 2 older brothers are in the Army; 1 is not who is the youngest Setup: The youngest wanted to know and understand WHY his brothers have joined and what it is that they are going through Once you see the film clips (7 or 8 of them), we will then discuss and process what you have seen So take notes as I will ask what the therapeutic issues are that you have observed. This is not intended to support any political view Film depicts what life is like “in the sandbox” and what it is like for the people related to them in the extended family Understanding this environment can help immensely in working with family members I say “family members” because this training is not just to help you with a military member who might see you in therapy; but also the members of the extended family that are being affected by these conflicts. In fact, it is more likely you will see extended family members for most of you who are away from military cities though the presence of national guard and reserves in this war are so extensive, they represent a high potential as clients also.

Fraser Center Experience Film Clip Comments
THERAPEUTIC ISSUES OBSERVED IN THE CLIPS FROM “BROTHERS AT WAR”: The adrenaline high, or adrenaline addiction – “It’s like the best!” Personality changes. No one returns the same from combat or lengthy deployments. Generalized and undifferentiated anger: short fuse, loss of patience, (increase in domestic violence and child abuse). “Now when he gets mad, he just screams.” 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.” 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.” Survivor guilt and loss: “It hurts a lot to lose fellow soldiers.” Family of origin issues: “I want to make my Dad proud.” Fantasy verses reality. (living on dreams and through TV series) Emotional numbing: “He used to be sensitive. Now, he shows no emotion and wants me to be the same way.” The ramifications of “sacrificing for family” and the sacrifices made by families. Key Points: NOTE: …Do not show the list of 10 items until AFTER the discussion Ask what they observed Consider writing them down if there is a place to do that (like a large pad of paper or a dry-erase board) Click and display the list of 10 items Compare their comments to the list above Ask if there are any questions about any of the points; either ones we provided or the ones they provided Balance the value of good discussion if there is a lot of discussion with TIME, don’t linger too long.

Fraser Center Experience www.frasercenter.com
HANDOUT THE FRASER CENTER SETTING: 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: 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 re-deployment (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. Key Points: Briefly review the Fraser Center, where it is in Hinesville right outside of a growing Ft Stewart with mostly military and family as clients Explain as many of these points as you want – YOU PICK the one’s you want Make reference to this chart AND the next three charts having a long list of observations from the Fraser Center Cover the 4 charts as a group. Suggest doing this by picking out ahead of time 1 or 2 from each page BE CONSCIOUS OF TIME Allow people to ask questions about any of the them if they want. So become familiar with these ahead of time

HANDOUT GENERAL OBSERVATIONS (continued…): 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. Key Points: Make reference to this chart AND the next three charts having a long list of observations from the Fraser Center Cover the 4 charts as a group. Suggest doing this by picking out ahead of time 1 or 2 from each page BE CONSCIOUS OF TIME Allow people to ask questions about any of the them if they want. So become familiar with these ahead of time

HANDOUT GENERAL OBSERVATIONS (continued…): Home is no longer a safe place to live. Many now carry weapons when not on military installations at home. The vast majority of returning troops are filled with undifferentiated anger and a short fuse. 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. A primary therapeutic issue is the soldier’s inability to re-connect emotionally with spouse and children. (exacerbated by anger and lack of patience). Chaplains are the mental and spiritual health “first responders” at home and in the combat arena. Special attention needs to be given to National Guard and Reserve Chaplains. There is a high incidence of their leaving the ministry. Both spouse and soldier recognize that the soldier is “changed” by combat deployment. Important family milestones and transitions have been missed. Soldiers may pursue activities which replicate the adrenaline rush of combat and sometimes re- enlist without spousal consultation in order to maintain the rush. Spousal dissatisfaction and resentment: power control issues upon redeployment. “I didn’t sign up for this.” The military spouse sacrifices education and career 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. Key Points: Make reference to this chart AND the next three charts having a long list of observations from the Fraser Center Cover the 4 charts as a group. Suggest doing this by picking out ahead of time 1 or 2 from each page BE CONSCIOUS OF TIME Allow people to ask questions about any of the them if they want. So become familiar with these ahead of time

