Veterans, Military Culture, and Intimate Partner Violence

1. Veterans, Military Culture, and Intimate Partner Violence Presented by : Shae Allen, LGSW, Domestic Violence/IPV Program Coordinator Emergency Department/Primary Care Transitional Social Worker United States Navy Veteran

2. Goals and Objectives • 1) Understand the Military/Veteran culture and potential correlation within DV/IPV. • 2) Learn to identify additional risk factors in screening for DV/IPV with Veteran and Military families. • 3) Gain understanding of deployment and combat related health hazards and stressors to enhance current screening interventions. • 4) Identify appropriate treatment and intervention strategies for Veterans experiencing DV/IPV. • 5) Learn to identify barriers to facilitating DV/IPV screenings and interventions with Veterans, military members, and their families. • 6) Gain overview of definitions and benefits associated with military service and Veteran benefits to assist in comprehensive screening.

3. The Need for Developing a Military and Veteran Cultural Competency • Diverse clients require diverse services. • As the delivery of a service becomes more population specific, the service become more effective. • Developing a military/Veteran cultural competency can aid in decreasing barriers that preclude effective interventions. • Allows us an opportunity to honor those who have honored us with their service.

4. So Why is a Veteran/Military Cultural Competency Relevant? • We will all work with Veteran populations. • Veterans can, and often do, correlate Veteran Healthcare with community services. • Community providers often provide specialized treatment that the Veterans Administration (VA) or Department of Defense ( DoD) does not provide. • Many Veterans are not eligible for VA Health Care services, or are not aware of their access to benefits. Community providers play a vital role in enhancing services to Veterans.

5. Agenda For Developing A Military and Veteran Cultural Competency: • Develop a basic understanding of the military branches and Veteran services. • Learn to identify common stigma and barriers to care. • Learn to identify combat and service related disabilities, specific conditions, and service member transitional concerns. • Understand how the personal beliefs of the service member or Veteran may affect their perception of circumstances. • Recognize the role that family members and caregivers play in the lives of service members and Veterans. • Become aware of how personal beliefs relating to military service, benefits, and political concerns may affect the development of cultural competency. • Identify strategies to utilize competency to enhance services to family members of service members and Veterans. • Learn to identify basic elements of military culture and service member identity. • Identify Military and Veteran service terminology/definitions.

6. Developing a Community of Practice • Military branches, instillations, and Veteran service providers often operate independently, and differ in response and intervention. • Community providers may often be unfamiliar with the military and Veteran Health Care system. • Community advocates and providers play a unique role in sharing expertise of local services, state laws and policies with Veteran health care providers. • Community providers often are in a position to assist service members, family members, and Veterans in accessing comprehensive care. • Sharing training, education, and information will lay the groundwork for developing a strong Community of Practice.

7. Focus on a Intimate Partner Violence Community of Practice • In December, 2013 the VHA finalized the “VHAPlan for Implementation of the DV/IPV Assistance Program”. • This included suggestions for developing a community of practice with community service providers. • In 1999, Department of Defense created a Task Force on Domestic Violence that included both military and community experts. • Recommendations from this Task Force have been integrated throughout military services. • Recommendations have included an emphasis on strong civilian/military partnership to prevent and assist with DV/IPV. • Many Military installationsand VHA services continue to develop practice methods and policies to include collaboration with community service providers within the DV/IPV community. • Community providers can affect the services provided to our service members and Veterans.

8. Veterans and Service Members in Maryland • There were 435,657 projected Veterans residing in Maryland during the year 2014. • 450,000 Maryland veterans and their families are eligible to utilize services provided by Maryland’s Commitment to Veterans. • According to the Department of Veterans Affairs, there are over 64,000 women veterans residing in Maryland. • http://servingtogetherproject.org/services/marylands-commitment-to-veterans-2/

9. Veteran/Military Populations and Intimate Partner Violence We Will- • Review DV/IPV services and response within the military and Veteran community. • Review barriers to accessing DV/IPV treatment within these populations. • Discuss service member/Veteran specific health care concerns that may correlate with DV/IPV concerns. • Identify appropriate treatment methods and intervention strategies for Veterans who are using/experiencing DV/IPV. • Discuss basic history and key elements of DV/IPV as it relates to the Department of Defense, Veteran Health Administration, and those who served.

