When Johnny Comes Marching Home

1. When Johnny Comes Marching Home Reintegration Problems and Concerns of Military Service Members Returning from Combat Presenters Dr. Edgardo Padin, Ph.D. Dr. John Schupp, Ph.D. Dr. Roger P. Buck, Ph.D.

2. Human Toll of Traumatic Events

3. Be presented in three general topic subsections: War’s impact on the individual How stress reactions impact interpersonal relationships of the returning veteran College program recommendations to best meet the needs of returning veterans Explore the complexities of human responses to, and recovery from traumatic experience. Characteristics needed in program development and support programs to ensure academic and vocational success in military veterans This Presentation will . . .

4. You may be permanently changed by a traumatizing experience, but you do not have to be permanently “damaged”. Roger P. Buck, Ph.D.

5. War and human stress reaction

6. The Five Major Trauma Research Topic Areas Psycho-Physiological Individual/Personal Characteristics Trauma Specific Characteristics Treatment Modalities/Outcomes Social Factors

7. Psycho-Physiological • Studies that provide insight into alteration in the brain as well as other physical reactions to trauma. Including the impact that Traumatic Brain Injury (TBI) has on cognitive processes. Individual/Personal Aspects • Identification of characteristics such as age, sex, moral development, and cognitive level and how these factors might determine an individual’s reaction to traumatic experiences.

8. Trauma Specific Issues • These research investigations reveal how different aspects such as intensity, duration, and type of trauma, impacts human responses. Treatment Modalities/Outcomes • There is a significant amount of literature which focuses on treatment outcomes and modalities utilizing the knowledge obtained from research. Evidence based best practice models are derived from this research.

9. Social Factors • The impact social support or lack of support has on an individual and their ultimate reactions to crisis/traumatic experiences.

11. Five Major Topic Areas • Psycho-Physiological • Individual/Personal aspects • Social Aspects • Trauma Specific Characteristics • Treatment Modalities and Outcomes

12. What is Trauma?

13. Researchers attempt to develop a clear understanding of “trauma” through critique and description of its characteristics - there is no single definition of trauma • Judith Herman reported: “trauma overwhelms the ordinary human adaptations to life” . . . “and trauma events generally involve threats to life, or bodily integrity or close personal encounters with violence and death” . . . And “confronts people with extremes of helplessness and terror and evokes the responses of catastrophe” • R. Cohen said that “a traumatic event is an event that severely challenges the long-held cherished beliefs and expectations of the individual exposed to it” • C. Monohan stated: “Trauma is an extraordinary frightening event that overwhelms the victim with feelings of terror and helplessness. . . . Encounter with defenselessness can create memorable emotional pain, confusion, and behavioral disruption.”

14. Diagnostic and Statistical Manual of Mental Disorders (4th ed.) DSM-IV • Trauma is referred to as “an extreme traumatic stress involving direct personal experience of an event that involves actual or threatened death or serious injury, or other threat to one’s physical integrity, or witnessing an event that involves death, injury, or a threat to the physical integrity of another person.” • Symptoms that occur following traumatic events fall into many different diagnostic categories with “anxiety disorders” (Post Traumatic Stress Disorder, PTSD) being one of the most prominent.

15. What factors determine response to potentially traumatic events

16. 16 Things We Know About Trauma • 1. People with childhood trauma are higher risk of health problems as adult • 2. Childhood trauma victims do increased risk behaviors (smoking, excessive alcohol use) • 3. Many people have significant trauma history which they don’t reveal • 4. Domestic violence, child abuse, alcoholic and neglectful parents cause trauma responses in their children • 5. Suicide rate among trauma survivors is higher than nation avg • 6. Military Reserves have higher suicide rate than regular military

17. 16 Things We Know About Trauma • 7. Combat veterans of today’s war have higher suicide rate than at any time in U.S. History • 8. Military personnel with multiple tours of duty in combat are higher risk for PTSD • 9. Trauma victims often don’t seek professional help • 10. Many military men and women do not seek professional help • 11. Much of the public and even many mental health professionals are uninformed of lifelong impact of trauma • 12. Some trauma victims become perpetrators

18. 16 Things We Know About Trauma • 13. Divorce rates and failed relationships are higher among people with trauma history • 14. There are predictable and normal responses to abnormal events that appear extreme but subside over time • 15. The whole person is affected by traumatic events: Physical, Cognitive, Emotional, Behavioral, Spiritual • 16. Population exposure model indicates the closer a person is in proximity to an event the more severe the response

19. Complex PTSD • Chronic Trauma results in more complex symptoms: • Concentration Camps • Prisoner of War • Prostitution Brothels • Repeated Child Abuse • Repeated tours of Combat in war zone

20. Complex PTSD • Difficulties experienced by those who have history of chronic trauma • Avoid talking and thinking about trauma experience due to overwhelming nature • Alcohol and substance abuse to avoid and to numb feelings • Self mutilation and other forms of self harm • Suicide

21. Complex PTSD Cont’d • Additional issues: • Person repeatedly abused is often mistaken as someone who has a “weak character” when they don’t leave a perpetrator • Survivors of chronic trauma are often misdiagnosed as having Borderline, Dependent, or Masochistic personality disorder • Survivors who are faulted for the symptoms they experience as a result of victimization are unjustly blamed • A new diagnosis may prevent clinicians, the public and those who suffer from trauma from mistakenly blaming survivors for their symptoms