HANDOUT GENERAL OBSERVATIONS (continued…): Due to young age, immaturity, and low educational levels, many soldiers and spouses have poor life skills: money management, parenting, communication, etc. Some soldiers return to empty bank accounts and houses. The military has greatly increased mental health support resources at home and abroad. The Army recognizes that it is still not adequate. 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. 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. Key Points: Make reference to this chart AND the next three charts having a long list of observations from the Fraser Center Cover the 4 charts as a group. Suggest doing this by picking out ahead of time 1 or 2 from each page BE CONSCIOUS OF TIME Allow people to ask questions about any of the them if they want. So become familiar with these ahead of time

Chris Warner’s Sources of Stress
Key Points: Chris Warner is Chief of Behavioral Health at Wynn Memorial Hospital, Ft Steward Point out the Blue bars They represent the Family Stressors which are the LARGEST stressors affecting the military --->> Number of Months 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 ; 172:

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 Key Points: Before we begin explaining factors about the Military Culture, here is an intake scenario. At the end of this section we will revisit this intake and see if, from a clinicians point of view, we understand it any differently. Scenario Text: A 20 year old male self refers to you for feeling “on edge”, “pissed off”, and having difficulty sleeping. He tells you that he is a SPC in the Army National Guard who returned about 4 months ago from a 15 month deployment to Iraq. In your first meeting he tells you he is a gunner attached to Bravo Company, 2nd Battalion, 7th Infantry Regiment, First Brigade Combat Team 3ID. He’s coming to see you because his First Sergeant expressed concern over his irritability during their last drill. He reports that he is still angry with everyone from his Company Commander down to his Platoon Leader for may decisions made down range. He is married with 2 children under the age of 4, one of whom was born during his deployment. He reports a strained relationship with his spouse who he says doesn’t get what he went through during his deployment. He also indicates that he plans to volunteer to deploy again as soon as possible.

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 Key Points: These are the 5 areas we are going to explore and try to better understand in the part of the workshop Language: enough said Beliefs: defenders of Democracy trust in the leadership distrust of civilians Value Systems: leave no one behind “The Group” practically becomes a ‘family system’ 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) – be sure the boss looks good; a way to get ahead back-logging trauma – keeping it covered up and contained; eventually it will come out though Material Products: Artifacts left behind from a culture – objects created and used by a cultural system Handouts: A2 Copy of excerpt by Ed Tick “What is a Warrior” from his book ‘War and the Soul’ The article provides a good description of the ethos and value system of the client or a member of their family system who may be sitting across from you Culture is associated with a social system and unique to a given system. Handout – A2

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 United States Army Reserve USANG United States Army National Guard E1-E9; O1-O10 Enlisted Ranks; Officer Ranks SPC Specialist, rank of E4, often referred to a “Spec 4” First SGT 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 NCO Non-Commissioned Officer, ranks E6 through E9 IEDs Improvised Explosive Devices FOB Forward Operating Base Sandbox Iraq and Afghanistan Down Range Deployed to anyplace where there is shooting. Outside the Wire Leave the safety of the “enclosed” military base (FOB) Taking the Pack Off Leaving mentally and physically from combat Top Cover Making sure the boss looks good Key Points: These are some basic terms....These only scratch the surface Language can help immensely in gaining trust with the military member or spouse This is less a factor wit the extended family It is best not to have to interrupt and ask for a definition unless directly asked if you know what it means (and you don’t know) or is such an important part of the therapy session and you judge it necessary. Best is make a note and check out the term after the session. Handouts: A3_1 Glossary – A3_2 Glossary – Alison Lighthall, RN, USAR A3_3 Glossary – John Mundt, Ph.D. A3_4 Glossary – Essential Learning on-line course Handout – A3_1, A3_2, A3_3, A3_4

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 Key Points: Just a set up chart to alert the audience what to expect

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 Key Points: GA has all services represented in the State GA is the 6th largest National Guard State dominated by transportation units prone to IEDs 2nd largest dependent and retiree population (undocumented) Handouts: A4 Shows 14 military bases in Georgia and the number people assigned to the bases and map locations Handout – A4

