1. Another Kind of Valor: A Day of Learning How to Better Serve Veterans and Their Families

2. Introduction “…and they shall beat their swords into plowshares, and their spears into pruning hooks: nation shall not lift up sword against nation, neither shall they learn war any more.” Is.2:4

3. Overview What am I going to learn? –The effects of war on returning Veterans and their families –The effects of war and differences among those who served in all military branches, and in services available to Veterans and their families –How to engage, talk to, work with Veterans and their families –Resources for Veterans and their families

4. Today’s Returning Veterans Who are returning vets? –Over 1.6 million soldiers have been deployed to Iraq or Afghanistan. –Over 1/3 of those soldiers have been deployed multiple times. –Global War on Terror (GWOT): 799,791 veterans are currently separated from the military. –As of January 2008, there were 299,585 GWOT Veterans who have sought health care through the VA. –Over 100,00 veterans have returned to California.

5. OEF: Operation Enduring Freedom OIF: Operation Iraqi Freedom GWOT: Global War on Terror DOD: Department of Defense VA: Veterans Administration VBA: Veteran Benefits Administration VHA: Veteran Health Administration Alphabet Soup: Veteran Key Terms

6. Major Issues for Combat Veterans Major Depression Post-Traumatic Stress Disorder (PTSD) Traumatic Brain Injury (TBI) Military Sexual Trauma (MST) Substance Abuse Suicide Job loss Family dissolution Homelessness Violence towards self and others Incarceration

7. Population: Regular Forces Population: Regular Forces What are concerns for those who served in active duty in the Army, Navy, Air Force, Marines and Coast Guard as well as the National Guard & Reserves? 46.6% of regular forces are under 25 years old. Many entered as teenagers and left home for the first time. They may return to an already unstable home environment with added stress from combat.

8. Population: National Guard & Reserves What are the concerns among National Guard and Reservist Veterans? –The average age of Guard and Reservists is 35.8 years old. –Many Guard and Reservists are forced to leave jobs at or near the peak of their career. –These “volunteer” soldier veterans are half as likely to file VA claims as their regular forces counterparts, and half as likely to have their claims approved.

9. Population: Women Military in the Military What are concerns among soldiers and Veterans who are women? –More women are engaging in combat roles in Iraq. –To date there are between 155,000- 180,000 women who have served in OIF/OEF. –Women are 2 to 4 times more likely than non-Veteran women to be homeless. –Preliminary research shows that women in war have much higher exposure to traumatic experiences than women in the community.

10. Population: Veteran Families What are some of the issues facing Veteran families? –PTSD frequently has a debilitating effect on Veterans’ ability to maintain employment and family relationships. –50-60% of spouses of brain injured Veterans reported having depression. –A drastic increase in the rate of child abuse and neglect in military families has been reported since 2002. –Resources for Spouses and children of Guard and Reservists lose all benefits 90 days after their soldier returns from war

11. Meeting and Greeting Veterans & Families Be quick to listen and slow to speak. When discussing combat experiences, ALWAYS avoid making character judgments. Never say anything as stupid and insensitive as: –So, did you kill anyone? –My mom told me not to date a vet. –Did your (son, daughter, spouse) come back crazy? –What do you think about the war?

12. Talking With Veterans & Families How should I talk to Veterans or their families about their experience? –With respect, compassion and patience. Talking about combat can be an awkward conversation. Ask factual, logistical questions like: –How long have you been home? –What did you do in the military? –How are you transitioning? Be honest and direct in order to earn their trust and build rapport.. –Welcome home. How can I help you? Thank you for your service.

13. Getting Help: Support and Resources Where can Veterans and their families go to get help? –Veterans Administration. –Vet Centers. –Community Organizations like: Coming Home Project Swords to Plowshares –YOU. –What are helpful resources that you would recommend?

