Supporting Our Military and their Families: An I ntegrative Approach Aimed at Improving Resiliency and Recovery

1. The Military Wellness Programat Holliswood Hospital Dr. Michael DeFalco, Psy.D. Program Director Aynisa Leonardo, LCAT, AT-R, BC Program Coordinator Supporting Our Military and their Families:An Integrative Approach Aimed at Improving Resiliency and Recovery

2. Accreditation Nurse Accreditation Statement PRIME Education, Inc. (PRIME®) is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's Commission on Accreditation. PRIME® designates this activity for 6.0 contact hours. Case Manager Accreditation Statement The Commission for Case Manager Certification designates this educational activity for 6.0 contact hours for certified case managers. NASW AccreditationThis program is pending NASW accreditation for Social Workers .

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5. Learning Objectives • Discuss integrated and complimentary treatment models for meeting the needs of service members, veterans, and their families •  Describe experiential therapy techniques, in combination with community based partnerships and collaborative efforts.

6. Holliswood Hospital Holliswood is a 125 bed private, inpatient hospital located in a quiet residential Queens community in NY. Out of the hospital’s five units, one unit consists of 25 beds, and is our Military Wellness Program. This program began in 2006. Currently, the program proudly treats an average of 300 service men and women per year.

7. The Military Wellness Program(Who We Are) The Military Wellness Program at Holliswood Hospital provides a trauma-informed clinical approach, where each individual receives intensive, evidence-based, progressive, and holistic treatments for post-traumatic stress, depression, anxiety, and substance misuse issues. *Our program is Tricare Approved* We offer a wide range of treatments for Active Duty service members, OEF/OIF/OND veterans, veterans from previous conflicts, as well as family members, in order to best maximize their treatment experiences and have positive outcomes.

8. Profile of Service Members Admitted to The Military Wellness Program (Who We Serve) • 90% male • Average age range 20-35+ • 85% have been deployed- OEF/OIF/OND • 75% are dually-diagnosed with a significant behavioral health disorder (depression, anxiety, PTS), as well as substance/alcohol misuse or dependence The Military Wellness Program at Holliswood Hospital www.militarywellnessprogram.com

9. Who We Serve 88 % Active Duty, 12% Retired or Discharged Army, National Guard, Air Force, Marines, Navy, and Coast Guard The Military Wellness Program at Holliswood Hospital www.militarywellnessprogram.com

10. Transitional Challenges that Service Members Commonly Face (Why We Serve) • Post traumatic Stress • Substance/Alcohol Misuse • Suicide Attempts • Military Sexual Trauma • TBI and resulting Cognitive Limitations • Chronic Pain/Physical Injuries • Emotional Injuries • Isolation/Disconnection from others • Identity Loss- Warrior to Civilian • Existential Conflicts • Hopelessness about self and future • Anxiety and Sleep Disturbance

11. Meeting Complex Needs (How We Serve): Holistic and Integrative Recovery Model- Allows for Bio-Psycho-Social-Spiritual components to be addressed in unison The Military Wellness Program at Holliswood Hospital www.militarywellnessprogram.com

12. The Military Wellness Program- Clinical Services (How We Serve) The following is a list of Clinical Services offered as part of our integrative model: · Assessment and diagnosis of primary and possible comorbid conditions ·       Evidence-Based and other Individual Therapy: 3-4 times per week · Trauma-Specific Exposure and Cognitive Therapies- weekly · Eye Movement Desensitization and Reprocessing- weekly · Brainspotting- weekly · Expressive Art Therapies- daily · Cognitive Behavioral Therapy- daily · Prolonged Exposure Therapy- weekly · Cognitive Processing Therapy- daily · Narrative Therapy- weekly ·  Creative Arts Therapy- daily ·       Expressive Therapies (writing, drama, narrative, music)- daily ·       Cognitive Behavioral Therapy, Dialectical Behavior Therapy- daily ·Evidence Based Group Therapy covering a wide range of topics- daily ·       Substance and Alcohol Recovery Treatment- daily The Military Wellness Program at Holliswood Hospital www.militarywellnessprogram.com

