Paving The Way Home Military Culture overview the culture of military families, issues and effective treatments, and sources of support 1 Blaine Everson.

Paving The Way Home Military Culture overview the culture of military families, issues and effective treatments, and sources of support 1 Blaine Everson doceverson@gmail.com 706-369-7911 Alan Baroody na4nb@yahoo.com 912-369-7777 Peter McCall petemccall1@gmail.com 770-329-6156

Presentation Goals There are 5 goals of this presentation: 1.Review ‘causes for concern’ and the need for private and public sector to work together to address these concerns 2.Review how CareForTheTroops is attempting to address these concerns and provide access to information for clinicians 3.Review key military culture issues that can impact the mental health of a military family 4.Review the recommended treatments for military trauma, what triggers to look for, and commonly encountered issues 5.Motivate all in attendance to continue the work to provide mental health support to all military family members 2

Agenda 3 TopicDurationComments Intro and Opening5 Presenters, Goals and Agenda Oath of Enlistment CareForTheTroops.org10 Overview Mission / Role of Clinicians Show Key Website Components for Clinicians Review Enrollment and Marketing Assistance Causes For Concern En’visioning’ the Issues 25 Brothers at War Trailer Audience Discussion Fraser Center Perspective Military Culture15 Jargon and Organization Deployment/Family Life Cycles Stressors Clinical Treatment Info15 Demographics PTSD-Signs and Treatments Family Therapy Approaches Case Study Q&A and Closing5 On-Going Discussion Handout – A0 …..an Example

CareForTheTroops, Inc. Who Are We – ‘Big Picture’ CareForTheTroops is working to help the military and their extended family members receive mental health services and support from the civilian elements of our society in the State of Georgia. CareForTheTroops is attempting to equip the civilian support services of society e.g. clinicians, with the capacities to be helpful. We are working toward “building a better net” to catch those that need help before they fall too far and reach moments of desperation. 4

CareForTheTroops Organization 5 Current Board of Directors: PresidentRev Robert Certain, Rector, Episcopal Church of St Peter and St Paul (USAF) Exec DirectorPeter McCall (USArmy) MemberBill Harrison, Partner, Mozley, Finlayson & Loggins LLP (USAF) MemberWilliam Matson, Exec Director, Pathways Community Network, Atlanta, GA MemberAlan Baroody, Exec Director, Fraser Counseling Center, Hinesville, GA MemberJoseph Krygiel, CEO of Catholic Charities, Archdiocese of Atlanta (US Navy) Current Partners: The Georgia Association for Marriage and Family Therapy (GAMFT) The EMDR Network of Clinicians in Georgia Pathways Community Network, Inc Fraser Counseling Center, Hinesville, Georgia (nearby Fort Stewart) Episcopal Diocese of Atlanta Presbytery of Atlanta and the Presbyterian Women of Atlanta Catholic Charities and the Archdiocese of Atlanta 501c3 status has already been approved by the IRS

CareForTheTroops Approach Person in need of support Spouse SiblingsGrandparents Parents Children 6 Military Member

How We Can Help Each Other 7 Help For You Use the web site as a resource www.CareForTheTroops.orgwww.CareForTheTroops.org Information and reference material Training Referrals Use your involvement with CFTT to help market your practice Help for Us Enroll in the CFTT database Publicize CFTT to community and congregations Would you consider being a Trainer using material like you see today?

Causes for Concern 9 1.Multiple deployments are common causing stress and family attachment issues 2.An April ‘08 Rand Study reported 37% have either PTSD, TBI, or significant Mental Stress (5% all 3). Some estimate >50% return with some form of mental distress 3.Suicide, alcoholism, domestic abuse and violent crimes rates are rising. Suicide is 33% higher in ‘07 over ’06, 50% higher in ‘08, and almost equal to ‘08 by May of ’09 4.Military Sexual Trauma (MST) is running at 16%-23% 5.In 2008, military children and teens sought outpatient mental health care 2 million times, a 20% increase from ‘08 and double from the start of the Iraq war (‘03) 6.DoD and VA facilities are stretched … the Aug 2009 VA claims backlog is 900,000 7.Many more Reservists & Guard than previous wars (54% as of mid ‘08) and they and families are more distant from DoD and VA support facilities 8.Other mental health, marriage, and family problems often occur with or leading up to PTSD requiring attention so they don’t get worse 9.Rand Study estimates that PTSD and depression among service members will cost the nation up to $6.2 billion in the two years after deployment. The study concludes that investing in proper treatment would actually save $2 billion within two years

