Post Traumatic Stress Disorder and The Military Veteran Student

1. Post Traumatic Stress Disorder and The Military Veteran Student Roger P. Buck Edgardo Padin-Rivera

2. Autonomy • The organism possess a certain degree of freedom… It acts according to its own inherent nature, which is based on intrinsic forces, and is not under the compulsion of outside influences

3. Autonomy • Characteristics: • Self Governing • Self Determination • Self Understanding • Intrinsic Forces • “Self” is known • “The World” is understood • “Shattered Assumptions”

4. Autonomy: Assumptions about the “Self” and the World Self World The World is a Safe Place Some Personal Control over the Environment Efficiently interacts with the Environment & Others Empowered to Keep Oneself & Loved Ones Safe in the World • Personal Empowerment • Sense of Personal Efficacy • Efficiently Manage Self and Decisions • Sense of Personal Power and Self Control • Capable of interacting effectively with others

5. Autonomy: Once Assumptions are Shattered Crisis with the SELF World VIEW Question the Safety of the World Question Self and ability to control any Aspect of Life in the World Questions Efficiency of Being and Interacting in the World Questions Personal Ability to keep Loved Ones and Self out of Harms Way • Failure to Maintain Sense of Personal Power • Question Ability to Self Manage • Question Efficiency and Effectiveness of Choices • Fear of Losing Control of Self and Uncertainty about the Future

6. Why the Self and World View are Changed • The Crisis Event Rendered the Person “HELPLESS” • Crisis events Cause a Person to Question Their SELF (Decision Making) • The Event is Incongruent with Beliefs about Self (Abilities and Strengths) • The Event is Incongruent with Belief about Safety of the World • An overpowering sense of failure, personal inadequacy, abandonment and/or Rejection Will Often Set in Due to This Incongruence

7. DANGER As A Profession • Military Veterans • Police Officers • Emergency Medical Technicians • Fire Fighters • Emergency Room Personnel • FBI, ATF, other dangerous professions

8. Danger Powerful vs. Powerless Mild danger vs. extreme

9. Danger • Impact of Traumatic Events • Self is Changed • Beliefs • Self Esteem • Personality Shift • Biological • Fear • Spiritual Crisis

10. Danger • Shatters one’s perception about themselves and their place in the world. • Shatters one’s sense of safety & security • Most Devastating effect: Autonomous ability to relax Ego Defenses – (isolation, anger, guilt, anxiety, depression)

11. Danger • Other Ego Defenses develop: • Inability to Trust • Inability to Establish or Re-Establish Intimacy • Emotional Numbing • Hyper-Sensitivity Toward Injustice • Pervasive Sense of Feeling Damaged

12. Symptoms: Physical, Cognitive, Emotional, Behavioral, Spiritual (P.C.E.B.S.)

13. P.C.E.B.S. Physical Cognitive Intrusive Thoughts Memory/Concentration Confusion Preoccupation Uncertainty Feeling Overwhelmed Poor Problem Solving Poor Abstract thinking Intrusive Images • Agitation • Fatigue • Headaches • Vision Problems • Hyper-arousal • Exhaustion • Chest Pain • Muscle Tremors • Grinding of Teeth

14. P.C.E.B.S. (Cont’d) Emotional Behavioral Hyper-vigilance Sleep Problems Substance Abuse Self Mutilation Cry easily Antisocial Acts Defiance of Authority Inability to Rest Erratic Movements Loss of Appetite • Anxiety • Depression • Hopelessness • Despair • Rapid Mood Swings • Unpredictable Mood • Denial • Agitation • Intense Anger

15. P.C.E.B.S. (Cont’d) Spiritual • Questioning Good and Evil • Attempting to Make Sense of Senselessness • Searching for the Meaning of the Experience • Struggling with Understanding Why • Questioning God/Faith

16. Human Toll: Depth of Change • Military Combat • Violent Law Enforcement Action • First Responders and Horrific Scenes • Natural Disasters • Virginia Tech Carnage • Columbine • 9/11 • Oklahoma City Bombing

17. What the Soldier Brings Home:Combat Stress, Trauma & Readjustment “No one comes back unchanged” COL (Dr.) Tom Burke,Department of Defense,Director of Mental Health Policy

18. Life on the Front To understand what the soldier brings home, one needs to look at how the environment of war gets inside the mind.

