The War at Home: Returning Veterans and After- Deployment Struggles

1. The War at Home: Returning Veterans and After- Deployment Struggles August 6, 2011 Samaritan Institute Annual conference Denver, CO

2. Three Learning Objectives: 1. Develop treatment plans that differentiate between Combat/ Operational Stress Reaction and Post Traumatic Stress Disorder 2. Recognize how the “Three Prime Directives” that sustained veterans in combat contribute to emotional disconnection and difficulties in personal life and relationships. 3. Address the treatment differences between PTSD and Mild Traumatic Brain Injury and how these differences must be handled through very different therapeutic modalities.

3. Presenter, Jerry Powell Licensed Marriage and Family Therapist NC Licensed Professional Counselor, NC, NCC AAMFT Clinical Member and Approved Supervisor Approved Clinical Supervisor Ordained ‘74 Director/Therapist at The Fayetteville Family Life Center, Fayetteville, NC; a Division of CareNet of North Carolina, part of Wake Forest Baptist Health, Department of Pastoral Care, Winston-Salem, NC. Adjunct Professor- Webster University, St. Louis, MO, Pope Air Force Campus, Fort Bragg, NC; Graduate Counseling Department. B.S. – 1975; William Jewell College, Liberty, MO. M.Div. 1978; Midwestern Baptist Theological Seminary, Kansas City, MO D.Min. 1989; -- Midwestern Baptist Theological Seminary, Kansas City, MO M.A., 1998, Community Counseling; Columbus State University, Columbus, GA. Married to Janet Smarr of Overland Park, KS.;Three grown, married children, five grandchildren.

4. Our time together today • Three parts about returning vets • Returning Veterans and their families • What we find works and what is not always helpful • Returning Vets with Mild Traumatic Brain Injury • Returning Vets with Post Traumatic Stress Disorder • How to respond to our Soldiers and families in distress…. • How to help Centers get in the mix.

5. Jerry Powell US Army Chaplain 1987-2007 Retired 2007 (Lieutenant Colonel) Served in Korea, Japan, Iraq, Texas, Georgia, New York, Kansas and North Carolina. Email: jepowell@wfubmc.edu Deployed to Iraq in 2005 as part of the Multi-National Force-Iraq (MNFI) Advisor to the Iraqi government on the writing of their constitution on areas of: religious freedom, rights of women & children, Non-governmental organizations Pastor to the Embassy Chapel and Chaplain to Multi-National Security Transition Command-Iraq (MNSTCI). Provided ministry coverage to Security details and teams and multi-national forces in Baghdad.

6. Review of materials • Handouts and take-aways • Case Presentation • Video resources • us.army.mil web site • Web searches for future use • Who are you and what are you doing here?

7. The high price of serving Personal Family Moral

8. Understanding the Returning Vet • How the veteran views his or her life after returning from combat • How the family views the veteran after the return to the family. • How the clinician can normalize their view of their life and their changes

9. What is it like? • “Go from Hero to Zero” • PTSD • Post-concussive Syndrome • Mild TBI • Readjustment difficulties

10. Time lines for healing • How long after the deployment to get to the “New Normal?” • When is the next deployment cycle? • How are Reserve and National Guard served? They are all normal— “I am pleased with how well you are doing…”

11. Understanding the Returning Vet • Everyone in direct combat comes back different. • Different does not necessarily mean better or worse, It just means “different” “My husband has deployed five times and every time he comes back he is a different person than the man that I married.” • Wife of a soldier in counseling

12. “Different” from a therapist’s view • This difference is not the ‘normal’ presentation of individual or couple/family distress or dysfunction. This ‘difference’ is not a developed cause and effect of relationship dynamics, but rather an imposed and unwanted intrusion in the family process that is difficult to clarify or address.

13. Coming home different • Coming home with a level of disappointment. • We all come home to a partner with a different level of disappointment.

14. Why we get disappointed in war • The first bullet changes our lives. • Dumb decisions get people hurt and killed • Innocent people get caught up in the stupidity • Undeserving people get awarded • Deserving people get nothing • Nothing is like we expected and there is nothing we can do about it.

