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1 1 Ahec veterans mental health project: (add the title of your program)

2 2 Speaker names/affiliations [Speaker’s name] [Speaker’s affiliation] [Speaker’s name] [Speaker’s affiliation] [Sponsoring Agency] [City & state of training] [Date]

3 3 welcome

4 4 There’s nothing normal about war. There’s nothing normal about seeing people losing their limbs, seeing your best friend die. There’s nothing normal about that, and that will never become normal…” Lt. Col. Paul Pasquina, MD, from the movie "Fighting For Life"

5 5 How many of you are: Current/former Service Members Spouse of a current/former Service Member Other family of a current/former Service Member Friend of a current/former Service Member Introduction

6 6 How many of you are: Physicians Psychologists Social workers Licensed Counselors Substance Abuse Marriage and Family Nurses Others

7 7 Lingo OIF = Operation Iraqi Freedom o Iraq war until 31 December 2011 OEF = Operation Enduring Freedom o current war in Afghanistan OND = Operation New Dawn o Iraq war since 1 January 2012

8 8 Scope of the Issue

9 9 In war, there are no unwounded soldiers. Jose Narosky

10 10 Scope of the Issue Length of combat operations As of November 27, 2006, OIF has lasted longer than WW II All volunteer force = multiple deployments Deployment maps

11 11 Scope of the Issue 2.2 million Service Members in Iraq and Afghanistan “Over 75% of Soldiers and Marines [in Iraq] surveyed reported being in situations where they could be seriously injured or killed; 62-66% knew someone seriously injured or killed; more than 1/3 described an event that caused them intense fear, helplessness or horror” (Office of the Army Surgeon General Mental Health Advisory Team [MHAT] IV, Final Report, Nov 06)

12 12 Scope of the Issue “The challenges are enormous and the consequences of non- performance are significant. Data…indicate that 38% of Soldiers and 31% of Marines report psychological symptoms. Among members of the National Guard, the figure rises to 49%. Further, psychological concerns are significantly higher among those with repeated deployments, a rapidly growing cohort. (Report of the DoD Task Force on Mental Health June 2007)

13 13 Scope of the Issue Psychological concerns among family members >1 million children in US under 11 years old experienced deployment of a parent – sometimes both – since 9/11

14 14 Scope of the Issue Psychological concerns among family members National concern First Lady Joining Forces initiative Support family members “Families serve, just not in uniform” Dr. Jill Biden

15 15 Sesame Street Series Deployments Homecomings Changes Grief and Military One Source at / /

16 16 Scope of the Issue July – September 2010 Surveyed 911 Army soldiers and Marines All deployed OIF/OEF Report released May 2011 Compared to surveys 2005, 2007, 2009 Office of the Army Surgeon General Mental Health Advisory Team (MHAT) VII Report, May 2011

17 17 Scope of the Issue Rates of acute stress higher than any previous year except 2007 o Acute stress o Depression o Anxiety Ratings of individual morale significantly declined since 2005 and 2009 Office of the Army Surgeon General Mental Health Advisory Team (MHAT) VII Report, May 2011

18 18 Scope of the Issue Suicide ideation rates the same Higher exposure to concussive events Service members on 3 rd to 4 th deployment had lower morale than those on 1 st Office of the Army Surgeon General Mental Health Advisory Team (MHAT) VII Report, May 2011

19 19 Scope of the Issue Experience Death of unit member48.6%73.4% Shooting at enemy29.6%78.5% IED exploded near them32.8%62.4% Responsible for death of combatant8.3%48.4% Office of the Army Surgeon General Mental Health Advisory Team (MHAT) VII Report, May 2011

20 20 Scope of the Issue Dramatic increase in combat exposure over previous surveys Behavioral health stigma unchanged Office of the Army Surgeon General Mental Health Advisory Team (MHAT) VII Report, May 2011

21 21 Scope of the issue: Rural

22 22 Scope of the Issue Defining rural o VA uses US Census Bureau’s definition “Urban”, “Rural” and “Highly Rural” o Urban Area: Any block or block group having a population density of at least 1000 people per square mile o Rural Area: Any non-urban or non-highly rural area o Highly Rural Area: Area having < 7 civilians per square mile (Frontier)

23 23 Scope of the Issue VA rural health o Legislation approved in 2006 o Recognizing needs of Rural Veterans o Establishment of the VA Office of Rural Health (ORH) o Special appropriations expand VA services for rural veterans

24 24 Scope of the Issue Who is rural? o 20% of the entire US population o 28% of all living veterans (6.1 million of all 22 million living veterans) o 41% of all veterans enrolled in VA o 3.3 million enrolled rural veterans o 54% all rural veterans enrolled (about double the enrollment non-rural)

25 25 Scope of the Issue Who is rural? o 44% of US military recruits o 39% of OEF/OIF/OND Veterans o 44% of soldiers killed in Iraq from communities < 20,000 people

26 26 Scope of the issue: why train civilians?

