Military Culture & Treatment - 101 GAMFT Chapter Workshop

Military Culture & Treatment - 101GAMFT Chapter Workshop three hour workshop to overview the culture of military families, effective treatments, and sources of support Blaine Everson doceverson@gmail.com 706-369-7911 Alan Baroody na4nb@yahoo.com 912-369-7777 Peter McCall petemccall1@gmail.com 770-329-6156

Presentation Goals • There are 5 goals of this presentation: • Better understand the basics of themilitary culture to build credibility while working with military families • Review key issues that can impact the mental health of a military family • Review the recommended treatments for military trauma, what triggers to look for, and commonly encountered issues • Review where clinical support material can be found via CFTT • Learn what the GAMFT initiative is with the CareForTheTroops.org organization

Agenda Handout – A0 …..an Example

MILITARY OATH OF ENLISTMENTrecited by all Service Members at their swearing in ceremony I, (NAME)… DO SOLEMNLY SWEAR… THAT I WILL SUPPORT AND DEFEND THE CONSTITUTION OF THE UNITED STATES… AGAINST ALL ENEMIES, FOREIGN AND DOMESTIC;… THAT I WILL BEAR TRUE FAITH AND ALLEGIANCE TO THE SAME;… AND THAT I WILL OBEY THE ORDERS OF THE PRESIDENT OF THE UNITED STATES… AND THE ORDERS OF THE OFFICERS APPOINTED OVER ME,… ACCORDING TO REGULATIONS AND THE UNIFORM CODE OF MILITARY JUSTICE,… SO HELP ME GOD. Speaking these words has far more emotional power than these words on paper could ever convey. Anyone who has done this for real knows, in that moment, that they are agreeing to defend a principle with their very lives. It is a moment they never forget. NOTE: the 3 dots … = it’s a break point, repeat after me. Handout – A1

Agenda

CareForTheTroops, Inc. • Who Are We – ‘Big Picture’ • CareForTheTroops is working to help the military and their extended family members receive mental health services and support from within the civilian elements of our society in the State of Georgia. • CareForTheTroops is attempting to equip the civilian support services of society e.g. clinicians, with the capacities to be helpful. • We are working toward “building a better net” to catch those that need help before they fall too far and reach moments of desperation.

Organization 501c3 status has already been approved by the IRS Current Board of Directors: President Rev Robert Certain, Rector, Episcopal Church of St Peter and St Paul (USAF) Exec Director Peter McCall (USArmy) Member Bill Harrison, Partner, Mozley, Finlayson & Loggins LLP (USAF) Member William Matson, Exec Director, Pathways Community Network, Atlanta, GA Member Alan Baroody, Exec Director, Fraser Counseling Center, Hinesville, GA Member Joseph Krygiel, CEO of Catholic Charities, Archdiocese of Atlanta (US Navy) Current Partners: The Georgia Association for Marriage and Family Therapy (GAMFT) The EMDR Network of Clinicians in Georgia Pathways Community Network, Inc Fraser Counseling Center, Hinesville, Georgia Catholic Archdiocese of Atlanta Cooperative Baptist Fellowship (CBF) of Georgia Episcopal Diocese of Atlanta Presbytery of Greater Atlanta/Presbyterian Women

Causes for Concern Multiple deployments are common causing stress and family attachment issues An April ‘08 Rand Study reported 37% have either PTSD, TBI, or significant Mental Stress (5% all 3). Some estimate >50% return with some form of mental distress Suicide, alcoholism, domestic abuse and violent crimes rates are rising. Suicide is 33% higher in ‘07 over ’06, 50% higher in ‘08, and almost equal to ‘08 by May of ’09 Military Sexual Trauma (MST) is running at 16%-23% In 2008, military children and teens sought outpatient mental health care 2 million times, a 20% increase from ‘08 and double from the start of the Iraq war (‘03) DoD and VA facilities are stretched … the Aug 2009 VA claims backlog is 900,000 Many more Reservists & Guard than previous wars (54% as of mid ‘08) and they and families are more distant from DoD and VA support facilities Other mental health, marriage, and family problems often occur with or leading up to PTSD requiring attention so they don’t get worse Rand Study (‘08) estimates that PTSD and depression among service members will cost the nation up to $6.2 billion in the two years after deployment. The study concludes that investing in proper treatment would actually save $2 billion within two years

