COMING HOME FROM WAR: A COMMUNITY’S RESPONSE TO OUR SERVICE MEMBERS/ VETERANS & FAMILIES “To care for him who shall have borne the battle, and for his widow, and his orphan” A. Lincoln

VIDEO

WHY ARE YOU HERE ?????????????

Why is it important that we dialogue about this? Relationship break up rate ^ Alcohol & Drug rate ^ Domestic Abuse rate ^ Homelessness ^ Suicide rate ^ Generational trauma Reintegration struggles ^

WHY A BRIEFING ON REINTEGRATION? History has taught REUNIONS are more stressful than separations: People grow and change Expectations are Different Experiences were different Understanding & having the right words to dialogue about changes and expectations has made significant strides in improving the reintegration process…

One of the hardest things to deal with when deploying a second time was validating the hardships or perceived hardships of the first deployment” “ One of the hardest things to deal with when deploying a second time was validating the hardships or perceived hardships of the first deployment” Unknown Iraqi Vet

Service members need 2 sets of skills: WAR/Survival/Uniform/Coping Skills HOME Skills

“ War Zone/Uniform Skills” are not the same skills we need at home “Normal” behavior for a service member is often not understood by family, friends, co-workers, or our communities. Service member needs 2 sets of skills: –WAR/Survival/Military Coping Skills –HOME/Civilian Skills

Mission Oriented WAR  Once a mission is assigned other, unrelated tasks, are unimportant  Decisions need to be quick, clear, accurate HOME/JOB/SCHOOL  Multiple competing tasks confusion/CHAOS cause confusion/CHAOS  May get angry/frustrated with those who get in the way of mission  Difficulty participating in cooperative decision making Civilians=9000+ decisions Service Members = 3000

THOUGHT What Can You Do To help yourself or a Veteran/SM who is struggling with participating in cooperative decision making?

12 Information/Talking WAR Restrict any information that may be used against you Learn new language HOME/JOB/SCHOOL  Give little information  Keep to self  Avoid talking  Social chatter a waste of time More comfortable talking with battle buddies “Civilianeze” foreign language Frustration & Isolation

THOUGHT What Can You Do To help yourself or a Veteran/SM who is having difficulty communicating in Civilianeze? Or communicating at all!

THE ENEMY WAR Divide people into allies & Enemies Assume people are the enemy first Evaluate whether someone can be relied on HOME/JOB/SCHOOL Assume enemy first Cont. to evaluate whether can be relied on in war zone Hinders social relationships Interferes with job & school opportunities May see everything in a negative light Lead to disrupted relationships, families,

Safety & Trust WAR Vigilance pays off Never Relax Assume everyone is the enemy “suspicious of others and things you have known & trusted” HOME/JOB/SCHOOL Avoid getting involved Suspicious of everyone Test people to earn trust Always on guard Isolative “being suspicious isolates you” Difficulty attending activities, going out in public, feeling safe with anyone but other service members.

THOUGHT What Can You Do To help yourself or a Veteran/SM who is not trusting and/or not feeling safe?

Emotions/Anger “NOT talking about your emotions in war (strength) only leads to CAN’T talk about emotions at home (weak)” WAR Control emotions Numbing (It don’t matter) Anger useful, protective, is a survival skill HOME/JOB/SCHOOL Insensitivity to others “look hot headed, hard headed” Decreased ability to read others emotions “you look / act emotionless” Decreased emotional enjoyment Irritability/defensiveness Increased aggression “fed by constant frustration” Increased alcohol/drug use to avoid feeling emotions avoid feeling emotions

THOUGHT What Can You Do To help yourself or a Veteran/SM whose anger issues are negatively affecting their life?

Authority WAR Little room for choice “do what you are told, when you are told” May have had much authority May not have faith in authority “bad decisions by authority = deadly consequences” HOME/JOB/SCHOOL May resent authority “who are you to tell me what to do” May be reluctant to let others have authority “may cause grades to fall at school” ”loss of jobs”, family issues, “etc” May take on too much authority, or, want none at all May lead to increased confrontations

THOUGHT What Can You Do To help a Veteran/SM to who is struggling with authority?

Closeness WAR Intense relationships Strong bonds, depending on each other for survival If losses, learn to avoid getting close HOME/JOB/SCHOOL Long term intimacy more complicated “lonely, not open with emotions” May expect same level of intensity of intimacy at home “not on the same page” May push loved ones away…. Uncomfortable admitting do not understand and cannot relate Love ones my push them away

THOUGHT What Can You Do To help a Veteran/SM to who is having struggles with intimacy with others?