22. Healing and Recovery

23. 7 Things Trauma Victims Seek to Recover • 1. Sense of Personal competency • 2. Personal autonomy (understand self and how to relate to the world) • 3.Understand personal impact & how to integrate the objective experience and their subjective responses • 4. Intimacy & Trust • 5. Trust in self and capacity to build trusting relationships • 6. Develop an understanding about the traumas impact on sense of connection with the world and others • 7. Personal identity, personality, self-image

24. Values/Spirituality • The importance of the spiritual component cannot be “understated” when traumatic experiences occur. • Those who have some belief in a power greater than themselves tend to develop an understanding of the event through “meaning” they assign. • Understanding and meaning are the first steps toward recovery and resilience.

25. 5 Major Aspects of Recovery and Resilience • Trauma focused Cognitive Behavioral Therapy – Treatment as needed • Four Central Dimensions of Recovery • Grief and Bereavement • Anniversaries • Memorials, Ceremonies and Rituals

26. Foci of TreatmentCRAFTS • Cognitive problems • Relationship problems • Affective problems • Family problems • Traumatic behavior problems • Somatic problems • (From Judith A Cohen, M.D., Medical Director, Center for Traumatic Stress in Children & Adolescents, Allegheny General Hospital, Pittsburgh, PA)

28. Grief and Bereavement • Grief: Process we go through in adjusting to loss of close relationship • Grief: inevitable companion to love and attachment • Death evokes realization of one’s own mortality & causes fear of death or conversely desire for death (Join a fallen comrade)

29. Grief and Bereavement Cont’d • Survivor guilt often exists • Guilt due to fact they are still living • Guilt for not saving the person • Guilt for not making the dying process easier for the person that died

30. Grief and Bereavement Cont’d • Complications of bereavement • Prolonged grief or traumatic grief • Onset or recurrence of Major Depressive disorder • Onset or recurrence of Panic Attacks • Increased vulnerability to PTSD • Alcohol and other substance abuse • Poor nutrition, low levels of exercise • Suicidal ideation • Onset or worsening of health problems

31. Anniversaries • Symptoms of anniversary reactions include: • Re-experiencing symptoms of PTSD • Reactivate feelings, physiological responses and thoughts that occurred at the time of the event • Avoidance symptoms as in PTSD • Avoid situations, places, or people that are connected to the event • Arousal symptoms as in PTSD • Nervous and on edge, unable to sleep or concentrate, increased irritability, and are more on guard

32. Memorials, Ceremonies and Rituals • Ritual can be defined as an expressive, symbolic act that creates a special time and space in which the participants experience themselves as a unique group • Rituals may be performed repetitively or once, public or private • Rituals may be sacred or secular, traditional or created • A created ritual may be appropriate for a specific individual or set of circumstances • For example: At the Oklahoma City Bombing during the ceremony all participants were given roses – there was a spontaneous act where many rescue workers threw their roses into the pit in honor of those killed on the site.

33. What is “Trauma Informed” • All supports and interventions: • Are based on the knowledge that symptoms exhibited by survivors are directly related to the traumatic event. • These experiences are the cause of mental health, substance abuse and behavioral problems. • Must address survivor needs with an awareness of the link between trauma event and predictable human responses which are normal responses to abnormal life events.

34. 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/) • Sidran Institute (www.sidran.org)

35. What the Soldier Brings Home:Combat Stress, Trauma & Readjustment Edgardo Padin-Rivera, Ph.D. VA Medical Center Cleveland, Ohio “No one comes back unchanged” COL (Dr.) Tom Burke,Department of Defense,Director of Mental Health Policy

36. 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.

37. Life on the Front:How Combat Shapes Minds, Emotions, & Behaviors Prolonged exposure to combat stress • Soldiers are under constant stress over long period of time • Are exposed to multiple types of terrorism and life threatening events. • May witness or participate in multiple atrocities • Develop a mindset of“act immediately, debate later”. • Habituated to rigid, highly structured “military” concrete thinking. • Being on constant alert, or“hyper-aroused” becomes a way of life.

38. 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.

39. Life on the Front:How Combat Shapes Minds, Emotions, & Behaviors In Iraq & Afghanistan, there is no true ‘safe zone’ or ‘rear’, there is a sense ofdanger in all areas and occupations all the time. The stresses and demandson cognitive and emotionalcapacities are many andalmost constant.

40. 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.

41. 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.

42. 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…

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

44. 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. • Profoundly realigned ideals, values & identity shaped by war. • Habituation to intensity and extreme emotions of combat life.

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

46. 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

47. 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.

48. Coming Home: Life, Work, Learning Problems Reconnecting with Friends & Community • Difficult for soldier to feel “at ease” with previous friends. • Soldier may find self unable to share experiences with non-combat acquaintances. Problems Reconnecting in Family • Military is seeing highest divorcerate and domestic violenceincidents in 30 years. • Stress, distrust, fear of intimacy, readjustment to new relationship.

49. 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?

50. 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)