27 27 Scope of the Issue Research on civilian health providers treating military families “Serving Those Who Have Served: Educational Needs of Health Care Providers Working with Military Members, Veterans, and their Families”

28 28 Scope of the Issue Web-based survey of 319 rural and urban community mental health and primary care providers funded by the VA Office of Rural Health Citation: Kilpatrick, D.G., Best, C.L., Smith, D.W., Kudler, H., & Cornelison- Grant, V. Charleston, SC: Medical University of South Carolina Department of Psychiatry, National Crime Victims Research & Treatment Center, 2011

29 29 Scope of the Issue Serving Those Who Have Served full report available at

30 30 Scope of the Issue Key Findings o 56% community providers don’t ask patients about military service o Only 16% served in the Armed Forces o Although VA is a national leader in provider training, only one third (31%) of community providers are VA trained

31 31 Scope of the Issue Key Findings o Community providers report less knowledge and confidence in treating  PTSD  Traumatic Brain Injury (TBI)  Substance abuse/dependence o Than treating  Depression  Suicidality  Other health issues

32 32 Scope of the Issue Key Recommendations o Train civilian providers  Understand military culture  Understand VA programs

33 33 Questions?

34 34 Basic Training – Military culture

35 35 Basic Training – Military Culture Understanding the nature of the military culture, combat and the stresses of living and working in a war zone are critical to establishing credibility with your patients or clients.

36 36 Basic Training – Military Culture “When I come to feeling overwhelmed…I want a one-on-one talk with a trained psychiatrist who’s either been to war or understands war.” Staff Sgt. Gladys Santos attempted suicide after three tours in Iraq Newsweek article February 11, 2008

37 37 Basic Training – Military Culture The military has its own laws, its own clothes and its own language. To serve them better and help ease their fears about treatment, we first need to understand what being a veteran is all about and be familiar with all things military. Scott Swain, 15-year Gulf War veteran, Senior Director Veterans Services Valley Cities Counseling and Consultation Auburn, WA

38 38 Basic Training – Military Culture

39 39 Basic Training – Military Culture Army/Army National Guard Navy/Naval Reserves Marine Corps/Marine Corps Reserve Air Force/Air National Guard/ Air Force Reserves Coast Guard*

40 40 Basic Training – Military Culture My uniform…

41 41 Basic Training – Military Culture Service Member (SM) o General term o Identify any sworn member of the service Veteran- person who has served in military Combat Veteran- person who has served in combat zone Disabled Veteran- person permanently disabled o Result of military service o Range from minor injury to severely disabled

42 42 Basic Training – Military Culture Military Occupational Specialty (MOS) o Advanced individual training o Hundreds of MOS

43 43 Basic Training – Military Culture Sample MOS positions o Food Services o Infantry o Artillery o Chemical and biological experts o Construction experts o Medical professionals

44 44 Basic Training – Military Culture Sample MOS positions o Lawyers o Investigators o Military Intelligence o Special Operations Command (SOCOM) members

45 45 Basic Training – Military Culture More about lingo… o DoD = Department of Defense o VA = Department of Veterans Affairs o IED = Improvised Explosive Device o VBIED = Vehicle Born IED (car or suicide bomb)

46 46 Basic Training – Military Culture Basic Training (Boot Camp for USMC) o Total control environment o Intended to take the SM out of comfort zone o Through physical and mental preparedness

47 47 Basic Training – Military Culture Service broken up into two major groups… o Combat  Infantry  Artillery  Combat Engineers  Special Forces  All male force

48 48 Basic Training – Military Culture Service broken up two major groups… o Combat Support  Administrative specialties  Police  Fire  Legal  Medical  Male and female SMs

49 49 Basic Training – Military Culture More about lingo… o FOB = Forward Operating Base o TDY = Temporary Duty o ROE = Rules of Engagement