Response Tactics WAR Act first, think later Maximum application of force and resources “every time” HOME/JOB/SCHOOL Unable to think first, act later “too much going on” “you look reckless & uncaring, inconsiderate & selfish” He/She may insist things not be out of place “you appear to be extreme” May find self training the family to survive in a war zone “DITTY BAG”

Predictability WAR Predictability makes you more vulnerable to enemy HOME/JOB/SCHOOL Avoid familiar places Keep a low profile Not be where expected to be Late, unexpected arrivals May be difficult to make and keep appointments

THOUGHT What Can You Do To help yourself or a Veteran/SM who is uncomfortable being in the same place at the same time? or one who cannot think first and act later, just always acting and reacting?

RESPECT WAR/Uniform  Following orders  Rank  Awards  Status  All one  Doing as your told no ?’s HOME/JOB/SCHOOL  Compromising  Allowing personal expression and disagreeing  Listening to everyone  Taking turns

THOUGHT What Can You Do To help yourself or a Veteran/SM whose ideas of Respect do not coincide with those of our society?

Hypervigilence “Adrenaline RUSH” WAR 6 Months a year or more of daily & nightly hypervigilence HOME/JOB/SCHOOL  Inability to slowdown, relax  Sleep changes “too little / too much”  Difficulty functioning without the adrenaline rush  Monitoring environment/ perimeter Attempts to relive the “RUSH” the “RUSH”

THOUGHT What Can You Do To help yourself or a Veteran/SM who is continuing to need constant adrenaline rush and doing it unsafely?

War may be hell… but home ain’t exactly heaven, either.

When a Service Member/Veteran comes home from war, He or She finds it hard………

…to listen to his someone whine about being bored

…to keep a straight face when people complain about potholes

…to be tolerant of people who complain about the hassle of getting ready for work

…to be understanding when a co-worker complains about a bad night’s sleep

…to control his panic when his wife tells him he needs to drive slower

…to be grateful that he fights for the freedom of speech

…to be compassionate when a businessman expresses a fear of flying

…to be silent when people pray to God for a new car

…to not ridicule someone who complains about hot weather

…to just walk away when someone says they only get two weeks of vacation a year

…to control his/ her rage when a colleague gripes about his coffee being cold

…to remain calm when his daughter complains about having to walk the dog

…to be civil to people who complain about their jobs

…to be happy for a friend’s new hot tub

…to be forgiving when someone says how hard it is to have a new baby in the house

…to not punch a wall when someone says we should pull out immediately

The only thing harder than being a Service Member…

is loving one.

A gentle reminder to keep your life in perspective. And when you meet one of our returning service members a veteran, and their families please remember what they’ve been through and show them compassion and tolerance.

Mission-FAMILY WAR ●“Holding down the Fort”, alone ●Independence ● Understanding & Patience HOME/JOB/SCHOOL Sharing responsibilities & decisions may be difficult ●Interdependence ● Understanding & patience ●Hard to give up independence ●New or different perspectives o Used to making their own decisions FOCUS ON ALL ASPECTS OF LIFE

Safety & Trust FAMILY WAR ● May feel unsafe alone o May Never Relax as they fear for SM safety ● Has to trust for help and support HOME/JOB/SCHOOL ●Sudden let down of FEAR for safety of SM, relief, safety and trust issues just beginning for SM ●Difficulty understanding when SM avoids getting involved Get used to attending activities, going out in public, activities without the service member, may be looking forward to SM participating

Emotions/Anger---FAMILY Talking about emotions at home (strength) WAR Control emotions, try not to be or show anger May hold back emotions from SM to protect them May “dump” or share all emotions with SM esp. if no other support systems Will have increased emotional needs due to stress HOME/JOB/SCHOOL May want to return to pre- deployment emotional exchange immediately Difficulty understanding and dealing with SM change in emotional responses May hold back as a defensive response to SM

REESTABLISHING Roles Might be Difficult

“ It was a kick in the stomach when my spouse told me she wasn’t sure she could depend on me with the kids.” 2 X Iraqi VET

How have family members changed?  More independent  Used to making their own decisions  New friends/relationships  Children may be significantly different  New routines  New perspectives  Changes in the environment

KIDS’ REACTIONS TO CHANGES IN FAMILY DYNAMIC Remember - the children have gone through this too……  Predictable overall  Vary by age of child  Will pass if you don’t make a big deal over it  Shouldn’t be taken personally

Two Types of Stress - ACUTE – “Fight or Flight” - CHRONIC

Acute Stress Body readies for “fight or flight”  Electrical changes in heart and sympathetic nervous system  Increased production of hormones & sugars  Immune system changes; blood pressure increases Experience:  Thrill  Exhilaration  Adrenaline rush   Results in:  Focused attention  Heightened strength  Feeling of competence  If stress is unmanaged, can result in ‘burnout’ Effects last at least 90 minutes

