Working with Veterans in the Community

Working with Veterans in the Community John Straznickas, MD Substance Use PTSD Team Leader San Francisco VA Medical Center

Thanks to our Veterans for their service to our Country

Increased SUD tx engagement with veterans Improve Identification of veterans Cross-Cultural “Military” Training The veteran re-integration process

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.

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

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?

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 (2nd Lt./Ensign) to O-10 (General/Admiral)

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

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

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

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

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

Not all veterans’ military service was the same Individual differences War differences – VN vs. OEF/OIF

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.

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

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

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

Keep the VA as a potential resource for services. Added resources Specialized services

Special challenges for war veterans. 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.

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

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

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

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.

Thanks for your service to our nations veterans Very rewarding to help the 1% of our Nation’s Warriors Find a way back Home

Working with Veterans in the Community