Military Branch Structures Example: U.S. Army
Core Values 84%% 2% 14% 84% Key points: This is just showing the Army; the handout covers the Navy, Marine and Air Force The “operational Army” and the “institutional Army both experience Trauma. The operational Army conducts worldwide operations and consists of the organizations shown on the chart. The institutional Army essentially supports the operational Army so it can function. It ensures adequate training, equipment, and logistical support. The key to the “structure” is that it helps define “role clarity” which can help with discipline, keep the belief system with a narrow focus, and be a good crutch to backlog trauma or cause trauma if the clarity is not met Enlisted members account for the majority of the military personnel (~84%). Enlisted personnel generally have a high school diploma or equivalent, and many have or working towards higher degrees. Warrant Officers are highly specialized experts in very specific career fields to provide knowledge and instruction in their primary specialty, e.g. a pilot. Commissioned Officers are similar to managers or leaders in a company. In general, officers have a minimum 4-year bachelor’s degree and additional advanced degrees are encouraged. Core values are important to understand as the client or family member may feel there is some discrepancy Conflict over these can be the basis for distress, grief, and the trauma being experienced. The 7 Army Core Values: Loyalty Bear true faith and allegiance to the US Constitution, the Army, your unit, and other Soldiers Duty Fulfill your obligations Respect Treat people as they should be treated Selfless Service Put the welfare of the Nation, the Army, and your subordinates before your own Honor Live up to the Army Values Integrity Do what’s right, legally and morally Personal Courage Face fear, danger, or adversity (physical or moral) Handouts: B1 Military Branch Values (Army, Navy, Marine, Air Force) B2 Enlisted Insignia B3 Officer Insignia Handout – B1, B2, B3

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 Key Points: 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’ This ‘unit’ represents a “hybrid” of primary and secondary groupings Violence – many have a history of violence which often plays a role The Great Lakes Naval Training Center study in 2005 shown that 80% of the attendees had a history of violence somewhere in their background Norms & Rules: formal and informal conduct stigma of mental health and PTSD cover of the boss (Top Cover) – be sure the boss looks good; a way to get ahead back-logging trauma – keeping it covered up and contained; eventually it will come out though

Reserve and National Guard Units vs Regular Army
Reserve / Guard Regular 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.) 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 on- post & 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 soldier’s unit Key Points: Left Side: Though there is cohesiveness that Guard Units are comprised of people from the same states, Reserve Units do not Many of items on the left side denote isolation: e.g. the spouse left behind does not have other nearby spouses; can’t relocate easily; health support not always available; and upon return support services may not be nearby Right Side: More “group” support and access to facilities is seen compared to the left side Family Readiness Groups (FRGs) help but vary in quality based on individual leadership. You should ask if they are involved or were involved. Encourage it if you find out they haven’t tried it and did not have a previously bad experience This charts depicts in large part why the civilian clinicians and support structure needs to learn and get involved. Handouts: C1 Reserve / National Guard Units vs Regular Army Shows the benefits of the Reserves Shows what the 7 Reserve Components are across the 5 Services Handout – C1

The next few charts provide some background of this war that might help you better understand your client and their presenting story and issues Key Points: Just a set up chart to alert the audience what to expect

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 Key Points: Especially important to understand these elements; especially if you yourself are a vet of another conflict. This war is different ! The OPTEMPO (Operations Tempo) is so much greater 2 deployments is common More than 2 are common also This keeps the entire family often resisting the transition process Both the outgoing and the incoming transition process Moral Code is stretched because there is not a well defined enemy in many situations This takes a toll over time In WW II people were away for 2-3 years sometimes letters were weeks maybe months late In this war, the troops can get information to and from home daily troops are distracted this distraction adds to stress

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) Key Points: The war is entering its 9th year with no immediate end to its continuance. 54% have been Guard/Reserve and that likely will not change greatly The Guard/Reserve ratio speaks to the need for Mental Health support in all Georgia communities, rural and urban. The total that have been deployed + the number currently in county show the LONG TERM need to expect. That’s why training like this is so important.

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 Key Points: Review Rand Study issues According to a 2008 Rand Corp. study, an estimated 31 percent of returning war veterans suffers from mental health issues. Only about half (53%) of those who need treatment seek it, and only a bit more than half of those who seek treatment get “minimally adequate care”. Based on other print media reports, the 31 percent report by the Rand Study seems low … closer to 50% have some form of mental health issue Increase in mental health treatments which continues to rise for good and bad reasons good – the military leadership is paying more attention to it bad - the reasons for the rise (stress, multi-deployments, etc) continue MST Military Sexual Trauma includes more than rape statistics only show what is reported affects both males and females Point out the significant portion of PTSD diagnoses (50%). Of course, this represents the population that was willing to seek help. Many don’t seek help and many who don’t have another sub-clinical diagnosis such as depression or anxiety. Handouts: C2 MST – Military Sexual Trauma definition from VA website Handout – C2