Chronic Stress Injury – Adaptation vs. Injury The “Stealth Bomber” of Stress Long term results of daily living Causes PHYSIOLOGICAL EFFECTS  Mediates Hormones and Neurotransmitters Serotonin, Dopamine, Noradrenaline, GABA, CRF, Steroids Exhaustion stage Available resources exhausted Performance becomes progressively worse Performance may stop

The Goal of most military training is to “HARDEN” (adapt) troops so they can operate under conditions where ACUTE STRESS is actually a CHRONIC condition. The Thing is…

What is Operational Stress? Combinations of physical and mental challenges (stressors) that can produce symptoms which temporarily interfere with performance. Can happen to even the bravest warriors as well as those who have not been in combat Operational stress can also produce positive behaviors. Negative effects diminish or resolve given time and positive support.

Combat / Operational Stress Reaction (COSR)

Physical Signs and Symptoms Common Fatigue Jumpiness Aches and pains Upset stomach, nausea Diarrhea or constipation Changes in eating (   ) Changing sleep patterns (   ) More Serious Flinching Startle reaction Shaking/Trembling Limbs/Eyes/Ears don’t work normally / “right” Spaced out

Cognitive (Thinking) Signs and Symptoms Common Poor concentration Difficulty making decisions Forgetfulness (short term) Flashbacks Nightmares Denial More Serious Disregard for rules/regs Thoughts of self-harm or harming others (suicidal or homicidal thoughts) Long term memory loss Loss of motivation Violent nightmares involving actual violence upon waking

Emotional Signs and Symptoms Common Frustrated / angry Lowered Self-esteem Worried Keyed up Guilty, ashamed Depressed / withdrawn Grief Numb Tearful Confused Sense of loss of control More Serious Panic attacks Feeling a sense of dread “Flat” expression Regression Immobilizing depression

Behavioral Signs and Symptoms Common Zoning out in meetings/class Failing deadlines/exams Arguments/fights with others  Tardiness / absenteeism Denial there are problems Avoiding “triggers” “I don’t care” attitude Hides true feelings Intimacy and relationship difficulties Job/Family difficulties Increased irritability/anger

Behavioral Signs and Symptoms More Serious Alcohol and drug use Suicidal/Homicidal gestures Dangerous/risk-taking behaviors Hypervigilance Domestic abuse/family violence Child abuse Withdrawal – stops performing Impulsive behavior

Post Traumatic Stress Disorder Symptoms are stronger in intensity and duration than COSR symptoms worsen over time If left untreated, ability to tolerate additional trauma or stressful situations is compromised

Social isolation, alienation, and withdrawal Remaining detached and emotionally distant from others, even in their presence

Nightmares that are disturbing in nature, often with associated sleep disturbances (i.e.; insomnia, nighttime awakenings)

Vivid flashbacks and recurrences of images that are painful, intrusive repetitive, and undesired

Combat Operational Stress Reactions are EXPECTED reactions to UNUSUAL situations ….. whereas Post Traumatic Stress Disorder is not a common problem. Other concerns: DEPRESSION TBI ANXIETY

DEPRESSION

SIGNS AND SYMPTOMS OF DEPRESSION Sleep disturbances Irritability (more than usual crankiness or grumpiness) Loss of energy (not just “tired”) Appetite disturbances (eat too much, eat too little) Lack of pleasure in favorite activities Anxiety (butterflies or knots in belly) Feeling helpless or hopeless Inability to concentrate or remember simple things Sadness for little or no reason

Traumatic Brain Injury – another war to fight

TBI Symptoms  Impaired hearing, vision, speech  Balance problems  Fatigue  Seizures  Memory loss  Concentration or processing difficulty  Organizational problems  Spatial disorientation  Impaired judgment and inability to multi-task  Failure to recognize deficits  Lowered self-esteem  Increased anxiety  Depression and mood swings  Sexual dysfunction  Impulsive behavior  Reminders needed to initiate or complete tasks

Many Disorders Mimic Each Other Depression Operational Stress/ COSR Post Traumatic Stress Disorder/MST Traumatic Brain Injury HopelessnessXXX X HelplessnessXXX X WorthlessnessX X XX AnxietyXXX Physical SymptomsXXXX Anger/IrritabilityXX/X Sleep DisordersXXXX Re-experiencingX Avoidance/NumbingX/X Arousal/AgitationXX/X/X Memory ProblemsXXXX Alcohol/*Drug AbuseXXX/XX Personality ChangesX X XX Grief/GuiltXXX X Spiritual TurmoilX X X X

Physical Injuries (all) - Combat Operational Stress Reaction - Operational Stress Reactions - Depression - Anxiety - Post-traumatic Stress REACTIONS PTSD

Treatments for COSR, PTSD, Anxiety, Depression, TBI etc Talk Therapy Medications SELF CARE – SUPPORT – BUDDY AID Family Care, Community care

Other TRAUMA Vicarious Trauma Generational Trauma What are we or can we be doing about this?