15. How we deal with the difference • Adrenaline junkie • Takes a higher jolt to get our attention • Faster bike/car; more alcohol; sex • Ignoring mortality • Refusing to heed higher HQ’s guidance.

16. What is different? • No sense of urgency/importance. • No way to make up for what was missed. • Low emotional/conversational energy level • Preference to stay with other vets • Home life: • Drinking • Avoiding family members • Limited decision making

17. Brothers at War • By Metanioa Films • Produced by Gary Sinese

18. 3 prime directivesduring combat • Stay alive • Stay safe • Take care of your buddies • Anything outside of the 3 Directives will appear irrelevant. This can seem to indicate lack of interest or energy in the relationship.

19. Is anybody angry here? Everyone who deploys returns with some level of anger after the deployment Everyone who deploys returns to someone with a level of anger after the deployment.

20. “He just screams” • No question on her part of commitment, but no way to counter his anger. • “He used to be sensitive, but that wore away…” • “He wants me to be tough like he has to be tough, and to show no emotion…”.

21. Diagnosis and Assessment • PTSD or redeployment issues? • Anxiety or Depression? • Readjustment or Axis II? • Low energy or chronic depression? • Use of medication

22. MTBIMild Traumatic Brain Injury What it is and what we do with it [Hint: Can’t find it in DSM]

23. STRETCHED TO THE LIMIT: Shock waves can damage healthy brain cells. [left] Sometimes just lightly twisting the cell is enough to do the job. THE DOWNWARD SPIRAL: The shearing not only causes physical damage to cells but can also unleash a Biochemical cascade that eventually causes cells to self-destruct [right]. Medi-Mation

24. Mild TBI vs.Moderate TBISevere TBI

25. Characteristics of MTBI • Same as PTSD • Losing the “filter” on their mouth (“Filter between the brain and mouth is out of adjustment”) • Losing higher level rationale and behavior. • Unable to recognize when they are out of control. • Brain damage in frontal cortex

26. PTSDHow do we recognize it?How do we treat it? Everyone with PTSD has the characteristics of MTBI; But everyone with MTBI does not have PTSD

27. List of meds • Wellbutrin/75 mg • Xanax (alzrazolam)/.5mg • Albuterol-inhaler • Singulair (montelukast)/10mg • Dilaudid (hydromorphone)2mg • Ambien (zolpidem)/10mg • Trazadone/50 mg • Vitamin B12 injection • Vitamin D3/400IU • Anxiety 2x day • Anxiety 1-2 3x day • shortness of breath1-2x • allergies 1x day • pain as needed • to sleep 1x day • to stay asleep 1x day • 1x mo • 5 tab/day

28. Presenting for treatment • How long after deployment do the concerns start surfacing? • Couples present for help with marriage, but what is the issue? • Individuals often have trouble presenting by themselves.

29. Treatment modalitiesDeveloping Treatment Plans • Purpose and choice of modalities • Exposure therapy • Cognitive/behavioral therapy • Behavior modification therapy • EMDR • Spiritual dimension • Value of “holding place” • How long will treatment take?

30. Permanent White Water • The goal: • Stay in the boat • Who has the energy for the relationship? • What will we do with their anxiety?

31. Coping skills • How much does the client want help? Is the help being accepted or resented by them when offered by family members? • How can we help with the anxiety during the time of healing? • How will we shape our sessions with them?

32. Clinician/theologian • How does treating combat vets affect you as a clinician? • How does a clinician take care of one’s self? • How do we help our teammates?

33. Theological Implications • Combat and trauma • Just War and supporting vets • Theology of combat and killing • Implications for our community

34. Community/Congregational Support • How do we recognize and honor our vets? • Do they feel welcomed and received? • How do we manage their differences?

35. Review of Materials • Web sites • Handouts • References

36. Discussion timeemail:jepowell@wfubmc.edu

37. Thank you Very much...