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 Key Points: For veterans, Iraq and Afghanistan is catastrophic from a multi-generational point of view. The analogy to use is this: Florida hurricanes are often disasters; but Katrina was catastrophic because it will take generations for the area of New Orleans and Mississippi to recover. 15 to 1 wounded ratio is good news – fewer are dying due to better medical techniques and technology bad news – The survivors and families need help; particularly mental health help Backlog continues to grow; the 900K in claims will likely exceed 1M soon Civilian/Private sector needs to step up and help The backlogs can contribute to the anxiety you will be met with when you first meet with some clients Point out the large population of children that attend non-DOD schools. This schooling statistic applies to Regular Army. Guard/Reserve children essentially are at 100%. Georgia has a very large population of veterans. The handouts show that the largest 5 year age grouping is 60-64 Unconfirmed, but believe Georgia has the 2nd largest population of veterans and dependents Handouts: C3 Military Veterans in Georgia by Age and Ethnicity; Active Duty and Reserve dependent data at the 4 largest Bases Handout – C3

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: ) "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 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: ) Key Points: Use the 289,000 to show a correlation to the 263,000 number predicted on the previous chart Point out the susceptibility of the Guard and Reserve members who comprise 54% of the those serving The last item shows the vulnerability that women face and that therapists should be cognizant of these high numbers.

OEF / OIF Experience - Summary
Indirect threats – not so much direct assaults and attacks IEDs, car bombs RPG, snipers Suicide bombings Powerlessness threat is indiscriminate not dependent upon skill or mastery relationship between loss of control and PTSD This generation’s war 1st Internet War (Vietnam was the TV War) Blogs, , 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 Key Points: Position these items as a SUMMARY of the CAUSES OF STRESS and ANXIETY that lead to mental health issues Indirect Threats – it’s 24/7, always there, and hard to let go of when home Powerlessness – Difficult for all Many Guard/Reserve were plucked from a more organized existence and suddenly were put is this powerlessness position. Difficult for family members also This Generation’s War – each point is good; especially cover the 1st two bullets (communications) and 4th bullet which are also the two primary reasons for suicide.

The next several charts will cover life within the military family and clinical treatment considerations Key Points: Just a set up chart to alert the audience what to expect

The Military Deployment Cycle
… or The Military Family Life Cycle (Original View) Soldier Deployment Separation Stress – Depression & Anxiety Family Adjustment w/o Soldier in Home – Out-of-Ordinary Behaviors Pre-reunion Stress – anxiety and worry about behavior away Reunion and homecoming – joy and anticipation Revitalize Relationships and “honeymoon” Family readjusts - Consequences for behavior Pre-deployment Conflict & Previous Stressor pile-up Pre-deployment Stress – anxiety and concern Key Points: “Transitions are often marked by crisis points in the family life cycle.” … quoted from one of Blaine’s charts start at 9 o’clock and read counter clockwise Assume that this is based upon a situation where there are multiple deployments which may help understand the scenario better Remember that multiple deployments are more the norm currently For Guard/Reserve add the factor of the increased and unexpected timing of deployments. Active Duty isn’t fully predictable, but a little more consistent and certainly expected Clinically, ask where in this cycle is your client when they are seeing you? … or …where in the cycle did the presenting issue begin to appear.

Military Family Life Cycle (…Multiple Deployment View)
<May be 1st deployment for both partners> <Missed 1st year of marriage> -Courting -Pregnant -Marriage Deploy Mid-tour leave New family begins in absentia Parental adj & young children Return & Reunion Resume normal routines Re-deploy Family w/ school agers Relocation Families w/ teens & possibly steps ETS or Retire <Divorce & remarriages w/ kids for previous relationships are common – complex stepfamily> Key Points: The situation has changed from the original cycle There is much more emotional numbing occurring The starburst items are more critical and are potentially more heightened emotionally. Transitions are often marked by crisis points in the family life cycle.

Military Family At-Risk Factors
Frequent Relocation years average Previous Deployments 87% Longer Separations month average Larger Families 42% ≥ 3 children Younger Mothers median age Blended Families % step-parents Education 21% w/o HS diploma Working Outside Home 44% Median Income < $30,000 (34%) Key Points: A Specialist (SPC E4) with 3 children qualifies for food stamps. Certainly many of these points relate to corporate and ‘every-day working class’ people too But the concurrence of these factors make for a background that clinically may be significant during the therapy process … or at least have an impact on the presenting issues Ask the audience if any they have had any experience that either confirms or contradicts the “context” of these factors? Ask the audience if any can contribute other factors that are significant? Keep trying to find a citation for these from Blaine Quality of Life Among U.S. Army Spouses During OIF, Dissertation, 2005, Dr. Blaine Everson

Separation HANDOUT 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. Key Points: Be sure to ask the client about the details of any separations and the timing of any separation relative to the presented problems/issues. It may help greatly in understanding clinically what is or has happened. The time leading up to a separation is part of the cycle where many do not want to open-up in fear and anticipation of the separation. They aren’t willing to go thru the pain again they previously experienced. This adds to the tension and anxiety of the person and family members.