Specific Emerging Issues  Motor vehicle accidents  Reintegration difficulties (Workplace/School )  Violence, Spouse abuse, Child abuse  Divorce/Relationship issues  Drug addiction/Alcoholism  Job Loss/ Homelessness  Feeling of not belonging  Medical problems, Mental Health problems, TBI (Traumatic Brain Injury)/MST  Suicide/Homicide

MOTOR VEHICLE ACCIDENTS I Don’t care attitude ALIEN Attempts to relive the “RUSH” the “RUSH” Learned driving

Domestic Violence

A current or former spouse, Persons who share a child, and current or former intimate partner with whom the abuser shares or has shared a common domicile.

Domestic Violence Includes: Coercive control and or threatening behavior including terrorizing behavior (threats to children, pets, property) Coercive control and or threatening behavior including terrorizing behavior (threats to children, pets, property) Physical assault or threat of physical violence with or without a weapon. Physical assault or threat of physical violence with or without a weapon. Stalking Stalking Sexual assault, threat of sexual assault or coercing a partner to engage in undesired sexual activity Sexual assault, threat of sexual assault or coercing a partner to engage in undesired sexual activity

Domestic Violence Includes: Obstructing a partner from receiving medical services Obstructing a partner from receiving medical services Intentional neglect by refusing or obstructing a mentally/physically incapacitated spouse from receiving appropriate social, mental, or medical services. Intentional neglect by refusing or obstructing a mentally/physically incapacitated spouse from receiving appropriate social, mental, or medical services.

Examples of Physical Abuse Physical force that causes physical injury to another. Physical force that causes physical injury to another. Pushing, slapping, punching, kicking, or biting Pushing, slapping, punching, kicking, or biting Inflicting bruises, welts, lacerations, fractures, burns, or scratches. Inflicting bruises, welts, lacerations, fractures, burns, or scratches. Strangling or assaulting with weapons Strangling or assaulting with weapons

A pattern of acts or omissions that adversely affect the psychological well being of an individual. A pattern of acts or omissions that adversely affect the psychological well being of an individual. Threats of harm to victim, children, and pets Threats of harm to victim, children, and pets Extreme jealousy and possessiveness Extreme jealousy and possessiveness Name calling, constant criticizing, insulting and belittling Name calling, constant criticizing, insulting and belittling Isolating tactics, economic, medical, or other restrictions. Isolating tactics, economic, medical, or other restrictions. Arguments alone are not sufficient to substantiate emotional maltreatment. Arguments alone are not sufficient to substantiate emotional maltreatment. Emotional Abuse

Characteristics of a Victim (possible) Characteristics of a Victim (possible) In all socio- economic, educational, racial and age groups In all socio- economic, educational, racial and age groups History of family violence History of family violence Low self esteem Low self esteem Feeling of powerlessness Feeling of powerlessness Lacks Trust Lacks Trust Unable to relax, poor sleep habits Unable to relax, poor sleep habits Takes blame for problems Takes blame for problems Guilty feelings Guilty feelings Peace keepers and care givers Peace keepers and care givers Depression or suicidal behaviors Depression or suicidal behaviors

Characteristics of an Abuser (possible) Family History of Abuse Family History of Abuse Extreme Jealousy Extreme Jealousy Controlling Behavior Controlling Behavior Isolation Isolation Blames Others for Problems Blames Others for Problems Dr. Jekyll and Mr./Ms. Hyde Personality Dr. Jekyll and Mr./Ms. Hyde Personality Alcohol or drug abuse Alcohol or drug abuse Hypersensitivity Cruelty to Animals or Children Uses Force During Sex Verbal Abuse Breaking or Striking Objects

Possible Affects of Domestic Violence on Children  Serious problems with temper tantrums  Continual fighting at school or between siblings  Lashing out at objects  Cruel or abusive to animals  Threats of violence  Models abuser’s behavior

Possible Short-term Effects on Children  Failure to thrive – age regression  Injuries from trying to protect parent  Withdrawal from family and friends  Poor school performance - fighting  Use of drugs and alcohol - pregnancy  Running away

WHY? What are we doing about it? Active Duty has a program…Reporting? Guard & Reserves and discharged Veterans must make use of community or civilian agencies. Are they culturally competent?

THOUGHT What Can WE Do TO help prevent and support the care of those involved in Domestic Violence, in SM/ family reintegration process esp.