50 50 Military Rank Divided into two groups: Officers Warrant Officers (WO1-CW5) Regular Line Officers (Second Lieutenant- General)

51 51 Military Rank Enlisted Lower Enlisted (Private – Specialist) Non-Commissioned Officers NCOs (Corporal – Sergeant Major)

52 52 Basic Training – Military Culture High standard of discipline Distinct ceremony and etiquette Creates shared rituals and common identities Emphasis on group cohesion & esprit de corps

53 53 Basic Training – Military Culture Connects service members to each other Continued into retirement o Wearing of service uniforms - parades and military unit apparel

54 54 Basic Training – Military Culture The military - way of life with own expectations o Work/family balance o Communication o Relationship with one’s employer

55 55 Basic Training – Military Culture For some military is… o Way to pay bills o Way to get  Health  Housing  Other benefits for family

56 56 Basic Training – Military Culture For many… o Military is a profession o Same way doctor is a profession

57 57 Basic Training – Military Culture Guard and Reserve culture Well luckily as a Reservist you are only dead for one weekend a month Joke told by a Reservist

58 58 Basic Training – Military Culture Guard and Reserve culture Formally a Strategic Reserve o Backfill the Active Duty force o Train one weekend a month o Two weeks a year

59 59 Basic Training – Military Culture Guard and Reserve culture Now an Operational Reserve o Some units deploy as often as Active Duty o Families often see themselves as Military Families o May lack community supports

60 60 Basic Training – Military Culture “When I first met my husband, I didn't know what it meant to be a military wife. I just knew that I loved a soldier. And that my love was strong enough to weather whatever life might hand us. In those early days, Ian was a typical ‘weekend warrior’. I lent him to the Army one weekend a month and two weeks during the summer. And I missed him terribly when he was gone. Especially those two weeks - they were a lifetime without him. But September 11th changed that. Suddenly, he was deploying as often as the Active Duty guys. New Orleans. Guantanamo. Afghanistan.” Randi S. Cairns Founder/Executive Director Home Front Hearts, Inc.

61 61 Basic Training – Military Culture Guard and Reserve culture o No typical RC experience o Deployment pattern depends on rank and MOS o Some RC deploy once a decade o Some deploy every 2-3 years

62 62 Basic Training – Military Culture Guard and Reserve culture o Many deployments fun – opportunity for growth for the service member and family o Some deployments scary and isolating o Yellow Ribbon - education o Operation Purple camp - kids

63 63 Basic Training – Military Culture Each uniformed service has its own culture Service members and military families hold a wide variety of views Do not make assumptions about the person in front of you Wait until they tell you

64 64 “I learned early that war forms its own culture. The rush of battle is a potent and often lethal addiction, for war is a drug, one I ingested for many years.... War exposes the capacity for evil that lurks not far below the surface within all of us. And this is why, for many, war is so hard to discuss once it is over.” Chris Hedges, Veteran War Correspondent, War is a Force that Gives Us Meaning

65 65 Questions?

66 Behavioral health issues 66

67 67 Introduction “For the first time in American history, 90% of wounded (soldiers) survive their injuries.” “A greater percentage of men and women are coming home with TBI and severe Post Traumatic Stress.” (Alive Day Memories: Home from Iraq HBO documentary)

68 68 Behavioral Health Issues > 1.2 million OEF/OIF veterans eligible for VA services (Sept 2010) 50% already sought VA care Three most common health issues o Musculoskeletal o Mental Health o Symptoms, Signs and Ill-Defined Conditions

69 69 Mental health Needs oef/oif vets (2014 projections) PTSD only4.7%113,978 MDD only4.7%113,978 PTSD and MDD9.1%220,680 Other MH Dx11.6%281,307 TOTAL30.1%729,943 National Council for Behavioral Health “Meeting the Behavioral Health Needs of Veterans: Operation Enduring Freedom and Operation Iraqi Freedom” November 2012

70 70 Behavioral Health Issues Ideally problems are picked up within DoD or VA continuum of care BUT… Only 50% of all OEF/OIF Veterans eligible for VA care have come to VA Where are the other 50%? “Silent majority” OEF/OIF veterans not coming to VA

71 71 Comparison National Vietnam veterans readjustment study (NVVRS) Only 20% Vietnam Veterans with PTSD (at the time of the study) had ever gone to VA for mental health care But… 62% of Vietnam Veterans with PTSD sought mental health care at some point Kulka et al. 1990, Volume II, Table IX-2

