1. TO CONSERVE FIGHTING STRENGTH 1 THERE IS A COST TO CARE KEVIN R. STEVENSON, LMSW-C, BCD LTC, MS CHIEF, SOCIAL WORK SERVICE UNCLASSIFIED INTRODUCTION STRESS AND THE FORCE TREATMENT CHALLENGES DOWN RANGE AND IN GARRISON UPON RETURN BEST TREATMENT PRACTICES ISSUES SOLDIERS AND THEIR FAMILIES FACE UPON RETURN

2. TO CONSERVE FIGHTING STRENGTH 2 THERE IS A COST TO CARE PURPOSE To discuss the treatment challenges of Providers “Down Range” and in “Garrison”. Discuss best Treatment practices. Identify issues Soldiers and their families face during deployment and upon return.

3. TO CONSERVE FIGHTING STRENGTH 3 THERE IS A COST TO CARE OUTLINE INTRODUCTION PURPOSE OUTLINE TREATMENT CHALLENGES “DOWN RANGE” AND IN “GARRISION” ISSUES SOLDIERS AND THEIR FAMILIES FACE UPON RETURN PERSONAL CHALLENGES SUMMARY CONCLUSION

4. TO CONSERVE FIGHTING STRENGTH 4 THERE IS A COST TO CARE TREATMENT CHALLENGES “DOWN RANGE” UNIT ACCEPTANCE (ARE YOU VIEWED AS A “FORCE MULITPLIER”) PROFESSIONAL ROLE CONFLICT AND JOINT SERVICE OPERATIONS TRAINING IN “BEST PRACTICE TECHNIQUES” - BRIEF PSYCHODYNAMIC PSYCHOTHERAPY - CBT - EYE MOVEMENT DESENSITIZATION AND REPROCESSING (EMDR) - PROLONGED EXPOSURE THERAPY - COGNITIVE PROCESSING THERAPY (CPT) - ANGER MANAGEMENT GROUP THERAPY DOD DIRECTIVE 6490.1, “MENTAL HEALTH EVALUATIONS OF MEMBERS OF THE ARMED FORCES,” SEPTEMBER 14, 1993

5. TO CONSERVE FIGHTING STRENGTH 5 THERE IS A COST TO CARE TREATMENT CHALLENGES “DOWN RANGE” BALANCING THE NEEDS OF THE SOLDIER AND MILITARY MISSION RELATIONSHIP AND BOUNDARIES CONFIDENTIALITY AND PRIVACY CONFLICTS WITH COMMANDERS CLINICIAN BURN-OUT AND SELF-CARE TEAMWORK, POPULATION SERVED, AND PRIDE IN SERVING COUNTRY BALANCING FAMILY AND MILITARY OBLIGATION “ MULITPLE DEPLOYMENTS”

6. TO CONSERVE FIGHTING STRENGTH 6 THERE IS A COST TO CARE TREATMENT CHALLENGES “GARRISON” UNDERSTANDING THE MILITARY CULTURE UNIQUE TREATMENT CONCERNS OF IRAQ AND AFGHANISTAN SOLDIERS PRIORITZING THE ASSESMENT FOCUSING ON THE PRESENTING PROBLEM BEST THERAPEUTIC TREATMENT METHODS

7. TO CONSERVE FIGHTING STRENGTH 7 THERE IS A COST TO CARE TREATMENT CHALLENGES “GARRISON” FLEXIBLE HOURS (EVENING CLINIC) SERVICES AND BENEFITS (CHILD AND ADOLESCENT TREATMENT) RESOURCES (CHILD CARE) NETWORK AND BUILD RELATIONSHIPS WITH… - VETERAN SERVICE OFFICER - VETERAN AFFAIRS MEDICAL CENTERS - LOCAL HOSPITALS AND CLINICS - VET CENTERS

8. TO CONSERVE FIGHTING STRENGTH 8 THERE IS A COST TO CARE ISSUES SOLDIERS AND THEIR FAMILIES FACE UPON RETURN MEDICAL PSYCHOLOGICAL FAMILY AND MARITAL TRANSITIONAL

9. TO CONSERVE FIGHTING STRENGTH 9 THERE IS A COST TO CARE MEDICAL TRAUMATIC BRAIN INJURY (TBI) AMPUTEES MUSCLE AND SKELETAL INJURIES CHRONIC PAIN MEDS VS NO MEDS INABILITY TO EXERCISE AND FUNCTION LOSS OF LIBIDO MOOD SWINGS

10. TO CONSERVE FIGHTING STRENGTH 10 THERE IS A COST TO CARE PSYCHOLOGICAL POST TRAUMATIC STRESS DISORDER (PTSD) MAJOR DEPRESSIVE DISORDER SUBSTANCE ABUSE ANXIETY DISORDER SEXUAL TRAUMA COMORBID DIAGNOSES OTHER ADDICTIONS

11. TO CONSERVE FIGHTING STRENGTH 11 THERE IS A COST TO CARE SUICIDE DATA There have been 88 reported active-duty suicides in the Army during calendar year 2009. Of these, 54 have been confirmed, and 34 are pending determination of manner of death. For the same period in 2008, there were 67 confirmed suicides among active-duty soldiers. During June 2009, among reserve component soldiers not on active duty, there were no confirmed suicides and two potential suicides; to date, among that same group, there have been 16 confirmed suicides and 23 potential suicides currently under investigation to determine the manner of death. For the same period in 2008, there were 29 confirmed suicides among reserve soldiers not on active duty.