13. Clinical Services - Continued • ·        Psychoeducation (specialized in trauma and addiction)- daily ·Medication management and dispensing when indicated- daily · Supervised visiting- daily · Encouragement/Facilitation of Positive Peer Support- daily ·        Access to Fitness Center- daily ·        Acupuncture- twice weekly ·        Movement Therapy and Tai Chi- weekly ·        Equine Therapy- weekly ·        NA/AA meetings, 12 step programming- weekly ·        Marital/Family Therapy- weekly ·     Family Reintegration Program, including Marital/Family Therapy- offered throughout course of treatment- includes clinical and respite services · Yoga- weekly ·        Pet Therapy- weekly ·        Meditation and Mindfulness Training- weekly ·        Peer/Community Supported Events- twice weekly • ·        World Trade Center Therapeutic Trips- monthly • ·        Vocational Skills Building and Networking- twice monthly The Military Wellness Program at Holliswood Hospital www.militarywellnessprogram.com

14. Physiology- Window of Tolerance- Bi-Phasic Trauma Response (Biological) Emotional reactivity Hyper-vigilance Intrusive imagery Obsessive/cyclical cognitive processing Tension, shaking, ungrounded. Hyper-arousal: too much arousal to integrate Window of Tolerance Optimal Arousal Zone Flat affect Inability to think clearly Numbing Collapse Hypoarousal: too little arousal to integrate

15. Mind-Body Focused Practices: Re-Gaining Control of One’s Physiology • Yoga- Trains somatic awareness, pain reduction, • thought clarity • Acupuncture- Targets symptoms directly, and non- • chemically (anxiety, chronic or acute pain, depression) • Meditation and Mindfulness- Teaches quieting response, • down regulation of Amygdala (stress center of brain) • EMDR and Brainspotting- Uses somatic and visual cues to • promote neurological movement and non-verbal trauma • processing and release The Military Wellness Program at Holliswood Hospital www.militarywellnessprogram.com

16. Trauma Processing Techniques • Prolonged Exposure- Strong evidence base, Effective in • treating symptoms of anxiety and hyper-arousal • In Vivo Desensitization- Opportunities to practice coping • strategies in real life scenarios • Cognitive Processing Therapy • EMDR (Eye Movement Desensitization and Reprocessing) • Brainspotting • Narrative Therapy- Provides contextual framework • Art Therapy- Symbolic representations

17. Expressive Treatments- Art Therapy (Psychological) “Oftentimes, in trauma, healing cannot be fully completed because traumatic experiences become locked in various areas of the brain. We can’t work trauma through just by talking about it. Talking is primarily a left hemisphere activity. In order to complete the healing process, a person must access the limbic system and the right hemisphere, where images, body sensations and feelings are stored. By accessing them, a person is then able to attach meaning to them and move this traumatic material to a more adaptive resolution.” ~BelleruthNaparstek, Invisible Heroes: Survivors of Trauma and How They Heal, 2005

18. Art Therapy: Metaphor Transformations Past, Present, Future The Military Wellness Program at Holliswood Hospital www.militarywellnessprogram.com

19. Art Therapy- Self Discovery and Externalization Developing Insight Representing the Unspeakable The Military Wellness Program at Holliswood Hospital www.militarywellnessprogram.com

20. Art Therapy- Phases of Recovery Depicted The Military Wellness Program at Holliswood Hospital www.militarywellnessprogram.com

21. Collaborative Murals Working Together, Healing Together- Validation and Peer Support The Military Wellness Program at Holliswood Hospital www.militarywellnessprogram.com

22. Collaborative Murals Identity Formation- Defining Oneself The Military Wellness Program at Holliswood Hospital www.militarywellnessprogram.com

23. Experience Based Therapies (Psych/Social) • Equine Therapy- Life themes emerge in • metaphor; promotes emotional • congruence, inter and intra-personal • connections • Voices of Valor- Partnered with • Music for all Seasons®, service • members engage in song writing and • production, representative • of their journeys • Community Reintegration Lunches- Informal peer to peer support, interaction, acceptance

24. Re-integration Process-Healing Together Peer Support- FDNY- Mutual Understanding Community Support- Hope for the Warriors