72 72 Post deployment issues – active and reserve components Study - 88,235 US soldiers returning from Iraq Active duty (AD) and Reserve component (RC) Completed Post Deployment Health Assessment (PDHA) Completed Post Deployment Health Reassessment (PDHRA) 6 months later Milliken, Auchterlonie & Hoge (2007). JAMA 298:

73 73 Post deployment issues – active and reserve components Post Deployment Health Assessment (PDHA) o Self-administered global health survey o War fighters return from deployment o De-mobilization unit o Chaotic environment o Screening tool not individual assessment o Lots of questions

74 74 Post deployment issues – active and reserve components PDHA include standard screening o Posttraumatic Stress Disorder (PTSD) o Major Depression o Alcohol Abuse o Traumatic Brain Injury o Other Mental Health problems Milliken, Auchterlonie & Hoge (2007). JAMA 298:

75 75 Post deployment issues – active and reserve components Post Deployment Health Assessment (PDHA) o Many not report symptoms  Do not recognize  Don’t want anything to interfere with going home

76 76 Post deployment issues – active and reserve components Post Deployment Health Reassessment (PDHRA) Performed 6 months post deployment Self report instrument followed by private review with health care provider VA and community reps onsite help with transition PDHA vs. PDHRA results on next few slides

77 77 Changes Active Duty and Reserve Component at pdhra Results… Roughly ½ with PTSD symptoms PDHA improved by PDHRA BUT… Twice as many new cases of PTSD at PDHRA Milliken, Auchterlonie & Hoge (2007). JAMA 298:

78 78 Changes Active Duty and Reserve Component at pdhra Results… Depression rates at PDHRA o Doubled in AD to 10% o Tripled in RC to 13% Identified as needing MH treatment post deployment o AD 20.3% o RC 42.4% Milliken, Auchterlonie & Hoge (2007). JAMA 298:

79 79 Changes Active Duty and Reserve Component at pdhra Milliken, Auchterlonie & Hoge (2007). JAMA 298: Results… 4-fold increase in concerns about interpersonal conflict Alcohol abuse rate high o AD 12% o RC 15% o Only 0.2% referred for treatment

80 80 Changes Active Duty and Reserve Component at pdhra Why RC is at greater risk than AD… AD - have on-going access to healthcare RC situation - o DoD health benefits (TRICARE) expire 6 months after deployment ends o Pay for coverage o Special VA benefits end at 60 months unless a service-connected condition identified)

81 81 Changes Active Duty and Reserve Component at pdhra Why RC is at greater risk than AD… o May be geographically separated from military and VA facilities o 1/2 service members beyond standard DoD benefit window by PDHRA o Lack of day-to-day contact with Battle Buddies o Added stress transition back to civilian life

82 82 Take Home Point Post deployment mental health cannot just be about PTSD anymore.

83 83 Identifying/treating post deployment mh issues in new combat vets and families OEF/OIF veterans seek care outside DoD/VA Family members also dealing with deployment-related stress Looking for help in the community Reduced capacity to treat family members in Military Treatment Facilities Is your practice prepared to identify or treat post deployment problems?

84 84 There should be NO WRONG DOOR to which OEF/OIF veterans or their families can come for help. Take Home Point

85 85 Questions?

86 86 Posttraumatic stress disorder (PTSD)

87 87 Introduction “The most complex and dangerous conflicts, the most harrowing operations, and the most deadly wars, occur in the head.” (Anthony Swafford, Jarhead from PBS video Operation Homecoming)

88 88 PTSD Characterized by a constellation of symptoms Follows exposure to an extreme traumatic event Involves actual or threatened death or serious injury

89 89 PTSD Response to the event must include o Intense fear, helplessness or horror o Symptoms persist more one month o May involve  Re-experiencing the traumatic event through intrusive recollections, dreams or nightmares  Avoidance of trauma-associated stimuli, such as people, situations, or noises

90 90 PTSD Response to the event may involve o Persistent symptoms of increased arousal  Sleep disturbance  Hypervigilance  Irritability  Exaggerated startle response

91 91 PTSD Diagnosis must be accompanied by clinically significant distress or impairment in o Social area o Occupational situations o Other important areas of function Problems must persist at least one month after the event

92 92 Traumatic Events in oeF/OIF/OND Multi-casualty incidents (Suicide Bombers, VB/IEDs, ambushes) Seeing the aftermath of battle Handling human remains Friendly fire Witnessed or committed atrocities

