Strategies for Building Resilience in Military Members, Veterans and their Families

1. Strategies for Building Resilience in Military Members, Veterans and their Families Presented by: Jim Messina, Ph.D., NCC, CCMHC, DCMHS Assistant Professor: Troy University-Tampa Bay

2. "The pessimist complains about the wind; The optimist expects it to change; The realist adjusts the sails." William Arthur Ward

3. Goals of Program At the end of this training, the trainees will be able to: • Identify what are the cognitive, behavioral, and psychological factors contributing to resilience in individuals, their families, their military units and their communities • Identify strategies for assisting others to develop and enhance resilience in the face of stressors facing military, veterans and their families pre- during- and post-deployment • Problem solve solutions for developing resilience strategies in their own clinical settings in which they work with the military members, veterans and their families; their military units and their communities

4. Before we look at Resilience We need to look at Suicide Why you ask should we look at suicide first? • I am a Red Cross Volunteer who works in Military Deployment Mental Health work with active military and I have heard over and over again when talking with military: “You aren’t going to talk about resilience to us today are you? I have had my fill of that stuff!” • On Saturday June 22, 2013 I facilitated two groups at a Yellow Ribbon event and met men and women military members who all had similar traits to another veteran whose letter to his family I got in an email on June 27, 2013 • I realized that the folks I have met at all of the Yellow Ribbon reintegration events I have been to, could just have easily been the person who wrote the letter to his family which was broadcast all over the world • What was the letter you ask? • It was a suicide letter left by a Veteran of the Iraq War who killed himself on June 10, 2013

5. We Are Killing Ourselves at an alarming Rate By 2010, in the developed world, suicide became the leading cause of death for people age 15-49 according to the Institute of Health Metrics and Evaluation, Global Burden of disease, 2010.

6. Suicide’s Grisly Toll In 2010 worldwide deaths from suicide outnumbered deaths from war (17,670), natural disasters (196,018), and murder (456,268).The Institute of Health Metrics and Evaluation, Global Burden of disease, 2010

7. Why do people die by suicide? According to Thomas Joiner: • “Because they want toand because they can” • “People will die by suicide when they have both the desire to die and the ability to die.” • When Joiner broke down “the desire” and “the ability,” he found what he believes is the one true pathway to suicide. It’s a “clearly delineated danger zone,” a set of three overlapping conditions that combine to create a dark alley of the soul • The conditions are tightly defined, and they overlap rarely enough to explain the relatively rare act of suicide. But what’s alarming is that each condition itself isn’t extreme or unusual, and the combined suicidal state of mind is not psychotic • On the contrary, Joiner’s diagram of suicide is composed of circles we all routinely step in, or near, never realizing we are in the deadly center until it’s too late. Joiner’s conditions of suicide are the conditions of everyday life and only resilience will pull us out

8. Thomas Joiner’s Model ofInterpersonal Theory of Suicide • Kimberly A. Van Orden et al., "The Interpersonal Theory of Suicide," Psychol Rev. 117(2) (2010): 575

9. Let’s Take a closer look at the three components of Suicide In getting ready for this program I receive an email link to a suicide letter from Daniel Somers who killed himself on June 10, 2013 Why is he relevant to this presentation you ask? • He was in the Iraq War and completed 2 deployments • In 2004-2005, he was assigned to a Tactical Human-Intelligence Team (THT) in Baghdad, Iraq, where he ran more than 400 combat missions as a machine gunner in the turret of a Humvee, interviewed countless Iraqis ranging from concerned citizens to community leaders and government officials, and interrogated dozens of insurgents and terrorist suspects • In 2006-2007, Daniel worked with Joint Special Operations Command (JSOC) through his unit in Mosul where he ran the Northern Iraq Intelligence Center. His official role was as a senior analyst for the Levant (Lebanon, Syria, Jordan, Israel, and part of Turkey) • In 2007 he was diagnosed with PTSD, TBI, and  Gulf War Syndrome, fibromyalgia and a host of other medical problems He sought treatment through therapy, medication, music and film production Daniel’s letter shows us the three components of Joiner’s Interpersonal Theory of Suicide and teaches us a lesson about the need for us to change how we work to help our Military, Vets and their families to grow in resilience