Brothers At War Film Clip http://www.brothersatwarmovie.com/ 10

Fraser Center Experience Film Clip Comments 11 1.The adrenaline high, or adrenaline addiction – “It’s like the best!” 2.Personality changes. No one returns the same from combat or lengthy deployments. 3.Generalized and undifferentiated anger: short fuse, loss of patience, (increase in domestic violence and child abuse). “Now when he gets mad, he just screams.” 4.Grief over absence during important life transitions (also, resentment by spouse at soldiers absence). “When I come home I just want to hug her, but she may not let me because she won’t know who I am.” 5.Intense bonding during deployment competes with and sometimes trumps marital and family bonds. “My friends here are closer than any I’ve had.” “These guys take you on as a brother.” 6.Survivor guilt and loss: “It hurts a lot to lose fellow soldiers.” 7.Family of origin issues: “I want to make my Dad proud.” 8.Fantasy verses reality. (living on dreams and through TV series) 9.Emotional numbing: “He used to be sensitive. Now, he shows no emotion and wants me to be the same way.” 10. The ramifications of “sacrificing for family” and the sacrifices made by families. THERAPEUTIC ISSUES OBSERVED IN THE CLIPS FROM “BROTHERS AT WAR”:

Chris Warner’s Sources of Stress 12 Warner CH, Breitbach JE, Appenzeller GN, et.al. “Division Mental Health: It’s Role in the New Brigade Combat Team Structure Part I: Pre-Deployment and Deployment” Journal of Military Medicine 2007; 172: 907-11. ---  >> Number of Months

14 Military Culture Sociologists define culture as … Language - nomenclature; acronyms, abbr. Beliefs – defenders of Democracy Value Systems – leave no one behind Norms & Rules – formal & informal conduct Culture is associated with a social system and unique to a given system. Handout – A2

Language Barriers for Civilians Glossary of Military Terms and Acronyms Military Cultural Competence 15 Handout – A3_1, A3_2, A3_3, A3_4 OEF Operation Enduring Freedom – it is a multinational military operation aimed at dismantling terrorist groups, mostly in Afghanistan. It officially commenced on Oct. 7, 2001 in response to the September 11th terrorist attacks. OIF Operation Iraqi Freedom - also known as the Iraq War; began on 3/20/2003. USAR United States Army Reserve USANG United States Army National Guard Title 10 – Title 3210=Federal Orders; 32=State Orders; these impact benefits available E1-E9; O1-O10Enlisted Ranks; Officer Ranks SPC Specialist, rank of E4, often referred to a “Spec 4” First SGTFirst Sergeant, rank of E7, lead enlisted person in a company. It and SSG, Staff Sergeant are key leadership ranks with lots of job pressures NCONon-Commissioned Officer, ranks E6 through E9 IEDsImprovised Explosive Devices FOBForward Operating Base SandboxIraq and Afghanistan Down RangeDeployed to anyplace where there is shooting. Outside the WireLeave the safety of the “enclosed” military base (FOB) Taking the Pack OffLeaving mentally and physically from combat Top CoverMaking sure the boss looks good www.rivervet.com/oif_glossary.htm

16 The next few charts cover organizational background to help understand the client, where he/she was positioned, and to better interpret the information and stories they might tell during their therapy

Branches of the Military 17 Georgia’s Military is dominated by Marine and Army units, though Air Force and Navy are represented as well. Georgia’s National Guard also has a large number of transportation units subject to IEDs on roads and highways. NOTE: Coast Guard is now under Homeland Security Handout – A4

Military Branch Structures Example: U.S. Army 18 Handout – B1, B2, B3 Core Values 84% 2% 14% 84% 2% 14%

19 Military Culture Belief and Value Systems; Norms and Rules Beliefs: Defenders of Democracy Trust in the leadership Role clarity Distrust of civilians Value Systems: Leave no one behind “The Group” practically becomes a ‘family system’ Top Cover - defend and support the boss Violence - many have a history of violence which often plays a role Norms & Rules: Formal and informal conduct Stigma of mental health and PTSD Cover of the boss (Top Cover) Back-logging trauma