RESPECT Respect each other’s feelings, friends, opinions R – Respect each other’s feelings, friends, opinions E – Exercise your listening skills S – Support each other’s goals and dreams P – Practice sharing responsibility E – Exhibit honesty and accountability C – Compromise, rather than sacrifice T – Treat each other as equals

Military Sexual Trauma

So Much to do today: Kill memory, kill pain, Turn heart into stone, And yet prepare to live again The sentence, Akhmatova, 1939, In “Against Forgetting”.Ed. Forche, 1993

Military Sexual Trauma (MST) 1 in 3 Women Sexually Traumatized in their life time (up to 50% before age 18) 1 in 8 Men

MST VICTIMS/SURVIVORS More at risk for PTSD than from Combat or auto accidents!!!!

COMPLEX TRAUMA  Anything that makes the emotions more intense and the meanings harder to resolve makes the trauma more severe or “complex  Complex trauma is the term we use for:  Situations that are relatively more psychologically complicated and toxic  Psychological adaptations people must make to cope with these toxic situations

Aftermath of Complex Trauma  Positive resolution is more elusive and difficult  Traumatic emotions and traumatically shaped schemas persist  Coping strategies endure, often unchanged  Ongoing struggle to maintain psychological balance

Why is MST associated with Complex Trauma?  Military Sexual Trauma (MST) is contextually complex trauma  Violation of military environment and safety  Complicates the meaning of the trauma  Limits the response options of victims  Many MST victims also have histories of prior trauma  Understanding complex trauma sheds light on confusing behaviors

Military Sexual Trauma is Complex  Perpetrators are usually known to the victim  Victims are typically young  The military is like a family  The military is hierarchical and authoritarian  Military culture places a premium on strength, self sufficiency and loyalty  Victims are in conditions of relative entrapment (restricted freedom of movement)  Re-exposure and re-victimization are likely  Not only by the perpetrator but by the culture itself

The Military Environment  The military provides training in aggression which sometimes results in coercion & humiliation  Perpetrators may have pre-military abuse or come from chaotic families  Perpetrators may feel harassed themselves and are “geared-up” for violence  Victims are “captive audience”  Differences in scrutiny and accountability of practices--Internal system for investigations

Conflicting Adaptational Behaviors  Acting like it didn’t happen  Not getting help when possible  Insufficient self-protection  Misplaced self-protection  Pronounced problems remembering accurately  Drinking, drugging  History of promiscuity either before or after the rape  Provocative dress and behavior

What Underlies Confusing Behaviors  Appeasement  Desire for some control  Intolerable emotional states  Negative schemas about the self  Efforts to maintain psychological balance  Dissociation  Mistrust

Why Do Sexual Trauma Survivors Have more Physical Problems?  Direct health effects of the assault  4-30% contract STD during the assault  4% sustain serious injury during assault  5% of women become pregnant  Indirect mechanisms through high risk behaviors (e.g., smoking, substance use, sexual behaviors)  Physiological mechanisms (e.g., dysregulation of the hypothalamic-pituitary-adrenal axis)  Increased emotional distress regarding physical problems

Barriers to Reporting  FEAR of harm  Embarrassment  Denial  Co-occurring offenses (Alcohol or drug charges)  Reputation  Lack of Knowledge  Fear for career  Fear that they will be blamed  Fear that no one will believe them

Women exposed to trauma show an increased risk for Alcohol issues even if they are not experiencing PTSD..

Impact of Trauma Over the Life Span  Effects are neurological, biological, psychological, and social in nature, including:  Changes in brain neurobiology  Social, emotional, and cognitive impairment  Adoption of health risk behaviors as coping mechanisms (eating disorders, smoking, substance abuse, self harm, sexual promiscuity, violence)  Loss of Military Career, sometimes any career  Severe and persistent behavioral health, health and social problems, and early death (Felitti et al., 1998; Herman, 1992)

Sexual Assault Prevention and Response (SAPR) Program ProgramDOD

Sexual Assault Defined Intentional sexual contact characterized by use of force, physical threat or abuse of authority or when the victim does not or cannot consent. It includes rape, non- consensual sodomy (oral or anal sex), indecent assault (unwanted or inappropriate sexual contact or fondling), or attempts to commit these acts. (DOD)

Sexual Assault  Can occur without regard to gender or spousal relationship or age of victim  “Consent” shall not be deemed or construed to mean the failure by the victim to offer physical resistance  Consent is not given when a person uses force, threat of force, coercion, or when the victim is asleep, incapacitated, or unconscious.