10. Daniel Somers’ June 10, 2013 Suicide Letter Quotes “The fact is, for as long as I can remember my motivation for getting up every day has been so that you would not have to bury me. As things have continued to get worse, it has become clear that this alone is not a sufficient reason to carry on. The fact is, I am not getting better, I am not going to get better, and I will most certainly deteriorate further as time goes on. From a logical standpoint, it is better to simply end things quickly and let any repercussions from that play out in the short term than to drag things out into the long term.” “You will perhaps be sad for a time, but over time you will forget and begin to carry on. Far better that than to inflict my growing misery upon you for years and decades to come, dragging you down with me. It is because I love you that I can not do this to you. You will come to see that it is a far better thing as one day after another passes during which you do not have to worry about me or even give me a second thought. You will find that your world is better without me in it.” Perceived Burdensomeness “I am a burden”

11. Daniel Somers’ June 10, 2013 Suicide LetterQuotes “I really have been trying to hang on, for more than a decade now. Each day has been a testament to the extent to which I cared, suffering unspeakable horror as quietly as possible so that you could feel as though I was still here for you. In truth, I was nothing more than a prop, filling space so that my absence would not be noted. In truth, I have already been absent for a long, long time.” Thwarted Belongingness “I am alone”

12. Daniel Somers’ June 10, 2013 Suicide LetterQuotes “My body has become nothing but a cage, a source of pain and constant problems. The illness I have has caused me pain that not even the strongest medicines could dull, and there is no cure. All day, every day a screaming agony in every nerve ending in my body. It is nothing short of torture. My mind is a wasteland, filled with visions of incredible horror, unceasing depression, and crippling anxiety, even with all of the medications the doctors dare give. Simple things that everyone else takes for granted are nearly impossible for me. I can not laugh or cry. I can barely leave the house. I derive no pleasure from any activity. Everything simply comes down to passing time until I can sleep again. Now, to sleep forever seems to be the most merciful thing.” Capability for Suicide “I am not afraid to die”

13. Daniel’s Final Words “This is what brought me to my actual final mission. Not suicide, but a mercy killing. I know how to kill, and I know how to do it so that there is no pain whatsoever. It was quick, and I did not suffer. And above all, now I am free. I feel no more pain. I have no more nightmares or flashbacks or hallucinations. I am no longer constantly depressed or afraid or worried I am free. I ask that you be happy for me for that. It is perhaps the best break I could have hoped for. Please accept this and be glad for me. Daniel Somers Capability for Suicide “I am not afraid to die”

14. Exposure to Adverse Conditions feeds the Capability for Suicide • Joiner’s research team has posited that military who have been exposed to combat have an increased capability for suicide • Recent research has found that this is not necessarily the case, in fact many military suicides have been by people who have not even been deployed (Bryan, Hernandez, Allison & Clemans, 2013) • So another source of Adverse Events which might be a contributory factor to capability for suicide could be the ACE Factors which are Adverse Childhood Experience Factors

15. What are the 10 ACE Factors? ACE (Adverse Childhood Experiences) Abuse 1. Emotional Abuse 2. Physical Abuse 3. Sexual Abuse Neglect 4. Emotional Neglect 5. Physical Neglect Household Dysfunction 6. Mother was treated violently 7. Household substance abuse 8. Household mental illness 9. Parental separation or divorce 10. Incarcerated household member Any one of these adverse experiences can drain one’s resilience

16. So What is Resilience? The APA Health Center (APA, 2004) says that: Resilience is the process of adapting well in the face of: • Adversity • Trauma • Tragedy • Threats • Significant sources of stress - such as family & relationship problems, serious health problems, or workplace & financial stressors It means "bouncing back" from difficult experiences!

17. So What are the Emotional Fears in Tough Times? • Fear of personal ineffectiveness or loss of ability to survive tough times • Fear of loss of job due to possible failure of one’s personal effectiveness or professional skills • Fear of impact of losing one’s job on one’s self-worth and self-esteem • Fear about impact on family & marriage if not able to meet financial & emotional needs in tough times

18. What are Key Factors Associated with Resilience? APA Help Center (APA, 2004) identifies them as: • The capacity to make realistic plans & take steps to carry them out • A positive view of yourself & confidence in your strengths & abilities • Skills in communication & problem solving • The capacity to manage strong feelings & impulses

19. Why the Need for Resilience • You need to build resilience to sustain your emotional health when faced with: wars, layoffs, life-altering events, natural disasters, death, change, divorce, health issues, financial difficulties, etc. • Being resilient doesn’t mean you won’t experience difficulty or distress. Emotional pain, anger, grief & sadness are common when you have troubles in tough times. • Developing resilience involves behaviors, thoughts & actions that can help you cope with stressful events. It helps restore balance in your life. Ashe, L. (2006). In Times of Trouble Build Resilience. Methodist Healthcare Employee Assistance Well Informed Program: 3.

