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Challenges in War and At Home Steve Scruggs, Psy.D. OEF/OIF Readjustment Program Team Leader Oklahoma City VA Medical Center Volunteer Clinical Assistant.

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Presentation on theme: "Challenges in War and At Home Steve Scruggs, Psy.D. OEF/OIF Readjustment Program Team Leader Oklahoma City VA Medical Center Volunteer Clinical Assistant."— Presentation transcript:

1 Challenges in War and At Home Steve Scruggs, Psy.D. OEF/OIF Readjustment Program Team Leader Oklahoma City VA Medical Center Volunteer Clinical Assistant Professor, OUHSC

2 Overview  Military culture  The making of a Warrior  Realities of combat  Readjustment problems  Successful transition

3 What Is Cultural Competency?   Cultural and linguistic competence is a set of congruent behaviors, attitudes, and policies that come together in a system, agency, or among professionals that enables effective work in cross-cultural situations. US Dept of Health and Human Services, Office of Minority Health

4 Culture/Competence   Culture refers to integrated patterns of human behavior that include the language, thoughts, communications, actions, customs, beliefs, values, and institutions of racial, ethnic, religious, or social groups.   Competence implies having the capacity to function effectively as an individual and an organization within the context of the cultural beliefs, behaviors, and needs presented by consumers and their communities. ( Adapted from Cross, 1989).

5 What does military culture value?  Obedience  Discipline  Structure (including hierarchy)  Toughness (mental and physical)  Training/Following SOPs (standard operating procedures)  Completing the mission regardless of hardships  Up or out

6 Why do people join? Idealistic I want to serve my country. I want to defend America. I want to lead people in battle. I want to be the best I can be. I want to test myself. Practical I’m not ready for college-don’t know. what I want to do. I want college money. I want to learn a skill. I was homeless and had no where to go. I thought it would help me shape up.

7 Enlisted/Officer 85%  E-1-3 Worker  E-4 Journeyman  Non- Commissioned Officers (NCO)  E-5-6 Mid Level  E-7-8 Senior NCO  E-9 Top 1% 15%  O-1-2 Platoon  O-3 Company  O-4-5 Mid level  O-6+ Senior leader Warrant Officers 1-4

8 Preparation for war  Intention exposure to stress, in a gradual, planned way  High expectations/commitment required  Training to promote “muscle memory”  Expectation is “You are going to war"  The mission is worth risking your life for…

9 The Role of Aggression  When faced with a threat (fight/flight) FIGHT! FIGHT!  Starts the first day of basic training  Used by role models (Drill Instructors, leaders)  Used to “motivate” troops  Learn to either shut up and do what you are told or get in someone’s face  Go immediately to aggression if any “push back”

10 The Development of a Warrior  Basic training  Military Occupation Specialty (MOS) training (AIT, Tech School)  Assignment to a unit  Learning the job in the “real” military  Pre-deployment training, with increased work hours and higher expectations  Deployment

11 Realities of Combat  Long hours  Constant vigilance (no battle lines to get behind)  The enemy intentionally seeks to disrupt (mortars at night, during chow)  Mission may be unclear (occupying force)  Ambiguous situations are common (friend or foe?)  Rules of Engagement (ROEs) may change arbitrarily

12 A Soldier’s Perspective  Constantly guarded, watchful and alert  Wired and tired  Increasingly gruff, impatient  Strong ties, strong dislikes  Worry about home or emotional distancing  Emotional numbing Do your job no matter what happens Do your job no matter what happens “Shut up and drive on…” “Shut up and drive on…”

13 Realities of Combat  When a traumatic event occurs, the mission is still the priority  Processing emotions related to traumatic events is often delayed or avoided  Numbing of emotions is adaptive (short term)  Distancing from others is adaptive (short term)

14 A Soldier’s Perspective…  Often, there is a disillusionment of: Experience Experience Military organization/Leadership Military organization/Leadership Self Self

15 Change in Outlook  Changes are life saving  Changes become “the new normal”  Changes may be celebrated I need this to be safe I need this to be safe Civilians are unprepared, stupid, naïve Civilians are unprepared, stupid, naïve  Reinforcing information is paid attention to or even sought out (news of drive by shooting, home invasions, robberies, mass shootings, etc.)

