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1. Title Slide ATR SERVICES AND THE MILITARY:PREPARING YOUR ATR STAFF AND SYSTEM 2:00 p.m. – 4:00 p.m. ESTFebruary 17, 2011 WEBINAR

2. Technical Information • You may ask a question at any time during the Webinar by typing it into the “Questions” field below the slide presentation, and then pressing “Enter.” Most questions will be addressed at the end of the presentation. • Today’s slides as well as additional resource materials are available in the “Downloads” area to the left of the slide presentation.

3. Opening Remarks

4. Moderator Welcome

5. Presenter Introductions Master Sergeant Stephanie A. Weaver Major Angela M. Halvorson Pamela Woll MA, CADP

6. Modules for Today’s Webinar • SAMHSA Priorities and Other Approaches for Addressing the Behavioral Health Needs of Military Members and Veterans • Military Culture • Serving the Military Client • Military Health Programs

7. Module 1: SAMHSA Priorities and Other Approaches for Addressing the Behavioral Health Needs of Military Members and Veterans

8. Need for Treatment and Recovery Support Services FY2010 National Guard evaluations • 6% (59) Primary problem was alcohol or drugs • 7% (69) Secondary problem was alcohol or drugs Suicides in the Army National Guard • Increased 77% from FY2009 to FY2010 • More than 52% were soldiers that have never deployed

9. National Guard Substance Abuse 25% deployed 75% never deployed

10. Drugs of Choice • Alcohol Marijuana Cocaine • Meth Rx Drugs

11. SAMHSA’s Strategic Initiatives Behavioral health care for military personnel and their families is one of SAMHSA’s eight strategic initiativesSource: SAMHSA’s Strategic InitiativeDownload:Strengthening Our Military Families

12. Top 5 Key Considerations • Ensure staff has basic military culture training • Ensure intake staff know military rules • Limited Use Policy • Command-directed requirements • Limitations on type of treatment (e.g., no methadone) • Collaborate with National Guard, base/post, leadership and substance abuse and mental health staff • Partner with VA and TRICARE • Ask for help when necessary

13. Module 2: Military Culture

14. Military 101 • Active and Reserve • All volunteer • U.S. Armed Forces • Five branches

15. Geographic Distribution 1.4 million now in 153 countries: Europe, the Former Soviet Union, East Asia/Pacific, North Africa, Near East, South Asia, Africa, and North, Central and South America 1.6 million deployed to Operation Iraqi Freedom (OIF)/Operation Enduring Freedom (OEF) since 2001

16. Who Enlists? • On average an enlisted • Individual is: • Educated • 92.1% active component (AC) officers have a bachelor’s or higher • <2% 2003-2005 recruits have no high school/GED • Middle-class • 17-29 years of age

17. Demographics Who Enlists? continued 3.8% Asian/ Pacific Islander 1.1% Native American 8.6% Hispanic African American 20.3% Caucasian 64.3%

18. Why? Patriotism Giving back Part of the solution Friends enlisted Education benefits A job Loyalty Finish the mission Home doesn’t work anymore

19. Military Ranks Leadership and Responsibility Officers Enlisted (84%) Officers (15%) Warrant Officers (1%)

20. Military Structure Clear, delineated unit structure Civilian-controlled Structured sub-units Unit terminology Chain of Command Drives Everything.

21. Military Culture Terminology Mindset Specific “way of doing business” Way of life

22. Military Mindset First trained to kill Mission first Ingrained Need to go back Follow orders Control Discipline

23. Military Values Army—Loyalty, Duty, Respect, Selfless Service, Honor, Integrity and Personal Courage Navy and Marine Corps—Honor, Courage and Commitment Air Force—Integrity First, Service Before Self, Excellence In All We Do Coast Guard—Honor, Respect and Devotion to Duty All—Leave No One Behind Above all, it is about honor and integrity for service, comrades and self.

24. “War is God’s way of teaching Americans geography.”—Ambrose Bierce

25. The Combat Zone

26. Sleep Deprivation

27. 80-100 Pounds!

28. Uncertainty Uncertainty Confusion Disruption

29. Constant Tactical Awareness No “front” Insurgency war “Even when it’s safe, it’s not safe” Accelerator and brake

30. Split-Second Decisions

31. Grief Multiple Losses, Grief and Guilt

32. Instant Communication Cell phones, texting, emails Stress and distraction: -In country -At home Stress building on stress “A distracted soldier is a dead soldier.”

33. The Military Family

34. War-zone stress poll • Clinical and Recovery Support Concerns

35. Untreated PTSD About HALFof those who meet DSM criteria for PTSD or depression have sought help or been evaluated.(Source: Tanielian & Jaycox, 2008) See also: Combat Duty in Iraq and Afghanistan, Mental Health Problems, and Barriers to Care

36. Am I “crazy”? No!

37. We’re wired to survive.

38. The Stress and Survival System

39. Fast system Slow system Avoidance Balancing Memory: Gaps Invasion Re-experiencing Complexity of stress effects model Challenges in reintegration back home It’s not simple! Resilience/risk in genetic legacy Resilience/risk in early development & attachment Services that address: Nature, intensity, chronicity of war-zone stress effects: • All these complexities Resilience/risk in later life experiences • Individual goals/needs • Cultural compatibility Resilience/risk in deployment experiences

40. Maintaining humility All we can know about an individual cannot compare with the world of what we can never know. Humility (don’t show)

41. Not showing up Not trusting future providers Not improving Flooding Shutting down Compulsive, reckless behavior Harm to self or others Problems with medication Safety model Safety First! Progressive nature of many post-deployment effects Neurological cues for sense of danger Give them: Fear of shame, judgment and discrimination • Skills • Choice • Control • Respect • Strength orientation • Gradual look at memories • Individual and military-specific • Med monitoring Danger of: Real risks in treatment and recovery Alienation from behavioral health & recovery cultures

42. One size does not fit all.

43. We all have resilience.

44. Module 3: Serving the Military Client

45. Huge Responsibility

46. At 24 Years of Age… “…a soldier, on average, has moved from home, family and friends and has resided in two other states; has traveled the world (deployed); been promoted four times; bought a car and wrecked it; married and had children; has had relationship and financial problems; seen death; is responsible for dozens of Soldiers; maintains millions of dollars worth of equipment; and gets paid less than $40,000 a year.” Source: Army HP/RR/SP Report 2010

47. Understanding Military Responsibilities: Enlisted • Non-commissioned officers (NCOs) execute mission/plan • Often told what to do and when to do it • Provide officers with recommendations • Not often the decision maker • Sr. NCOs have more decision-making ability • Deployed enlisted leaders have more decision-making ability • NCOs teach and instruct and mentor others

48. Understanding Military Responsibilities: Officers • As young as 22 • Leader of troops • Planners/strategists • Responsible for troops and equipment • Responsible for ensuring mission execution and success • Ultimate authority in his or her unit • Plan, direct, control, coordinate • Lead from the front

49. Cultural Impact on Program Assessments and Data • SAMHSA does NOT require any data collection beyond GPRA requirements • Suggestions: • Ask about veteran status or military service • Ask about deployment history (how many times, to where, etc.) • Share trends in data with military leadership. For example: • See a lot of alcohol cases from the National Guard or marijuana use from people just returning from a deployment

50. Reframing: Therapy vs. Training