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Military Culture & Treatment - 101 GAMFT Chapter Workshop three hour workshop to overview the culture of military families, effective treatments, and sources.

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Presentation on theme: "Military Culture & Treatment - 101 GAMFT Chapter Workshop three hour workshop to overview the culture of military families, effective treatments, and sources."— Presentation transcript:

1 Military Culture & Treatment GAMFT Chapter Workshop three hour workshop to overview the culture of military families, effective treatments, and sources of support 1 Blaine Everson Alan Baroody Peter McCall

2 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 2

3 Agenda 3 TopicDurationComments Intro and Opening10 Presenters, Goals and Agenda Oath of Enlistment CareForTheTroops.org20 Overview Mission / Role of Clinicians Show Key Website Components for Clinicians Review Enrollment and Marketing Assistance En’visioning’ the Issues40 Brothers at War Trailer Audience Discussion Fraser Center Perspective Military Culture35 Jargon and Organization Deployment/Family Life Cycles Stressors Clinical Treatment Info45 Demographics PTSD-Signs and Treatments Family Therapy Approaches Case Study Insurance Considerations15 Insurance Ctr. Q&A and Closing15 On-Going Discussion Handout – A0 …..an Example

4 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. 4 Handout – A1 NOTE: the 3 dots … = it’s a break point, repeat after me.

5 Agenda 5 TopicDurationComments Intro and Opening10 Presenters, Goals and Agenda Oath of Enlistment CareForTheTroops.org20 Overview Mission / Role of Clinicians Show Key Website Components for Clinicians Review Enrollment and Marketing Assistance En’visioning’ the Issues40 Brothers at War Trailer Audience Discussion Fraser Center Perspective Military Culture35 Jargon and Organization Deployment/Family Life Cycles Stressors Clinical Treatment Info45 Demographics PTSD-Signs and Treatments Family Therapy Approaches Case Study Insurance Considerations15 Insurance Ctr. Q&A and Closing15 On-Going Discussion

6 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. 6

7 Organization 7 Current Board of Directors: PresidentRev Robert Certain, Rector, Episcopal Church of St Peter and St Paul (USAF) Exec DirectorPeter McCall (USArmy) MemberBill Harrison, Partner, Mozley, Finlayson & Loggins LLP (USAF) MemberWilliam Matson, Exec Director, Pathways Community Network, Atlanta, GA MemberAlan Baroody, Exec Director, Fraser Counseling Center, Hinesville, GA MemberJoseph 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 501c3 status has already been approved by the IRS

8 Causes for Concern 8 1.Multiple deployments are common causing stress and family attachment issues 2.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 3.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 4.Military Sexual Trauma (MST) is running at 16%-23% 5.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) 6.DoD and VA facilities are stretched … the Aug 2009 VA claims backlog is 900,000 7.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 8.Other mental health, marriage, and family problems often occur with or leading up to PTSD requiring attention so they don’t get worse 9.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

9 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 9

10 Approach Person in need of support Spouse SiblingsGrandparents Parents Children 10 Military Member

11 11 The next set of charts provide a simulation of using the website with clinicians in mindwww.CareForTheTroops.org

12 This is the top of the Home Page

13 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

14 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.

15 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.

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

17 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

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

19 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.

20 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.

21 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.

22 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.

23 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.

24 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 (www.emdrhap.org ) will conduct Weekend 1 (Part I) training Friday through Sunday, Jan 15 th to 17 th in Athens, Georgia. The training facilities used in Athens are at Milledge Avenue Baptist Church, 598 South Milledge Avenue, Athens, GA www.emdrhap.org 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 (www.samaritannega.org ), GAMFT-The Georgia Association for Marriage and Family Therapy (www.gamft.org ), and The CareForTheTroops, Inc. non-profit organization (www.CareForTheTroops.org ).www.samaritannega.orgwww.gamft.orgwww.CareForTheTroops.org 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.www.emdrhap.org/training/toregister/listEvents.php SCHOLARSHIPS: Apply for the CareForTheTroops scholarship at Download the Application Document, complete and or mail it to the address shown on the document.www.careforthetroops.org/emdrevent.php 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: 1.Practice in Georgia 2.Attend and successfully complete both Part I and Part II EMDR training by HAP 3.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 4.Be willing to work with military clients and their extended family members 5.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 6.Attend and complete Part II within 12 months of completing Part I 7.Be responsible for all other costs, fees, and expenses associated with the training weekends.

