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Returning Service Members and Veterans Recognition, Recovery, and Resources Sherry J. Riney, LCSW Supervisory Social Worker, Trauma Recovery Program VA.

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Presentation on theme: "Returning Service Members and Veterans Recognition, Recovery, and Resources Sherry J. Riney, LCSW Supervisory Social Worker, Trauma Recovery Program VA."— Presentation transcript:

1 Returning Service Members and Veterans Recognition, Recovery, and Resources Sherry J. Riney, LCSW Supervisory Social Worker, Trauma Recovery Program VA Palo Alto Health Care System Christopher J. Petrone, LCSW OEF/OIF/OND Program Manager VA Southern Oregon Rehabilitation Center/Clinics “Serving Those Who Served”

2 Department of Veteran Affairs (VA) “To care for him who shall have borne the battle and for his widow and his orphan.” - Abraham Lincoln

3 VA Facilities Medical Centers and Health Care Systems Vet Centers Community Based Outpatient Clinics (CBOCs) VA Community Living Centers Independent Output Clinics Residential Rehabilitation Centers National and State Cemeteries Regional Offices

4 Acronyms Operation Enduring Freedom (OEF) Afghanistan Operation Iraqi Freedom (OIF) Iraq Operation New Dawn (OND) Troop withdrawal from Iraq Global War on Terrorism (GWOT)

5 Basic OEF/OIF/OND VA Eligibility Served in active army, naval, air, or coast guard service Separated under any condition other than dishonorable Served in National Guard or Reserves and Federally activated to serve in a theatre of combat in Iraq/Afghanistan and completed the full period called to active duty (exceptions for those injured in line of duty, hardship, early outs) If enlisted after 1981, must have served 24 continuous months or the full period called to serve (exceptions for those injured in line of duty, hardship, early outs) If in Doubt……Apply!

6 Service-Connection A service-connected rating is an official ruling by VBA that an illness or condition is directly related to active military service Benefits awarded in increments of 10%; paid in monthly checks ‘8 Priority Groups’ depending on such things as: Service Connection, Purple Heart Recipient, Prisoner of War, Above/below Income Threshold.

7 Special Eligibility for OEF/OIF/OND Vets VA provides enhanced enrollment eligibility and five years of cost-free health care to veterans who served in a theater of combat operations, for any injury or illness which may possibly be associated with this service (as determined by treating clinician).

8 Special Eligibility for OEF/OIF/OND (cont.) Cost-free one-time assessment of dental conditions for recently separated veterans who: Served for 90 days or more Apply within 180 days of separation Did not receive necessary dental care from military within 90 days of release or discharge

9 Some Numbers… Data presented on the following slides are from: Analysis of VA Health Care Utilization among Operation Enduring Freedom (OEF), Operation Iraqi Freedom (OIF), and Operation New Dawn (OND) Veterans Office of Public Health and Environmental Hazards Veterans Health Administration Department of Veterans Affairs April 2011

10 Demographics: OEF/OIF/OND Veterans Using VA Health Care Approximately 2.2 million service members have been deployed (OEF/OIF/OND) since 2002 (as of 12/31/2010) 1,285,631 OEF, OIF, and OND veterans who have left active duty and become eligible for VA health care since FY 2002 –691,031 (~54%)* Former Active Duty troops –594,600 (~46%) Reserve and National Guard *Percentages reported are approximate due to rounding.

11 Among all 1,285,631 separated OEF/OIF/OND Veterans: –51% (654,348) of total separated OEF/OIF/OND Veterans have obtained VA health care since FY 2002 (cumulative total) 615,577 of 654,348 (~94%) evaluated OEF/OIF/OND patients have been seen as outpatients only by VA and not hospitalized 38,771 of 654,348 (~6%) evaluated OEF/OIF/OND patients have been hospitalized at least once in a VA health care facility

