1. Returning from the War Zone
Circle of Recovery, Inc.
Karen Kelly, Ph.D., LPC, NCC,MAC,CCS,ACRPS,CAMF,CDC,CIPS BCISII,CCJS,CRRI
Circle of Recovery, Inc. 2013

2. Returning From the War Zone
Goal: The service member has returned and the household is in flux. Individuals working with returning veterans have an opportunity to learn the necessary skills and understanding for reintegrating families with their returning service member.
Circle of Recovery, Inc. 2013

3. Returning From the War Zone
Objectives: By the end of the training participants will be able to:
Understand the common reactions to war
Understand the possible effects of the deployment phases on military members and their families
Gain tips for assisting families in their reuniting with the military member
Understand the importance of conducting a clinical assessment to assist the member and their family.
Circle of Recovery, Inc. 2013

4. Returning From the War Zone
Although reunions are happy times, it can also bring about stress and uncertainty, A returning service member may have had different experiences during deployment and changes may have occurred. Members and their families both need time and assistance in adjusting to the challenges of returning home. It helps to know what kinds of challenges they face and how to prepare them or help them work through these challenges.
Circle of Recovery, Inc. 2013

5. Returning From the War Zone
United States Armed Forces
There are seven uniformed services; five are armed services. The others are: United States Public Health Service Commissioned Corps
National Oceanic and Atmospheric Administration Commissioned Corps
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6. Returning From the War Zone
The five armed forces of the United States include:
Army
Navy
Marine Corps
Air Force
Coast Guard
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7. Returning From the War Zone
Difference Between Active and Guard/Reserve
Active
Full-time (24/7)
Families move with member when not deployed
Move every 3-5 years
Free Full benefits (medical, dental, etc.)
Full family support programs on-post
Guard / Reserve
Part-time One weekend a month / two weeks a year (unless deployed)
Live in the community
Limited medical or dental benefits through the military (w/cost)
Can be recalled to active duty within 24 hour
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8. Returning From the War Zone
Values in the Armed Forces
Army Navy Air Force Marines
(Core Values)
Loyalty Honor Integrity First Honor
Duty Courage Service Before Self Courage
Respect Commitment Excellence in All We Do
Commitment
Selfless Service
Honor
Integrity
Personal Courage
Circle of Recovery, Inc. 2013

9. Returning From the War Zone
Since September 11, 2001, more than two million service members have deployed.
Currently, there are over 2.2 million service members, and over three million dependents.
Currently, over 90,000 reservists and national guardsmen are activated.
The estimated U.S. veteran population is over 23 million.
Circle of Recovery, Inc. 2013

10. Returning From the War Zone
Over 90,000 Reservists and National Guardsmen are activated
•Since 9/11 more than 2 million service members have deployed
•Service members back from deployment: Approximately percent with PTSD or depression
Approximately 19.5 percent with traumatic brain injury
•Approximately 50 percent of returning service members who need treatment for mental health conditions seek it -slightly more than half receive adequate care
•2004 through percent of U.S. veterans met criteria for SUD vs. 9.2 percent of general population in 2006 (12 or older)
Circle of Recovery, Inc. 2013

11. Returning From the War Zone
2005 –2009: More than 1,100 members of the Armed Forces took their own lives; an average of 1 suicide every 36 hours
2010 Army suicide rate among active-duty soldiers decrease slightly 2009 = 162; 2010 = 156
Number of suicides in the Guard and Reserve increases by 55% = 80; 2010 = 145
More than half of the National Guard members who died by suicide in 2010 had not deployed
Suicide among veterans accounts for as many as 1 in 5 suicides in the U.S.
Circle of Recovery, Inc. 2013

12. Returning From the War Zone
M/SUDs caused more hospitalizations among U.S. troops in 2009 than any other cause
In 2009, on any given night, approximately 107,000 veterans were homeless
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13. Returning From the War Zone
War Zone experiences:
Being attacked or ambushed 60%
Receiving incoming fire 86%
Being shot at 50%
Discharged weapon 36%
See dead bodies 63%
Knowing someone seriously injured or killed 79%
Circle of Recovery, Inc. 2013

14. Returning From the War Zone
Most service members coming from war zones will have stress reactions.
Gender differences in re-entry
Post deployment stage
Impact on family
Circle of Recovery, Inc. 2013