25 Chapter Workshops Military Culture 101-Clinical Treatment Issues 25 NOTE: Check with your local GAMFT Chapter and also with the web site for changes and updates. ChapterChair / Contact PersonCo-PresenterDateTimeLocation CoastalKathryn Klock-PowellAlanNov 6th10am-1pmHinesville MiddleBruce ConnAlanNov13th10:30-1:30Macon NortheastDavid Fowler/Dennis CainBlaineNov 20th11am - 2pmAthens SouthJeff BickersBlaineNov 21st9am - noonValdosta SouthwestElaine Gurly/Lori Ann LandryBlaineJan 8th1pm - 4pmAlbany Metro AtlLicia FreemanAlanJan 15thnoon - 3:30Decatur NorthwestJoan RobinsonBlaineJan 22nd11:30 - 3:30Sandy Springs EastJohn Hill/Sid GatesBlaineFeb 5th8:30 - noonAugusta Westnone TBD Columbus

26 Final Comments 26 Help For You 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?

27 Agenda 27 TopicDurationComments Intro and Opening10 Presenters, Goals and Agenda Oath of Enlistment CareForTheTroops.org20 Overview Mission / Role of Clinicians Show Key Website Components for Clinicians Review Enrollment and Marketing Assistance En’visioning’ the Issues40 Brothers at War Trailer Audience Discussion Fraser Center Perspective Military Culture35 Jargon and Organization Deployment/Family Life Cycles Stressors Clinical Treatment Info45 Demographics PTSD-Signs and Treatments Family Therapy Approaches Case Study Insurance Considerations15 Insurance Ctr. Q&A and Closing15 On-Going Discussion

28 Brothers At War Film Clip 28

29 Fraser Center Experience Film Clip Comments 29 1.The adrenaline high, or adrenaline addiction – “It’s like the best!” 2.Personality changes. No one returns the same from combat or lengthy deployments. 3.Generalized and undifferentiated anger: short fuse, loss of patience, (increase in domestic violence and child abuse). “Now when he gets mad, he just screams.” 4.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.” 5.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.” 6.Survivor guilt and loss: “It hurts a lot to lose fellow soldiers.” 7.Family of origin issues: “I want to make my Dad proud.” 8.Fantasy verses reality. (living on dreams and through TV series) 9.Emotional numbing: “He used to be sensitive. Now, he shows no emotion and wants me to be the same way.” 10. The ramifications of “sacrificing for family” and the sacrifices made by families. THERAPEUTIC ISSUES OBSERVED IN THE CLIPS FROM “BROTHERS AT WAR”:

30 Fraser Center Experience 30 THE FRASER CENTER SETTING: 1.Clients include Veterans, Active Duty Soldiers, and Military Dependents 2.Clients primarily from FT Stewart (3 rd 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: 1.The children of military families are often the first to be brought in for therapy – secondary trauma. “Is daddy going to die?” 2.The length, number, and frequency of deployments decreases family resiliency upon re-deployment (returning home from a deployment). 3.The number of engagements “outside the wire” increases the likelihood of Combat Stress Symptoms (transient, acute, & PTSD). 4.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.” 5.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. HANDOUT