93 93 Traumatic Events in oeF/OIF/OND Witnessing death/injury of close friend/favored leader Death/injury of women and children Feeling/being helpless to defend or counter- attack

94 94 Traumatic Events in oeF/OIF/OND Being unable to protect/save a colleague or leader Killing at close range Killing civilians/“avoidable” casualties or deaths

95 95 PTSD/Depression, Combat Exposure and Rurality 56% of Rural Veterans screened positive for PTSD and/or Depression o Significantly higher rate than Urban Veterans (32%) o May reflect finding of higher Combat Exposure Scale scores among rural Veterans Rural Veterans and the West Virginia 2008 Legislative Study. J. Scotti & H. Heady, University of West Virginia

96 96 PTSD/Depression Associated with Decline in Function Rural Veterans and the West Virginia 2008 Legislative Study. J. Scotti & H. Heady, University of West Virginia

97 97 Being Rural Predicts Greater Declines Rural Veterans with PTSD/Depression have lower levels of function on every level than: Rural Veterans without PTSD/Depression OR: Urban Veterans with or without PTSD/Depression

98 98 Treatment VA/DoD Clinical Practice Guidelines

99 99 Clinical Practice Guidelines Assist clinicians in learning about available treatments Reviewing their evidence base Making practical, patient-specific choices

100 100 Clinical Practice Guidelines Provide clinical algorithms to walk clinicians through necessary steps o Screening and initial assessment o Treatment and re-assessment Most relevant VA/DoD Clinical Practice Guideline for the Management of Posttraumatic Stress

101 101 VA/DoD Clinical Practice Guideline for the Management of Posttraumatic Stress Created by a working group of VA and DoD clinicians and researchers Separate algorithms defined for primary care providers and mental health professionals Evidence tables for each recommendation Substantial literature review included Available at isorder_PTSD.asp isorder_PTSD.asp In the public domain

102 102 Other Clinical Practice Guidelines The International Society for Traumatic Stress Studies o World’s largest international multidisciplinary professional organization working in the field of psychological trauma o Comprehensive set of treatment guidelines

103 103 Other Clinical Practice Guidelines o Link to November 2012 guidelines o mplex_PTSD_Treatment_Guidelines&Template=/CM/Conten tDisplay.cfm&ContentID=5185 mplex_PTSD_Treatment_Guidelines&Template=/CM/Conten tDisplay.cfm&ContentID=5185

104 104 Other Clinical Practice Guidelines The American Psychiatric Association o Practice Guideline for Patients with Acute Stress Disorder and Posttraumatic Stress Disorder o practice-guidelines practice-guidelines

105 105 Treatment Options

106 106 Cognitive Therapy (CT) Identify and clarify patterns of thinking Identify distressing trauma-related thoughts Convert these thought patterns into more accurate thoughts Address core beliefs about self, others, larger world

107 107 Exposure Therapy (eT) Reduce the fear associated with traumatic experience through repetitive, therapist- guided confrontation of feared places, situations, memories, thoughts, and feelings Exposure can be “imaginal” or “in vivo” Reduced intensity of emotional and physiological response is achieved through habituation.

108 108 Stress Inoculation Training (SIT) Anxiety management o Among the most useful psychotherapeutic treatments for PTSD clients o Determined by Expert Consensus Guideline Series

109 109 Stress Inoculation Training (SIT) SIT can be thought of as a set of skills for managing stress and anxiety o Breathing control o Deep Muscle Relaxation o Assertiveness Training o Role Playing o Covert Modeling o Thought Stopping o Positive Thinking o Self Talk

110 110 Eye Movement Desensitization and Reprocessing (EMDR) Accessing and processing traumatic memories to bring these to resolution. The client focuses on emotionally disturbing material while at the same time focusing on an external stimulus (usually therapist directed bilateral eye movements, hand tapping, sounds)

111 111 Pharmacotherapy Strongest evidence o Specific serotonin reuptake inhibitors (SSRI’s) o Venlafaxine Many drugs from a wide range of classes have been studied in PTSD Little evidence for their use except as adjunctive treatment Antipsychotics often prescribed in military settings

112 112 A Point of Caution Little evidence to support the use of Critical Incident Debriefing in the prevention of PTSD Debriefing in heterogeneous groups may actually increase the risk of PTSD by re- traumatizing survivors who are not prepared to be re-exposed to horrific memories