Reporting a Sexual Assault 2 Methods in which a Service Member can report a sexual assault  Restricted  Unrestricted

Unrestricted Reporting  Allows the Service Member who is sexually assaulted to report the assault and permits the commencement of an official investigation of his or her allegations using the current reporting channels.  The victim will still receive prompt sensitive support, medical treatment, and counseling.

Restricted Reporting  Allows a victim of sexual assault to confidentially disclose the details of his or her assault to specified individuals without triggering the investigative process.  This option gives the victim access to medical care, counseling, and support. Without the pressure of others finding out.  Commander will be notified of an assault and any other non-identifying information.

Specified Individuals (Restricted Reporting) Individuals who are NOT required to report the sexual assault to authorities and will support the victim and protect their privacy.  SARC (Sexual Assault Response Coordinator)  VA (Victim Advocate)-Available at every Installation and Reserve Center  Chaplains  Medical Personnel  Military OneSource

MST Care for Guard and Reserve  SARC  Chain of Command  Chaplain  Combat Stress  VA/ Women’s Center  Vet Center  FAC  CIVILIAN SECTOR

Guard & Reserve Care  Care Differences  Community  On-Off Base  Medical discharges  Investigation challenges  Case Challenges (Mobilized, Different Services

How to Access Care for Military Sexual Trauma (MST)  Each VA has an MST Coordinator  MST coordinators assess need for care and facilitate veterans access to care  List on or call your nearest VA and ask for their MST coordinator

MILITARY VETERANS SUICIDES SLIPPERY SLOPE BALANCING ACT

 950 suicide attempts each month by veterans who are receiving some type of treatment  Seven percent of the attempts are successful  11 percent of those who don’t succeed on the first attempt try again within nine months. Military Times, : Apr 24, 2010

Mental illness among military personnel is a major concern. A study of returning soldiers, identified 20 percent of active and 42 percent of reserve component soldiers as requiring mental health treatment.

Drug or alcohol use frequently accompanies mental health problems and was involved in 30 percent of the Army's suicide deaths from 2003 to 2009 and in more than 45 percent of non-fatal suicide attempts from 2005 to 2009.

Article found on U.S. Medicine “ Efforts to prevent suicides among Servicemembers are not working, according to a new report that warns that the problem is likely to get much worse as more troops return from deployment”

Statistics  Army's total for 1st Quarter Calendar Year for active-duty 23 for not-on-active-duty  1st Quarter Calendar Year for active-duty 32 for not-on-active-duty.

Recently reported risk factors Relationship issues #1Relationship issues Financial Issues #2Facing UCMJ charges #3Substance Abuse Usually multifactoral…

ARMY RESERVE SUICIDES  STATISTICS ARE AREDifficulttomeasure  NUMBER OF ARMY RESERVE SUICIDES INCLUDE NON- PARTICIPANTS, Med. Hold Discharges  ARE NEW SERVICE MEMBERS NOT YET DEPLOYED  Means of choice Gun, hanging, Death by Cop

ARMY RESERVE SUICIDES LEADERSHIP CHANGES  Younger  No experience  No mentorship  Own Issues OLDER LEADERS  Burned out  Own Issues  Do not always support Mental Health issues, needs, concerns  Fear and lack of understanding

Military: Absence of protective factors  Staying in one place (transfers)  Ability to rest  Unhampered access to therapy and treatments  Being able to talk to peers  Ability to share concerns with family and friends who understand

Military: Absence of protective factors  Legal Problems  Leadership not knowing, ?too tired, overwhelmed?  Military screenings ineffective  Drug, alcohol and prescription abuse  Military slogans: You are only as strong as your weakest link, Death before dishonor,  “Dragging your unit down” is viewed as a dishonorable thing

HELPING VETERANS/SERVICE MEMBERS TO NOT SEE SUICIDE AS AN OPTION What can we do?

ASSESSMENT  Must be Culturally Competent, understand that they are forever different and know what those differences are.  Treat each Service Member/Veteran with the utmost respect and regard.  STIGMA, Emphasize that seeking help in times of distress displays courage, strength, responsibility, and good judgment. (Vietnam Vet wife’s story)  Do not assume that because they have not been deployed yet or did not see combat that this is not a concern, do not leave them out of the team  Evaluate for warning signs, means, plan

Military Risk Factors (Kim Ruocco, “Combating Suicide” The Officer magazine Military Risk Factors (Kim Ruocco, “Combating Suicide” The Officer magazine)  Difficulty getting help, stigma and concern that it will derail a career thru interfering with deployments and assigned duties.  Sleep deprivation due to duty  Frequent separations from support systems  Losing sense of belongingness, essential to military culture  Desensitization to idea of death and pain  Knowing how to die very easily and access to means

Intervention

MILITARY LEADERS

INTERVENTION & PREVENTION  Leadership  ACE  ASIST  Comprehensive DOD, VA, Community Programs  Resiliency  STIGMA  Service Member and Family Health  Comprehensive Soldier Fitness Program  Include Family, Battle Buddies, other VETS, Community

Life after Intervention Treatment and time helped heal Him and allowed him to stay in the Army. He deployed to Iraq again in 2008 and returned home June 1, 2009, "more at peace," he says "There is life after PTSD," He says. "I'm a survivor. I'm not holed up in a room with an M-4. Yes, you can acknowledge the issue and get through it."

