1. Working with Veterans in Crisis: Unique and Shared Characteristics with Civilians in Crisis Kimberley L. Mullen, Ph.D. Veterans Crisis Line Clinical Care Coordinator

2. VETERANS HEALTH ADMINISTRATION Outline Overview of the Veterans Crisis Line Understanding the VCL Caller: Myths and Truths How to Help: PTSD Discussion and Questions

3. VETERANS HEALTH ADMINISTRATION Outline Overview of the Veterans Crisis Line Understanding the VCL Caller: Myths and Truths How to Help: PTSD Discussion and Questions

4. VETERANS HEALTH ADMINISTRATION Overview of the Veterans Crisis Line Partners with Substance Abuse Mental Health Services Administration (SAMHSA), National Suicide Prevention Lifeline (Lifeline), American Foundation for Suicide Prevention (AFSP), and Department of Veterans Affairs (VA) Marketing via Reingold, VA Central Office Communications Department, Office of Public and Intergovernmental Affairs (OPIA) Network of Suicide Prevention Coordinators across the country 6 Lifeline-affiliated back-up centers for phones, 3 for Chat 365/24/7

5. VETERANS HEALTH ADMINISTRATION Overview of the Veterans Crisis Line Staff at Canandaigua VA – 257 Responders (and rising) – 18 Social Service Assistants – 15 Shift Supervisors – 8 Support Staff (Timekeepers, Schedulers, Administrative Officers) – 3 Clinical Care Coordinators, Kimberley Mullen, G. Lee Judy (off-site), position to be filled – 2 Assistant Program Managers, Julianne Mullane and Rich Barham – Program Manager, Vic Bridges – Deputy National Suicide Prevention Coordinator, Caitlin Thompson – National Suicide Prevention Coordinator, Jan Kemp (based in D.C.) – Information Technology and Housekeeping staff provided by Canandaigua VA – Staff are represented by AFGE and SEIU unions

6. VETERANS HEALTH ADMINISTRATION Overview of the Veterans Crisis Line

7. VETERANS HEALTH ADMINISTRATION Overview of the Veterans Crisis Line

8. VETERANS HEALTH ADMINISTRATION Overview of the Veterans Crisis Line

9. VETERANS HEALTH ADMINISTRATION Overview of the Veterans Crisis Line

10. VETERANS HEALTH ADMINISTRATION Overview of the Veterans Crisis Line

11. VETERANS HEALTH ADMINISTRATION Outline Overview of the Veterans Crisis Line Understanding the VCL Caller: Myths and Truths How to Help: PTSD Discussion and Questions

12. VETERANS HEALTH ADMINISTRATION Understanding the VCL Caller: Myths and Truths “I don’t know anything about the military, Veterans, or the VA, so I can’t help.”

13. VETERANS HEALTH ADMINISTRATION Understanding the VCL Caller: Myths and Truths “ I don’t know anything about the military, Veterans, or the VA, so I can’t help.” MYTH! Truths: Veterans are people too! Everything you know about working with civilian callers holds true. – ASIST model – Validate emotions, not content VCL Responders don’t have extensive knowledge of the VA either! SPC’s are our link. One story you need to know to understand military culture: Bolt Cutters

14. VETERANS HEALTH ADMINISTRATION Understanding the VCL Caller: Myths and Truths “All Veterans have guns.”

15. VETERANS HEALTH ADMINISTRATION Understanding the VCL Caller: Myths and Truths “All Veterans have guns.” Myth … and best to act as if it’s the truth. Truths: It’s important to ask about the presence of weapons and encourage separation from the weapon and, ideally, disarming the weapon (placement in safe, removal of ammunition, keys/combination to safe and/or ammo with trusted other.) Veterans are more likely to have homicidal ideation. – If you’re wondering if it’s an issue, ask. – If you can assess suicide, you can assess homicide (plans, means, intent, timeline). The only difference is consideration of duty to warn. – As with suicide, differentiate between thoughts/urges and intention to act.

16. VETERANS HEALTH ADMINISTRATION Understanding the VCL Caller: Myths and Truths “I don’t have to listen to someone who is yelling and cursing and will end the call.”

17. VETERANS HEALTH ADMINISTRATION Understanding the VCL Caller: Myths and Truths “I don’t have to listen to someone who is yelling and cursing and will end the call.” MAYBE Truths: Veteran callers tend to be angrier than civilian callers. Working through the anger may take longer, thus causing the average Veteran call to be longer (~20 minutes). Notice the difference between ABUSE and ANGER. Set limits if necessary.

18. VETERANS HEALTH ADMINISTRATION Understanding the VCL Caller: Myths and Truths “All Veterans have PTSD (posttraumatic stress disorder).”