15. Returning From the War Zone
Cumulative lengths of deployments associated with:
Increase in emotional difficulties among military children
Increase in mental health diagnoses among U.S. Army wives
Children of deployed military personnel experience:
Increase in school, family, and peer-related emotional difficulties compared with national samples
Circle of Recovery, Inc. 2013

16. Returning From the War Zone
Active Duty, National Guard, Reserve, and Veteran Military Families endure on-going strain:
Frequent Deployments
Separation
Exposure to Combat
Military Sexual Trauma
Unmet Health and Behavioral Health Needs
Community providers are not always equipped / trained to meet needs
Circle of Recovery, Inc. 2013

17. Returning From the War Zone
Gaps exist in available care
Need for increased coordination between military and civilian health and behavioral health systems
SAMHSA working with DoD, VA, States, Territories, Tribes, and communities
Decrease barriers
Increase military families’ access to culturally competent, trauma-informed services regardless of where they choose to seek care
Circle of Recovery, Inc. 2013

18. Returning From the War Zone
Family System/Dynamics
Deployment – assignment of military personnel to temporary unaccompanied tours of duty; extended separation
•Pre-Deployment – preparation
•Deployment – separation
•Post-Deployment – homecoming, reunion, reintegration
Circle of Recovery, Inc. 2013

19. Returning From the War Zone
Goals for Military Members and Families:
Address reintegration issues Trauma
PTSD/TBI
Isolation
•Suicide prevention and prevention of homelessness
•Peer support
•Education
•Access to health care
Circle of Recovery, Inc. 2013

20. Returning From the War Zone
Cumulative lengths of deployments are associated with more emotional difficulties among military children and more mental health diagnoses among U.S. Army wives.58, 59
Children of deployed military personnel have more school-, family-, and peer-related emotional difficulties, compared with national samples
Circle of Recovery, Inc. 2013

21. Returning From the War Zone
Pre-Deployment
Stage 1: Anticipation of loss Stage 2: Detachment and withdrawal Tips for managing pre-deployment
Deployment
Stage 3: Emotional disorganization
Stage 4: Recovery and stabilization
Tips for managing pre-deployment
Reunion
Stage 5: Anticipation of homecoming
Stage 6: Renegotiation of marriage contract
Stage 7: Reintegration and stabilization
Circle of Recovery, Inc. 2013

22. Principles that Guide VA Mental Health Care for Veterans
Certain basic principles form the foundation of all VA mental health care.
Focus on Recovery
Holistic Coordinated Care
Mental Health Treatment in Primary Care
Principal Mental Health Provider (PMHP
Around-the-Clock Service
Care That is Sensitive to Gender and Cultural Issues
Care Close to Home
Evidence-Based Treatment
Family Support
Circle of Recovery, Inc. 2013

23. Returning From the War Zone
Circle of Recovery, Inc. 2013

24. What Military Patients Want Civilian Providers to Know
“My memories are full of jargon,” Senior Master Sgt Leonard Macari says. “If I finally open up to a counselor, I don’t want to have to stop and explain acronyms like MRE or terms like ‘I did a 5 and 25.’ I want my therapist to know what I’m talking about. Otherwise, there’s a disconnect that’s hard to get past,” the Rhode Island National Guardsman explains.
Circle of Recovery, Inc. 2013

25. Returning From the War Zone
“Other service members agree that civilian providers, while professionally competent, often lack an understanding of the warrior’s way of life as well as their experiences, challenges and language. That lack of knowledge and appreciation is often the reason military patients discontinue treatment with a community- based behavioral health service provider after only one visit, say experts”.
Circle of Recovery, Inc. 2013

26. Returning From the War Zone
Fear of Repercussions "Some of our military personnel who are suffering from post- traumatic stress disorder, major depression, a traumatic brain injury, and/or substance abuse are choosing private-sector providers over military therapists for fear of discrimination or jeopardizing their career or their spouse’s career,”
Circle of Recovery, Inc. 2013

27. Returning From the War Zone
“Finding a community-based provider who understands the military culture and language is hit or miss; and that understanding can be the difference between receiving ongoing, effective treatment and not return-ing for a second appointment.”
Circle of Recovery, Inc. 2013