HANDOUT 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.) Key Points: Returning home and re-integration after the separation oddly can be another time of heightened anxiety. Some grow fearful in anticipation of the re-integration process. Stress and anxiety often starts before they come home Some never let down or “take off their pack” as they anticipate If another separation is imminent, check out with client, or if a couple both members, if they are willing to work at therapy. It may be important to focus on this issue early in the therapy dialogue. The HANDOUT covers some the more common issues faced upon returning home: …here are a few, the handout has more appearance of trauma symptoms financial/job issues that may have surfaced changes in alcohol and drug use (both spouses) presence of MST occurences Handouts: D1 Summary of Problems Experienced Upon Returning Home Handout – D1

Relocation HANDOUT Families in the military (U.S. Army in particular) relocate every three to five years. Inconsistency of services b/w the installations Ft. Hood vs. Ft. Stewart). Requires readjustment for family members who may lag behind service member both physically & emotionally Key Points: This has been a long term issue when working with the military and their families. Similar to former times in the 70s to 90s in corporate-america. But that doesn’t make this any less significant to cover.

Deployment Related Stressors for Spouses
HANDOUT Key Points: This provides a good summary of what spouses face during “separation” These are also issues seen by extended family members and may be impacting them as well. One connection to recall is what was mentioned earlier about “communications today between home and the war-zone”. It allows these issues to be known almost on a daily and sometimes hourly basis to the spouse overseas. Though it may be helpful to the spouse here on this side of the “pond”; it may cause stress and anxiety to the spouse overseas. These then feed into the Reunification and Separation states we just covered !! Loneliness Susceptibility of extra-marital affairs

Deployment Related Stressors for Spouses
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) Key Points: To further support the previous chart, here are some statistics published earlier in 2009. “Positive” means how significant it is. The 3 most significant stressors are: Loneliness … Communications with the spouse … Being a single parent Warner CH, Appenzeller GN, Warner CM, Grieger T. “Psychological Effects of Deployments on Military Families” Psychiatric Annals ; 14:

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 Key Points: These are a few areas where Active Duty and Reserve/Guard vary Though both have some aspects of each other’s system The key here is once you find out whether your client is Regular/Reserve/Guard, you might listen if any of these stressors present themselves in your client’s dialogue Active Component Stressors: -Permanent Change of Station)PCS): Active Component service members are required to move to different duty stations after a period of time in order to meet the needs of the mission and provide opportunities for leadership and career development. Although the duration of time on station varies between services and career fields, generally service members (and their families) PCS approximately every 2-4 years. While moving is often seen as a positive thing by many service members and their families, it can be a stressful process requiring a rebuilding of community, separation from family or established friends, change of schools for children and a change of job for a spouse. -Temporary Duty (TDY): Service members often have a travel assignment at a location other than their duty stations. TDYs can be to attend training, conferences or meetings or to fill in temporarily to complete a mission. They typically last between a few days to a few months but must be shorter than a year. -Deployment: A deployment is when a service member is called to duty somewhere other than their permanent duty station (without his or her family). Deployment lengths vary depending on branch of service, career field, and amount of time needed to complete a mission but currently range from approximately 6-15 months. Deployments may be in support of a conflict or humanitarian in nature. -Foreign residence: Currently many duty stations and deployment locations are outside of he US in overseas locations. Overcoming cultural differences, language barriers, and separation from friends and family can be challenging for service members and their families. -Risk of injury or death: This as well as concern for a loved one’s safety are real stressors for service members and their families. -Behavioral expectations: In keeping with each service’s core values, there are many expectations regarding how military members should act in their professional and personal life. While activities engaged in during off-duty time are up t the service member, there is a high level of scrutiny and visibility within the military community that can create pressure at time. These expectations and the pressure that goes with them can also extend to military families whose members are also expected to conform to certain behavioral expectations. Reserve/Guard Component Stressors: While reservists do not PCS like Active duty members, they have many challenges associated with being “citizen soldiers” versus full time service members. -Mobilization and deployment: When reserve members are mobilized and deploy they leave behind their full-time lives including jobs, families, and communities. Many times these communities are not close to military installations where support and health care services are available to families. -Leaving a civilian job can be extremely stressful especially if the member is self-employed or owns his/her business. Like Active Component service members, Reservists are facing unprecedented multiple deployments which require repeated and extended service away from whatever endeavors they pursued in their normal lives (jobs, attending school, running a business). -When Reservists are demobilized and return home, often times they are not in areas near a military facility for healthcare and other services. This isolation from a strong military community can be difficult to adjust to post-deployment.