31 Fraser Center Experience 31 GENERAL OBSERVATIONS (continued…): 6.While deployed, soldiers also fight on the homefront via internet and cell phone with their spouses. Homefront stressors may be higher than combat stressors. 7.Viewing internet pornography and internet sex chat is becoming a norm for deployment and effects marriages upon return. 8.Many soldiers maintain their unit bonds following re-deployment to the detriment of their family bonds. 9.Returning soldiers rarely talk with spouses about combat experiences. 10.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. 11.Illegal/prescription drugs and alcohol are prevalent and are used as common coping mechanism by soldiers (deployed and at home) and by their spouses. 12.While deployed, many soldiers are constantly sleep deprived and share each others medications (i.e. ambient, provigil). Hooked on Energy Drinks. 13.The suicide rate of re-deployed) soldiers and spouses is on the increase. 14.Most soldiers know of at least one other soldier in their unit who “ate his gun” or was blown up by an IED. 15.There is a high incidence of rape and sexual molestation of deployed female soldiers. 16.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. HANDOUT

32 Fraser Center Experience 32 GENERAL OBSERVATIONS (continued…): 17.Home is no longer a safe place to live. Many now carry weapons when not on military installations at home. 18.The vast majority of returning troops are filled with undifferentiated anger and a short fuse. 19.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. 20.A primary therapeutic issue is the soldier’s inability to re-connect emotionally with spouse and children. (exacerbated by anger and lack of patience). 21.Chaplains are the mental and spiritual health “first responders” at home and in the combat arena. 22.Special attention needs to be given to National Guard and Reserve Chaplains. There is a high incidence of their leaving the ministry. 23.Both spouse and soldier recognize that the soldier is “changed” by combat deployment. 24.Important family milestones and transitions have been missed. 25.Soldiers may pursue activities which replicate the adrenaline rush of combat and sometimes re- enlist without spousal consultation in order to maintain the rush. 26.Spousal dissatisfaction and resentment: power control issues upon redeployment. “I didn’t sign up for this.” The military spouse sacrifices education and career 27.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. HANDOUT

33 Fraser Center Experience 33 GENERAL OBSERVATIONS (continued…): 28.Due to young age, immaturity, and low educational levels, many soldiers and spouses have poor life skills: money management, parenting, communication, etc. 29.Some soldiers return to empty bank accounts and houses. 30.The military has greatly increased mental health support resources at home and abroad. The Army recognizes that it is still not adequate. 31.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. 32.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. HANDOUT

34 Chris Warner’s Sources of Stress 34 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 2007; 172:  >> Number of Months

35 Agenda 35 TopicDurationComments Intro and Opening10 Presenters, Goals and Agenda Oath of Enlistment CareForTheTroops.org20 Overview Mission / Role of Clinicians Show Key Website Components for Clinicians Review Enrollment and Marketing Assistance En’visioning’ the Issues40 Brothers at War Trailer Audience Discussion Fraser Center Perspective Military Culture35 Jargon and Organization Deployment/Family Life Cycles Stressors Clinical Treatment Info45 Demographics PTSD-Signs and Treatments Family Therapy Approaches Case Study Insurance Considerations15 Insurance Ctr. Q&A and Closing15 On-Going Discussion

36 Intake Scenario Your New Client 20 year old male SPC in USANG, 4month Post-Deployment from OIF Gunner from 1 st 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 36

37 37 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 Culture is associated with a social system and unique to a given system. Handout – A2

38 Language Barriers for Civilians Glossary of Military Terms and Acronyms Military Cultural Competence 38 Handout – A3_1, A3_2, A3_3, A3_4 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-O10Enlisted Ranks; Officer Ranks SPC Specialist, rank of E4, often referred to a “Spec 4” First SGTFirst Sergeant, rank of E7, lead enlisted person in a company. It and SSG, Staff Sergeant are key leadership ranks with lots of job pressures NCONon-Commissioned Officer, ranks E6 through E9 IEDsImprovised Explosive Devices FOBForward Operating Base SandboxIraq and Afghanistan Down RangeDeployed to anyplace where there is shooting. Outside the WireLeave the safety of the “enclosed” military base (FOB) Taking the Pack OffLeaving mentally and physically from combat Top CoverMaking sure the boss looks good

