Military Culture & Treatment - 101

1. Military Culture & Treatment - 101 three hour workshop to overview the culture of the military and its families, issues affecting treatment, and sources of support Peter McCall, Exec Dir petemccall1@gmail.com 770-329-6156

2. Introduction and Ground Rules • This is not a political forum • Questions are encouraged for group discussion • Be respectful of others • If the discussions, material, or videos at any time become too disturbing feel free to leave the room till you feel comfortable enough to return

3. Sources of Materials • CareForTheTroops 2009/2010 Military Culture 101 Workshop • The Fraser Counseling Center Staff, Hinesville, GA • Dr Blaine Everson, Clinical Dir, Samaritan Counseling Center, Athens, GA • Major Chris Warner, Winn Army Community Hospital, Fort Stewart , GA • Spiritual Wounds of War material • Kent D. Drescher, Ph.D., National Center for PTSD – Menlo Park • LTC Peter E. Bauer, MS USAR, LMFT, currently at Ft Hood • Chaplain Bill Carr, D. Min., LMFT, VA Hospital, Atlanta, Ga • Alan Baroody, LMFT, Presbyterian Minister, Exec Dir Fraser Counseling Center • VA Website • 2010 AAMFT Annual Conference Workshop 303 • TriWest Healthcare Alliance “Help From Home” DVD • “Care For Returning Vets” presentation from the ELCA Bureau for Federal Chaplaincies • Other citations on charts and handouts

4. Presentation Goals • There are 5 goals of this presentation: • Understand the basics of themilitary culture and veteran issues • 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 • Provide an understanding of resources available and how CFTT can help • Ultimately, build more credibility for working with military families

5. Agenda Handout – A0 …..an Example

6. Opening Videos These three movie trailers provide a good backdrop to the Veterans Issues we are about to discuss. Please take notes as a discussion will be conducted after the next section. The run time is approximately 8 minutes.

7. Veteran Issues • Multiple deployments are common causing stress and family attachment issues. • As of Oct 2008, multiple deployment breakdown: 60% = 1x 36% >= 2x 4% >= 4x • “Typical Deployment Durations” Army and Marine 1 year (Ex Aviation and Spec Forces 4-6 months) Navy 6-9 months Air Force ~6 months • 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 • Other mental health, marriage, and family problems often occur with or leading up to PTSD requiring attention so they don’t get worse • In 2009, 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) • 43% of Service Members have children • Average number of children per military family is 1.97 (AAMFT 2010 Annual Conference) • 42% rise in children’s visits in 2009 over 2004 per Tricare • 84% of Regular Military Service Members’ children attend public school, not DoD base schools

8. Veteran Issues (cont.) • Suicide, alcoholism, drug abuse, domestic abuse and violent crimes rates are rising. In 2010: military suicides exceeded civilian suicides. • Army and Marine have higher suicide rates than Navy and Air Force • More are occurring Stateside and many go unreported for insurance reasons and are post-discharge • Female suicide rate triples when deployed (recent NIMH study), though still lower than male rate • In GA, per the CDC from 2006-2008, 500 suicides of people identified as current or former military . This represents 19.4% of all suicides during those years. The Age breakdown is as follows: 20-29 8.4% 50-59 21.2% 30-39 10.8% 60-69 31.8% 40-49 16.3% 70+ 55.8% • 18 vet suicides out of 30 attempts per day; 5 are already being treated by the VA. Women try more with less success than men …Army Times 04/2010 • Illicit drug use in the military was 5% in 2005, but now nonmedical use of prescription drugs is the most common form of drug abuse. SPICE is becoming very common. • 24.8% reported binge drinking >1x per week in the past 30 days vs 17.4% for same-age civilians • Military Sexual Trauma (MST) is running at 16%-23% • Includes harassment and assault • Almost as significant among males as among females (Newsweek, April 2011) • Mostly enlister personnel under 25 yrs old (DOD 2010 Annual Report) • Single strongest predictor of PTSD in women - as combat is for men (Natelson, 8/05/10). • 80% of assault victims fail to report the offense. (Natelson, 8/05/10) Handout – A1 A2