HOMELESSNESS  30 % of Homeless are Veterans What do you think are the causes??

What to do for homeless vets ?  EVALUATE NEED  HOPE  HELP  ACCESS MILITARY, CIVILIAN, VETERANS AFFAIRS  ACCEPTANCE  UNDERSTANDING  AGAIN CULTURAL COMPETENCE  FAMILY, SUPPORT SYSTEM INVOLVEMENT  TREAT UNDERLYING ISSUES

Alcohol abuse is the most prevalent problem Army soldiers screened 3 to 4 months after returning from deployment to Iraq showed that 27 percent met criteria for alcohol abuse and were at increased risk for related harmful behaviors (e.g., drinking and driving, using illicit drugs) Army soldiers screened 3 to 4 months after returning from deployment to Iraq showed that 27 percent met criteria for alcohol abuse and were at increased risk for related harmful behaviors (e.g., drinking and driving, using illicit drugs)

deployed service members Exposed to combat situations were at greater risk for binge drinking as compared to non-deployed service members and deployed service members who were not exposed to combat.

The Connection between Combat Exposure and Alcohol Use Alcohol use connected with combat exposure, PTSD, and depression. Alcohol/drug use to escape or alleviate uncomfortable feelings. self-medicate distressing thoughts or feelings that arise from having PTSD or depression or the experience of a stressful life eventself-medicate

Connection between alcohol and PTSD The severity of hyperarousal symptoms of PTSD found to be strongly connected with the use of substances that have a depressant or anti-anxiety effect, such as alcohol

ALCOHOL & DRUG USE Increased use noted among returning service members Self-medication Sleep Increase feelings of invincibility (leads to dangerous and/or illegal acts) Avoid feelings (interferes with healing/processing of feelings)

ALCOHOL & DRUG USE Means of social support (eventually leads to isolation) Excuse for behaviors (not taking responsibility) Decreases potential for eventual reintegration May lead to job loss, family loss, legal problems, suicide

WAR ZONE / MILITARY SKILLS DO NOT AUTOMATICALLY CHANGE WHEN they COME HOME.

READJUSTMENT  No definite time period  Can take weeks or months depending on length of separation, experiences, resources NEW WAYS OF THINKING  Requires NEW WAYS OF THINKING

Coping and Problem-Solving Depend on a combination of many factors:  Extent, duration, & intensity of the problem  Nature of the problem  Number & type of co-occurring problems  Resources available  Presence/absence of a social support network  Existential beliefs  Developmental history  Experience/maturity  Cognitive capabilities  Physical health

Mission Stressors “Now” Culture shock “Celebrity” status Family and Friends Work or School Health Finances Changed perspectives “Finding” the year lost Ungrateful people Lack of understanding You name it…

REESTABLISHING ROLES CAN BE CHALLENGING

Communication is the bedrock of intimacy CLOSENESS  TRUST  COMMUNICATION

HELPING VETERANS, SERVICE MEMBERS AND FAMILIES REINTEGRATE What can we do?

OUT IN THE TRENCHES How do we reach them?  Family Readiness Picnics  Phone calls from the VA  Phone calls from family (68%)  Grocery store, Hospital Employees, Parking lots  Military One Source  Briefings, PDHRA’s, Veteran Organizations  Contact from Commands/Battle Buddies / Employers / Friends…..YOU………

 Veteran may feel discounted or disrespected  Family members may have new power and responsibilities  May feel they have been displaced  May have new priorities for their lives  May have achieved a new level of maturity  Children and friends have grown and changed …………. Recognize What May Have Changed…..

 “Culture shock”  Problems Driving  Workplace has changed; or, may have no workplace  Veterans who have seen combat - old work/job may seem dull by comparison  May not be interested in things they were interested in before they left Recognize What May Have Changed…

Identify how they may feel…………  They may have little patience for “nonsense”  Their sense of humor may have changed  They may feel uncomfortable being a “Civilian”  May feel uncomfortable in a crowd  They often want to take on more job responsibilities  They may feel unneeded at work or that they do not belong  Their thoughts may still be overseas with buddies/others who are still serving over there

Identify how they may feel…  Lose the sense they had of being “heroes” or, are embarrassed to be thought of as heroes  Feel that no civilian could ever understand their experiences  Their “head” is still in the war zone: a sense of disconnectedness in present environment: forget names, directions, old tasks, etc.  May be fearful of future deployment/may not want to plan for the future (ex. School, job advancement, family planning, etc.)  May feel that the stress of civilian life is trivial and have a hard time fitting in.