Mission of CareForTheTroops.org • Work to improve the ability of the civilian mental health infrastructure in the State of Georgia, then nationally, to work with military family members • Facilitate connecting military families to providers of spiritual and psychological services familiar with the military culture and trauma • Focus on addressing combat stress recovery as well as other spiritual and mental health related problems impacting the marriages and families of military veterans • Educate and train clinicians, congregation and community leaders, extended family, and civilian groups about the military culture and trauma associated with military deployments in order to better assess and treat mental health symptoms, and provide more effective referrals and care • Provide opportunities for additional trauma treatment training to clinicians • Operate in an interfaith, non-political manner, focusing on the humanitarian interest that benefits the veterans and their extended family members

Approach Affected Systems Extended Family Members Person in need of support Congregations Children Employers Spouse Parents Military Member Siblings Grandparents Community

The next set of charts provide a simulation of using the www.CareForTheTroops.org website with clinicians in mind

This is the top of the Home Page

Home Page The drop-down menu for Mental Health Professional is opened up. In this case, selecting the Enroll with CFTT page Note the other options available

This focus is on the Top Menu In particular this shows the “Mental Health Professional” options. The Menu that drops down shows the tasks most often used by the Mental Health Professionals.

Top of the Enrollment Page The info asked is completely voluntary. We do not ask you to volunteer time and any financial info is left between you and the client. We are looking for people with background, training, and experience.

Moving down the same page. Info about your office , license, language, and education. HANDOUT

Moving further down the same page. Info about your insurance, specialties, and training Text boxes are there for free-form input ref insurance and specialties HANDOUT

Moving to the end of the form. Info about your experience, unique background. This is also where you enter your ID and password. HANDOUT

Back to the top of the Home Page A key piece of the web site is the Resource Library with the 4 selections shown. This material is updated periodically. The reference material is weekly.

This shows the first 4 search results for Fulton County in the database. This is intended for use by congregation sources, clinicians, and people in need searching for a therapist who wants to work with military families.

Training is key. This shows the training events we are aware of. Both from CFTT and from other organizations. Please visit it periodically and also let us know of training you hear about to share with others.

Training is key. We have just added OnLine Training from 2 sources: Alliant Univ. The VA Much of the training is free, a wide selection of courses, and some is eligible for CEUs with a nominal fee attached.

EMDR TRAINING Weekend 1 (Part I) January 15-17, 2010 Athens, Georgia Weekend 2 (Part II) - TBA • The EMDR HAP (Humanitarian Assistance Program) Training organization (www.emdrhap.org ) will conduct Weekend 1 (Part I) training Friday through Sunday, Jan 15th to 17th in Athens, Georgia. The training facilities used in Athens are at Milledge Avenue Baptist Church, 598 South Milledge Avenue, Athens, GA 30605. • Weekend 2 (Part II) training will be scheduled 3-6 months later with details TBA. • This training is jointly sponsored by the The Samaritan Counseling Center of Northeast Georgia (www.samaritannega.org ), GAMFT-The Georgia Association for Marriage and Family Therapy (www.gamft.org ), and The CareForTheTroops, Inc. non-profit organization (www.CareForTheTroops.org ). • AUDIENCE: This training is for licensed (and some licensable) counselors working in a non-profit environment. Specific details are available at the following web location: www.emdrhap.org/training/ . • COST: $350 for each weekend. Lodging and meals are the responsibility of the participant. • SCHOLARSHIPS: A limited number are available to cover the full HAP Fee for Weekend 2 (Part II) for those that meet the criteria below. So please apply early if one is needed. • ENROLLMENT: • TRAINING: Enroll for the HAP Part I training is done on-line through the HAP website: www.emdrhap.org/training/toregister/listEvents.php. Look for this events’ description on the web page. • SCHOLARSHIPS: Apply for the CareForTheTroops scholarship at www.careforthetroops.org/emdrevent.php . Download the Application Document, complete and email or mail it to the address shown on the document. • Additional information about this weekend such as schedule, lodging, restaurants, etc. can be found at the following web location: www.CareForTheTroops.org/emdrevent.php . HAP Participant Requirements EMDR PART I AND PART II are available for licensed mental health clinicians at the masters degree level or above, or for masters level clinicians on a licensure track, with permission of their licensed clinical supervisor. In keeping with its mission, HAP normally trains only clinicians working 30 or more hours per week in community based, non-profit settings. Exceptions have been made for private practice clinicians who have made a substantial commitment to pro bono service in the community. CareForTheTroops(CFTT) Scholarship Criteria It is the intent of CFTT to incent attendance of both EMDR Training Weekends (Part I and Part II) in order to increase the number of fully qualified EMDR Therapists to treat trauma in Georgia. Participants must: Practice in Georgia Attend and successfully complete both Part I and Part II EMDR training by HAP Enroll in the CareForTheTroops Therapist Database at the completion of Weekend 1 and stay enrolled at least 2 years. More Info about this is available at www.careforthetroops.org/clinician_cftt_enroll.php Be willing to work with military clients and their extended family members Pay the HAP Training Fee for Part I. CareForTheTroops will pay the HAP Training Fee for Part II which means you must attend a Part II by HAP Attend and complete Part II within 12 months of completing Part I Be responsible for all other costs, fees, and expenses associated with the training weekends.