16 Return/Reunion  Honeymoon phase  Disappointment due to problems or unmet expectations  Others expect the soldier to quickly return to “normal”  Frustration builds  Expression of anger is more intense and not acceptable (like it was in theater of combat)

17 Common Readjustment Issues  Problems getting and staying asleep  Occasional nightmares  Constantly alert and guarded  Uncomfortable in crowded places  More gruff, irritable  More goal oriented (have problems relaxing)  Thinking about combat experiences (even when you don’t want to)

18 Why do sleep problems develop after combat and trauma? (Dr Rob Braese)   Unhealthy or erratic sleep patterns Night shift, long missions   Reinforcement Poor sleep is often rewarded (when you are alert and sleep light you feel safer) Good, sound sleep is often punished (attacks at night often make people feel vulnerable)

19 Why do sleep problems develop after combat and trauma?   New sleep habits More caffeine, drinking to fall asleep   Physical changes following deployment Pain and injuries make it hard to sleep   Mental changes following deployment Feeling "on edge“ Have to do a perimeter check if woken

20 Transition Difficulties  Continuously training for war  Routine/Structure  Constant vigilance  Constantly “hitting the gas”  When faced with fight/flight-FIGHT  Little training for peace  No routine, no external structure  Increased perception of threat  No strategies to “hit the brakes”  Reactions scare others

21 Differences with members of National Guard & Reservists  Many have established families and careers (that get disrupted by deployment)  Families do not live on military bases (with support)  Do not have regular contact with fellow soldiers after return (limited support system)

22 Substance Abuse Seal et al. (2011) Drug and Alcohol Dependence  About 1 in 10 had an alcohol use disorder and 1 in 20 had a drug use disorder  Risk Factors: Male sex, age under 25, never-married or divorced status, and greater combat exposure  Almost 3/4 also received a diagnosis of PTSD or depression.  Those with PTSD or depression were about 4x more likely to have a drug or alcohol problem.  Close to those seen in Vietnam Veterans.

23 Family Problems Sayers, Farrow, Ross & Olsin, 2009 Journal of Clinical Psychiatry  40.7% feeling like a guest in their house  25.0% children are not warm toward them or are afraid of them  37.2% not sure of their family role Among separated partners  53.7% shouting, pushing or shoving  27.6% partner is afraid of them N=199

24 Military Mindset/Academic Mindset  Functional  Practical-Get er’ Done  Subject Expert  Minimize Debate  Overcome Obstacles  Accomplish the Mission  Abstract  Thoughts and Ideas  Everyone’s opinion  Invite Discussion  Discussion Enhances  Embrace the Journey

25 War Zones Require a Unique Set of Skills & Behaviors James Monroe, Ed.D. Boston VA WAR ZONE SKILLS  Vigilance/Distrust  Chain of command  Mission Orientation  Act, then think  Numb or control emotions  Avoid closeness HOME SKILLS  Trust  Cooperation  Juggling Multiple Responsibilities  Think, then act  Express feelings  Create intimacy

26 Stress Injuries Occur When Stress Is Too Intense or Lasts Too Long CAPT W. Nash, USN  Adaptation – A gradual process – Can be traced over time – Individual remains in control – Reversible  Injury – May be more abrupt – A derailment, change in self – Individual loses control – Irreversible (though can heal)

27 Three Mechanisms of Stress Injury TRAUMATRAUMA An impact injury Due to events involving terror, horror, or helplessness GRIEFGRIEF A loss injury Due to the loss of people who are cared about FATIGUEFATIGUE A wear-and- tear injury Due to the accumulation of stress over time COMBAT / OPERATIONAL STRESS