Reserve and National Guard Units vs Regular Army 20 Units are small & based in local communities. Part-time soldiers, often working with local police, fire, and EMS. Families may be left in a town with little or no support services. Mostly support units in Georgia (transport, MP, etc) Likely to work within local communities Can’t relocate easily when activated Lack of military related health services - PCP not Tricare approved Make use of family or local supports (congregation, etc.) Units are based at major military installations. Full-time soldiers who expect to be deployed. Families are left at their post where a variety of support is in place both on- post & in communities. Are part of a larger fighting force including 1/5 combat units. Live on-post or nearby; other family support Less need to relocate when deployed Access to a variety of health, welfare, & educational services Support groups in-place through soldier’s unit Handout – C1 Reserve / GuardRegular

21 The next few charts provide some background of this war that might help you better understand your client and their presenting story and issues

Why is this war different? Volunteer vs. draft Multiple deployments Type of suicide bombings Never any safety, no real recovery time Use of civilians as shields and decoys by the enemy Deliberately targeting our moral code COMMUNICATION! Internet, cell phones, etc. IEDs, RPGs (TBI, hearing loss, neuro-chemical effects) Advancement in medical treatments 22

OIF/OEF - Statistics 23 As of 12/1/2008 1.7M troops deployed 4207 US Military killed in Iraq (excludes civilians) 627 US Military killed in Afghanistan (excludes civilians) 65,000+ US Military wounded 54% deployed are Reserve / Guard (4/08) Deployed as of 09/2009: ~ 130K troops in Iraq ~ 160K civilian contractors in Iraq ~ 65K troops in Afghanistan (more are being sought as of Oct 2009)

15 wounded for every 1 fatality (Vietnam was 3 for 1) VA predicts that it will treat 263,000 OIF/OEF vets in 2008 and 330,000 in 2009 Current backlog of veterans is 400,000 (as of 2008) Claims backlog is over 900,000 (as of Aug 2009) Heaviest of that backlog is mental health (Ex: Virginia VA community mental health services has a waiting list of 5,700 as of early 2008) 550,000 school age children of active duty Service Members (Reg/Res/NG) 84% of Regular Military Service Members’ children attend public school, not DoD base schools Georgia has over 750K veterans 24 OIF/OEF - More Statistics Handout – C3

According to a new American Journal of Public Health study on veterans' mental health diagnoses –Of the 289,328 veterans who entered VA care in 2008, nearly 37% had mental health problems, including post traumatic stress disorder (about 22%) and depression (roughly 17%). (ref: http://www.ajph.org/cgi/content/abstract/AJPH.2008.150284v1 ) http://www.ajph.org/cgi/content/abstract/AJPH.2008.150284v1 –"Weekend warriors" over 30 years old in the national guard and reserves who left stable family, work and community environments for combat zones were especially susceptible to mental health problems. A recent (July, 2009) US government accountability office report found that nearly 20% of women veterans suffer from PTSD (ref: http://www.gao.gov/new.items/d09899t.pdf )http://www.gao.gov/new.items/d09899t.pdf 25 OIF/OEF – and some more Statistics

26 The next several charts will cover life within the military family and clinical treatment considerations

27 Soldier Deployment Separation Stress – Depression & Anxiety Family Adjustment w/o Soldier in Home – Out-of- Ordinary Behaviors Pre-reunion Stress – anxiety and worry about behavior away Reunion and homecoming – joy and anticipation Revitalize Relationships and “honeymoon” Family readjusts - Consequences for behavior Pre-deployment Conflict & Previous Stressor pile-up Pre-deployment Stress – anxiety and concern The Military Deployment Cycle … or The Military Family Life Cycle

Military Family At-Risk Factors 28 1.Frequent Relocation 3.3 years average 2.Previous Deployments 87% 3.Longer Separations 7.3 month average 4.Larger Families 42% ≥ 3 children 5.Younger Mothers 26.5 median age 6.Blended Families 31% step-parents 7.Education21% w/o HS diploma 8.Working Outside Home 44% 9.Median Income < $30,000 (34%) Quality of Life Among U.S. Army Spouses During OIF, Dissertation, 2005, Dr. Blaine Everson

29 Deployment Related Stressors for Spouses STRESSORPOSITIVE RESPONSE Feeling Lonely90.0% (271) Having Problems Communicating with my Spouse61.2% (184) Experiencing the Death of a Close Friend or Relative33.2% (100) Managing and Maintaining Family/Personal Finances47.2% (142) Personal/Family Health Issues43.2% (130) Being Pregnant during the Deployment26.9% (81) Raising a Young Child while my Spouse is not Present63.2% (190) Childcare39.9% (120) Managing and Maintaining the Upkeep of my Home49.1% (148) Having Reliable Transportation19.9% (60) Caring/Raising/Disciplining Children with my Spouse Absent 56.5% (170) Balancing between Work and Family Obligations/Responsibilities 53.4% (159) The Safety of my Deployed Spouse96.4% (290) Warner CH, Appenzeller GN, Warner CM, Grieger T. “Psychological Effects of Deployments on Military Families” Psychiatric Annals 2009; 14: 56-62.