12 Demographic Characteristics of OEF, OIF, and OND Veterans Utilizing VA Health Care % OEF/OIF/OND Veterans* (n = 654,348) % OEF/OIF/OND Veterans* (n = 654,348) SexUnit Type Male88.1Active Duty54.4 Female11.9Reserve/Guard45.6 Birth Year Cohort † Branch 1980 – 199444.8Air Force12.2 1970 – 197926.5Army61.4 1960 – 196921.1Marines13.4 1950 – 19596.5Navy12.8 1926 – 19491.1 Rank Enlisted91.2 Officer8.8 * Percentages reported are approximate due to rounding. † A range of birth years is now being reported rather than a range of ages to capture with greater precision the age distribution of OEF/OIF/OND Veterans utilizing VA health care. This began with the 3rd Qtr FY 2009 report.

13 Frequency of Possible Diagnoses among OEF and OIF Veterans Diagnosis (Broad ICD-9 Categories)*FrequencyPercent † Infectious and Parasitic Diseases (001-139) 95,42614.6 Malignant Neoplasms (140-209) 8,2901.3 Benign Neoplasms (210-239) 38,1405.8 Diseases of Endocrine/Nutritional/ Metabolic Systems (240-279) 193,85929.7 Diseases of Blood and Blood Forming Organs (280-289) 21,4883.3 Mental Disorders (290-319) 331,51450.7 Diseases of Nervous System/ Sense Organs (320-389) 278,12442.5 Diseases of Circulatory System (390-459) 131,36420.1 Disease of Respiratory System (460-519) 162,59024.9 Disease of Digestive System (520-579) 230,59335.2 Diseases of Genitourinary System (580-629) 90,52213.8 Diseases of Skin (680-709) 131,25220.1 Diseases of Musculoskeletal System/Connective System (710- 739) 358,02454.7 Symptoms, Signs and Ill Defined Conditions (780-799) 322,03549.2 Injury/Poisonings (800-999) 180,22827.5

14 Heavy Battle Gear – Contributing to Musculoskeletal Complaints

15 Environmental Exposures

16 Frequency of ‘Possible’ Mental Disorders among OEF/OIF/OND Veterans since 2002 Disease Category (ICD 290-319 code) Total Number of OEF/OIF/OND Veterans 2 PTSD (ICD-9CM 309.81) 3 177,149 Depressive Disorders (311)130,410 Neurotic Disorders (300)110,256 Affective Psychoses (296)78,184 Alcohol Dependence Syndrome (303)36,033 Nondependent Abuse of Drugs (ICD 305) 4 24,621 Specific Nonpsychotic Mental Disorder due to Organic Brain Damage (310) 22,838 Special Symptoms, Not Elsewhere Classified (307)21,587 Sexual Deviations and Disorders (302)18,241 Drug Dependence (304)18,185

17 Unique Health Issues From Each War Era  World War I – Poison gas  World War II – Peptic ulcers/GI problems  Korea – Cold injuries  Vietnam – “Agent Orange”  Persian Gulf I – Unexplained Medical Symptoms (u/k environmental exposures)  OEF/OIF/OND – TBI/Polytrauma (“signature injury”)

18 The Emotional Cycle of Deployment: A Military Family Perspective Cycle of Deployment The Emotional Cycle of Deployment: A Military Family Perspective Pre-Deployment Deployment Sustainment Re-Deployment Post-Deployment cycle-of-deployment-military-family-perspective

19 How does combat affect health? Blast Exposure TBI Musculoskeletal Pain Depression PTSD Deficits in Social Role Functioning Financial Stress Vocational Challenges Marital Stress Clinical Diagnosis (What the Clinician sees) Impairment in Function and Social Reintegration (What the Veteran experiences)

20 Posttraumatic Stress Disorder

21 What is Posttraumatic Stress Disorder (PTSD)? The person has been exposed to a traumatic event in which both of the following have been present: The person has experienced, witnessed, or been confronted with an event or events that involve actual or threatened death or serious injury, or a threat to the physical integrity of oneself or others. The person's response involved intense fear, helplessness, or horror. Note: in children, it may be expressed instead by disorganized or agitated behavior.

