Chapter 12

1. Chapter 12 Assessing, Preventing And Treating Substance Use Disorders In Active Duty Military Settings

2. Historical Background • Efforts to minimize the harmful effects of alcohol consumption have been noted as early as 1770. • During the American Civil War alcohol was used medically, and daily consumption of rum was common in part because it was thought to enhance coping skills before engaging in battle. • During the Vietnam War, the use of marijuana increased, coinciding with its increased consumption throughout civilian society. Marijuana was surpassed by heroin in prevalence of use later in the war. • In 1971, the Army began urine testing for opiates, barbiturates and amphetamines. Active service members returning from Vietnam who tested positive were required to undergo a 30-day treatment program.

3. Substance Use During the Global War on Terrorism • Concern about substance use has never been as great as it is today–especially regarding alcohol. • In light of the increases in combat technology, “even modest amounts of alcohol can impair crucial decision-making abilities and negatively affect military operations.” • The unique stressors associated with the demands of protracted conflict in the Global War on Terrorism led to a near doubling of Army soldiers diagnosed with alcoholism or alcohol abuse between 2003 and 2009, and similar increases were observed among Marines. • Members of those two branches may be particularly vulnerable to increases in alcohol abuse in light of their relatively greater number of combat tours and deployment cycles.  

4. Prevention • In 1971 Congress enacted a law that mandated that the Secretary of Defense develop programs to identify, treat, and rehabilitate drug dependent persons in the armed forces. • In response, the Secretary required each branch of the armed forces to develop programs to prevent substance abuse. • The early prevention efforts emphasized detection and education. • During and after the 1980s standardized prevention programs were developed in each branch of the military and are currently  mandated for all troops.

5. Prevention Continued • Specialized training is  provided to the chain of command and to prevention specialists assigned to various units. • Examples of prevention efforts: • A public website to support local commands • On-site substance screenings and prevention education by substance abuse counselors  for all branches of the armed forces • Dissemination of prevention information and program availability via armed forces print, radio, and TV media • Provision of prevention briefs to educate the chain of command upon deployment regarding the availability of local illegal and/or addictive substances in the area to which they are heading • After an alcohol-related incident, referral of the offending service member to an early intervention program usually consisting of 15 to 20 hours of education  and discussion to improve awareness of the harmful effects of alcohol abuse

6. Assessment • There are five ways that someone can be identified as needing treatment: • medical referral • legal investigation/apprehension • command-driven • biochemical testing (which includes alcohol breath testing) • self-referral

7. Assessment Process • The clinician conducting the predeployment screening should begin by asking about the individual’s predeployment emotions and coping styles • Next, the clinician is advised to focus specifically on substance use with a comment such as the following • “Some people find that drinking a bit more alcohol, smoking a few more cigarettes, or pouring some extra java helps relieve the stress—have you noticed this in yourself?” If the answer suggests the possibility of a substance abuse tendency, the clinician should conduct a more formalized screening regarding the quantity and frequency of substance use. If the answers suggest a problematic amount of use, the clinician should next ask four “CAGE” questions.

8. The Four CAGE Questions • C — Have you ever felt that you should CUT down on your drinking? • A — Have people ANNOYED you by criticizing your drinking? • G — Have you ever felt bad or GUILTY about your drinking? • E — Have you ever had a drink first thing in the morning to steady your nerves or get rid of a hangover (i.e., as an EYE-OPENER)?

9. Ethical Dilemma • Unless the identification was made by self-referral to a civilian provider off base, the commander must be informed that the service member is in need of treatment.   • Consequently, the uniformed military clinician  who conducts the assessment faces a balancing act between the need of the commander to know if the service member is fit to perform his or her military duties and the needs of the individual who is being assessed. • Regardless of the branch of the armed forces, the interests of national defense and safety are paramount.