14. Resource: Veterans Affairs (VA) The Department of Veterans Affairs Veteran’s Health Administration Vet Centers Veterans Benefits Administration Can’t all veterans go to the VA? –No. Generally, veterans must have an honorable discharge, have served 24 continuous months, demonstrate financial need, and/or have a service connected disability. –OIF/OEF Veterans who served in combat are eligible for 5 years of free health care and may be eligible for 90 days of dental care after separation. –Veterans must apply separately to the VHA and the VBA. –Vet Centers are designed to serve combat veterans, their surviving family members and victims of military sexual trauma (MST). –Provide marital and family counseling with counselors who are a Veteran as a conduit for care.

15. Barriers to Assistance I sent a veteran to the VA for help, so they should be okay, right? –Hopefully. Veterans do not always receive immediate assistance. –The backlog in Veteran benefit claims has risen to 600,000. –As of June 2007, there were 202,705 GWOT Veterans filing claims for the first time. –The AVERAGE WAIT TIME for an initial decision on a claim 183 days! –The time frame for a claim decision, including appeals, can exceed 10 years

16. What can I do to Help Veterans and Their Families? Learn –About military culture, experiences of soldiers, and the needs of military, Veterans and their families. Give –Them some of your time and energy, your appreciation, and your resources. Be an Advocate –For military, Veterans, and their families Talk –To them with respect and honor, listening with compassion and patience.

17. Engagement Skills Practicing empathy Providing choice Removing barriers Providing feedback Clarifying goals

18. PTSD: Combat Stressors Being in constant alert for an IED/‘Booby trap’ or other life threatening dangers. Feeling responsible for the death of an enemy and fellow human. Seeing or experiencing the death or injury of a friend or fellow soldier. Being shot at or exposed to other dangers. Sexual trauma.

19. Symptom Response Acute stress reaction – immediate Acute stress disorder – up to 1 month Acute PTSD – 1 to 3 months Chronic PTSD – 3 months and beyond

20. PTSD: Diagnostic Criteria Re-experiencing: thoughts, nightmares, flashbacks, emotional reactions, physiological reactions. Avoidance: Avoid thoughts, reminders, amnesia; detachment, numbing, anhedonia. Arousal, sleep disturbance, concentration problems, anger, hypervigilance, hyper startle response.

21. PTSD: Impact on Families Intimate relationships: –Directly effect the relationship: Anger responses, withdrawal of affection, unpredictable responses –Indirect affect on relationship skills e.g. impaired communication skills, avoidance, numbing, etc. – Perception of the relationship: satisfaction with relationship reduced

22. PTSD: Impact on Families Spouse/partner Direct impact of PTSD symptoms Indirect: added stress, lack of intimacy Domestic violence Secondary trauma: “Contagious” PTSD Compassion fatigue Caregiver burden

23. PTSD: Impact on Children Direct effects: developmental milestones delayed, adjustment issues, frightened of parent Indirect effects: parenting skills/role changes, compromised e.g. hypervigilance, avoidance/withdrawal, anger/aggression Child at risk: increased risk taking, neglect, violence, substance abuse

24. Stages of Recovery and Treatment Ohio Spaniol, Gagne, et al Prochaska & DiClemente Stage of Treatment Treatment Focus Dependent unaware Overwhelmed by disability Pre- contemplation Engagement outreach practical help crisis intervention relationship building Dependent aware Struggling with disability Contemplation/pr eparation Persuasion psycho-education set goals build awareness Independent aware Living with disability ActionActive Treatment counseling skills training self-help groups Inter- dependent aware Living beyond disability Maintenance Relapse Prevention prevention plan skills training expand recovery

25. Motivational Interviewing asking open-ended questions listening reflectively affirming change-related participant statements encouraging self-motivational statements handling resistance without direct confrontation

26. What Helps Cognitive Behavioral Therapy (CBT) Eye Movement Desensitization and Reprocessing (EMDR) Brainspotting Support Groups Assistance with daily living support as needed. Spiritual and Social supports. What have you found to be helpful in serving returning Veterans and their families?