22 What are some symptoms of PTSD? Reliving the Event (Re-experiencing symptoms): Nightmares, thoughts, images Avoiding situations that remind you of the event: Avoid talking or thinking about the event Feeling Numb: No positive/loving feelings; lose of interest Feeling Keyed Up (Hyperarousal): Easily startled, angry, on guard, trouble sleeping -

23 PCL – M (17 Questions) Response: Not at all, A little bit, Moderately, Quite a bit, Extremely Repeated, disturbing memories, thoughts, or images of a stressful military experience? Repeated, disturbing dreams of a stressful military experience? Avoid thinking about or talking about a stressful military experience or avoid having feelings related to it? Avoid activities or situations because they remind you of a stressful military experience? Loss of interest in things that you used to enjoy? Feeling emotionally numb or being unable to have loving feelings for those close to you? Trouble falling or staying asleep? Feeling irritable or having angry outbursts? Having difficulty concentrating? Being “super alert” or watchful on guard?

24 What is Traumatic Brain Injury(TBI) ? ‘mild’ TBI = Concussion Symptoms of mTBI: Headaches, Dizziness Excessive fatigue (tiredness) Concentration problems, Forgetting things (memory problems) Irritability, Balance problems, Vision change Sleep disturbance, Sensitivity to bright light Moderate/Severe = extended period of unconsciousness or amnesia

25 Overlapping Symptoms mTBIPTSDPainDepression Attention/concen tration XXXX Memory XXX Fatigue XXXX Lightheadedness XX Sensitivity to light/sound XXX Slowed thinking XXX Irritability XXXX

26 The “New Normal” Challenges and Opportunities Changes: Thinking, Emotions, and Behavior Factors to Consider Stigma Warrior identity Avoidance Age (developmental stage) “If I just had a job, etc…” Delayed onset ‘At risk’ behaviors (Driving, Substances, Impulsivity, Violence) Things are just different Between two worlds

27 Services – ‘Inside the Box’  Post Deployment Health Clinic: Integrating Primary Care, Mental Health, Social Work and related services …  OEF/OIF/OND Care Management  Specialized and Evidence Based Care: Medical and Mental Health services  Vet Center and Community Providers

28 OEF/OIF/OND Care Management Offers standardized process of evaluation and care to identify needed services and connect with appropriate resources “Warm Welcome” to VA – introduction to facility; “Spear of the Arrow” (Trust, Rapport) Post-deployment health screening and referrals to: Primary care, mental health, dental, prosthetics, etc. Referral for compensation claims, GI Bill, employment assistance; referral to Vet Center for counseling (1:1, Family) Answers questions regarding health care benefits, helps navigate the VA system One person to call for all questions/concerns

29 OEF/OIF/OND Care Management for Severely Ill/Injured Enters veteran’s information into designated tracking database for Severely Ill/Injured Ensures all referrals made are addressed: (prosthetics, special compensation, adaptive housing, etc.) Coordinates with Polytrauma Center (if patient referred to/from that facility) Coordinates with Military Case Manager or Federal Recovery Coordinator with updates on veteran’s status and progress

30 Post-Deployment Assessment (Biopsychosocial) Military History (Rank, MOS, Deployments, Hostile Fire) Medical Issues (combat injuries, pain), including TBI Mental Health (PTSD, Depression, S/I, H/I, Index Trauma, counseling and treatment history) Substance Abuse (types; pattern of use) Social/Family, Legal and Academic/Vocational History

31 WOMEN VETERANS OEF/OIF/OND female veterans may experience both military sexual trauma (MST) and combat trauma 24% of female OEF/OIF/OND veterans accessing VA health care screened positive for MST (vs. 1% male) Survivors of childhood abuse are at risk for re-traumatization, depression, and substance abuse

32 PTSD Treatments Psychoeducation Skills Building Anxiety/Symptom Management Prolonged Exposure (PE) Cognitive Processing Therapy (CPT) Eye Movement Desensitization Reprocessing (EMDR) Acceptance/Commitment Therapy (ACT) Process (‘Talk’) Therapy