Chapter WorkshopsMilitary Culture 101-Clinical Treatment Issues NOTE: Check with your local GAMFT Chapter and also with the www.CareForTheTroops.org web site for changes and updates.

Final Comments • Help For You • Use the web site as a resource • Information and reference material • Training • Referrals • Use you involvement with CFTT to help market your practice • Help for Us • Enroll in the CFTT database • Publicize CFTT to community and congregations • Would you consider being a Trainer using material like you see today?

Agenda

Brothers At War Film Cliphttp://www.brothersatwarmovie.com/

Fraser Center ExperienceFilm Clip Comments THERAPEUTIC ISSUES OBSERVED IN THE CLIPS FROM “BROTHERS AT WAR”: The adrenaline high, or adrenaline addiction – “It’s like the best!” Personality changes. No one returns the same from combat or lengthy deployments. Generalized and undifferentiated anger: short fuse, loss of patience, (increase in domestic violence and child abuse). “Now when he gets mad, he just screams.” Grief over absence during important life transitions (also, resentment by spouse at soldiers absence). “When I come home I just want to hug her, but she may not let me because she won’t know who I am.” Intense bonding during deployment competes with and sometimes trumps marital and family bonds. “My friends here are closer than any I’ve had.” “These guys take you on as a brother.” Survivor guilt and loss: “It hurts a lot to lose fellow soldiers.” Family of origin issues: “I want to make my Dad proud.” Fantasy verses reality. (living on dreams and through TV series) Emotional numbing: “He used to be sensitive. Now, he shows no emotion and wants me to be the same way.” The ramifications of “sacrificing for family” and the sacrifices made by families.

Fraser Center Experiencewww.frasercenter.com HANDOUT THE FRASER CENTER SETTING: Clients include Veterans, Active Duty Soldiers, and Military Dependents Clients primarily from FT Stewart (3rd Infantry Division) and Hunter Army Airfield GENERAL OBSERVATIONS MADE BY FRASER CENTER THERAPISTS WHO WORK WITH OIF/OEF VETERANS, ACTIVE DUTY SOLDIERS, AND MILITARY DEPENDENTS: The children of military families are often the first to be brought in for therapy – secondary trauma. “Is daddy going to die?” The length, number, and frequency of deployments decreases family resiliency upon re-deployment (returning home from a deployment). The number of engagements “outside the wire” increases the likelihood of Combat Stress Symptoms (transient, acute, & PTSD). Over time, the constant threat of incoming mortar rounds and IED incidents increases likelihood of CSS and PTSD for those who remain primarily in “green zones.” The primary concerns of combat troops are: Mission First, staying safe, keeping their buddies safe, getting home, and what is happening at home with their spouse and families.

Fraser Center Experiencewww.frasercenter.com HANDOUT GENERAL OBSERVATIONS (continued…): While deployed, soldiers also fight on the homefront via internet and cell phone with their spouses. Homefront stressors may be higher than combat stressors. Viewing internet pornography and internet sex chat is becoming a norm for deployment and effects marriages upon return. Many soldiers maintain their unit bonds following re-deployment to the detriment of their family bonds. Returning soldiers rarely talk with spouses about combat experiences. There is a high rate of infidelity among soldiers and spouses during deployments. This is not necessarily the “deal breaker” that it might be in civilian life. Illegal/prescription drugs and alcohol are prevalent and are used as common coping mechanism by soldiers (deployed and at home) and by their spouses. While deployed, many soldiers are constantly sleep deprived and share each others medications (i.e. ambient, provigil). Hooked on Energy Drinks. The suicide rate of re-deployed) soldiers and spouses is on the increase. Most soldiers know of at least one other soldier in their unit who “ate his gun” or was blown up by an IED. There is a high incidence of rape and sexual molestation of deployed female soldiers. Soldiers and spouses express a great deal of anger toward perceived incompetency in the chain of command, or in procedures, which have a direct negative impact upon their lives.