28 Operational Stress Injuries Correlate with DSM-IV Diagnoses TRAUMATRAUMAGRIEFGRIEFFATIGUEFATIGUE Combat / Operational Stress PTSDPTSD AlcoholAlcohol DrugsDrugs DepressionDepressionAnxietyAnxietyAngerAnger Prepared by Capt. William Nash, MC, USN HQ, Marine Corps

29 Combat Stress PTSD Typical Reactions Mild/Moderate/Severe to Combat Experiences Combat Stress PTSD Typical Reactions Mild/Moderate/Severe to Combat Experiences

30 What Causes PTSD? Risk Factors  Intensity of trauma exposure  Frequency of trauma exposure  Killing  Prior traumatic events  Combat verses Combat Support  Poor Leadership  Lack of support (family, friends, etc.)  Context/Meaning  Transition (military to civilian life)  Avoidance of trauma related thoughts, memories or activities

31 What Causes PTSD? Protective Factors  Training  Experience (Habituation)  Unit cohesion/ leadership  Expectations  Sense of purpose in suffering of self and/or fellow service members  Support on return  Resilience

32 DSM-IV Criteria for Post Traumatic Stress Disorder (PTSD)?  Life threatening situation(s)  Strong psychological reaction, e.g. intense fear, helplessness, or horror  About 2/3 of combat veterans have at least one situation that was very frightening, about 10-20% have PTSD

33 DSM-IV Criteria for PTSD

34 DSM-5 Criteria A  Exposure to actual or threatened death, serious injury or sexual violation. The exposure to actual or threatened death, serious injury or sexual violence in one or more of the ways:

35 DSM-5 Criterion A 1. Directly experiencing the traumatic event 2. Witnessing, in person, the event(s) as it occurred to others 3. Learning that the traumatic event occurred to a close family member or close friend. In cases of actual or threatened death of a family member or friend, the event(s) must have been violent or accidental

36 DSM-5 Criterion A 4. Experiences repeated or extreme exposure to aversive details of the traumatic event(s) (e.g. first responders collecting human remains; police officers repeatedly exposed to details of child abuse)  Note: Criterion 4A does not apply to exposure through electronic media, television, movies, or pictures, unless this exposure is work-related)

37 DSM-5 Criteria for PTSD  Four distinct diagnostic symptom clusters  Re-experiencing  Avoidance  Negative cognitions and mood  Arousal

38 Re-experiencing symptoms  Spontaneous memories of the traumatic event  Recurrent dreams related to it  Flashbacks or other intense or prolonged psychological distress

39 Avoidance Symptoms  Avoidance refers to intentionally pushing out of one’s mind: Distressing memories Distressing memories Thoughts Thoughts Feelings Feelings Avoiding external reminders of the trauma. Avoiding external reminders of the trauma.

40 Negative Thinking and Mood  Negative cognitions and mood represents myriad feelings: Persistent and distorted sense of blame of self or others Persistent and distorted sense of blame of self or others Estrangement from others Estrangement from others Markedly diminished interest in activities Markedly diminished interest in activities (Less common) An inability to remember key aspects of the event (Less common) An inability to remember key aspects of the event

41 Arousal Symptoms  Arousal is marked by: Aggressive, reckless or self-destructive behavior Aggressive, reckless or self-destructive behavior Sleep disturbances Sleep disturbances Hyper-vigilance or related problems. Hyper-vigilance or related problems.  Both “fight” and “flight” reactions

42 Mild TBI - PTSD: Overlapping Symptoms Scholten/Collins  Postconcussion Syndrome (PCS) Insomnia Insomnia Memory Problems Memory Problems Poor concentration Poor concentration Depression Depression Anxiety Anxiety Irritability Irritability Fatigue Fatigue Noise/light intolerance Noise/light intolerance Dizziness Dizziness Headache Headache  PTSD Insomnia Memory problems Poor concentration Depression Anxiety Irritability Re-experiencing Avoidance Emotional numbing

43 Successful Recovery  Overcoming barriers to treatment  Assessing the problem  Normalizing reactions  Engaging in/Completing Treatment  Aftercare, if needed