12. TO CONSERVE FIGHTING STRENGTH 12 THERE IS A COST TO CARE SUICIDE DATA OEF/OIF SUICIDES ACTIVE-DUTY MILITARY FORCES Marines, active-duty forces, deployed, 2003: 2 Army, active-duty forces, deployed, 2003: 25 Marines, active-duty forces, deployed, 2004: 7 Army, active-duty forces, deployed, 2004: 11 Marines, active-duty forces, deployed, 2005: 4 Marines, active-duty forces, deployed, 2006: 4 Army, active-duty forces, deployed, 2005-2006: 120 Marines, active-duty forces, deployed, 2007: 6 Army, active-duty forces, deployed, 2007: 115 Army, active-duty forces, deployed, January-August 2008: 62 Army, active-duty forces, deployed, through August 2008 (suspected): 31 Army, active-duty forces, between deployments, 2002-2008: ??? Army, active-duty forces, suicide attempts, 2002: 350 Army, active-duty forces, suicide attempts, 2007: 2.100 [5 per day] VETERANS Marines, active-duty, prior deployed, 2003: 6 Marines, active-duty, prior deployed, 2004: 10 Marines, active-duty, prior deployed, 2005: 8 Marines, active-duty, prior deployed, 2006: 5 Marines, active-duty, prior deployed, 2007: 12 Veterans, separated from service, under VA care, 2002-2005: 141 Veterans, separated from service, under VA care, 2006: 113 Veterans, separated from service, not under VA care, 2002-2008: ??? [*at least 139] OEF/OIF SUICIDE TOTALS: Active-duty military forces: 356 [+another 31 suspected] Veterans: 295 [+another 139 not officially counted by DoD or VA]

13. TO CONSERVE FIGHTING STRENGTH 13 THERE IS A COST TO CARE FAMILY AND MARITAL COMMUNICATION AVOIDANCE AND ISOLATION ANGER AND RESENTMENT UNREALISTIC EXPECTATIONS RETURNING TO COMBAT ZONE FEELINGS OF BEING … - MISUNDERSTOOD - A FAILURE - EXCLUDED

14. TO CONSERVE FIGHTING STRENGTH 14 THERE IS A COST TO CARE MILITARY DIVORCE RATES : By Rod Powers, About.com Filed In: Family & Domestic & Divorce Separation Dec 15 2008 The military divorce rate continues to climb slightly over previous years, according to Department of Defense statistics. The overall divorce rate for military personnel during fiscal year 2008 was 3.4 percent, compared to 3.3 percent in 2007 and 2006. Among the DOD services for FY 2008: Army. Enlisted divorce rate was 3.9 percent. Officer divorce rate was 2.3 percent. Overall divorce rate was 3.5 percent. Air Force. Enlisted divorce rate was 4.1 percent. Officer divorce rate was 1.6 percent. Overall divorce rate was 3.5 percent. Navy. Enlisted divorce rate was 3 percent. Officer divorce rate was 1.5 percent. Overall divorce rate was 3 percent. Marine Corps. Enlisted divorce rate was 4.1 percent. Officer divorce rate was 1.6 percent. Overall divorce rate was 3.5 percent. The general population divorce rate in the United States, for the 12 months proceeding Feb 2008 was 3.6 percent, according to the most recent National Vital Statistics Report, prepared by the Center for Disease Control and Prevention. Historically, female service members get divorced at a rate of more than double of military men:

15. TO CONSERVE FIGHTING STRENGTH 15 THERE IS A COST TO CARE MILITARY DIVORCE RATE BY GENDER Service 2006 Male Divorce Rate 2006 Female Divorce Rate Army 2,5% 7.9% Air Force 2.6% 6.2% Navy 2.9% 6.9% Marine Corps 2.9% 7.1% Service 2007 Male Divorce Rate 2007 Female Divorce Rate Army 2.6% 8.1% Air Force 2.9% 6.5% Navy 2.8% 6.5% Marine Corps 3.0% 8.1% Service 2008 Male Divorce Rate 2008 Female Divorce Rate Army 3.0% 8.5% Air Force 2.9% 6.5% Navy 2.5% 6.3% Marine Corps 3.2% 9.1%

16. TO CONSERVE FIGHTING STRENGTH 16 THERE IS A COST TO CARE TRANSITION COPING WITH LIFE OUTSIDE THE ARMY LOW SELF ESTEEM UNEMPLOYMENT FINANCES FORECLOSURES HOMELESSNESS CHILD CARE COLLEGE NEW CAREER CHOICES

17. TO CONSERVE FIGHTING STRENGTH 17 THERE IS A COST TO CARE PERSONAL CHALLENGES ACCEPTANCE AVOIDANCE AND ISOLATION DEPRESSION AND PTSD SUICIDAL THOUGHTS IRRITABLE AND ANGRY SHOULDER, BACK, AND KNEE PAIN TREATMENT MEDICATION

18. TO CONSERVE FIGHTING STRENGTH 18 THERE IS A COST TO CARE SUMMARY TREATMENT CHALLENGES “DOWN RANGE” AND IN “GARRISION” ISSUES SOLDIERS AND THEIR FAMILIES FACE UPON RETURN PERSONAL CHALLENGES

19. TO CONSERVE FIGHTING STRENGTH 19 THERE IS A COST TO CARE QUESTIONS

20. TO CONSERVE FIGHTING STRENGTH 20 THERE IS A COST TO CARE CONCLUSION Our goal has to be a clear focus to provide the best care to our Soldiers and their family members. It is just as important to ensure we focus on provider resilience. There is still a real stigma related to seeking mental health service. If the stigma is not reduce our Soldiers face a never ending battle for years to come. Lets make the difference and reshape the future of returning Soldiers and their families.