20. What are the Factors which Impact Resilience • The Rand Corporation in 2011 identified this definition “Resilience is the capacity to adapt successfully in the presence of risk and adversity” (Jensen and Fraser, 2005), which they utilized in their study: Promoting Psychological Resilience in the U.S. Military. The Rand group identified four distinct contributors to factors which build resilience in the military: • The individuals, • Their families, • Their military units • Their communities

21. Individual Factors were: • Positive coping: The process of managing taxing circumstances, expending effort to solve personal and interpersonal problems, and seeking to reduce or tolerate stress or conflict, including active/pragmatic, problem-focused, and spiritual approaches to coping • Positive affect: Feeling enthusiastic, active, and alert, including having positive emotions, optimism, a sense of humor (ability to have humor under stress or when challenged), hope, and flexibility about change • Positive thinking: Information processing, applying knowledge, and changing preferences through restructuring, positive reframing, making sense out of a situation, flexibility, reappraisal, refocusing, having positive outcome expectations, a positive outlook, and psychological preparation • Realism: Realistic mastery of the possible, having realistic outcome expectations, self-esteem and self-worth, confidence, self-efficacy, perceived control, and acceptance of what is beyond control or cannot be changed • Behavioral control: The process of monitoring, evaluating, and modifying emotional reactions to accomplish a goal (i.e., self-regulation, self-management, self-enhancement)

22. Family Factors were: • Emotional ties: Emotional bonding among family members, including shared recreation and leisure time • Communication: The exchange of thoughts, opinions, or information, including problem-solving and relationship management • Support: Perceiving that comfort is available from (and can be provided to) others, including emotional, tangible, instrumental, informational, and spiritual support • Closeness: Love, intimacy, attachment • Nurturing: Parenting skills • Adaptability:Ease of adapting to changes associated with military life, including flexible roles within the family

23. Military Unit Factors were: • Positive command climate: Facilitating and fostering intra-unit interaction, building pride/support for the mission, leadership, positive role modeling, implementing institutional policies • Teamwork: Work coordination among team members, including flexibility • Cohesion: Unit ability to perform combined actions; bonding together of members to sustain commitment to each other and the mission

24. Community Factors were: • Belongingness: Integration, friendships, including participation in spiritual/faith-based organizations, protocols, ceremonies, social services, schools, and so on, and implementing institutional policies • Cohesion: The bonds that bring people together in the community, including shared values and interpersonal belonging • Connectedness: The quality and number of connections with other people in the community; includes connections with a place or people of that place; aspects include commitment, structure, roles, responsibility, and communication • Collective efficacy: Group members’ perceptions of the ability of the group to work together

25. Resilience is a personal strength which: • Is the ability to positively adjust to adversity • Can be applied to building personal strengths • Is gained through building positive & nurturing professional relationship • Is the maintaining of positivity • Develops emotional insight • Is the achieving of life balance & spirituality • Results in becoming more reflective Jackson, D., Firtko, A. & Edenborough, M. (2007). Personal resilience as a strategy for surviving and thriving in the face of workplace adversity: a literature review. Journal of Advanced Nursing:60(1):1-9.

26. Resilience results in Adaptation Adaptation is measured by: • High prevalence in the community of mental & behavioral health • Adequate role functioning at work & home • A high quality of life by all Norris, F. H.; Stevens, S. P.; Pfefferbaum, B.; Wyche, K.F. & Pfefferbaum, R.L. (2008). Community Resilience as a Metaphor, Theory, Set of Capacities, and Strategy for Disaster Readiness. American Journal of Community Psychology: 41(1–2):127–150.

27. Factors Associated with Resilience (APA, 2004) • The capacity to make realistic plans & take steps to carry them out • A positive view of self & confidence in one’s strengths & abilities • Skills in communication & problem solving • The capacity to manage strong feelings & impulses All of these are factors that people can develop in themselves.

28. So how does Resilience Work? • Is a reflex & way of facing or understanding the world • Is deeply etched in a person’s mind & soul • Results in facing reality with staunchness • Makes meaning of hardship instead of crying out in despair & improvising solutions out of thin air Coutu, D. (2002). How Resilience Works. Harvard Business Review: 80(5):46-51.