19. Life on the Front:How Combat Shapes Minds, Emotions, & Behaviors • 86% received artillery fire. • 93% were shot at with small arms. • 77% fired at the enemy. • 95% saw dead bodies or remains. • 89% were attacked or ambushed. • 86% know a troop injured or killed. • 65% saw dead or injured American. • 69% saw injured women/children and were unable to help. • -- These numbers correspond in part to a study in the New England Journal of Medicine and pertain to service members in Iraq.

20. Life on the Front:How Combat Shapes Minds, Emotions, & Behaviors No true ‘safe zone’ or ‘rear’, in Iraq & Afghanistan, there is a sense of danger in all occupationsand areas all the time. The stresses and demandson cognitive and emotionalcapacities are many andalmost constant. Being on constant alert, or“hyper-aroused” becomes a way of life.

21. Life on the Front:How Combat Shapes Minds, Emotions, & Behaviors Prolonged exposure to combat stress • Most soldiers exposed to multiple terrorism or life threatening events. • Some may have participated in atrocities. • Often develop a mindsetof “act immediately, debate later”.

22. Life on the Front:How Combat Shapes Minds, Emotions, & Behaviors Exhaustion is constant. The soldier does not have energy or time to process events until after leaving the battlefield. The violence is scary, but also exhilarating and immediately rewarding. Many returning soldiers say combat wasthe most exciting and importantthing they have ever done. Many are bored when they come home.

23. Life on the Front:How Combat Shapes Minds, Emotions, & Behaviors Many face loss of comrades that can be emotionallydevastating. Nothing is moreimportant to a soldier than his warbrothers. For many service members,a comrade’s death is an overwhelmingexperience, often leadingto prolonged unresolvedmourning and anger.

24. What the Soldier Brings Home Post-Combat Battlemind • Heightened sensory awareness of sights, sounds & smells. • Action oriented ways of coping with new experiences. • Identification and closeness with their military unit and comrades who have shared similar experiences. • Regimentation into highly structured and efficient routines. • Confused about ideals, values & identity shaped by war. • Habituation to intensity and extreme emotions of combat life.

25. What the Soldier Brings Home The PTS Syndrome • Intrusive thoughts/memories • Nightmares • Avoidance/isolation • Anger/angry outbursts • Hyper-startle response • Flashbacks • Hyper vigilance • Feelings of grief, guilt, & loss…

26. What the Soldier Brings Home It’s not just about PTSD • Disillusionment with “civilian life” & activities. • Challenging of one’s previous identity& core beliefs. • Irritability & anger toward non-military. • Profound feeling of alienation. • Social isolation. • Memories of events that can bedifficult to “square” with civilian reality. • Self-blame or guilt for acts of war. • Despair or hopelessness about future. • Physical health problems • Alcohol and drug abuse

27. What They Say Are Problems (from Focus Groups) Wanting to be left alone - Social avoidance/isolation Sensitivity to loud noises and jumpiness – hyper-arousal Anger, lack of patience - irritability Chronic joint pain, generally ankle, knee and back pain Memory problems or "lapses“ - trouble concentrating Drinking or smoking too much Personality changes, emotionally distressed Body image issues: scars, weight changes, etc. Coming Home: Life, Work, Learning

28. Coming Home: Life, Work, Learning Obstacles to Restoring Previous Ties • Homecoming feelings of joy and euphoria are short lived (Eventually not reinforcing). • Attempts to restart old ways of interacting, old roles fail. • Difficulties arise in trying to generate a “new normal” (rigidity, fears, isolative struggles get in the way). • Civilian life at home may not have the edge and adrenaline and “life or death” purpose associated with wartime duty. • Problems of internal chaos impinge on relationships.