Summary of Stressors 30 For Active Component Families Permanent Change of Station (PCS) Temporary Duty (TDY) Deployment Foreign Residence Risk of Injury or Death Behavioral Expectations Additional for Reserve/Guard Component Families “Citizen Soldier” Mobilization and Deployment Separation from School, Jobs, etc Demobilization

31 …a closing thought on the Military Culture they believe they are getting a square deal “The capacity of Soldiers for absorbing punishment and enduring privations is almost inexhaustible so long as they believe they are getting a square deal, that their commanders are looking out for them, and that their own accomplishments are understood and appreciated.” GENERAL Dwight Eisenhower, 1944

Demographics - Young Adults in the Military 33 46.6% of all service members are <= 25 yrs old 53% of enlisted members are <= 25 yrs old 24.8% reported binge drinking >1x per week in the past 30 days vs 17.4% for same-age civilians Higher smoking rates (40% vs. 35.4%) than same-age civilians Illicit drug use in the military was 5% in 2005, but nonmedical use of painkillers is the most common form of drug abuse. Source: Military Family Research Institute at Purdue University.(2005). 2005 demographics report. Arlington, VA: Office of the Deputy Under Secretary of Defense, Military Community and Family Policy. Retrieved January 7, 2009, from www.cfs.purdue.edu/mfri/pages/military/2005_Demographics_Report.pdf Handout – D2

Demographics – GENDER AND RANK 34 Women represent approximately 15% of the military force. Representation of women is slightly lower for Senior Enlisted and General Officers.

Demographics – MARITAL STATUS 35 RED = Civilian BLUE = Total DOD Marital Status Divorce Trends AC=Active Duty RC=Reserves/Guard

Demographics – Suicide 36 Two dominant factors: 1.Financial Stress 2.Concerns with Intimate Partners The 2008 overall Army rate was 24/100K, a 33% increase 70% increase reported from 2005 to 2008 Handout – E1

Psychological Injury Continuum: ASR to COSR to PTSD 37 ASR (acute stress reaction) produces biological, psychological, and behavioral changes. ASD (acute stress disorder) means it has become disruptive and destructive. COSR(combat and operational stress reaction) is expected, common, and occurs throughout deployment to some degree. Pretty much everyone comes home with some version of combat and operational stress. PTSD(post traumatic stress disorder) becomes classified if COSR symptoms are daily, interfere, and “last longer than 1 month”

SIGNS / SYMPTOMS OF (COMBAT) PTSD 38 HYPER-AROUSAL: Fight/Flight/Freeze, Angry, poor sleep, argumentative, impatient, on alert, tense (hyper-vigilant), intense startle response, speeding tickets (once home) and other risky behavior. NUMBING/AVOIDANCE: Withdrawn, secretive, detached, controlling, removes all reminders, avoids similar situations, ends relationships with people associated with trauma, etc. RE-EXPERIENCING: Nightmares, flashbacks, intrusive thoughts

PTSD: Cues or Triggers 39 Think “full body”: memories are laid down in all sensory spheres (smell, sound, vibrations, colors, etc) Terrain: desert, urban Weather: heat wind, humidity Songs Smells Driving: signature trigger for OIF/OEF vets (assess driving safety !) Nature of war in Iraq and Afghanistan Need for high speeds, evasive maneuvers Importance of a driving assessment People: automatic response to persons who appear Middle Eastern, children Situational: mimic loss of control powerlessness (e.g. dentist chair, anesthesia, OB-GYN exam, endoscopy, etc)

PTSD: non-DSM 40 What does PTSD feel like – What do you “hear” in therapy 1.Sense of immediacy (“happening right now”) 2.Re-experiencing of original memories and sensory impressions 3.Involuntary 4.Guilt Rational or irrational Understanding atrocities “Survivor Guilt”, also guilt for leaving, being intact 5.Grief Multiple losses without time to grieve Affective numbing, anger/revenge Impact of pre-war losses, post-war losses Deaths of loved ones during deployment 6.Other Feelings Anger at Government Mistrust of Authority Desire to return to the war zone Damage to spirituality Handout – F1, F2

