1. Combat Trauma, Substance Dependence, and Treatment Providers: Understanding What We’ll Never Fully Understand Rodney J.S. Deaton, MD, JD Clinical Director, Substance Abuse Treatment Section, Richard L Roudebush VA Medical Center Associate Professor of Clinical Psychiatry, Indiana University School of Medicine

2. The National Institute on Drug Abuse (NIDA) “Prescription drug abuse doubled among US military personnel from 2002 to 2005 and almost tripled from 2005 to 2008.” “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).” “Drug or alcohol abuse... 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.”

3. Goals Workable Model for to Use in Individual and Group Settings A “Provocative” Encouragement

4. What Doesn’t Work “Silo” Treatment “Business as Usual” Trauma Treatment (i.e., Combat Trauma = Other Trauma)

5. Seeking Safety Najavits, Lisa M. Seeking Safety: A Treatment Manual for PTSD and Substance Abuse Developing Specific Skills of Emotional Regulation So That More Trauma-Focused Work Can Proceed

6. Judith Herman’s Model of Trauma Treatment Phase of Safety Phase of Mourning Phase of Re-Connection

7. The Advantage From the beginning, the veteran is urged to see combat PTSD and substance use disorders as inextricably linked

8. The Recurring Message You never need to use substances to cope. There is always a better (in the long run) alternative

9. Description of Course Twenty-Four Related, Yet Independent Units Focus on Safety (Strength? Principles?) Strong Focus on Case (Self) Management

10. CAVEATS

11. Harm Reduction: Abstinence as Goal, Not as Pre- Requisite

12. Relapse = Trigger for More Focused Interventions, NOT Bump-Up of Care Level

13. “Cookbook Therapy” --and Safety from Emotional Overload (for both veteran and clinician)

14. Summary Self-Medication Meets Biological Substrate

15. Issues with Combat Trauma/Military Culture Do YOU Have What It Takes?

16. Types of Trauma Acts of God Acts of Others Acts of Self

17. Volunteers in Time of War: Honor and Intensity

18. Love, Rage—and Horrific Excitement Dare You Look Inward?

19. Personality and Personality “Disorders” Entitlement and the Ubiquity of Shame “Posttraumatic Identity”

20. “Readiness” Can Your Prescribers “Hack It”? Are You Physically Ready? Are You Worthy of Respect? or the Art of Managing the Hysterical

21. On Street Hustlers, Rebellious Rakes, and Good-Old Country Boys

22. Further Resources www.seekingsafety.org Van Winkle, Clint. Soft Spots: A Marine’s Memoir of Combat and Post Traumatic Stress Disorder Johnson, James D. Combat Trauma: A Personal Look at Long-Term Consequences Shay, Jonathan. Achilles in Vietnam.