COMING HOME: REFUGE OR A NEW COMBAT ZONE? Kathryn Karusaitis Basham, PhD, LICSW June 26, 2008

INTRODUCTION: REUNION FOR FAMILIES FOLLOWING DEPLOYMENT LESSONS LEARNED  What are the challenges, stressors and rewards of coming home for soldiers and their families?  How does research inform our understanding of the effects of combat on soldiers and their families?

Focus  Effects of deployment on attachments for soldiers, their partners and families?  Protective and risk factors, including gender, race and ethnicity?  Relationship patterns expressed by traumatized couples?  Practice methods that facilitate renewed attachments, improved affect regulation and re-connection.

After The Parade

RESPONSES OF FAMILIES  Positives Enhanced self esteem Enhanced self esteem Pride and mastery Pride and mastery Sense of duty and honor Sense of duty and honor  Return to civilian life: shifts in roles work, reintegration to community work, reintegration to community  Caregiving

RESPONSES OF FAMILIES  Secondary trauma (Stamm, 1999) with PTSD-like symptoms of hyperarousal, avoidance and numbing)  Marital conflict, attachment ruptures and divorce (Jensen et al. 1995; Jordan et al. 1992)  Intimate partner violence (Clark & Messer, 2005; McCarroll et al. 2000)  Parenting issues and attachment adjustments (Samper et al. 2004)  Effects on children (Rosenheck & Fontana, 1998; Marshall et al. 2005)

“What’s this they say, Billy, about a new, more virulent strain of teen-ager?”

Victim-Victimizer-Bystander Scenario  Central relationship pattern with survivors of trauma (Staub, 1989, 2003; of trauma (Staub, 1989, 2003; Herman, 1992) Herman, 1992)  Victim (person who is victimized), the victimizer (offender) and a bystander (who often remains detached) relate in this scenario.  Trauma survivor experiences victimization in the “here and now” AND internalizes the victim-victimizer-bystander relationship template that guides her world view.

“I’ll abandon my medium- and shorter range missiles if you abandon yours.”

COUNTERTRANSFERENCE TRAPS WITH TRAUMATIZED FAMILIES PASSIVE INDIFFERENCE HELPLESS VICTIMIZATION HELPLESS VICTIMIZATION RESCUER ENACTMENT RESCUER ENACTMENT AGGRESSION AGGRESSION REACTION FORMATION REACTION FORMATION

RACE, ETHNICITY AND DEPLOYMENT  Lessons learned from Vietnam re. experiences for African American, Hispanic and American Indian veterans (Hoge et al. 2002)  Current demographics for OEF/IEF OEF/IEF  New immigrants and non-citizen residents residents

WOMEN AND COMBAT  Wide range of duties with greater exposure to combat (Vogt et al. 2005)  Role adjustment as single mothers and caregivers (Kang, 1995)  Military sexual assault (Goldzweig et al. 2006) (Goldzweig et al. 2006)

MENTAL HEALTH EFFECTS  Acute Stress Response  Post Traumatic Stress Disorder (Seal et al. 2007)  Depression (Fiedler et al. 2002)  Suicide (Toomey et al. 2007)  Panic disorder  Somatic complaints  Substance use disorder (Jordan et al. 1991)  Disability (Physical, Cognitive and Mental Health)  Traumatic brain injury

GUIDING PRINCIPLES :CLINICAL SOCIAL WORK PRACTICE GUIDING PRINCIPLES :CLINICAL SOCIAL WORK PRACTICE  Relationship and connection  Resilience  Empowerment  Cultural responsiveness

Role of Psychodynamic Theory  Strengths and vulnerabilities established in childhood that influence experiences of self and relationship with others  Power of unconscious/conscious phenomena  Realm of symbolic meaning  Unique meaning of narrative of individual  Transference/CT

ATTACHMENT PATTERNS SECURE ATTACHMENT (i.e. mutual, reciprocal and sustainable relationships) relationships) INSECURE ATTACHMENT INSECURE ATTACHMENT Dismissing—fears of intimacy, intense Dismissing—fears of intimacy, intense self –reliance and aloofness self –reliance and aloofness Preoccupied-ambivalence, rage when disappointed and “keeping score” Preoccupied-ambivalence, rage when disappointed and “keeping score” Disorganized/Disoriented -extremes of rigidity and inflexibility, emotional chaos, potential violence Disorganized/Disoriented -extremes of rigidity and inflexibility, emotional chaos, potential violence

TRAUMATIC STRESS RESPONSE AND AFFECT DYSREGULATION  Attachment injuries and affect dysregulation (chronic repetition of traumatic stress response)  “Rage storms”  Interference with mentalization (i.e. a capacity to regulate affect where there is a level of consciousness of the affect within oneself as well as within another person (Fonagy et al. 2002).  Interruption of : attachment (careseeking or proximity seeking) attachment (careseeking or proximity seeking) caregiving (offering a safe haven) and caregiving (offering a safe haven) and exploration (curiosity and initiative) exploration (curiosity and initiative)

PRACTICE APPROACHES  Individual treatment for veteran -Relationship-based psychodynamic -Relationship-based psychodynamic - Cognitive-Behavioral (CBT)  Exposure therapy Cognitive-Behavioral (CBT) Cognitive Processing Treatment (CPT) Cognitive Processing Treatment (CPT) - EMDR, Somatic Experiencing, neural relaxation  Couple and family therapy -Phase oriented with relationship-base and psychoeducational focus  Group therapy and re-building through community

What helps soldiers, families and clinicians? BATTLEMIND SKILLS BATTLEMIND SKILLS  B uddies (Social Support)  A dding/subtracting family roles  T aking control  T alking it out  L oyalty and commitment  E motional balance  M ental health and readiness  I ndependence  N avigating the Army System  D enial of self (self-sacrifice)

RATIONALE FOR COUPLE/FAMILY THERAPY PROMOTE SECURE ATTACHMENTS REDUCE MENTAL HEALTH SYMPTOMATOLOGY MINIMIZE SECONDARY TRAUMATIZATION INCREASE KNOWLEDGE RELATED TO TRAUMA-RELATED EFFECTS RESTORE A SENSE OF RE-CONNECTION AND SOCIALVINDICATION

PHASE ORIENTED COUPLE/FAMILY THERAPY PRACTICE  Biopsychosocial Assessment  Phase I: Safety, stabilization and establishing a context for change  Phase II: Reflection of trauma narratives  Phase III: Consolidation of new perspectives, attitudes and behaviors

PHASE ONE SAFETY, SELF-CARE AND STABILIZATION PHASE ONE SAFETY, SELF-CARE AND STABILIZATION  Establishing safety  Self-care –physical health –mental health –sleep, nutrition and exercise –substance use, abuse and/or addiction –bio-behavioral behavioral strategies for stress reduction, self-soothing and affect regulation. stress reduction, self-soothing and affect regulation.  Support systems (e.g. spirituality/religion, family, work and community).  Assessment of stability of family