10. Veterans, Service Members and Intimate Partner Violence • IPV Within Veteran and Military Populations: • Basic core factors of DV/IPV are no different • Characteristics of service, stigma, and military lifestyle can result in unique risk factors • Transitional and combat/deployment experience may exacerbate IPV, or cause an increase in frequency of events • To care for service members and Veterans experiencing or using Intimate Partner Violence, it is imperative to understand the culture of that client.

11. Where Do We Start?

12. Active Duty • The largest percentage of service members in each branch serves on Active Duty. • Their service is full-time, whether deployed overseas or domestically. • Active-duty service members receive a salary paycheck and full benefits, including health care, housing allowance and 30 days of paid vacation per year. • They receive full healthcare and housing allowance for spouses and dependents. Dependents of a spouse can also receive healthcare benefits.

13. Reserve Duty • Each Service has a corresponding Reserve, and most states and territories have an Army National Guard and Air National Guard unit. • Reserve members receive the same training as active-duty peers, but do so close to home until deployed. • Many hold full-time jobs or attend school full time in additional to service. Often all of the above. • Army National Guard • Most U.S. states and territories have an Army National Guard unit. Both the president and state governors can call on them as needed. They are sometimes deployed internationally alongside full-time service members, but most often work in disaster relief or other emergency situations within the United States. • Air National Guard • Like Army National Guard units, Air National Guard units are found in most U.S. states and territories. Air National Guard members also have civilian jobs and train close to home, although they can be deployed abroad. They receive the same training as their active-duty counterparts, and their roles include defending the nation by air, delivering aid following a natural disaster or providing emergency health care.

14. Basic Military Structure Branches of Service

15. Five Active Branches of the Military • Army– The oldest branch of the Military, the Army protects the security of the United States and its resources. • Navy – The Navy defends the right to travel and trade freely on the world’s oceans and protects national interests overseas. • Marine Corps – Working closely with the Navy, the Marine Corps is often first on the ground in combat situations. • Air Force – The Air Force protects American interests at home and abroad with a focus on air power. • Coast Guard – The Coast Guard is a military, multi-mission, maritime service within the Department of Homeland Security. Its core roles are to protect the public, the environment and U.S. economic and security interests in any maritime region, including international waters and America’s coasts, ports and inland waterways.

16. A Complex Culture, Not Your Average Job • Each Branch has its own primary mission, symbolism, and core values. • Branches of service will share a focus on: • Discipline/structure • Pride in service • Professional ethos of Loyalty • Self-sacrifice • Code of honor • Focus on hierarchy and rank structure • Emphasis on group cohesion • Esprit de corps that connects service members and Veterans to each other The individual is secondary to the unit

17. Why A Military Career? • Loyalty and Honor • Courage • Physical Challenge • Community/peer support • Recognition • College benefits • Income • Vocational training • Pride • Encouragement from teachers/recruiters/family members

18. Enlistment Requirements and Exclusions • Age requirements: • Physical health requirements: • Substance abuse history: • Mental health history: • Criminal history limitations:

19. Moral Waivers Required for Enlistment A moral waiver is an action by United States armed officials to accept, for induction into one of the military services, a recruit who is in one or more of a list of otherwise disqualifying situations: • Adult felonies • Juvenile felonies that involved violence • Offenses involving the sale or transfer of illegal drugs • Sex offenses • Domestic violence that falls under the Lautenberg Amendment: • The 1996 Lautenberg Amendment to the Gun Control Act of 1968 makes it unlawful for anyone who has been convicted of a misdemeanor of domestic violence to possess firearms