10. Armed Forces Treatment Programs • Treatment features: • Mandatory, with focus on military preparedness and maintaining personnel. • Command staff and clinical staff members comprise a rehabilitation team, chaired by a clinician. • Combines coercion with treatment. • The soldier also learns about patient rights and receives assurances of support to alleviate his or her fears. • Responsibilities of command and clinical staff are separated, with professional clinical staff being responsible for clinical decision-making • Treatment duration: 3 months to one year • Treatment plan is based on the principle of requiring the least intrusive, least restrictive treatment environment needed according to therapeutic needs • Treatment is provided by a multidisciplinary team that emphasizes motivational enhancement over confrontational drama

11. An Empirically Supported Outpatient Treatment Approach: Seeking Safety (Najavits) • Safety not only from substances, but also from dangerous relationships and from extreme symptoms. • Applicable to comorbid substance use disorders. • Begins with check-in questions. • Next, a quotation is read aloud by the client to foster client emotional engagement in the session. • The clinician then asks about the meaning of the quotation and links it to the session topic. • Most of the session then involves client reading a handout on a new coping skill, followed by the clinician summarizing the key points of the handout and then asking the client how those points relate to the client. • The rest of the session is devoted to discussing how the topic relates to the client’s life and to rehearsing the new coping skill. • The session ends with a check-out period in which clients identify what they got out of the session and whether there are any problems with it, and then answering the clinician’s question, “What is your new commitment?”

12. When Seeking Safety Is Provided in Military Settings: Seeking Strength • The name Seeking Strength should be used instead of Seeking Safety because “military personnel must go into harm’s way, and thus the term Seeking Safety may be inaccurate for them. Also, most military and veterans are men, and the term strength may be more appealing than ‘safety’” • Use examples that emphasize the bonding that occurs in military settings (e.g., bonding like warriors or teams) • Address prominent concerns for military and veterans: • difficulty with feelings (which are often devalued or “trained out” in military contexts • issues with perpetration of violence (feeling “like a monster”) • betrayal, such as when they are not supported on their return • difficulty readjusting to civilian life • issues with authority and control • Women in the military also have major challenges such as having experienced high rates of military sexual trauma, being vastly outnumbered by men, and trying to function in a highly male-oriented culture. • Understand how trauma and substance abuse may occur in the military. Traumatic experiences that are typical in military settings include military sexual trauma, handling bodies or body parts, watching buddies die, and traumatic brain injury.

13. An Empirically Supported Outpatient Treatment Approach: Motivational Interviewing (Miller & Rollnick) • Strategically paradoxical in that it is directive in a client-centered manner that relies on active listening and gentle feedback techniques. • When applied to soldiers with substance use disorders, the clinician elicits the soldier’s own concerns about the disorder and helps the soldier articulate reasons to change the problematic behavior. • Although the fundamentals of nondirective counseling are employed, the MI counselor selects appropriate moments to intervene with directive strategies while at the same time avoiding argumentative persuasion • Provided in two phases: • Phase 1 stage: Focus is on building rapport, exploring the soldier’s reluctance or ambivalence about changing, and increasing his or her readiness to change. The counselor does this by using an OARS approach, which refers to the following: • Asking Open questions • Affirming • Reflecting • Summarizing

14. Motivational Interviewing (MI) Continued • Phase 2 stage: Focus on strengthening a growing commitment to change and developing action plans for achieving specific change goals. • Four principles that guide MI: • Express empathy • Develop discrepancy • Roll with resistance • Support self-efficacy

15. An Ecosystem Perspective (Weiss et al.) • The two foregoing empirically supported treatment approaches, while having been applied in military contexts, were not developed specifically for treating active duty service members or veterans. • There are special challenges associated with engaging and maintaining this population in treatment due to military training and deployment schedules and the distinct nature of the military lifestyle and culture. • Consequently, in order to be effective with military personnel or veterans, the foregoing empirically supported approaches need to be provided in the context of a systems-ecological approach.

16. Discussion Questions • What are some factors that explain the high prevalence of substance use disorders in active duty military settings? • Why is substance use so dangerous in those settings? • Which prevention or treatment strategies or approaches described in this chapter seem to have the best chances for being effective in active duty military settings? Why? • Based upon the insights discovered in this chapter, what new applications will enhance your work as a mental health professional in working with military members and their families?