…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 Key Points: But at some point, what gets contained must release. if they hold in the stress and trauma too long, it just might explode someday ! Ask yourself where is your client in relationship to this point in time? BETRAYAL TRAUMA – explain it and how it relates to this quote

Demographics - AGE Enlisted Officers Key Points:
Preponderance of younger age groups in both enlisted and officer compared to their civilian counterparts. Expect to hear more responsibility given to younger age group than what would be expected from civilian clients. This added responsibility can then add to factors affecting stress, anxiety, acting out, and other symptoms It can also add to the separation and re-integration stressors for both the military member and their spouse…and in some cases the extended family. Officers

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. Key Points: Young adult are the single largest group in the military Three key statistics can help understand the potential background of the military member within the family Binge drinking is more prevalent than comparable age-group civilians Higher smoking rates too Rather than illicit drug use, you might inquire about nonmedical use of painkillers Handouts: D2 Young Adult Statistics – 4 Charts Source: Military Family Research Institute at Purdue University.(2005) demographics report. Arlington, VA: Office of the Deputy Under Secretary of Defense, Military Community and Family Policy. Retrieved January 7, 2009, from Handout – D2

Demographics – GENDER AND RANK
Women represent approximately 15% of the military force. Representation of women is slightly lower for Senior Enlisted and General Officers. Key Points: In terms of rank, gender composition is similar to the overall gender representation in the military for junior enlisted, NCOs, Company and Field Grade Offers. Representation of women is slightly lower for Senior Enlisted and General Officers. The 15% of women will likely grow some more overtime The “spouse” left home during deployments and needing mental health support may be a “male” The issues that lead to the need for mental health support may increasingly require inquiry if male-female relationship issues were involved MST is on the rise. Remember it affects males as well as females.

Demographics – MARITAL STATUS
RED = Civilian BLUE = Total DOD Divorce Trends Marital Status AC=Active Duty RC=Reserves/Guard Key Points: Data extracted from RAND National Defense Research Institute: Currently, military members are slightly more likely to be married than their civilian counterparts as a result of the trend the last 5 years. Divorce: While it has been hypothesized that the current operational tempo and multiple deployments would result in an increase in marital dissolution, a recent study published by the RAND Corp. revealed that while divorce has increased in the military, the rate is no higher than it was in the mid 90’s during peacetime with a significantly lower operational tempo. The Rand Study indicates divorces in the military now are consistent with the mid-90s. The OPTEMPO has not affected the divorce issue. The difference in divorce rate by gender is quite notable with females more likely than males to divorce. In addition, across the Reserve/Guard and Active Duty, enlisted members are at higher risk for divorce.

Demographics – Suicide
Two dominant factors: Financial Stress Concerns with Intimate Partners The 2008 overall Army rate was 24/100K, a 33% increase 70% increase reported from 2005 to 2008 Key Points: Very significant issue that is getting tons of attention Two most prominent factors affecting suicide are: 1. Financial Stress 2. Concerns involving their intimate partner(s) 70% increase from 2005 to 2008 The 2008 numbers were reached by June 2009; project is that it may double. Recently, an 18 month task force formed by Congress/President and the CFTT President (Rev Robert Certain) was asked to participate. Meetings started in Sept 2009. STATESIDE suicide is on a large increase Access the Crisis Intervention contact information available on (left side of every page) Handouts: E1 Military Suicide Risk Assessment Handout – E1

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” Key Points: Everything is not PTSD Make a point to discuss it as a “continuum” Try to discuss the issue that has recently arisen about over-diagnosis of PTSD Also point out that the Military has previously maintained a very strict definition of PTSD and often there has been difficulty with the “pre-existing condition” issue so that coverage is not provided That all seems to possibly be changing to the positive as the issue of an individual proving their connection to a very specific traumatic event is being relaxed Rand Study reports 20% have PTSD though 50% or more have other sub-clinical symptoms