20. Language and Acronyms • The military and Veteran community has its own unique language and terminology • Common Acronyms: • SM-Service Member • PTSD-Post Traumatic Stress Disorder • TBI- Traumatic Brain Injury • MST-Military Sexual Trauma • DoD-Department of Defense • VHA-Veterans Health Administration • VBA-Veterans Benefit Administration • OIF/OEF/OED-Combat periods that often refer to returning combat Veterans • SC-Service-Connected Disability

21. Understanding the Language • Use of language/acronyms may indicate services your client has accessed, could potentially access, and identify possible risk factors. • Individual service members, military branches, VHA,VBA, and family or community members may inter-use terms and definitions. • Terms may have different meanings within different contexts. • Learn to recognize terminology, and when to ask for clarification on: • What does this term means? • What service/benefit your client is correlating the term to? • Most importantly….What does the term mean to them?

22. For Example… What Does PTSD Mean: • To an active duty, deployed service member? • To a Vietnam Veteran? • To a recently returned combat Veteran? • To a spouse of a service member/Veteran? • To a community provider treating a service member/Veteran for childhood trauma • To the Veterans Benefits Department? • To a Veterans Health Care Provider? • To a Community service provider?

23. The Military Service Member Understanding The BattleMindset • Many strengths and skills developed during military service will solidify a Veteran identity. • Many service members and Veterans have been significantly trained in vigilance, resilience, and responsive behavior. • Aggression and hyper-vigilance are useful tools within military service, but often translate into social and behavioral difficulties when returning home. Learn to assist your client in identifying behavior as a strength vs. a barrier

24. Battlemindeness • Battlemindis a framework developed by the military to understand that the combat skills and mindset that prepared service members for deployment and combat may now negatively affect social and behavioral health at home. • Battlemind is the Soldier’s inner strength to face fear and adversity in combat with courage. • Battlemind may become “hazardous” to social & behavioral health in the home zone… • This relates to many aspects of service member transition, but can have specifically have an impact on DV/IPV.

25. BATTLEMIND War Zone Home Zone Withdrawal Controlling Inappropriate Aggression Hypervigilance “Locked and Loaded” at Home Anger/Detachment Secretiveness Guilt Aggressive Driving Conflict • Buddies (cohesion) • Accountability • Targeted Aggression • Tactical Awareness • Lethally Armed VS. • Emotional Control • Mission Operational Security (OPSEC) • Individual Responsibility • Non-Defensive (combat) Driving • Discipline and Ordering

26. The Military “Norm” • You cant quit….even when it hurts • You cant call in sick, you can walk it off • If you are sick, you have to go to “sick call” • You will miss important family events, and your family will be proud to support you • You will face danger • You will never leave a comrade behind • Belief that you: • Never quit • Never show pain • Never give up • Never give in

27. Military and Veteran Cultural Norms • Learn to assist client in differentiating between military/Veteran norms and common elements of IPV/DV • Within the Veteran and Military culture it is common for someone to tell you: • What to wear • Wear to sleep • Where to go • Where to live • Where you can go • Who you can call • What to eat • When to eat

28. Military Identity • Each member has a mission. • That mission is….the needs of the “Army, Navy, Air Force…” • Focus on the mission and group survival, individual often not considered. • Often stigma relating to identifying “individual” concerns. • Physical pain • Stress or depression • Financial problems • This often translates into transitional concerns or barriers to seeking care as a Veteran.

29. LGBT Service Members • LGBT service members may present with complex barriers to seeking care for a range of healthcare services, to include DV/IPV. • Active Service LGBT members may face increased stigma, fear of disclosure, and lack of support with other service members or peer groupswhen disclosing or reporting IPV. • Transgendered individuals are prohibited from serving in the United States Military if identified. However, many transgendered individuals continue to serve. Fear of retribution can be a strong barrier to seeking assistance given the contextual concerns. • “Don’t Ask, Don’t Tell”(DADT) • A law and policy implemented since 1993 that provided that homosexual conduct is a bar to service in the Armed Forces. • Law was repealed in 2013, but continues to impact stigma.