29. Coming Home: Life, Work, Learning Greatest need after traumaticexperiences is for activeengagement, affiliation, andcomfort available throughsupportive relationships. Biggest (unrealized) fear of most returning soldiers is engagement, affiliation, and intimacy.

30. Coming Home: Life, Work, Learning Problems Reconnecting with Friends & Community • Difficult for soldier to feel “at ease” with “civilians” who do not understand military or combat life (will gravitate toward veterans). • Soldier may find self unable to share experiences with non-combat friends: “they wouldn’t understand”, “they would react with horror or shock”).

31. Coming Home: Life, Work, Learning Difficulties with Public Interactions • Tension about the “politics” of war; public has mixed views of the war. • Awkwardness on both sides: Public may not always know what to do or say. • Veteran too often becomes a community media event. • Veteran unsure who he/she can talk to. Questions can arise about: What will they want me to talk about? What can I talk about? How will they react to a story or event?

32. Coming Home: Life, Work, Learning Workplace Problems • Veteran ability and employer expectations may conflict. • Veteran may be unable to do same work • Same exact job may not be available. • Post-war images and memories may intrude on ability to concentrate. • Co-workers may behave differently toward him/her. • Veteran may feel others expect things he/she may not be able to do or meet.

33. Coming Home: Life, Work, Learning Learning Environment Problems Veteran learning capacity vs instructor expectations. • May not be able to focus on single subject for long periods of time. • Has difficulty with “vague” subject matter or mixed conclusions. Need for concrete outcomes. • mTBI issues may create short term memory deficits (difficulty with details, memorization, etc)

34. Coming Home: Life, Work, Learning Learning Environment Problems • Internal chaos (intrusive images and memories) may intrude on ability to concentrate, pay attention. • Hyper-arousal (on guard), in crowds, among new persons, changing environments (new classroom each course), may create tension, irritability, anxiety. • Tendency toward social isolation leads to difficulty seeking help for studies, working with other students. • May feel others expect things he/she may not be able to do. • Other students may behave differently toward him/her. • Subject Matter or presentation may arouse anger, irritation, isolating response (politics, history, social sciences are especially red flags).

35. Coming Home: Life, Work, Learning The perception of positive community supportwhether or not it is used is one of the best known antidotes to chronic mental health problems after a traumatic event. So…

36. Fifteen Environmental Cues That May Trigger Increased Symptoms • Cues that May Cause Agitation, Anxiety, Panic, Intense Anger, Apprehension, Sadness: • Inefficient Support Services • Non-Compassionate Attitude of Staff Members • Waiting in Long Lines for Services • Getting the “run-around” about Administrative Paperwork • Immoral and Unethical Practices by Staff, Faculty or Students • Lack of Clear “Chain of Command” to resolve problems or concerns

37. Environmental Cues (Cont’d) • Lack of Respect for & Acknowledgment of Veteran and Their Service • Lack of Respect by Faculty or Staff for Sacrifice of Veteran’s Friends Killed and Injured in War • Childish Behavior by “Traditional Teenage Students” (Loud Music after lights out – Dorm life) • Roll Call • Overall Lack of effective and efficient leadership at the college • Timeliness of GI Bill Processing and Other Financial Supports • Large, Loud and Crowded Classrooms • Classrooms Where Veteran Cannot Sit With Back to the Wall • Chaotic Classroom – Instructor Not in Charge

38. Sensory Triggers to Consider • Visual: • Use of Laser Pointer • Emergency Light Flashing • Middle Eastern Student/Clothing • Human Suffering • Dry/Arid Environment