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 Key Points: This behavior may exhibit itself early … or …evolve over time and in parts. This is one reason why the CFTT efforts is going to be a long term approach All symptoms do not have to be present Go over the symptoms carefully Ask if anyone has seen these in a client … or has seen other symptoms Tell Robert Certain’s story or any other story that you know of and would prefer to tell of being able to distinguish a person with PTSD based on some of the symptoms mentioned above. Here is Robert’s story: It is about an Asst Chaplain from one of Georgia’s Bases visiting the Roosevelt Center in Warm Springs. While on a tour of the facility with a crowd of people (12-15) from the Base, Robert noticed that the Asst Chaplain never fully engaged with the crowd, was somewhat stand-offish not unlike a secret service type of person. Often he stood away from the crowd with his back to the wall constantly watching around the group and at the exits and entrances. Robert, after awhile, decided to engage in a conversation with him and started off asking if he had served “in the sandbox” and if so how recently. He had and he had been back nearly 6 months. Robert mentioned that he had observed that the Chaplain had not fully engaged with the group and asked how he was doing. That began a discussion of length which confirmed that he was suffering some degree along the continuum of PTSD. Again, use this or another story and ask the audience if they have any similar stories to share with the others in the audience.

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) Key Points: Be sure to cover DRIVING The Trauma experience inhibits the brain when it occurs so you revert back to your primitive state. Language in particular is often inhibited So what you remember is VISUAL … as well as other basic senses like sounds, smells. That is why these senses are often the triggers for someone with PTSD

PTSD: non-DSM What does PTSD feel like – What do you “hear” in therapy
Sense of immediacy (“happening right now”) Re-experiencing of original memories and sensory impressions Involuntary Guilt Rational or irrational Understanding atrocities “Survivor Guilt”, also guilt for leaving, being intact 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 Other Feelings Anger at Government Mistrust of Authority Desire to return to the war zone Damage to spirituality Key Points: These are additional symptoms that you “hear” in therapy These are “feelings” that you may hear your client express in their stories and their presenting issues Be sure to cover these in some detail … at least the numbered items. Feel free to ask if anyone in the audience has had a client with PTSD with these feeling? Handouts: F1 PTSD DSM IV Criteria – the current official criteria (3 charts) F2 Warning Signs, Triggers, and Coping Strategies by Kathy Platoni, Psy.D., Col, MS, USAR (8 pages) Handout – F1, F2

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 Key Points: Happens in all wars More so in OEF/OIF due to improved medical techniques (ironically). Why know about TBI ? For this audience, you are less likely to have patients with TBI (but possibly) You are more likely to have family members who are caretaking a spouse or family member with TBI

MST: Military Sexual Trauma
2008 Rand Study reported 16% - 23% experienced MST Reported MST were 1,700 in 2004 and 2,947 in 2006 VA indicates that 1 in 4 female veterans using the VA reported at least one MST The VA Day Hospital Program estimates 3-5 female referrals have MST 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 Key Points: A handout is provided that goes into detail provided by the VA to define MST For today, here is a definition Military sexual trauma refers to both sexual harassment and sexual assault that occurs in military settings. The handout goes further into definitions of harassment and assault A range is provided due to difficulty in reporting Frequently unreported Affects males as well as females Not just during deployment but gig issue post-deployment during the “Reunification” stage MST continues to rise and be a significant issue Listen for the presence of MST when hearing the client’s stories. Handouts: C2 MST – Military Sexual Trauma definition from VA website Handout – C2