19. VETERANS HEALTH ADMINISTRATION Understanding the VCL Caller: Myths and Truths “All Veterans have PTSD (posttraumatic stress disorder).” MYTH! But it is very common in Veteran and 3 rd party Callers concerned about Veterans. Let me help…

20. VETERANS HEALTH ADMINISTRATION Outline Overview of the Veterans Crisis Line Understanding the VCL Caller: Myths and Truths How to Help: PTSD Discussion and Questions

21. VETERANS HEALTH ADMINISTRATION PTSD Overview Sources: 1.“Highlights of Changes from DSM-IV-TR to DSM-5,” American Psychiatric Association 2. “Posttraumatic Stress Disorder in DSM-V,” American Psychiatric Association 3. National Center for PTSD: www.ptsd.va.gov/professional/pages/diagnostic_criteria_dsm-5.asp www.ptsd.va.gov/professional/pages/diagnostic_criteria_dsm-5.asp Learn more: Charles W. Hoge, M.D. http://dcoe.health.mil/Training/Monthly_Webinars/2013_Webinars.aspx

22. VETERANS HEALTH ADMINISTRATION PTSD Overview PTSD MAKES SENSE! If you experienced a traumatic event(s) (criterion A), that you kept remembering even though you would prefer to forget (criterion B) and try to avoid anything that reminds you about it (criterion C), wouldn’t you feel badly, have a negative view on life (criterion D) and try to prevent anything like that from happening again (criterion E)? I would!

23. VETERANS HEALTH ADMINISTRATION How to help: The Caller experiencing PTSD symptoms As always, LISTEN, reflect, paraphrase, and empathize Stay present with the Caller—just be with them, riding the waves of emotion. Use a soothing tone of voice, but do not condescend BE GENUINE – Don’t pretend you have been there if you haven’t. – Honestly reflect how their story makes you feel: “That sounds so overwhelming,” “That would have made me angry too,” “Your story is heartbreaking,” “I can’t imagine how awful this has been for you.” – Your quiet tears and sniffles are okay! Just don’t make the call about you. – It is an honor to be “the first person I’ve ever told.” Let them know that.

24. VETERANS HEALTH ADMINISTRATION How to help: The Caller experiencing PTSD symptoms Avoid pat answers and clichés – Time does not heal – They will not forget – They don’t believe it will get better or that they will be okay Avoid comparing or sharing your own experiences: even if you have experienced the exact same type of trauma, even if you were standing next to them when the trauma occurred, each person experiences trauma differently. Support posttraumatic growth: “the positive changes individuals may experience following a traumatic event. For example, following a traumatic event, some people report positive changes in their goals, priorities, relationships with others, and spirituality as a result of re-evaluating or modifying their assumptions about the world and their life.”

25. VETERANS HEALTH ADMINISTRATION How to help: The Caller experiencing PTSD symptoms Sometimes Callers will be in the midst of a flashback or have just awoken from a nightmare: 1.Help them calm their body first, – Let them know you are there and have as much time as they need to help them get calm (you may need to repeat yourself) – Your tone is critical. Speak more slowly than normal. Use short sentences. Say their name to bring them into the present with you. Let them know they are not currently in danger, even though it feels like it. – Encourage attention to the breath: in and out. – Breathe slowly and audibly to model (think of the yawn effect)

26. VETERANS HEALTH ADMINISTRATION How to help: The Caller experiencing PTSD symptoms Sometimes Callers will be in the midst of a flashback or have just awoken from a nightmare: 2. Next help them calm their mind – Do you want to tell me about the dream/flashback? (And accept their answer!) – Has this happened before? – How have you coped before? – Grounding skills Bring awareness to their surroundings – “Where are you now? Tell me what you see around you.” – “Describe something in the room to me as if I’m an alien.” Strong physical sensations (ice water, snap of a rubber band) can help, but do not accidentally encourage non-suicidal self-directed violence

27. VETERANS HEALTH ADMINISTRATION How to help: The 3 rd party caller/support person with a loved one experiencing PTSD symptoms – Many of the suggestions for helping the Caller experiencing PTSD symptoms apply to the 3 rd party caller/support person who is coping with a loved one’s PTSD. – Deal with the current crisis as you would normally, especially if the 3 rd party is in danger. – Additional resources: Coaching Into Care Caregivers Support Line

28. VETERANS HEALTH ADMINISTRATION Listening to trauma stories Never push someone to disclose a story, but instead ask if they would like to share it. Sometimes the story will pour out despite the Caller’s intention. Remain non-judgmental. Listen for changes in affect: – If they seem to be becoming MORE upset, reflect that. You can (gently) stop them and ask if they would like to continue. Always do so with the Caller’s comfort in mind, not your own. – If they seem to be calmer after telling the story, reflect that too. “I can hear that talking has helped you calm down” paves the way for getting the person to a therapist/SPC.

29. VETERANS HEALTH ADMINISTRATION Listening to trauma stories MOST IMPORTANTLY: TAKE CARE OF YOURSELF EVERY DAY – Self-care regimens are crucial – Take a break/walk after a tough call – Talk to a colleague in the moment – Try to leave your experience in the call center – Remember the trauma is theirs and you do not lessen their pain by taking it on – Use EAP or a personal therapist – Attend or begin discussion sessions

30. VETERANS HEALTH ADMINISTRATION Outline Overview of the Veterans Crisis Line Understanding the VCL Caller: Myths and Truths How to Help: PTSD Discussion and Questions Kimberley.mullen2@va.gov 585-393-7613