Fraser Center Experiencewww.frasercenter.com HANDOUT GENERAL OBSERVATIONS (continued…): Home is no longer a safe place to live. Many now carry weapons when not on military installations at home. The vast majority of returning troops are filled with undifferentiated anger and a short fuse. There is a statistically verifiable increase in domestic violence and child abuse among military families. Child abuse increases as the stressors increase in the life of the non-deployed spouse. A primary therapeutic issue is the soldier’s inability to re-connect emotionally with spouse and children. (exacerbated by anger and lack of patience). Chaplains are the mental and spiritual health “first responders” at home and in the combat arena. Special attention needs to be given to National Guard and Reserve Chaplains. There is a high incidence of their leaving the ministry. Both spouse and soldier recognize that the soldier is “changed” by combat deployment. Important family milestones and transitions have been missed. Soldiers may pursue activities which replicate the adrenaline rush of combat and sometimes re-enlist without spousal consultation in order to maintain the rush. Spousal dissatisfaction and resentment: power control issues upon redeployment. “I didn’t sign up for this.” The military spouse sacrifices education and career With increased monetary incentives and a lowering of recruitment standards the quality of the troops has been increasingly lowered: no GED necessary, accepting recruits with DSM-IV diagnosable conditions and on meds, increase of gangs in the army.

Fraser Center Experiencewww.frasercenter.com HANDOUT GENERAL OBSERVATIONS (continued…): Due to young age, immaturity, and low educational levels, many soldiers and spouses have poor life skills: money management, parenting, communication, etc. Some soldiers return to empty bank accounts and houses. The military has greatly increased mental health support resources at home and abroad. The Army recognizes that it is still not adequate. The military is going out of their way to encourage soldiers to seek out mental health treatment, yet the stigma against seeking help continues to exist. Spirituality is an important tool in the healing process as it is an important issue among those who have been in combat. It may not be express in typical “religious” language.

Chris Warner’s Sources of Stress --->> Number of Months Warner CH, Breitbach JE, Appenzeller GN, et.al. “Division Mental Health: It’s Role in the New Brigade Combat Team Structure Part I: Pre-Deployment and Deployment” Journal of Military Medicine 2007; 172: 907-11.

Agenda

Intake Scenario Your New Client • 20 year old male • SPC in USANG, 4month Post-Deployment from OIF • Gunner from 1st BCT 3ID • “on edge”, “pissed off”, difficulty Sleeping • First SGT concerned over his irritability • Anger towards leadership for decisions made downrange • Married with 2 children, <4 yrs old, one born during his deployment • Marital discord • Wants to deploy again ASAP

Military Culture Sociologists define culture as … • Language - nomenclature; acronyms, abbr. • Beliefs – defenders of Democracy • Value Systems – leave no one behind • Norms & Rules – formal & informal conduct • Material Products – weapons systems Culture is associated with a social system and unique to a given system. Handout – A2

Language Barriers for CiviliansGlossary of Military Terms and AcronymsMilitary Cultural Competence OEF Operation Enduring Freedom – it is a multinational military operation aimed at dismantling terrorist groups, mostly in Afghanistan. It officially commenced on Oct. 7, 2001 in response to the September 11th terrorist attacks. OIF Operation Iraqi Freedom - also known as the Iraq War; began on 3/20/2003. USAR United States Army Reserve USANG United States Army National Guard E1-E9; O1-O10 Enlisted Ranks; Officer Ranks SPC Specialist, rank of E4, often referred to a “Spec 4” First SGT First Sergeant, rank of E7, lead enlisted person in a company. It and SSG, Staff Sergeant are key leadership ranks with lots of job pressures NCO Non-Commissioned Officer, ranks E6 through E9 IEDs Improvised Explosive Devices FOB Forward Operating Base Sandbox Iraq and Afghanistan Down Range Deployed to anyplace where there is shooting. Outside the Wire Leave the safety of the “enclosed” military base (FOB) Taking the Pack Off Leaving mentally and physically from combat Top Cover Making sure the boss looks good www.rivervet.com/oif_glossary.htm Handout – A3_1, A3_2, A3_3, A3_4

The next few charts cover organizational background to help understand the client, where he/she was positioned, and to better interpret the information and stories they might tell during their therapy

Branches of the Military Georgia’s Military is dominated by Marine and Army units, though Air Force and Navy are represented as well. Georgia’s National Guard also has a large number of transportation units subject to IEDs on roads and highways. NOTE: Coast Guard is now under Homeland Security Handout – A4

Military Branch StructuresExample: U.S. Army Core Values 84%% 2% 14% 84% 2% 14% Handout – B1, B2, B3

Military CultureBelief and Value Systems; Norms and Rules • Beliefs: Defenders of Democracy Trust in the leadership Role clarity Distrust of civilians • Value Systems: Leave no one behind “The Group” practically becomes a ‘family system’ Top Cover-defend and support the boss Violence :many have a history of violence which often plays a role • Norms & Rules: Formal and informal conduct Stigma of mental health and PTSD Cover of the boss (Top Cover) Back-logging trauma