113 113 Barriers To Treatment Treatment beliefs not addressed Fears of failure and fears of success Labels and stereotypes Avoidance Realistic concerns

114 114 A National Demonstration Project Citizen Soldier Support Program Directory of BH Providers o Validated licenses o Lists special interests and relevant training o Specifies insurances accepted including TRICARE o Google mapping to site of care

115 115 Traumatic brain injury (tbi)

116 116 TBI Not considered a “behavioral health” disorder Included in this training o Signature disorder of OEF/OIF as is PTSD o Often co-occurring with PTSD o Sometimes difficult to distinguish the two

117 117 TBI Ask about o Proximity to explosions o Thrown from a vehicle o Lost consciousness (knocked out or down)  For how long  Have symptoms of concussion after the blast (dizziness, headache, irritability, etc.)

118 118 TBI Current symptoms o Headaches o Dizziness o Memory problems o Balance problems o Ringing in ears o Irritability o Sleep problems o Fatigue o Change in ability to smell or taste o Sensitivity to sound or light o Trouble with  Concentration  Attention  Thinking

119 119 TBI May co-exist with PTSD One might be mistaken for the other Screen with o The 3-Question Screening Tool o Developed by the Defense and Veterans Brain Injury Center (DVBIC)

120 120 Triaging TBI Consider consultation – Rehabilitative Medical Specialist – Neurologist – Speech Pathologist – Audiologist – Vision Assessment

121 121 Combat/operational stress reactions and injuries

122 122 Combat stress injury Happens to a person (not chosen) Involves loss of normal integrity Causes loss of function at least temporarily Provokes predictable self-protective or healing symptoms Cannot be undone (though it usually heals) Capt. Bill Nash in Combat Stress Injury

123 123 Combat stress injury - Trauma Participant in or witness to event(s) involving Horror Feelings that you or someone close to you will die Helpless Powerless Capt. Bill Nash in Combat Stress Injury

124 124 Combat stress injury - Discomfort/fatigue Accumulation of stress over time Environmental hardships Capt. Bill Nash in Combat Stress Injury

125 125 Combat stress injury - Grief Loss of people cared about In Iraq and at home Capt. Bill Nash in Combat Stress Injury

126 126 Beyond diagnosis Problems of returning combat veterans and families functional not clinical o Work Stress/Unemployment o Educational/Training Need o Housing Needs  Homeless  Functionally homeless

127 127 Beyond diagnosis Problems of returning combat veterans and families functional not clinical o Financial and/or Legal Problems o Family Issues  Lack of Social Support  Estrangement  Family Breakup  Kids in trouble

128 128 Beyond PTSD and TBI diagnosis Psychological trauma may…. o Surface indirectly - exacerbation of chronic physical ailments  Shortness of breath in an asthmatic  Racing heart in a person with congestive heart failure)

129 129 Beyond PTSD and TBI diagnosis Psychological trauma may…. o Be expressed in new somatic symptoms  Headaches  Abdominal pain Present as new or exacerbated substance abuse Lie veiled behind vague complaints of poor energy, poor sleep or malaise

130 130 Common Themes/ Presenting Problems Marriage, relationship problems Medical issues Financial hardships Endless questions from family and friends Guilt, shame, anger Lack of structure

131 131 Common Themes/ Presenting Problems Feelings of isolation Nightmares, sleeplessness Lack of motivation Forgetfulness Anger Feeling irritable, anxious, “on edge”

132 132 Public Health Model Most war fighters/veterans do not develop a mental illness All war fighters/veterans and their families face important readjustment issues

133 133 “He’s been to war…and war is a place where you lose who you were. And then if you get back, you don’t have any idea who you are, and you’re scared to death of what you might become” November 27, 2012 episode of TV show Parenthood (In reference to a man who served 2 tours of duty in Iraq. Spoken to his girlfriend by her grandfather, a veteran of Vietnam)

134 134 Public Health Model Public health - population-based approach o Less about making diagnoses o More about helping individuals and families retain a healthy balance despite the stress of deployment

135 135 Public Health Model Incorporates Recovery Model and other principles President’s “Freedom Commission on Mental Health” o There is a difference between having a problem and being disabled Public health approach requires o Progressively engaging o Phase-appropriate integration of services

136 136 Public Health Model Treatment programs must o Be driven by the needs of the Service Member/veteran and his/her family o Not by DoD and VA traditions o Meet prospective users where they live

