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

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

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

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

Returning From the War Zone United States Armed Forces There are seven uniformed services; five are armed services. The others are: United States Public Health Service Commissioned Corps National Oceanic and Atmospheric Administration Commissioned Corps Circle of Recovery, Inc. 2013

Returning From the War Zone The five armed forces of the United States include: Army Navy Marine Corps Air Force Coast Guard Circle of Recovery, Inc. 2013

Returning From the War Zone Difference Between Active and Guard/Reserve Active Full-time (24/7) Families move with member when not deployed Move every 3-5 years Free Full benefits (medical, dental, etc.) Full family support programs on-post Guard / Reserve Part-time One weekend a month / two weeks a year (unless deployed) Live in the community Limited medical or dental benefits through the military (w/cost) Can be recalled to active duty within 24 hour Circle of Recovery, Inc. 2013

Returning From the War Zone Values in the Armed Forces Army Navy Air Force Marines (Core Values) Loyalty Honor Integrity First Honor Duty Courage Service Before Self Courage Respect Commitment Excellence in All We Do Commitment Selfless Service Honor Integrity Personal Courage Circle of Recovery, Inc. 2013

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

Returning From the War Zone Over 90,000 Reservists and National Guardsmen are activated •Since 9/11 more than 2 million service members have deployed •Service members back from deployment: Approximately 18.5 percent with PTSD or depression Approximately 19.5 percent with traumatic brain injury •Approximately 50 percent of returning service members who need treatment for mental health conditions seek it -slightly more than half receive adequate care •2004 through 20067.1 percent of U.S. veterans met criteria for SUD vs. 9.2 percent of general population in 2006 (12 or older) Circle of Recovery, Inc. 2013

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

Returning From the War Zone M/SUDs caused more hospitalizations among U.S. troops in 2009 than any other cause In 2009, on any given night, approximately 107,000 veterans were homeless Circle of Recovery, Inc. 2013

Returning From the War Zone War Zone experiences: Being attacked or ambushed 60% Receiving incoming fire 86% Being shot at 50% Discharged weapon 36% See dead bodies 63% Knowing someone seriously injured or killed 79% Circle of Recovery, Inc. 2013

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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