39 39 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

40 Branches of the Military 40 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 Handout – A4

41 Military Branch Structures Example: U.S. Army 41 Handout – B1, B2, B3 Core Values 84% 2% 14% 84% 2% 14%

42 42 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

43 Reserve and National Guard Units vs Regular Army 43 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 Handout – C1 Reserve / GuardRegular

44 44 The next few charts provide some background of this war that might help you better understand your client and their presenting story and issues

45 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 45

46 OIF/OEF - Statistics 46 As of 12/1/ M 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)

47 OIF/OEF - Profile 47 NG and Reserve did not expect deployment (reminder: GA is 6 th largest NG state) Multiple deployments is the norm 2008 Rand Study indicates: 53% of those that need treatment sought Mental Health treatment in ‘ % 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 Handout – C2

48 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 48 OIF/OEF - More Statistics Handout – C3

49 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: )http://www.gao.gov/new.items/d09899t.pdf 49 OIF/OEF – and some more Statistics

50 OEF / OIF Experience - Summary Indirect threats – not so much direct assaults and attacks IEDs, car bombs RPG, snipers Suicide bombings 2. Powerlessness threat is indiscriminate not dependent upon skill or mastery relationship between loss of control and PTSD 3.This generation’s war 1 st 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

51 51 The next several charts will cover life within the military family and clinical treatment considerations

52 52 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 The Military Deployment Cycle … or The Military Family Life Cycle (Original View)

53 53 Military Family Life Cycle (…Multiple Deployment View) Transitions are often marked by crisis points in the family life cycle. -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 Return & Reunion Relocation Families w/ teens & possibly steps ETS or Retire

54 Military Family At-Risk Factors 54 1.Frequent Relocation 3.3 years average 2.Previous Deployments 87% 3.Longer Separations 7.3 month average 4.Larger Families 42% ≥ 3 children 5.Younger Mothers 26.5 median age 6.Blended Families 31% step-parents 7.Education21% w/o HS diploma 8.Working Outside Home 44% 9.Median Income < $30,000 (34%) Quality of Life Among U.S. Army Spouses During OIF, Dissertation, 2005, Dr. Blaine Everson

55 55 Separation 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. HANDOUT

56 56 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.) Handout – D1 HANDOUT

57 57 Relocation 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 HANDOUT

58 58 Waiting Spouse of Service Member Length & Number of Deployments Children’s Well-being Parenting Strains – # & ages of kids Work/Life Balance Relational Quality w/ Deployed Spouse Fear of Injury or Death Of Service Member Family Finances Deployment Related Stressors for Spouses HANDOUT

59 59 Deployment Related Stressors for Spouses STRESSORPOSITIVE RESPONSE Feeling Lonely90.0% (271) Having Problems Communicating with my Spouse61.2% (184) Experiencing the Death of a Close Friend or Relative33.2% (100) Managing and Maintaining Family/Personal Finances47.2% (142) Personal/Family Health Issues43.2% (130) Being Pregnant during the Deployment26.9% (81) Raising a Young Child while my Spouse is not Present63.2% (190) Childcare39.9% (120) Managing and Maintaining the Upkeep of my Home49.1% (148) Having Reliable Transportation19.9% (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 Spouse96.4% (290) Warner CH, Appenzeller GN, Warner CM, Grieger T. “Psychological Effects of Deployments on Military Families” Psychiatric Annals 2009; 14:

60 Summary of Stressors 60 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

61 61 …a closing thought on the Military Culture they believe they are getting a square deal “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

62 Agenda 62 TopicDurationComments Intro and Opening10 Presenters, Goals and Agenda Oath of Enlistment CareForTheTroops.org20 Overview Mission / Role of Clinicians Show Key Website Components for Clinicians Review Enrollment and Marketing Assistance En’visioning’ the Issues40 Brothers at War Trailer Audience Discussion Fraser Center Perspective Military Culture35 Jargon and Organization Deployment/Family Life Cycles Stressors Clinical Treatment Info45 Demographics PTSD-Signs and Treatments Family Therapy Approaches Case Study Insurance Considerations15 Insurance Ctr. Q&A and Closing15 On-Going Discussion

63 Demographics - AGE 63 Enlisted Officers

64 Demographics - Young Adults in the Military % 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. 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

65 Demographics – GENDER AND RANK 65 Women represent approximately 15% of the military force. Representation of women is slightly lower for Senior Enlisted and General Officers.

