1. Working with Veterans and Their Families: Post-Traumatic Stress Disorder (PTSD), Other Key Issues, and Clinical Dilemmas James Munroe Ed.D. Boston VA Healthcare System May 19, 2007

2. A Unique Situation We know a lot more than in the past We know a lot more than in the past It is an ongoing war It is an ongoing war Discharged, active and reserve Veterans Discharged, active and reserve Veterans Males and Females Males and Females Possible redeployment Possible redeployment A work in progress A work in progress We are learning a lot more We are learning a lot more

3. DoD Roster November 2006 (Since 2002) 631,174 OEF/OIF separated from active duty 631,174 OEF/OIF separated from active duty 46% Former Active Duty 46% Former Active Duty 54% Reserve and National Guard 54% Reserve and National Guard 205,097 sought VA health care (32%) 205,097 sought VA health care (32%) 4.0% of 5.3 million vets receiving care 4.0% of 5.3 million vets receiving care 36% Received possible Mental Health Dx 36% Received possible Mental Health Dx

4. Frequency of Possible Mental Disorders Among OIF/OEF Veterans PTSD 33,754 PTSD 33,754 Non-Dependent use of drugs 28,732 Non-Dependent use of drugs 28,732 Depressive Disorders 23,462 Depressive Disorders 23,462 Neurotic Disorders 18,294 Neurotic Disorders 18,294 Affective Psychoses 12,386 Affective Psychoses 12,386 Alcohol Dependence 5,413 Alcohol Dependence 5,413 Acute Reaction to Stress 2,273 Acute Reaction to Stress 2,273

5. Scope of the Problem (Returning Screens and Follow Up) 26% with mental health disorders 26% with mental health disorders 23% to 40% sought VA mental health care 23% to 40% sought VA mental health care Concern about stigmatization as barrier to treatment (Kang et al. 2005) Concern about stigmatization as barrier to treatment (Kang et al. 2005) Stigma is the greatest in those with the most need for care (Hoge et al. 2004). Stigma is the greatest in those with the most need for care (Hoge et al. 2004). 77% to 60% are in the community 77% to 60% are in the community

6. Barriers to Treatment Stigma of Mental Health Stigma of Mental Health Damage to Career Damage to Career Perception of Weakness Perception of Weakness Eagerness to go Home Eagerness to go Home Access to Services Access to Services Mental Health Mentality Mental Health Mentality PTSD Focus PTSD Focus VA Reputation VA Reputation

7. Overcoming Barriers Point of Contact Point of Contact Center for Returning Veterans Center for Returning Veterans Extended Hours Extended Hours Community Access (CBOCs) Community Access (CBOCs) Primary Care Connections Primary Care Connections Public Health Mentality Public Health Mentality

8. Outreach Returning Units Returning Units Family Meetings Family Meetings Educational Materials Educational Materials Professional and Community Presentations Professional and Community Presentations PDHRAs PDHRAs VHA CRV staff VHA CRV staff Vet Center staff Vet Center staff VBA Benefits counselors VBA Benefits counselors Eligibility and sign up Eligibility and sign up

9. DSM IV Criteria for PTSD Experienced Event(s) Experienced Event(s) Death, threat to physical integrity Death, threat to physical integrity Fear, helplessness, horror Fear, helplessness, horror Re-Experiencing Re-Experiencing Intrusive memories, dreams, flashbacks Intrusive memories, dreams, flashbacks Avoidance and Numbing Avoidance and Numbing Reminders, triggers Reminders, triggers Detachment, restricted emotions Detachment, restricted emotions Arousal Arousal Irritability, sleep disturbance Irritability, sleep disturbance Concentration loss, hypervigilant, startle response Concentration loss, hypervigilant, startle response

10. Transitioning War Zone Skills (8 Skills) Safety Safety Trust and the Enemy Trust and the Enemy Mission Orientation Mission Orientation Decision Making Decision Making Response Tactics Response Tactics Predictability and Intelligence Predictability and Intelligence Emotional Control Emotional Control Talking Talking

11. Safety Living in a war zone requires being constantly alert for survival. Living in a war zone requires being constantly alert for survival. Situations at home that resemble war dangers may trigger survival habits. Situations at home that resemble war dangers may trigger survival habits.

12. Trust and the Enemy When the enemy is among the population, soldiers quickly learn not to trust people. When the enemy is among the population, soldiers quickly learn not to trust people. Someone who is being friendly or helpful at home may be seen as being manipulative. Someone who is being friendly or helpful at home may be seen as being manipulative.

13. Mission Orientation Once a mission is assigned all other non-related tasks are unimportant. Once a mission is assigned all other non-related tasks are unimportant. The same focus of concentration can be problematic with multiple goals and tasks. The same focus of concentration can be problematic with multiple goals and tasks.