44 Barriers to treatment  Stigma  Worry about impact on military or civilian career  Worry about being seen as “crazy” or “paranoid”  Finding resources  Negotiating bureaucracies  Getting to treatment (low wage jobs, no paid time off)

45 Assessing the problem  Sometimes well meaning, caring people can push a combat veteran to talk…  Triggers either fear and distance or overexposure and feeling overwhelmed  “I thought talking about it was going to make me feel better, but instead…”

46 Normalizing reactions  You are not crazy  It makes sense to be watchful, guarded and alert (You are not paranoid)  You developed skills to help you adapt to a difficult and dangerous environment  These skills saved your life in war zone, so may seem essential to keep  These skills may not be working so well for you now

47 Engaging in treatment  This is often a big step  Outcome research for substance abuse shows equal improvement whether self referred or “a nudge from the judge”  Matching the person with a treatment that is acceptable to them is key

48 Treatment Options Symptom Management  More acceptable to many veterans  Easy to “try out”  Gives practical, “how to” skills and fast relief (e.g. with meds)  Best approach for limited symptoms (e.g. nightmares) Trauma Focused  Research strongly indicates best choice for improvement (with Evidenced-Based Psychotherapies)  Systematic  Time limited (usually 12-15 sessions)

49 Avoidance and Treatment  Since avoidance is a symptom of PTSD, the person will be tempted to cancel or not show for sessions  Completing treatment is difficult, especially if engaged in trauma focused treatment

50 Free Self Help Treatment Options  Afterdeployment.org Put together by the Dept of Defense and offers help for sleep, anger, PTSD, family issues, etc. Put together by the Dept of Defense and offers help for sleep, anger, PTSD, family issues, etc.  Maketheconnection.net Developed by the VA to help veterans connect with other veterans from the same era with similar issues. Developed by the VA to help veterans connect with other veterans from the same era with similar issues. Mobile App: PTSD Coach ncptsd.gov Mobile App: PTSD Coach ncptsd.gov

51 Learning Alternative Ways to Respond  Respond rather than react Changing “muscle memory” Changing “muscle memory”  Learn assertive versus passive or aggressive responses

52 What makes reactions better or worse?  Worse:  Looking at situations as if you are still in war zone  Insisting immediate improvement  Assuming that all alarming reactions are “true alarms”  Becoming a hermit  Better:  Reminding yourself you are not in a war zone  Staying in situations long enough to allow the alarm reaction to go down  Being around people even though it may feel awkward at first

53 Evidence-Based Therapies  Prolonged Exposure (PE) and Cognitive Processing Therapy (CPT) are treatments endorsed by the Veterans Administration as evidence-based treatments for PTSD.  EMDR is a promising treatment for PTSD.

54 A Qualification (Hoge-2010)  Effect sizes  Meds (59% recovery versus 39% placebo)  Psychotherapy (41% Exposure Therapy versus 29% Supportive (no specific)  CPT 3 versus 40%  Partial versus Complete Recovery from PTSD may be the case for many veterans

55 Prolonged Exposure (PE)  PE is a 10-15 session program that is done in 90 minute individual sessions. There is also considerable out of session “homework” involved.  15+ Randomized Controlled Trials/Many “Effectiveness” studies  The Veteran monitors symptoms by completing a symptom checklist (PCL-M).  www.ptsd.va.gov/public/pages/prolonged- exposure-therapy.asp www.ptsd.va.gov/public/pages/prolonged- exposure-therapy.asp www.ptsd.va.gov/public/pages/prolonged- exposure-therapy.asp

56 Prolonged Exposure (PE)  PE is a treatment that helps survivors of trauma to emotionally process their experiences.  Veterans are helped to confront their trauma memory. This is done to decrease their fear and anxiety. An example of this is the rider that is encouraged to “get back on the horse” after being thrown off. The rider overcomes the fear of being thrown again. This also prevents the fear from affecting other areas of his life.