66 Demographics – MARITAL STATUS 66 RED = Civilian BLUE = Total DOD Marital Status Divorce Trends AC=Active Duty RC=Reserves/Guard

67 Demographics – Suicide 67 Two dominant factors: 1.Financial Stress 2.Concerns with Intimate Partners The 2008 overall Army rate was 24/100K, a 33% increase 70% increase reported from 2005 to 2008 Handout – E1

68 Psychological Injury Continuum: ASR to COSR to PTSD 68 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”

69 SIGNS / SYMPTOMS OF (COMBAT) PTSD 69 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

70 PTSD: Cues or Triggers 70 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)

71 PTSD: non-DSM 71 What does PTSD feel like – What do you “hear” in therapy 1.Sense of immediacy (“happening right now”) 2.Re-experiencing of original memories and sensory impressions 3.Involuntary 4.Guilt Rational or irrational Understanding atrocities “Survivor Guilt”, also guilt for leaving, being intact 5.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 6.Other Feelings Anger at Government Mistrust of Authority Desire to return to the war zone Damage to spirituality Handout – F1, F2

72 TBI: Traumatic Brain Injury 72 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

73 MST: Military Sexual Trauma Rand Study reported 16% - 23% experienced MST 2.Reported MST were 1,700 in 2004 and 2,947 in VA indicates that 1 in 4 female veterans using the VA reported at least one MST 4.The VA Day Hospital Program estimates 3-5 female referrals have MST 5.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 Handout – C2

74 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” 74 VA Opinion of PTSD Interventions Handout – G1, H1

75 … 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 2007 and The document revealed there was also a spike in the number of service members' children hospitalized for mental health reasons

76 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, Handout – H2

77 Intake Scenario – Revisit and Review 77 Your New Client 20 year old male33% of Reserves are in the age range of SPC in USANG, 4 month Post-deployment from OIFSPC means rank is E4, not yet an NCO USANG means Guard just back from Iraq(OIF) Gunner from 1 st BCT 3ID1 st BCT – First Brigade Combat Team; 3ID=3 rd Infantry Division; he probably saw up-close, ground combat “on edge”, “pissed off”, difficulty sleepingThese 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 irritabilityFirst 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 discordEnlisted 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.

78 Agenda 78 TopicDurationComments Intro and Opening10 Presenters, Goals and Agenda Oath of Enlistment CareForTheTroops.org20 Overview Mission / Role of Clinicians Show Key Website Components for Clinicians Review Enrollment and Marketing Assistance En’visioning’ the Issues40 Brothers at War Trailer Audience Discussion Fraser Center Perspective Military Culture35 Jargon and Organization Deployment/Family Life Cycles Stressors Clinical Treatment Info45 Demographics PTSD-Signs and Treatments Family Therapy Approaches Case Study Insurance Considerations15 Insurance Ctr. Q&A and Closing15 On-Going Discussion

79 TriCare - Ceridian 79 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 Handout – I1, J1, J2, K1

80 Agenda 80 TopicDurationComments Intro and Opening10 Presenters, Goals and Agenda Oath of Enlistment CareForTheTroops.org20 Overview Mission / Role of Clinicians Show Key Website Components for Clinicians Review Enrollment and Marketing Assistance En’visioning’ the Issues40 Brothers at War Trailer Audience Discussion Fraser Center Perspective Military Culture35 Jargon and Organization Deployment/Family Life Cycles Stressors Clinical Treatment Info45 Demographics PTSD-Signs and Treatments Family Therapy Approaches Case Study Insurance Considerations15 Insurance Ctr. Q&A and Closing15 On-Going Discussion

81 What This Presentation WAS About 81 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

82 In Closing…Consider These Next Steps 82 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 Handout – L1, M1


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