Reserve and National Guard Units vs Regular Army Reserve / Guard Regular • Units are small & based in local communities. • Part-time soldiers, often working with local police, fire, and EMS. • Families may be left in a town with little or no support services. • Mostly support units in Georgia (transport, MP, etc) • Likely to work within local communities • Can’t relocate easily when activated • Lack of military related health services - PCP not Tricare approved • Make use of family or local supports (church, etc.) • Units are based at major military installations. • Full-time soldiers who expect to be deployed . • Families are left at their post where a variety of support is in place both on-post & in communities. • Are part of a larger fighting force including 1/5 combat units. • Live on-post or nearby; other family support • Less need to relocate when deployed • Access to a variety of health, welfare, & educational services • Support groups in-place through soldier’s unit Handout – C1

The next few charts provide some background of this war that might help you better understand your client and their presenting story and issues

Why is this war different? • Volunteer vs. draft • Multiple deployments • Type of suicide bombings • Never any safety, no real recovery time • Use of civilians as shields and decoys by the enemy • Deliberately targeting our moral code • COMMUNICATION! Internet, cell phones, etc. • IEDs, RPGs (TBI, hearing loss, neuro-chemical effects) • Advancement in medical treatments

OIF/OEF - Statistics • As of 12/1/2008 • 1.7M troops deployed • 4207 US Military killed in Iraq (excludes civilians) • 627 US Military killed in Afghanistan (excludes civilians) • 65,000+ US Military wounded • 54% deployed are Reserve / Guard (4/08) • 1% of US population is directly touched by military service; more if you consider civilian contractors • Deployed as of 09/2009:~ 130K troops in Iraq~ 160K civilian contractors in Iraq~ 65K troops in Afghanistan (more are being sought as of Oct 2009)

OIF/OEF - Profile • NG and Reserve did not expect deployment(reminder: GA is 6th largest NG state) • Multiple deployments is the norm • 2008 Rand Study indicates: • 53% of those that need treatment sought Mental Health treatment in ‘08 • 16-23% have experienced MSTMST = Military Sexual Trauma • 2yr post-deployment cost $6.2B • OIF vs OEF – VA indicates a OIF vet is 2x likely to seek help than a OEF vet • As of 04/08, 120K mental health dx’s, 50% were diagnosed w PTSD • “Homecoming Concept” = alienation, detachment, isolation, avoidance, boredom Handout – C2

OIF/OEF - More Statistics • 15 wounded for every 1 fatality (Vietnam was3 for 1) • VA predicts that it will treat 263,000 OIF/OEF vets in 2008 and 330,000 in 2009 • Current backlog of veterans is 400,000 (as of 2008) • Claims backlog is over 900,000 (as of Aug 2009) • Heaviest of that backlog is mental health (Ex: Virginia VA community mental health services has a waiting list of 5,700 as of early 2008) • 550,000 school age children of active duty Service Members (Reg/Res/NG) • 52,000 children of Reserve and National Guard Service Members affected • 84% of Regular Military Service Members’ children attend public school, not DoD base schools • Georgia has over 750K veterans Handout – C3

OIF/OEF – and some more Statistics According to a new American Journal of Public Health study on veterans' mental health diagnoses • Of the 289,328 veterans who entered VA care in 2008, nearly 37% had mental health problems, including post traumatic stress disorder (about 22%) and depression (roughly 17%). (ref: http://www.ajph.org/cgi/content/abstract/AJPH.2008.150284v1 ) • "Weekend warriors" over 30 years old in the national guard and reserves who left stable family, work and community environments for combat zones were especially susceptible to mental health problems. 2008 American Journal of Public Health study A recent (July, 2009) US government accountability office report found that nearly 20% of women veterans suffer from PTSD (ref: http://www.gao.gov/new.items/d09899t.pdf )

OEF / OIF Experience - Summary • Indirect threats – not so much direct assaults and attacks • IEDs, car bombs • RPG, snipers • Suicide bombings • Powerlessness • threat is indiscriminate • not dependent upon skill or mastery • relationship between loss of control and PTSD • This generation’s war • 1st Internet War (Vietnam was the TV War) • Blogs, email, cell phone (cameras) 24 hr new sites • New versions of the “Dear John/Jane” letter • Home trouble as a leading stressor (financial, intimate partner) • Reservists/Guard: repeated, unpredictable separations from family/job

Military Culture & Treatment - 101 GAMFT Chapter Workshop