33 VA General Care Primary Care Community Based Outpatient Clinics Outpatient Mental Health Clinic Day Treatment Program Acute Psychiatry

34 Specialized Outpatient PTSD Programs PTSD Clinical Teams (PCTs) provide group and one-to-one treatment Substance Use PTSD Teams (SUPTs) treat the combined problems of PTSD and substance abuse Women's Stress Disorder Treatment Teams (WSDTTs) provide women veterans both one-to-one and group treatment

35 Specialized Intensive PTSD Programs PTSD Day Hospitals (DH) are outpatient and provide one-to-one and group treatment for 4-8 hours each visit (daily or several times a week) Evaluation and Brief Treatment of PTSD Units (EBTPUs) provide PTSD treatment for a brief time ranging from 14 to 28 days PTSD Residential Rehabilitation Programs (PRRPs) provide PTSD treatment and case management to help the trauma survivor return to healthy living in the community (PRRP admissions tend to be 28 to 90 days long)

36 Specialized Intensive PTSD Programs (cont.) Specialized Inpatient PTSD Units (SIPUs) provide trauma-focused treatment (from 28 to 90 days) PTSD Domiciliary (PTSD Dom) provide live-in treatment for a set period of time to help the veteran improve and move to outpatient mental health care Women's Trauma Recovery Program (WTRP) live-in program focuses on war zone-related stress as well as MST; provide PTSD treatment and case management to help the women return to healthy living in the community (60 to 90 days long)

37 Clinical Programs Men’s Trauma Recovery ProgramMen’s Trauma Recovery Program –Began in 1978 –Predated the DSM-III diagnosis for PTSD –120 beds/40 current –One of two PRRPs in VISN 21 (other is Hawaii) Women’s Trauma Recovery ProgramWomen’s Trauma Recovery Program –Began in 1992 –10 beds –Gender-specific focus –Only PRRP for women in VISN 21

38 Clinical Programs Military related trauma (combat, MST, training accidents, abuses/assaults etc.) Veterans from all eras Active Duty, National Guard, Reserve Complex cases with multiple comorbidities Multidisciplinary staff Multidisciplinary treatment plan Rolling admissions

39 Site for Clinical Education On-site trainees –Psychiatry residents –Psychology interns –Psychology practicum students –Social work interns –Nursing students –RNP students –Chaplain CPE students NCPTSD Clinical Training Program Training site for DoD healthcare providers nation-wide and internationally

40 Populations Served Men and Women Late adolescence and young adulthood Aging veterans Ethnically Diverse Under- and unemployed Prior psychiatric hospitalizations Suicidal ideation and attempts Multiple lifetime traumas Substance use/abuse/dependence Aggression and violent behavior

41 Why Residential Treatment? Intensity –Immersion –Length of stay Microcosm of real life –Problematic behaviors will emerge –Opportunities for new results Community –Being part of/acceptance –Behavior shaping

42 TRP Treatment Treatment goals : –Restore individuals to their highest level of functioning –Promote reintegration into their communities –Facilitate reconnection with families and loved ones General Principles:  normalize common combat stress reactions  normalize responses  Physiological, psychological, behavioral  minimize stigma/fears/treatment concerns  aim for proactive/preventive interventions  focus on adaptive strengths  improve personal disclosure and interpersonal trust

43 Treatment Matching Ability to tolerate direct feedback/give feedback Ability to take responsibility for own behaviors Ability to tolerate uncomfortable emotions (e.g., no threats of violence, no leaving groups, etc) Willingness to try new behaviors/use new coping strategies No acute issues (e.g., acute SI, HI, psychosis, severe cognitive impairment) Commitment to refrain from self-injurious behaviors