25. Experience Based Therapies (Psych/Social) • Therapeutic Out Trips: • Community Events- Allows for re-definition of self • within community, desensitization to external stimuli • Fishing Trips- Healthy • alternatives to • substance/alcohol misuse, • focus, clarity, • camaraderie The Military Wellness Program at Holliswood Hospital www.militarywellnessprogram.com

26. Existential Treatment(Spiritual) • Including meaning-oriented and philosophical thought helps guide clients toward accepting pain as a part of life. • “Soul Wound” • Warrior mentality- How to support a transition back into society with a sense of value and purpose • Integrating past experiences- Role inversions The Military Wellness Program at Holliswood Hospital www.militarywellnessprogram.com

27. World Trade Center Therapeutic Trips • All levels of healing, concurrently • Desensitization- In vivo exposure • Community Re-integration and connectivity • Grief, Loss, Acceptance- Emotional Progression The Military Wellness Program at Holliswood Hospital www.militarywellnessprogram.com

28. World Trade Center Therapeutic Trips “This event has given me more closure, showed me there is hope, and made me feel that I mean something. It made me feel alive.” The Military Wellness Program at Holliswood Hospital www.militarywellnessprogram.com

29. The Grieving Process as part of Recovery • The Levels of Loss- related to combat, identity, purpose, family, self • How/where/when to grieve • Cathartic process is healing • Ambiguous Conflict- Misplaced feelings of anger, frustration, regret, resentment, guilt The Military Wellness Program at Holliswood Hospital www.militarywellnessprogram.com

30. “I felt a purpose in my enlistment in the US Navy. I served for those who lost their lives that day and the many who perished trying to save lives. I began calling the site “Ground Hero” because 343 heroes died trying to save thousands who were murdered that day.”

31. Making the intangible tangible- Closure • Loss is an intangible process, finding a sense of Closure • The WTC trips help to give shape to experiences- Provides context • Feeling forgotten, cast aside- WTC site as a parallel metaphor, • The Memorial site contains tangible symbols of Resiliency, Hope, Rebuilding The Military Wellness Program at Holliswood Hospital www.militarywellnessprogram.com

32. “The sound of people speaking quietly, the sounds of the water, sends a sense of peace and closure to me. Ground Hero has given me a place to see, touch, hear and feel that my service is done. My injury to me was worth it and what an honor it is to be able to touch the Survivor’s tree with my embattled hand. I am a survivor, my life will continue, just as the 9/11 Memorial will continue to survive and grow.”

33. The Military Wellness Program Partnership with Hope for the Warriors® ~World Trade Center Therapeutic Trips: Through our partnership with Hope For The Warriors®, service members within the program are accompanied by Holliswood and Hope for the Warriors staff, in addition to FDNY and NYPD, on a tour of the National 9/11 Memorial site, followed by a lunch at a local firehouse hosted by FDNY. ~Above and Beyond Vocational Rehabilitation Workshops: Through our partnership with Hope For The Warriors®, quarterly vocational workshops are held on-site to assist service members in developing resumes, interview skill building, and network opportunities to promote a successful vocational transition. ~Community Support Lunches: Hosted by Hope For The Warriors®, service members and veterans in treatment are able to break bread in an informal stetting on a weekly basis. Regular attendees include program staff, and local individuals/organizations whose missions are to support our military, such as Friends of Firefighters, members of FDNY, NYPD, and peer mentors within the community. ~Family Reintegration Program:Spouses, caregivers, and/or significant family members of warriors in our treatment program are brought to New York to take part in a four-day intensive clinical workshop aimed at educating and supporting family members and improving military family resiliency. Transportation, food, lodging, and respite services are provided by Hope For The Warriors®. The Military Wellness Program at Holliswood Hospital www.militarywellnessprogram.com

34. Family Reintegration Program Mission: The Family Reintegration Program aims to, first and foremost, support wounded warriors and their families by engaging the warrior and their spouse/caregiver in a therapeutic experience that promotes family communication, recovery and resiliency.

35. Summary of FRP Stakeholders Meeting- June 14, 2011 Pre-Inception • Spouses/families have REAL problems as well • Issues of LOSS- identity, marital partner, family identity, loss of HOPE “We are a care-giving team, not a family” • Spouses/families are TIRED- feel isolated in caregiver role; overwhelmed • “I need time to be me” • Spouses/families are ANGRY- at husbands, at the military- at the VA/caregivers • “War destroyed him, then he destroyed the family” • Lack of vetted resources- education about illness, skills to manage self, Wounded • Warrior, and family, who to turn to • Lack of productive involvement in treatment of WW- from intake through D/C • “Caseworkers don’t talk with me and he only tells me ¼ of what was said and done” • “Are gains in treatment real, and will they last?”