14. Decision Making In war, decisions must be made quickly and clearly without discussion. In war, decisions must be made quickly and clearly without discussion. At home, decisions making is slow and involves a lot of discussion. At home, decisions making is slow and involves a lot of discussion.

15. Response Tactics Hesitating in responding may be dangerous or even deadly, act first, think later. Hesitating in responding may be dangerous or even deadly, act first, think later. Life and death responses are rare at home, thinking first and acting later is important. Life and death responses are rare at home, thinking first and acting later is important.

16. Intelligence and Predictability Information can be used by the enemy to anticipate and stage attacks. Information can be used by the enemy to anticipate and stage attacks. Social chatter at home may seem frivolous or even dangerous. Social chatter at home may seem frivolous or even dangerous. If the enemy can predict your location or movements they can attack you. If the enemy can predict your location or movements they can attack you. Be unpredictable, show up late or early, take round about routes. Be unpredictable, show up late or early, take round about routes.

17. Emotional Control Soldiers learn to numb fear into an ability to react quickly and decisively. Soldiers learn to numb fear into an ability to react quickly and decisively. The numbing to improve war zone skill, may get in the way at home. The numbing to improve war zone skill, may get in the way at home. Anger enhances the ability to use force effectively in war. Anger enhances the ability to use force effectively in war. Veterans may have strong defensive or aggressive reactions to home situations. Veterans may have strong defensive or aggressive reactions to home situations.

18. Talking During the war, there may be little time to talk about powerful events. During the war, there may be little time to talk about powerful events. Talking realistically at home may make people leave quickly or change the subject. Talking realistically at home may make people leave quickly or change the subject. What needs to be talked about? What needs to be talked about?

19. Collateral Damage Beyond Effects on Veterans Beyond Effects on Veterans Beyond the Individual Diagnosis of PTSD Beyond the Individual Diagnosis of PTSD Veterans belong to families Veterans belong to families Effects on Families Effects on Families Effects on Children Effects on Children Effects do not require a diagnosis Effects do not require a diagnosis

20. Intergenerational Transmission (Danieli, 1998) Avoid separation, protect parents Avoid separation, protect parents Dissociation and numbing Dissociation and numbing Belief world is not safe Belief world is not safe Sense of foreboding Sense of foreboding Emotional constriction Emotional constriction Headaches, insomnia Headaches, insomnia More psychiatric treatment More psychiatric treatment

21. Mechanisms of Transmission Silence Silence Over-disclosure Over-disclosure Identification Identification Re-enactment Re-enactment

22. Silence “IT” cannot be talked about “IT” cannot be talked about Elephant in room is ignored Elephant in room is ignored Behaviors do not make sense Behaviors do not make sense Others create sense with few facts Others create sense with few facts Distorted beliefs Distorted beliefs Walking on eggshells Walking on eggshells May be generalized May be generalized

23. Over Disclosure Detailed descriptions of events Detailed descriptions of events Horrible material unprocessed Horrible material unprocessed Told at inappropriate times Told at inappropriate times May show powerful emotions May show powerful emotions May show no emotions May show no emotions Sometimes used to teach or shock Sometimes used to teach or shock May be used to stop questions May be used to stop questions

24. Identification Traumatized parent too distant Traumatized parent too distant Responds to survival behaviors Responds to survival behaviors Children learn to emulate behaviors Children learn to emulate behaviors Closeness through approval Closeness through approval Children copy more behaviors Children copy more behaviors Children go to war Children go to war

25. Re-Enactment Acting out trauma themes Acting out trauma themes Family induced to carry out roles Family induced to carry out roles Parallel emotions generated Parallel emotions generated Survival skill demonstrated Survival skill demonstrated Family learns war zone skills Family learns war zone skills Peacetime skills diminished Peacetime skills diminished

26. How Children May Present (8 Clues) Do children feel unsafe or fearful? Do children feel unsafe or fearful? Are they mistrustful or suspicious? Are they mistrustful or suspicious? Are they overly focused or withdrawn? Are they overly focused or withdrawn? Are decisions rigid or defiant? Are decisions rigid or defiant? Do they act first, think later? Do they act first, think later? Are they unpredictable or evasive? Are they unpredictable or evasive? Are they emotionally flat or angry? Are they emotionally flat or angry? Do they avoid talking? Do they avoid talking?

27. Resources Web site: istss.org Web site: istss.org Web site: ncptsd.org Web site: ncptsd.org Do you know the nearest VA? Do you know the nearest VA? Do you know the nearest Vet Center? Do you know the nearest Vet Center? What are your local resources? What are your local resources? Point of Contact: Mel Tapper 857-364-6780; 617-515-3961 Transitioning From the War Zone: Information for Veterans and Those Who Care Transitioning From the War Zone: Information for Veterans and Those Who Carejames.munroe@va.gov