30. Women Service Members

31. Women Service Members • As of 2011, there were estimated 203,000 female service members (2011 Department of Defense Demographic Report). • In 2011, women made up 2.7% of the military's front-line units (2011 Department of Defense Demographic Report). • Women were previously barred from the infantry, but were allowed to serve on gun crews, air crews and in seamanship specialties. • Despite the prior ban on combat, women who served in Iraq and Afghanistan often found themselves engaged in firefights • 67 of the nearly 3,500 Americans lost in hostile fire in Iraq were female service members. • Female service members experience unique concerns with: • Stigma and perceived barriers to care • Specific health care needs • Higher correlation risks with military sexual trauma than male service members • Unique risk factors with IPV • In 2013, the ban was lifted on women serving in combat.

32. Women Service Members and IPV • Active duty women with 1 child or 3 or more children were 2 times more likely to experience physical and/or sexual abuse than women in the military with no children (Campbell et. al, 2003). • Prevalence rates of IPV experienced by active duty women varies between 13.5-58% (Campbell et. al, 2003). • In the sample of active duty military women from the greater Washington, DC metropolitan area, 29.9 percent reported adult lifetime intimate partner violence, defined as physical and/or sexual assault from a current or former intimate partner (Campbell et. Al, 2002). • Female service members are often fearful of reporting incidents due to the lack of confidentiality and privacy as well as limited victim services. • Many female service members will seek community providers to maintain privacy.

33. Military Factors Relating to DV/IPV • Reporting options • (Restricted vs. Un-restricted) • Spouse/Family member concerns • Jurisdiction issues • Protection orders

34. Military Reporting Options “Restricted Reporting” “Un-Restricted Reporting” Individual can access same services as restricted reporting, but a legal investigation is started. Once there is an un-restricted report, the individual cannot choose to revert to restricted. Commanders of both parties will be notified, if applicable. • Give service member experiencing violence time to receive information and support before reporting. • Allows those to disclose details of violence to authorized individuals and/or receive medical attention without starting a legal investigation. • The alleged offender’s Commander or law enforcement is not made aware of services. • Those authorized to receive a Restricted Report are domestic abuse victim advocates, the supervisor of victim advocates or a healthcare provider, including those on the Family Advocacy Program.

35. The Lautenberg Amendment • “Gun Ban for Individuals Convicted of a Misdemeanor Crime of Domestic Violence,” Pub. L. 104-208, 18 U.S.C • Amendment bans access to firearms by individuals convicted of crimes of domestic violence. • May require military member to be discharged or re-assigned. Impact on strict reporting procedures relating to DV/IPV and service members. • Often precludes family members from reporting DV/IPV, as fear of loss of individual’s military service is a concern.

36. Soldiers and Sailors Civil Relief Act • Soldiers & Sailors Civil Relief Act (SSCRA), legislation designed to help ease the economic and legal burdens on military personnel called to active duty status. • Can protect service members from attending court hearings relating to custody, divorce, and civil proceedings. • http://www.bwjp.org/files/bwjp/files/SCRA_and_Protection_Orders.pdf

37. Military Spouses and Partners • Spouses and intimate partners often “hold down the home front” as our service members deploy. • They often move frequently, become isolated, delay careers and education, may be economically dependent, and share children with the service members.

38. Military Experience into Veteran Identity • Veterans often strongly identify with their military service, beliefs, and military values. • Military members and Veterans may be unable to identify their transitional issues, or be aware of concerns. • Service members and Veterans may maintain pride associated with why behaviors were developed, even during negative outcomes. • It is important to be able to assist the Veteran in clarify the different responses to these mindsets. • Learn to use the strengths that have been developed to work through negative patterns of behavior.