44 Treatment goals are accomplished through a variety of groups and interventions…

45 Groups Cognitive Processing Therapy (CPT) Acceptance/Commitment Therapy (ACT) Family Issues Cross-Cultural Issues Group Spirituality and Trauma Understanding PTSD Problem Area Review Conflict Resolution Affect Management Communication Group Emotion Regulation Leisure Education/Art Therapy

46 Groups (cont.) Seeking Safety 12 Step AA/NA Harm Reduction Community Council Community Meeting Milieu Group/ Goal Setting Group Vet’s Recovery Group Choral Group Project CARE Cycling Program – more than 40,000 miles logged and 220 riders Assistance Dog Training Program “Paws for Purple Hearts”

47 Veterans Readjustment Counseling Centers (“Vet Centers”)  Individual and Group Counseling  Military Sexual Trauma Counseling  Marital/Family Counseling  Bereavement Counseling  Drug and Alcohol Referral  Liaison with VA & Community Resources  Benefits Assistance Referrals  Community Education and Career Referrals

48 National Center for PTSD For Veterans and the General Public PTSD Overview Other Common Problems Types of Trauma Assessment Treatment Self Help and Coping Family and Friends Specific to Women Return from War In the Community PTSD Research Mobile Apps: PTSD Coach Videos Web Resource Links For Providers and Researchers About Us Subscribe Search PILOTS* Get Help for PTSD

49 VA Substance Use Treatment First-time screening for alcohol or tobacco use in all care locations Short outpatient counseling including focus on motivation Intensive outpatient treatment Residential (live-in) care Medically managed detoxification (stopping substance use safely) and services to get stable Continuing care and relapse prevention Marriage and family counseling Self-help groups Drug substitution therapies and newer medicines to reduce craving Decisions as to which services are provided and how intense they are will be based on the patient’s needs and desires

50 VA Mental Health Mental Health Home Depression Families Get Help Homelessness Mental Health Recovery Military Sexual Trauma PTSD Returning Veterans Substance Abuse Suicide Prevention Veteran Students Veterans At Work Women Veterans About VA Mental Health For Providers

51 Opportunities – ‘Outside the Box’  Become more ‘Family-Centric’  Peer Mentoring = Previous and Current Eras  GI Bill and Vocational Rehab (Role Fulfillment)  Non-Conventional Interventions and Support Horses for Heroes, Recreation Services, Service Dogs, Tele-health, PDA’s  ‘MyHealtheVet’  Social Media - Facebook, Twitter

52 Special Focus Veterans Crisis Line: (800) 273-TALK (8255) (press 1 for veterans) Safe Driving Initiative Rural Health (tele-health, vans…) “Ending Homelessness” Veteran Justice Outreach Caregiver Legislation (OEF/OIF/OND Veterans)

53 COMMUNITY SUPPORT FOR RETURNING COMBAT VETERANS Awareness of possible issues/problems Awareness of community resources “Cultural Competence” Community support for employment Volunteer/donate to community groups offering financial or other support to returning veterans Raise awareness of combat veteran issues in churches, community organizations, etc. Make referrals to VA for benefits/health care

54 Resource List for OEF/OIF Military Families Developed by Michelle Sherman, Ph.D. (available on Conference Site) BOOKS For Veterans / Service Members (and Adult family members) For Kids For Teens WEBSITES Military and VA Emotional Health: Deployment: Injury / Traumatic Brain Injury Issues about Children/Youth (kids, parents and educators) VIDEOS For Adults/Parents For Youth For Providers

55 Online Resources q-war-clinician-guide.asp

56 Literature and Movies Literature   War and The Soul. Edward Tick, PhD. (2005)  On Killing. (1995); On Combat (2007). Lt. Col Dave Grossman  Tears of a Warrior: A Family’s Story of Combat and Living with PTSD. Janet and Tony Seahorn (2008)  Courage After Fire. Armstrong, Best, Domenici (2006)  Once a Warrior, Always a Warrior. Charles W. Hoge, MD (2010)  The Devil’s Sandbox. John R. Bruning (2006) Movies  This is War  The Hurt Locker  Brothers

57 Welcome Home!

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