PTSD Treatments 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” VA Opinion of PTSD Interventions Key Points: One size does not fit all – no one treatment technique fits all PTSD situations The chart above was extracted from the VA website showing the 4 approved techniques for the treatment of PTSD CFTT is trying to provide EMDR training to civilian therapists in Georgia as funding becomes available. CFTT’s first training offering is in Athens the weekend of Jan 15, 16, 17, 2010. Why we picked EMDR: short training cycles (2 3-day weekends) more mobile shorter therapy duration to achieve some impact and fit insurance benefits, e.g. Ceridian limit of 12 sessions The following information can be found on the CFTT website in greater detail. Sourced in part from the VA website CT is based on the premise that what we think affects our emotions, what we choose to do or avoid, and our physiological reactions. ET is a deliberate method designed to expose the mind to intense emotional fear (your past trauma) in controlled doses, and teach your body that it now not need be disturbed by traumatic memories, as they are just memories, and that you do not any longer have to take seriously these unbidden memories of your past traumatic experience/s. SIT is a flexible individually-tailored multifaceted form of cognitive-behavioral therapy. In order to enhance individuals' coping repertoires and to empower them to use already existing coping skills, an overlapping three phase intervention is employed. The initial conceptualization phase a collaborative relationship is established between the clients and the therapist (trainer). The second phase of SIT focuses on skills acquisition and rehearsal that follows naturally from the initial conceptualization phase. The final phase of application and follow through provides opportunities for the clients to apply the variety of coping skills across increasing levels of stressors (inoculation concept as used in medical immunization or in social psychology to prepare individuals to resist the impact of persuasive messages). EMDR incorporates elements of cognitive-behavioral therapy with eye movements or other forms of rhythmic, left-right stimulation, such as hand taps or sounds. Eye movements and other bilateral forms of stimulation are thought to work by “unfreezing” the brain’s information processing system, which is interrupted in times of extra stress, leaving only frozen emotional fragments which retain their original intensity. Once EMDR frees these fragments of the trauma, they can be integrated into a cohesive memory and processed. Handouts: G1 EMDR: Know the Facts ref Providing EMDR Mental Health Services for the Military H1 Table: Using Symptoms and Neurobiology in Considering Treatments Handout – G1, H1

… 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 and 2008. The document revealed there was also a spike in the number of service members' children hospitalized for mental health reasons. Key Points: Before closing, let’s briefly touch upon a item that is on the rise The prolonged length of OEF and OIF are having a significant effect on the children 230,000 dependents of ACTIVE DUTY have a parent at war. 320,000 Reserve/Guard. 550K Total These are not cumulative numbers, but a ‘snapshot’ number currently In 2008 there were 2 million client visits (52,000 sought care) … double the number from 2003 The increase from 2007 to 2008 was 20% These number are for active duty only; they do not include families of vets and Reserve/Guard who are not activated. Since early summer 2009, there has been an increase in the number of articles and reports on the children of military families For therapists, they should be attentive to the this situation and seek out information about the children when working with family members

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 Key Points: Starting to close the Clinical Treatment Section Mention there is a song with lyrics in the Handouts that speak to the feelings and plight of a returning vet who is suffering from what he/she has seen. Next is the Intake Scenario interpretation Handout: H2 Lyrics to “The Things That I Have Seen”, song from Blue Divide Handout – H2

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. Key Points: The chart covers each of the points well Do try to cover each of them, they go quickly Why he wants to go back ASAP is important. Do try to cover the suggested reasons listed. As you may remember… A 20 year old male self refers to you for feeling “on edge”, “pissed off”, and having difficulty sleeping. He tells you that he is a SPC in the Army National Guard who returned about 4 months ago from a 15 month deployment to Iraq. In your first meeting he tells you he is a gunner attached to Bravo Company, 2nd Battalion, 7th Infantry Regiment, First Brigade Combat Team 3ID. He’s coming to see you because his First Sergeant expressed concern over his irritability during their last drill. He reports that he is still angry with everyone from his Company Commander down to his Platoon Leader for may decisions made down range. He is married with 2 children under the age of 4, one of whom was born during his deployment. He reports a strained relationship with his spouse who he says doesn’t get what he went through during his deployment. He also indicates that he plans to volunteer to deploy again as soon as possible.

TriCare - Ceridian TriCare MFTs are eligible for TriCare
LPCs need supervision by an M.D. 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 Key Points: Need help from Alan A ‘30’ Disability Rating or more is needed if you expect to be seen at the VA NG / Reserve are only eligible for equal amount of time they are active Handouts: I1 AAMFT Statement reference TriCare Eligibility J1 TriCare Provider File Application J2 TriCare On-Line Learning Reference K1 Ceridian Application Information Handout – I1, J1, J2, K1

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

In Closing…Consider These Next Steps
Look for more training opportunity to learn about treating the military. Visit If not yet trained in a trauma treatment technique, consider getting that training, e. g. EMDR (Jan 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 Handouts: L1 CareForTheTroops Reference and Research web sites M1 Veterans Resource Reference Handout – L1, M1

Military Culture & Treatment GAMFT Chapter Workshop

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Military Culture & Treatment GAMFT Chapter Workshop

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