39. Military and Veteran Cultural Training Can… • Assist in decreasing stigma relating to seeking treatment. • Increase provider knowledge of obstacles/barriers to reporting DV/IPV within military and Veteran populations. • Provide an understanding of the impact that military service and Veteran benefits can indicate, as both a strength and a barrier to seeking care. • Allow the provider to develop a stronger rapport with client, and assist in comprehensive care coordination.

40. United States Veterans

41. United States Veterans • According to the 2010 US Census Data, there are 22,658 Million Veterans in the United States. • More that 1.3 Million of those Veterans have served in multiple wars. • Veterans are at risk for unique concerns, such as combat related PTSD, TBI, MST, transitional difficulties, homelessness, and higher rates of divorce and DV/IPV within certain populations.

42. Definition: • “For the purposes of VA health benefits and services, a person who served in the active military service and who was discharged or released under conditions other than dishonorable is a Veteran”. • Many Veteran services and benefits will correlate with specific factors relating to individual service. • Veterans may not identify with Veteran services: • I did not serve in combat • I am not over 65 • Female Veteran services

43. Types of Discharge

44. The DD-214 • The DD Form 214, Certificate of Release or Discharge from Active Duty • Form is required to access VA benefits, unless previously utilized • If lost, new copy can be requested via Veterans Service Records through National Archives. Can be completed online or via paper form SF-180 • Example DD-214

45. Recognized War Eras • World War I (April 6, 1917 – November 11, 1918) • World War II (December 7, 1941 – December 31, 1946) • Korean conflict (June 27, 1950 – January 31, 1955) • Vietnam era (February 28, 1961 – May 7, 1975 for Veterans who served in the Republic of Vietnam during that period; otherwise August 5, 1964 – May 7, 1975) • Gulf War (August 2, 1990 – through a future date to be set by law or Presidential Proclamation)

46. Structure of U.S. Department of Veterans Affairs The Department of Veterans Affairs is comprised of : • Veteran Benefit Administration (VBA), Veteran Health Care Administration (VHA), and National Cemetery Administration (NCA). • Service members may use one benefit, and not have applied or be eligible for another. • Enrollment in the VHA is not guarantee of VBA Benefits (Such as service-connected disability). • Those with awarded service-connected disabilities or use of VBA benefits, may have never utilized VHA services. • VHA and VBA do not always share record and chart systems, and Veterans may be required to release information for correlation.

47. Veterans Benefit Administration • Provides benefits and services to Service Members, family members, and Veterans, may include: • Service-connected disability payments • Education benefits • Home loan eligibility • Survivor benefits • Vocational Rehabilitation programs

48. Veterans Healthcare Administration • Minimum duty requirements are often determined in consideration with discharge type, service-related disabilities, medical conditions, and specific war-era contextual factors. • Veteran Healthcare services often include in-patient services, outpatient services, specialty care, mental health treatment, and substance abuse treatment. • Not every VHA will provide identical services, or have identical process for accessing care.

49. RETURNING VETERANS PROGRAM • Operation Enduring Freedom, Operation Iraqi Freedom, Operation New Dawn (OIF/OEF/OND). • Developed to meet the needs of troop members returning from recognized Global War on Terror Theaters of Combat or countries in support of these efforts. • Allow for a transition from Department of Defense to Veteran Health Administration. • Provides five free years of health care to eligible Veterans. • Provides case management services to allow for a navigation of available health care and benefits.

50. Women Veterans • Though the overall population of Veterans is decreasing, there is a rapid increase in women Veterans (Department of Veterans Affairs). • Women Veterans comprise 7.5 percent of the total Veteran population and nearly 5.5 percent of all Veterans who use VA health care services. (Department of Veterans Affairs). • There are 26,574 women currently enrolled for care in VISN 5 (Many Maryland VA Health Care Facilities fall within this VISN).