1. John Straznickas, MD Substance Use PTSD Team Leader San Francisco VA Medical Center April 25 2012

2. Improve Identification of veterans Cross-Cultural “Military” Training The veteran re-integration process

3. Military Culture Take-home Points Take a stance where your patient teaches you about their veteran experience. It’s got similarities and differences for each veteran Know the basic language of the military Assess weapons differently Engage differently depending on their view of their military/veteran status Assess whether a referral to the VA is useful for them.

4. Examine your own biases Your view of weapons Your view of war Your view of the soldier Separating the soldier from the war Your view of people who commit violence Separating the person from the soldier

5. Basic Military History Which Branch did they serve in? Army, Navy, Air Force, Marines, Coast Guard They are NOT the same. Particular allegiance to their units Active Duty, National Guard or Reserves? What was their job/MOS?

6. Basics of a Military Hx What was their Rank – Enlisted or Officer Enlisted – E-1 (Pvt) up to E-9 (Sergent Major/Master Chief Petty officer) Officers W-0 (Warrant Officer) up to @W-5(Chief W. Officer 5) O-1 (2 nd Lt./Ensign) to O-10 (General/Admiral)

7. How SUD affects Rank Rank does not increase while in the military Demotion of rank Disciplinary action?

8. Basic Military History Did they serve in a combat-zone ? How many tours “Outside the Wire.” No safe zones MOS doesn’t say much about exposure to combat Cooks and Clerks can see combat

9. Basic Military History Type of Discharge from the Military: Honorable General under honorable conditions Dishonorable

10. Basic Military History Unwanted sexual advances? Men and Women are both affected At least 25% of Women veteran 1/5 reportedly raped. Still a culture of hiding/minimizing sexual injury This is not ‘only’ work-place harrassment. They ‘live with’ their abuser.

11. A veteran’s relationship to weapons Assume they have a weapon Their weapon is an important part of their identity For protection more than for harm. Separate the gun from the bullets If lethality is active, negotiate storing bullets with a friend or getting a trigger lock.

12. Individual differences War differences – VN vs. OEF/OIF

13. Cross-Cultural perspectives Your patient has been trained within a strong cultural environment. Viewing ‘veteran’ as a racial-identity Your patient will have a unique response to military culture and to his identity as a veteran.

14. The ‘Military’ as a culture Cultural values Honor Respect Leave no brother behind Protect yourself - weapons Chain of command Follow orders

15. Ways veterans can present to community-based programs Conformity – devalues the military and emphasizes the civilian life Dissonance – ambivalent about the two ‘cultures’ Immersion/Resistance – Idealization of the military and denigration of the civilian culture Helms’ Racial Identity Model

16. Using this Model to work with veterans in the community. The ‘conforming’ veteran Don’t challenge the devaluing Don’t actively join the devaluing The ‘dissonant’ veteran Use Motivational Interviewing techniques to explore the ‘yes-but’ communications The ‘immersion/resistance’ veteran Don’t challenge the devaluing Focus on the present problem and solution

17. Added resources Specialized services

18. Age old problem of coming home and re-integrating. Homer & Sophocles as Lit. Based Therapy (LBT)

19. Odysseus and the Sirens

20. Typical Warrior Challenges A hazardous path at multiple levels Reluctant to talk about the war Past-Present-Future time distortions Soldier-Civilian integration Frustrating journey

21. Reluctant to talk about the war Legitimate fears of Judgments – morally questionable Misunderstandings of what war is. “It’s not like the movies” Facing painful combat experiences/death

22. Can be a high stakes process

23. High Co-occurrence of SUD/PTSD Look for PTSD in all your SUD patients. Intrusions – NMs Avoidance – isolation, numbness Hyper-arousal – Insomnia, irritability These symptoms get worse in early sobriety. Don’t confuse avoidance symptoms with resistance

24. Substances as a barrier ‘home’

25. SUD/PTSD and AA Avoidance of AA is misunderstood as resistance. Issue of ‘God’ or a benign higher power. War is NOT benign. Issue of groups increase PTSD hyper-arousal Issue of listing amends and making amends – Amends done for their violent soldier duties are a trigger for relapse.

26. Honorable Service Pride in our work