137 137 Public Health Model Treatment programs must o Not wait for them to find their way to the right mix of our services o Increase access and reduce stigma

138 138 Take home point Post deployment mental health problems are more FUNCTIONAL than CLINICAL

139 139 When a Service Member is wounded, a family is wounded Dr. Michael Wagner Director, Family Assistance Center Walter Reed Army Medical Center 2004

140 140 Perceived Family Support: A Key Predictor of Resilience Social support (including perceived family support) was the most important protective factor against development of PTSD among male and female Vietnam Veterans in the NVVRS King, D. W., King, L. A., Fairbank, J. A., Keane, T. M., & Adams, G. (1998). Resilience-recovery factors in posttraumatic stress disorder among female and male Vietnam veterans: Hardiness, postwar social support, and additional stressful life events. Journal of Personality and Social Psychology, 74,

141 141 Combat/operational stress Affects family members o Sympathy o Depression o Grief o Fear and worry o Loss of sleep o Avoidance o Guilt and shame o Anger o Drug and alcohol abuse o Health problems

142 142 Deployment cycle Pre-deployment Deployment Post-deployment

143 143 Assessment – Pre-Deployment Pre-deployment o Deployment orders can change/be revised o Worry about safety of loved ones and themselves o “Activities of Daily Living”  Finances  Health care  Child care  Pets

144 144 Assessment – Pre-Deployment Pre-deployment o Single Parents o Reservists  Jobs  Houses  Family members o Preparing to not come home

145 145 Assessment - Deployment Deployment stress in theater and at home – Messages you get Messages you don’t get Value of instant communication and disadvantages – News Coverage – Internet Facebook/Social Networking for good and ill

146 146 Assessment – post deployment Post Deployment – Garrison life Rules, rules, rules Excess adrenaline and distractibility

147 147 Assessment – post deployment Post Deployment – Readjustment to family life EVERYONE changed/Fifth Wheel Effect Perceived lack of control over family The complexity & pressures of daily life Missing Buddies – AD vs RC Turning in weapons /protective gear

148 148 Erin’s Rules of Thumb for Successful Deployment Reunions Rule #1: Beware the fairytale! – Don’t expect life to be perfect. Don’t set yourself or your significant others up for disappointment. Rule #2: Make realistic expectations and be patient. – Instead of expecting the fairytale, plan for a good reunion, including things to say, do, and talk about. – Give yourselves time to adjust to being back together. Both parties have changed.

149 149 Erin’s Rules of Thumb for Successful Deployment Reunions Rule #3: Avoid “pissing contests!” – Both parties had it bad. No one wins when partners fight over who did more work and who suffered the most. – It only takes one person to stop this contest. Rule #4: Use good timing! – A basic rule of communication is: if you want someone to hear what you are saying, say it when they are listening.

150 150 Erin’s Rules of Thumb for Successful Deployment Reunions Rule #5: Avoid the “stupid questions:” – Did you kill anyone? – How was it? – Are you glad to be home? – Any variation of: Was it hot?, Did you see any camels?, Did you talk to any Iraqis/ Afghanis? Rule #6: Thank each other! – Don’t forget who kept the house standing while the other was fighting for the freedom to have it.

151 151 Positive aspects of deployment Foster maturity Encourage independence Strengthen family bonds

152 152 Key Question Ask EACH patient this question… Are you or a close family member a current or former service member?

153 153 Assessment Questions Why did you join the ( branch of service )? What did you hope to accomplish? Tell me about any combat tours o How many? o When? o Where? o MOS? o Intensity in combat?

154 154 Assessment Questions Were you satisfied with training and preparation you received? Were you satisfied with leadership and equipment while deployed? How do family members feel about the military? About the separations?

155 155 Assessment Questions Primary Care PTSD Screen (PC-PTSD) Combat Exposure Scale (CES) PTSD Checklist – Civilian Version (PCL-C) Trauma Symptom Checklist - 40 (TSC-40) 3 Question DVBIC TBI Screening Tool Other measures as appropriate

156 156 Women’s issues

157 157 Integration of Women in Military 1993: Congress opens combat ships to women : First female pilots in all branches 2005: First woman awarded the Silver Star for combat action. 2008: First woman promoted to rank of 4-star General (Army).