TBI: Traumatic Brain Injury 41 Signature Injury of OIF/OEF Prevalence hard to estimate Approximately 2100 Afghanistan troops diagnosed since 2001 as of 08/2007 VA reports 61,285 OIF/OEF vets had preliminary screen, 11,804 were positive (20%) Prevalence has probably been underestimated so far Explosions account for 3 of 4 combat-related injuries Improvements in war zone medical treatment decreases fatalities but may impact rise in TBI Soldier return home with “poly-trauma” Symptoms: headaches, tinnitus, dizziness, balance problems, sleep problems, persistent fatigue, speech, hearing and vision impairment, sensitivity to light and sounds, heightened or lessened senses, impairments in attention and concentration, memory problems more like dementia than amnesia, poor impulse and anger control

MST: Military Sexual Trauma 42 1.2008 Rand Study reported 16% - 23% experienced MST 2.Reported MST were 1,700 in 2004 and 2,947 in 2006 3.VA indicates that 1 in 4 female veterans using the VA reported at least one MST 4.The VA Day Hospital Program estimates 3-5 female referrals have MST 5.Treatment Considerations May be compounded by combat trauma Frequently unreported Trauma occurs in context of where the solder lives and works (comparable to incest) Military Culture emphasizes cohesion Males victims as well as female Female perpetrators as well as male Largely male population in the VA where female veterans go for help Handout – C2

PTSD Treatments Cognitive Therapy (CT) Exposure Therapy (ET) Stress Inoculation Training (SIT) Eye Movement Desensitization & Reprocessing (EMDR) Generally individually oriented and systemically focused – “One size does not fit all” 43 VA Opinion of PTSD Interventions Handout – G1, H1

… A Extra Word About The Children Currently, there are about 230,000 American children and teenagers with an active duty mother or father at war. [Another 320,000 from Reserve/Guard families. 550K total] Nearly half of all troops deployed in support of the recent wars are parents — most of whom are on their second or subsequent deployments. (Aug ‘09) In 2008, military children and teens sought outpatient mental health care 2 million times, which was double the number at the start of the Iraq war (2003), according to an internal Pentagon document obtained by The Associated Press. An article published by the Associated Press (August 9, 2009) notes a Pentagon report indicating a 20 percent increase in the number of active duty dependent children hospitalized for mental health needs between 2007 and 2008. The document revealed there was also a spike in the number of service members' children hospitalized for mental health reasons. http://www.msnbc.msn.com/id/32585278/ns/health-kids_and_parenting/ http://cbs3.com/wireapnewspa/Camp.for.military.2.1147685.htmlhttp://www.msnbc.msn.com/id/32585278/ns/health-kids_and_parenting/ http://cbs3.com/wireapnewspa/Camp.for.military.2.1147685.html 44

Realizing the bridge is down… “Home—the place many think is the safe haven to find relief from the stress of war—may initially be a letdown. When a loved one asks, ‘What was it like?’ and you look into eyes that have not seen what yours have, you suddenly realize that home is farther away than you ever imagined.” Down Range: From Iraq and Back, by Cantrell & Dean, 2005 45 Handout – H2

What This Presentation WAS About 47 There were 5 goals of this presentation: 1.Review ‘causes for concern’ and the need for private and public sector to work together to address these concerns 2.Review how CareForTheTroops is attempting to address these concerns and provide access to information for clinicians 3.Review key military culture issues that can impact the mental health of a military family 4.Review the recommended treatments for military trauma, what triggers to look for, and commonly encountered issues 5.Motivate all in attendance to continue the work to provide mental health support to all military family members

In Closing…Consider These Next Steps 48 Look for more training opportunity to learn about treating the military. Visit www.CareForTheTroops.orgwww.CareForTheTroops.org Consider training in a trauma treatment technique If you are willing to work with military families, enroll in the CareForTheTroops database, complete a Tricare application, and enroll with Military OneSource Consider being a trainer to outreach to community organizations, congregations, and other counselors to participate in the CFTT initiative to market your practice Handout – L1, M1

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Paving The Way Home Military Culture overview the culture of military families, issues and effective treatments, and sources of support 1 Blaine Everson.

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