“Fought for Freedom to live the good life but do not live one”

Don’t let them isolate/segregate Don’t let them think they are going “crazy” Don’t act like their issues are unimportant Don’t let them let the negative attitudes/behaviors of others influence their behavior Don’t make excuses for their behavior or ignore potential underlying issues What to Do For the Veteran

HOPE, HELP, WORTH Be Respectful Be Competent Be Culturally Competent Include all family members Simplify complicated procedures Consider schedules, needs, resources Help work the system Include military systems as appropriate

GETTING BACK TO WORK AND SCHOOL  Don’t push for job changes or leaving military service right away  Need time to process and defuse before making big decisions about the future  Job may change and probably won’t be as exciting as BEFORE

What to Do For the Veteran/SM returning or starting school.  Ongoing education for others  Assist them to articulate their struggles and concerns  Mentors who get it  Environment with easily accessible help for Combat Stress or other issues, including resources, real life, written, web based.

What to Do For the Veteran/SM returning or starting school.  Learning environment that supports learning with mTBI, PTSD,COSR, etc.  Paperwork, system advocate to assist with system processes  Safe place to go to be away from triggers etc when necessary with others who get it.

Re-entering the Workforce May require accommodations  Modified work schedule  Re-introduction to the work, orientation to job, training & feedback  Job checklists & cues  Breaking work into manageable steps to improve sequencing  Changes in office location to minimize distractions

What else? HONOR THE WARRIOR…….

How ELSE can you help?  Relationships  Share in community outreach/family outreach  Veteran/SM/Family friendly Communities  Provide and support access to service members and families, Help work the system  Education and feedback  Fighting stigma  Mentor new veterans – and their families  Support Yellow Ribbon and other programs

PROVIDERS  Culturally Competent  Recognize the need they have to incorporate self as a Military Person/VET and a Civilian  Hope  Help  Worth  Financial Support and Assistance  Relationship Support  Know available Military, VA, and Civilian Resources and make use of them all

REINTEGRATION Where do we go from here?  Research  Resiliency training of troops and families, include buddy aid training, first responder  Educating and supporting - SM/Families/Communities  DOD increasing support and use of military, civilian, and VA Behavioral Health Resources  Continue the fight against the stigma  Education and more education  Treating the whole system (Family & Community)  Community care and support!!!!

 Performance expectations must be clear  Make use of the veteran’s newly acquired experience, maturity, and sense of responsibility  Support veteran’s input  Touch base regularly to insure the veteran has “settled in”  Be alert for signs of difficulty coping: alcohol abuse, drug abuse, acting out, SUICIDE Offer Support

Meet them where they are at Listen to their stories (if they want to talk) Help empower them to see the ways they have coped in the past Walk with them unconditionally Help them to incorporate who they were and who they are now (The good the bad and the ugly!!!)

Support Resiliency in Service Members/VETS and Families Comprehensive Soldier Fitness Program, Army..Other Services Yellow Ribbon Program DOD and Community IDEAS?

What’s the Difference Between a Stress Adaptation and a Stress Injury?  Adaptation - The path of change can be traced over time - Individual feels like he/she is still himself -A more gradual process -A focus of training and leadership  Injury – May be more abrupt – A derailment, a change in self – Individual feels like he/she is not in control Two ways of looking at Battlefield Stress

What Did They Gain? Lifetime membership in a culture of less than 1% of all Americans… Experience Confidence Camaraderie Personal growth Veteran status A great shot record

POINTS TO PONDER !!!!!  “No One Comes Back Unchanged” (COL (DR.) Tom Burke, DOD, Director of Mental Health Policy)  War changes persons (SM & Families) for the better,just as any stressful experience can.  Reintegration, coming home is a time for growth, new challenges and using strengths and support.  Help is available, ACCEPTABLE, and works. “They” is “Us” – they’re our families, our friends, our neighbors, our coworkers

“The day soldiers stop bringing you their problems is the day you have stopped leading them. They have either lost confidence that you can help them or concluded that you do not care. Either case is a failure of leadership" General Colin Powell

Websites National Center for Post Traumatic Stress US Army Center for Health Promotion and Preventive Medicine, CHPPM National Institute of Mental Health Tragedy Assistance Program for Survivors (TAPS) MilitaryOne Source Nationalresourcedirectory

THANK YOU FOR CARING

Questions ?