158 158 Integration of Women in Military Women still restricted from following warfare specialties (with exceptions): Air Force o Para-rescue o Combat Controllers Army o Infantry o Armor o Artillery o Special Forces o Combat Engineering

159 159 Integration of Women in Military Women still restricted from following warfare specialties (with exceptions): Marine Corps: o Infantry o Armor o Artillery o Combat Engineering o Reconnaissance o Riverine Assault Craft Navy o Submarines o SEALs

160 160 Mental Health Diagnoses Among OEF/OIF Veterans By Gender

161 161 Possible Sources of Gender Differences in PTSD Presentation AND Diagnosis Women o May be exposed to different range and intensity of stressors o Have different rules about their involvement in combat o More research needs to be done to compare men and women on type, number, length, frequency, and intensity of deployments and/or traumatic experiences

162 162 Possible Sources of Gender Differences in PTSD Presentation AND Diagnosis Factors that affect differing rates of PTSD diagnosis in men vs. women o Race o Ethnicity o Age o Rank differences

163 163 Possible Sources of Gender Differences in PTSD Presentation AND Diagnosis When and how men and women present mental health issues May affect apparent differences between men and women Career impact of reporting a mental health problem may be different for women than for men

164 164 Possible Sources of Gender Differences in PTSD Presentation AND Diagnosis Clinicians may have gender-specific biases o Less likely diagnosis PTSD in women? o More likely diagnosis personality disorder in women? Women OEF/OIF veterans have different tendencies to seek help outside of DoD/VA than men

165 165 “I don’t think there’s enough emphasis on women coming home. Like a lot of the videos they show and things they talk about, they all show men’s problems…they don’t show women coming home that don’t look as good as they used to or that their hair is all falling out or anything. It’s all about men. Female Veteran

166 166 Conclusions Men and Women are equal but not the same There is a clear need for gender-specific approaches to the readjustment and health of Women Veterans

167 167 Questions?

168 minute break

169 169 Department of Veterans Affairs (VA) overview

170 170 Care access points 88 comprehensive home-care programs 4 DoD/VA Polytrauma Centers My HealtheVet 21 Veterans Integrated Service Networks (VISNs)

171 171 VA Overview 23.4 million veterans currently alive Nearly 3/4 served during a war or an official period of conflict Women 8% of all veterans (roughly 1.8 million women veterans) Make the Connection GnQodWBoAAg

172 172 VA Overview About 1/4 US population eligible for VA benefits or services o Veterans o Family member of veterans Provides health care o 5.5 million veterans o Roughly 1 in 5 veterans About 10% of VA users are women veterans

173 173 VA Overview VA has 153 medical centers o at least one in each state o Puerto Rico, District of Columbia 909 ambulatory care and community-based outpatient clinics 47 residential rehabilitation treatment programs 232 Veterans Centers

174 174 Questions?

175 175 Tricare presentation

176 176 Call to action

177 177 Review of take home points… No wrong door to enter to seek help Know something about military culture Post deployment MH is not just PTSD Issues of service members & family are more functional vs. clinical Ask all patients about military service

178 178 Post deployment MH problems Now that you’ve found them…what to do o Be aware of services available through DOD, VA, and other organizations o Look for ways to make your office/agency environment ‘military friendly’ o Ask about military service on your intake form

179 179 Post deployment MH problems Now that you’ve found them…what to do o When a military family member comes to you for care:  Ask them why they came to see you  Then ask what else they would like to talk about  Observe body language and energy level  Listen to what they do say but also to what they don’t say

180 180 Post deployment MH problems Now that you’ve found them…what to do o Key - develop a supportive and collaborative therapeutic alliance with the patient and with his/her significant others

181 181 Work at State/Community Levels May enhance access for service members, veterans and family members about seeking help within the DoD/VA continuum May enhance quality of services veterans and family members receive in community

182 182 Work at State/Community Levels National Guard programs organized by state Each state has its own veterans outreach program Builds a system of interagency communication/coordination Serves well at times of disaster

183 183 Questions?

184 184 Key question #1 Ask each patient this question… Are you or is anyone in your family a current or former service member?

185 185 Key question #2 Ask yourself this question… Is my practice prepared to identify or treat post deployment problems?

186 186 Web-Based Resources Collaborative development of self-help resources with assessment, tailored feedback, intervention and self-monitoring Information clearinghouses and regional resources

187 187

188 188 Programs on AfterDeployment.org

189 189

190 190 Finally - just to prove that camouflage works…

191 191 Questions?

192 192 Boots on the ground [Speaker’s name] [Speaker’s affiliation]

193 193 evaluations


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