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

2. Thanks to our Veterans for their service to our Country

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

4. 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.

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

6. 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?

7. Basics of a Military Hx What was their Rank – Enlisted or Officer Enlisted – E-1 (Pvt) up to E-9 (Sergeant 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)

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

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

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

11. Military Sexual Trauma - MST Unwanted sexual advances? Men and Women are both affected At least 25% of Women veteran 1/5 reportedly raped – under-reported Culture of hiding/minimizing sexual injury Loss of trust in a valued institution This is not ‘only’ work-place harrassment. They ‘live with’ their abuser. Their abuser is protected by the chain of command

12. A veteran’s relationship to weapons Assume they have a weapon Their weapon is an important part of their identity For protection - not harm. Separate the gun from the bullets Use trusted friends, colleagues Trigger locks If lethal ideation is active, get a safety plan

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

14. 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.

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

16. 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

17. 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

18. Added resources Specialized services

19. Age old problem of coming home and re-integrating. Homer & Sophocles More difficult due to the fact that only 1% of the population has done active duty.

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. 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

23. 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.

24. Very rewarding to help the 1% of our Nation’s Warriors Find a way back Home