36. Family Reintegration Program: Scope and Services • For wounded warriors admitted to the Military Wellness Program at Holliswood Hospital for inpatient care, the Family Reintegration Program will transport their spouse/family member to New York, FREE OF CHARGE for a four-day therapeutic workshop that will include the following elements: • Focused education and skills training to better understand and manage posttraumatic • stress, mood dysregulation, and substance misuse issues • Conjoint/marital or family therapy with the warrior-in-treatment and the • spouse/family member, focusing on strengthening resiliency within the family unit • Direct communication to the spouse/family member about their warrior’s treatment, • including expectations for recovery and ways to maximize treatment gains • Ongoing follow-up and support for the spouse/family member following the program • week, and after their warrior has been discharged from the Military Wellness Program • Respite/self-care opportunities for the spouse/family member, while lodging in NY, • including access to support groups, dinner, recreational activities in Manhattan, and/or • spa services.

37. 37% 132 Service Members have participated in this program from Sep 2011-April 2013 With 88 of their Spouses and 134 of their Family Members

38. Family Reintegration Program: Number Participants per year

39. Family Reintegration Program “Of all the years as a military spouse, I’ve never received this type of treatment. Thank you for remembering the spouses.” “The treatment we’ve received from your organization is beyond words. I feel like a Queen.”

40. Family Reintegration Program "I am so grateful for this opportunity to participate with and support my son's treatment. I can't say enough about the love and quality of care provided to all of us. Thank you.“  "Everyone has been very nice. Thank you everyone for your support and giving us the chance to become closer in the family. Memory of a lifetime! Thanks for my wonderful miracle that I received!"

41. Clinical Social Work within the Family Reintegration Program Family Therapy in an Acute Setting: • Mirrors the service member’s treatment in that it is intensive, family members are involved in several sessions a day including individual, couples, and group sessions • Utilizes problem-solving techniques and future-oriented questions to focus on achievable goals • Highly individualized based on case by case needs • Through a process of reciprocal healing, the entire family unit learns how to develop a “new normal” of balanced and productive family dynamics, with convergent goals and expectations.

42. Family Reintegration Program

43. Family Reintegration Program “Since we started this program, I am starting to see a difference in how my husband is handling his PTSD, and how much better we’re communicating. I feel the treatment is actually working” The Military Wellness Program at Holliswood Hospital www.militarywellnessprogram.com

44. Efficacy of MWP Treatment- Recent Data(It Works!) Improvement in Post Traumatic Stress Symptoms Outlined Below: * Patients complete the PCL-M assessment upon admission and again at discharge. * The measurement of change is the difference between their two scores. * The above data indicates that 74% individuals who enter our program with Moderate PTSD leave the program no longer meeting diagnostic criteria.

45. Efficacy of MWPTreatment- Recent Data(It Works!) Improvement in Post Traumatic Stress Symptoms Outlined Below: *Patients complete the QIDS assessment upon admission and again at discharge. *Change is measured by the difference in scores on the depression scale from beginning to end of treatment.

46. ~ Accessibility ~ To make a referral, you can contact our Intake Office, 7AM-midnight, 7 days/week, 365 days/year. Call 718-776-8181 x2204 For off-hour referrals, you can contact the Nursing Supervisor at 718-776-8181, x2231 , or “0” The Military Wellness Program at Holliswood Hospital www.militarywellnessprogram.com

47. Contact Info: For inquiries about The Military Wellness Program at Holliswood Hospital, contact: Dr. Michael DeFalco, Psy.D. Program Director (o) 718-776-8181 x2335 Mdefalco1@libertymgt.com OR AynisaLeonardo, LCAT, ATR Program Coordinator (0) (718) 776-8181 x2200 (c) (646) 599-0577 Aleonardo@libertymgt.com The Military Wellness Program at Holliswood Hospital www.militarywellnessprogram.com