28. Returning From the War Zone
“Most members of the military and their families are covered by TRICARE, which covers behavioral health care provided on military bases and also sometimes among private providers who get TRICARE certification”.
Circle of Recovery, Inc. 2013

29. Returning From the War Zone
But the status of National Guard and Reservists as ‘citizen soldiers’ means that their health care benefits differ from those of other soldiers. Many of those deployed to Iraq or Afghanistan find their benefits for substance abuse and mental health services are very limited upon their return. Most of them receive these services from community providers.
Circle of Recovery, Inc. 2013

30. Returning From the War Zone
COMMON DISORDERS FROM THE WAR ZONE:
Traumatic Brain Injury
Combat Stress Injury
Post Traumatic Stress Disorder
Generalized Anxiety Disorder
Panic Disorder
Depressive Disorders
Circle of Recovery, Inc. 2013

31. Returning From the War Zone
Ranges from mild to severe – concussions to major intracranial trauma
Concussive episodes – IED, RPG, etc.
Symptoms include: of memory loss, poor concentration, sleep problems, body aches, pain, high BP, fatigue
R/O b/w mTBI & PTSD
Exposure to deployment related stressors & operations
Physical, emotional & cognitive impact
Symptoms may morph into major clinical syndrome
Combat Exposure Scale is valid & reliable for assessment of CSI
Traumatic Brain Injury
Combat Stress Injury
Circle of Recovery, Inc. 2013

32. Returning From the War Zone
UNDERSTANDING POST TRAUMATIC STRESS & COMBAT STRESS
PTSD: three symptom sets
Hyperarousal – startles easily & hyper-vigilance
Intrusions – flashbacks & nightmares (terrors)
Constriction of affect – numbing or dissociation
Combat Stress Injury:
Physical hardships >noise, blasts, dirty, malnourished
Cognitive > +/- information, mission ambiguity, lack of contextualizing
Emotional > fear of injury or death of comrades, shame/guilt, helplessness, killing
Social > social support vs. privacy issues; public opinion
Spiritual > forgiving; self-forgiveness; loss of faith
Circle of Recovery, Inc. 2013

33. What kinds of war-zone stressors did soldiers in the Iraq war confront?
Preparedness.
Some Veterans may report anger about perceiving that they were not sufficiently prepared or trained for what they experienced in the war.
Circle of Recovery, Inc. 2013

34. Returning From the War Zone
Combat exposure.
It appears that the new Iraq War entails more stereotypical exposure to warfare experiences such as firing a weapon, being fired on (by enemy or potential friendly fire), witnessing injury and death, and going on special missions and patrols that involve such experiences, than the ground war offensive of the Persian Gulf War, which lasted three days.
Circle of Recovery, Inc. 2013

35. Returning From the War Zone
Aftermath of battle.
Veterans of the new Iraq War will no doubt report exposure to the consequences of combat, including observing or handling the remains of civilians, enemy soldiers, U.S. and allied personnel, or animals, dealing with POWs, and observing other consequences of combat such as devastated communities and homeless refugees.
Circle of Recovery, Inc. 2013

36. Returning From the War Zone
Perceived threat.
Veterans may report acute terror and panic and sustained anticipatory anxiety about potential exposure to circumstances of combat, including nuclear (e.g., via the use of depleted uranium in certain bombs), biological, or chemical agents, missiles (e.g., SCUD attacks), and friendly fire incidents.
Circle of Recovery, Inc. 2013

37. Returning From the War Zone
Difficult living and working environment.
These low-magnitude stressors are events or circumstances representing repeated or day- to-day irritations and pressures related to life in the war zone.
Circle of Recovery, Inc. 2013

38. Returning From the War Zone
Concerns about life and family disruptions.
Soldiers may worry or ruminate about how their deployment might negatively affect other important life-domains.
Circle of Recovery, Inc. 2013

39. Returning From the War Zone
Sexual or gender harassment.
Some soldiers may experience unwanted sexual touching or verbal conduct of a sexual nature from other unit members, commanding officers, or civilians in the war zone that creates a hostile working environment.
Circle of Recovery, Inc. 2013