57 PE – 2 main components  Imaginal exposure: Client recounts their worst traumatic event in detail repeatedly in session (and daily listens to tapes of themselves out of session)  In-vivo exposure: Client develops a hierarchy of avoided situations and exposes themselves to these situations for 30-45 minutes daily (starting with situations that are 30 on a 0-100 scale)

58 Resources for Therapist and Patient  Prolonged Exposure Therapy for PTSD: Emotional Processing of Traumatic Experiences Therapist Guide (Treatments That Work) Edna Foa, Elizabeth Hembree, Barbara Olaslov Rothbaum Edna FoaElizabeth HembreeBarbara Olaslov RothbaumEdna FoaElizabeth HembreeBarbara Olaslov Rothbaum  Reclaiming Your Life from a Traumatic Experience: A Prolonged Exposure Treatment Program Workbook (Treatments That Work) Barbara Rothbaum, Edna Foa, Elizabeth Hembree Barbara RothbaumEdna FoaElizabeth HembreeBarbara RothbaumEdna FoaElizabeth Hembree  PE app (ncptsd.gov)

59 Center for Deployment Psychology Course 113 (Online): Cognitive Processing Therapy (CPT) for PTSD in Veterans and Military Personnel National Center for PTSD The Course Cognitive Behavioral Psychotherapies for PTSD outlines the components and empirical support for two evidence-based treatments: Prolonged Exposure (PE) and Cognitive Processing Therapy (CPT).

60 Cognitive Processing Therapy (CPT)  12 Session structured psychotherapy approach  7 Randomized Controlled Trials/Many “Effectiveness” studies  Based on a social cognitive theory of PTSD that focuses on how the traumatic event(s) is construed and coped with by a person who is trying to regain a sense of mastery and control in his/her life  Based on the Cognitive Therapy Model developed by Aaron Beck, M.D.  Also utilizes therapeutic writing strategies developed by James Pennebaker, Ph.D.

61 Cognitive Processing Therapy  CPT is a 12 session program that can be done in individual (much research basis) or group sessions (emerging research basis).  There is also some out of session “homework” involved-writing about the trauma and writing about one’s thoughts and emotions. This is reviewed with the therapist in session.

62 Cognitive Processing Therapy (CPT)  CPT begins with education about trauma. It looks at the normal reactions to the trauma. The therapy then moves to look at and evaluate your thinking and beliefs about the events. You are finally asked to "talk" about your experiences by writing about them. You read them to the therapist (and/or group members).

63 CPT  Reading about your trauma is followed by a discussion of "stuck points." Stuck points are memories or thoughts you have been unable to move past. They continue to impact on your ability to live a full life. The Veteran monitors symptoms by completing a check list (PCL-M).

64 Treatment Model: Cognitive Processing Therapy (CPT)  Focus on the content of cognitions and the effect that distorted cognitions have upon emotional responses and behavior  Sees PTSD as a disruption or stalling out of a normal recovery process – and works to determined what interfered with normal recovery

65 Eye Movement Desensitization and Reprocessing (EMDR)  EMDR is a treatment for traumatic memories that involves elements of exposure therapy and cognitive behavioral therapy, combined with techniques like eye movements or hand taps that cause the patient’s attention to alternate back and forth across the midline.

66 EMDR Outcome Studies  EMDR has been shown to be more effective than placebo wait list, psychodynamic, relaxation, or supportive therapies. However, research comparing EMDR to other CBT therapies shows significantly better results have been maintained with CBT than EMDR, particularly over time.

67 Aftercare  Many veterans will benefit from ongoing support  This can be community based or may be part of a formal mental health treatment program

68 OEF/OIF/OND Readjustment Program (405) 456-2855 Carly Hobbs, Program Support Assistant Yan Feng, M.D., Medical Director Gina Pierce, M.D., Psychiatrist Shannon Thomas, M.D., Psychiatrist Steve Scruggs, Psy.D., Team Leader steven.scruggs@va.gov Susan Shead, LCSW, Social Worker Amber Ward, LCSW, Social Worker Rob Braese, Ph.D., Staff Psychologist Anna Colston, PA-C, Physician Assistant Regan Settles, Ph.D., Postdoctoral Fellow


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