39. Sensory Triggers to Consider • Other Senses • Loud Noises • Helicopter Blades • Smells (Raw Sewage) • Smells (Sweat) • Oppressive Heat • Taste/Smell of Middle Eastern Foods • Sitting in uncomfortable chairs with back pain, knee injuries other chronic medical concerns

40. Twelve Administrative Action Items • 1. Ask the Vets • 2. Special Supports During Registration for Rapid Enrollment • 3. Veteran Task Force • 4. Encourage and Develop Peer Support Organization (Student Veterans of America) • www.studentveterans.org • 5. Host Veteran Recognition and Welcoming Activities • 6. Specific College Policy and Procedures addressing action if student deployed • 7. Institution Admin consistency: GI Bill, Course Credit for Military Schooling, Financial Aid etc.

41. Administrative Action (Cont’d) 8. Present “Veteran Awareness and Sensitivity” training for all Staff & Faculty 9. Create a Veteran Resource Center & Devote Office Space 10.Register as Service Member Opportunity College (SOC) 11.Develop a Veteran Foundation Account to Assist Student Veterans with Tuition, Books, Fees and Household Emergencies 12.Presidential and Senior Leadership Support

42. Fifteen Faculty and Staff Actions To Consider • 1. Recognize you “Will” Have Higher Numbers of Both Male and Female Veterans With Traumatic Stress History • 2. Recognize the Cultural Diversity That Exists Between Traditional Students and Military Veterans • 3. Military Veterans are Permanently Changed Due to Experiences and are Often in a Period of Intense Adjustment and Transition • 4. Military Veterans with Combat Experience will Have Normal and Predictable PCEBS

43. Faculty and Staff Action • 5. Recognize there are Potential Cues in the College Environment That Will Trigger PCEBS Symptoms • 6. Recognize Some Veterans will meet ADA Criteria for Support Due to Injury (TBI) • 7. Understand there are Major Financial Stresses Due to GI Bill Delays, Federal Red Tape, VA Medical Appointments etc. • 8. Readjustment after Extreme Experiences Cause Family Strain As Well as College Stressors

44. Faculty and Staff Action 9. Recognize the Veteran is Reintegrating Into More Than One Environment. 10.Some Veterans will Admit Their Veteran Status While Others May Keep it Quiet (Women Veterans) 11.Honor and Respect Differing Viewpoints and Strong Emotional Commitment to a Position or Belief 12.Be Flexible with Attendance and Classroom Assignments

45. Faculty and Staff Action • 13. Recognize and Support Military Dependents • 14.Learn the Various Trauma Symptoms That Occur with all Trauma Victims • 15. Know all Veteran Support Services on Your Campus and in the Community

46. Institutional Services to Provide • Local College Military Veteran Task Force Determines Specific Services - To Include the Following as a Minimum • Orientation Program specific to veterans • One stop Center of Excellence • Veterans Advisory Council • Prevention Program • Veteran Volunteer Program • Develop “on-line” and Print Educational Information

47. Resource Listing • National Center for Post Traumatic Stress Disorder (NCPTSD) (www.ncptsd.va.gov) • National Child Traumatic Stress Network (NCTSN) (www.nctsn.org) • National Center for Trauma Informed Care (NCTIC) (www.mentalhealth.samhsa.gov/nctic/ ) • Student Veterans of America (www.studentveterans.org)

48. If you see a returning service member this month, just say thank you.

49. Contact Information • Roger P. Buck, Ph.D. • Director, Counseling Services • 3301 Hocking Parkway • Hocking College • Nelsonville, OH 45764 • Phone: 740 753-6133 • Buck_r@hocking.edu

50. Contact Information • Edgardo Padin-Rivera, Ph.D. • Louis Stokes Cleveland DVA Medical Center • 10,000 Brecksville Road, Brecksville, OH 44141 • Phone: (440)- 526-3030 xt. 6900 • Email: edgardo.padin@va.gov