40. Returning From the War Zone
Assessment: There are many potentially important variables to assess when working with a Veteran of the Iraq War:
Work functioning
Interpersonal functioning
Recreation and self-care
Physical functioning
Psychological symptoms
Past distress and coping
Previous traumatic events
Deployment-related experiences
Circle of Recovery, Inc. 2013

41. Returning From the War Zone
Because PTSD and other trauma reactions change how a trauma survivor feels and acts, traumatic experiences that happen to one member of a family can affect everyone else in the family.
Circle of Recovery, Inc. 2013

42. Returning From the War Zone
Depression
One source of depression for family members can be the traumatic event itself. All traumas involve events where people suddenly find themselves in danger. When this happens in a situation or place where people are used to feeling safe, just knowing the event happened could cause a person to lose faith in the safety and predictability of life.
Circle of Recovery, Inc. 2013

43. Returning From the War Zone
Fear and worry
Knowing that something terrible can happen "out of the blue" can make people very fearful. This is especially true when a family member feels unsafe and often reminds others about possible dangers. Very often, trauma survivors feel "on edge" and become preoccupied with trying to stay safe.
Circle of Recovery, Inc. 2013

44. Returning From the War Zone
Avoidance
Just as trauma survivors are often afraid to address what happened to them, family members are frequently fearful of examining the traumatic event as well. Family members may want to avoid talking about the trauma or trauma-related problems, even with friends.
Circle of Recovery, Inc. 2013

45. Returning From the War Zone
Guilt and shame
Family members can feel guilt or shame after a traumatic event for a number of reasons. A family member may experience these feelings if he or she feels responsible for the trauma.
Circle of Recovery, Inc. 2013

46. Returning From the War Zone
Anger
Anger is a very common problem in families that have survived a trauma. Family members may feel angry about the trauma and its effect on their lives. They may be angry at whoever they believe is responsible for the traumatic event (this includes being angry at God).
Circle of Recovery, Inc. 2013

47. Returning From the War Zone
Negative feelings
Sometimes family members have surprisingly negative feelings about the traumatized family member. They may believe the trauma survivor no longer exhibits the qualities that they loved and admired.
Circle of Recovery, Inc. 2013

48. Returning From the War Zone
Drug and alcohol abuse
Drug and alcohol abuse can become a problem for the families of trauma survivors. Family members may try to escape from bad feelings by using drugs or drinking. A child or spouse may spend time drinking with friends to avoid having to go home and face an angry parent or spouse.
Circle of Recovery, Inc. 2013

49. Returning From the War Zone
Health problems
Family members of trauma survivors can develop health problems for a number of reasons. Bad habits, such as drinking, smoking, and not exercising may worsen as a result of coping with a loved one's trauma responses.
Circle of Recovery, Inc. 2013

50. Returning From the War Zone
What can providers do to help families of trauma survivors?
Provider should not assume that the family problems are a direct result of vet’s readjustment issues/return
Family issues/ problems may have existed prior to move or last deployment (history)
Presenting issues should be viewed within larger focus of recent service (events)
Circle of Recovery, Inc. 2013

51. Returning From the War Zone
What can providers do to help families of trauma survivors?
Trauma survivors and their families often don't know what to do to care for themselves. As a provider, you can encourage survivors and families to learn more about trauma and its effects. Family members of a traumatized person should find out as much as they can about PTSD and get help for themselves, even if their loved one doesn't seek treatment. Family members can encourage the survivor to inquire about education and counseling, but they should not pressure or try to force their loved one to get help. Classes or treatment may also be useful for stress and anger management, addiction, couples communication, or parenting.
Circle of Recovery, Inc. 2013

52. Returning From the War Zone
Resources/References:
Beder, J. (Ed.) (2012) Advances in Social Work Practice with Military
Families. Routledge.
Everson, R. & C. Figley (Eds.) (2011) Families Under Fire. Routledge.
Figley, C. & W. Nash (Eds.) (2007) Combat Stress Injury. Routledge.
Hall, L. (2008) Counseling Military Families. Routledge.
Hoge, C. W. (2010) Once A Warrior… Guilford.
Blaine Everson, Ph.D., LMFT, Samaritan Counseling Center
National Center for PTSD
SAMHSA
Veterans Administration
Resource List (handout)
Circle of Recovery, Inc. 2013