29. What weakens one’s Resilience? • Fear of diminution or loss of one’s personal strength • Fear of displacement in work roles or possible failure of effectiveness of one’s professional skills • Fear that one would not be able to cope with unemployment & would lose sense of identity & worth when one lost professional or work role • Fears about the anxieties arising in marital & family relationships if one should lose one’s job Martindale, B. (2007). Resilience and Vulnerability in Later Life. British Journal of Psychotherapy: 23(2):205-216.

30. Self-Assessment • Take the Personal Resilience in Tough Times Self-Assessment • Rate each item for you on a scale from 1 to 10 • 1 = never • 5 = occasionally • 10 = frequently

31. What does this Assessment Tell You? • If you rated 10 or more items over 8 or if you rated 15-20 over 5 • You are most likely to experience some level of resilience in facing tough times

32. Ways to Build Your Resilience (APA, 2004) • Make connections • Avoid seeing crises as insurmountable problems • Accept that change is a part of living • Move toward your goals • Take decisive actions • Look for opportunities for self-discovery • Nurture a positive view of yourself • Keep things in perspective • Maintain a hopeful outlook • Take care of yourself

33. So What can you do to help others Build their Resilience? • Surprisingly in preparing for this presentation I realized that my entire career has been focused on building resilience & helping folks build a sense of “Belonging” while letting go of a sense of “Being a Burden” while simultaneously developing a rational perspective on life so as to let go of the “Capacity to commit Suicide” • When I retired from private practice in 1999 my wife reminded me that I was successful in never having a successful suicide on my watch! • What did I do then, you as mental health professionals can do today to help our military, veterans & their families build their resilience by • increasing their sense of belonging • Increasing their feeling needed, wanted & cherished • wanting to live life to the fullest

34. Use the SEA’s Model of Recovery • The Self-Esteem Seekers Anonymous model of recovery is on www.coping.us • The model is a set of tools which make recovery a workable process for anyone committed to making changes in life so as to grow in self-esteem, build their resilience and let go of the three major factors of Joiner’s Interpersonal Theory of Suicide • The work is most effective in a SEA’s group which is a 12 Step model weekly program where each week the participants explore the following TOOLS for Recovery in the SEA’S System of Recovery

35. Sea’s Tools for Recovery • TEA System http://www.coping.us/seastoolsforrecovery/teasystem.html • ALERT System http://www.coping.us/seastoolsforrecovery/alertsystem.html • ANGER System http://www.coping.us/seastoolsforrecovery/angersystem.html • LET GO System http://www.coping.us/seastoolsforrecovery/letgosystem.html • CHILD System http://www.coping.us/seastoolsforrecovery/childsystem.html • RELAPSE System http://www.coping.us/seastoolsforrecovery/relapsesystem.html

36. TEA System • Thoughts • Emotions • Actions

37. TEA System

38. ALERT System • ASSESS • LESSEN • EASE OUT • RELAX • TAKE STEPS

40. ANGER System • ACCEPT • NAME IT • GET IT OUT • ENERGIZE • RELEASE

42. LET GO System • LIGHTEN NEED • EXERCISE RIGHTS • TAKE STEPS • GIVE UP CONTROL • ORDER LIFE

44. CHIILD System • CALM • HEAL • INFORM • LIGHTEN • DIRECT

46. RELAPSE System • RECOGNIZE • EXERCISE • LEARN • ACT • PROTECT • SUPPORT • EVALUATE

47. RELAPSE System

48. SEA’s Tools for Coping – Tool Cheston www.coping.us • The SEA's Program Manual • Laying the Foundation • Tools for Handling Loss • Tools for Personal Growth • Tools for Relationships • Tools for Communications • Tools for Anger Work–Out • Tools for Handling Control Issues • Growing Down: Tools for Healing the Inner Child • Tools for a Balanced Lifestyle: A Manual for a Guilt Free System of Healthy Living • Pathfinder Parenting: Tools for Raising Responsible Children and • A personal journal — a notebook or audio file in which daily reactions, feelings, and insights are recorded. It is also used to record the completing the 12 steps Workbook in the SEA's program.

49. What Can You Do? • What can you do to help Military, Vets and their family members build resilience? • Brainstorm three things which you can do to help your clients build resilience • Ok Let’s Go!

50. Coach Clients on Building Resilience • Have clients assess their own level of resilience during tough times • Teach them about what are the best ways to build their own resilience in tough times • Encourage “resilience building lifestyle” changes in their lives