9. Veteran Issues (cont.) • DoD and VA facilities are stretched … the Aug 2009 VA claims backlog was 900,000; the April 2010 backlog was improved to 605,000 • April 2010 back up to 756,000 • 450,00 claims are taking over 125 days (USA Today, Apr 2011) • The U.S. Bureau of Labor Statistics reports the unemployment rate among post 9/11 veterans as 15.2% in January 2011, well above the 9.6 percent rate for non-veterans. • The VA said in Dec 2010 that more than 9,000 OIF/OEF vets were homeless (UPI); women are the fastest growing segment of this population. • 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. This may be one of the most significant affecting the future mental health impact on our communities and our society • Current numbers are in the 48% range • By design, approximately 33% should be Guard and Reserve • A large number of civilian contractors are also part of the deployed forces • 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. Investing in proper treatment would actually save $2 billion within two years.

10. Fraser Center Experiencewww.frasercenter.com 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.

11. Fraser Center Experiencewww.frasercenter.com 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.

12. Fraser Center Experiencewww.frasercenter.com 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.

13. Fraser Center Experiencewww.frasercenter.com 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.

14. Interview Videos Here are three clips from the Alive Day and Brothers at War movies. They represent interviews that further reinforce the issues the soldiers have to deal with before and after deployments. Again, please take notes as a discussion will be conducted following these clips. Run time approximately 18 minutes.

15. 10 Minute Break After a “Light” Clip The Snow Car !

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

17. 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 – B1

18. Military CultureBranches of the Military Georgia’s Military presence is dominated by Marine and Army units, though Air Force and Navy are well represented too. Georgia’s National Guard also has a large number of transportation units subject to IEDs on roads and highways. It was ill-prepared when first deployed in 2003. Georgia is 6th largest National Guard State. With the current base closing plan, GA will be one of the 5 largest military states along with TX, CA, NC, VA NOTE: Coast Guard is now under Homeland Security Handout – B2

19. Military CultureMilitary Branch Structures - Example: U.S. Army Core Values 84%% 2% 14% 84% 2% 14% Services – Army, Navy, Marines, AF, CG Components - Active, Guard, Reserve Handout – B3

20. Military CultureLanguage - Glossary of Military Terms / Acronyms 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. Operation New Dawn – post OIF operations USAR United States Army Reserve (Federal) USANG United States Army National Guard (State) 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 Gunnie A Marine First Sergeant 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 Army Soldier Navy Sailor Marine Marine Air Force Airmen Handout – C1 C2 C3 C4 C5

21. Military CultureKey ‘Descriptors’ • Service Before Self • Political • Mobile • Family Secondary • Technical • Education Structured Standardized Authoritarian Esprit de Corps Focused on Mission Disciplined

22. 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

23. Military CultureRegular/Active Duty vs Reserve/Guard Units Regular / Active Reserve / Guard • 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. • 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 • 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 • Need to make use of family or local supports (church, etc.) though FRG’s are very helpful Handout – D1

24. …a closing thought on the Military Culture “The capacity of Soldiers for absorbing punishment and enduring privations is almost inexhaustible so long as they believe they are getting a square deal, that their commanders are looking out for them, and that their own accomplishments are understood and appreciated.” GENERAL Dwight Eisenhower, 1944

25. The next few charts cover the Veteran Experiencesand Stressors that are related to the OEF and OIF veteran and to other veterans and their families to help you better understand your client and their presenting story and issues.

26. The Veteran Experience • Fear of Death • Killing • Survivor Guilt • Unreality • Strong Bonds • About Face • Unfinished Business • Seared Memory • Multiple Losses • Teamwork • Survival Mindset • Cautious of People • Soul Searching • Lack of Understanding

27. The Veteran ExperienceWhy 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 • Nation-building activities and interactions with local leaders

28. The Veteran ExperienceProfile of Differences by Era • Vietnam • military cohorts • relatively homogenous • enlisted and drafted • fewer Reservists/Guard • fewer civilian contractors • average age 18-22 • not married • no children • no career developed • adolescents— early stages of development • one tour (12-13 mos) were typical • communications via phone, mail • wounded/killed ratio 3:1 • OIF / OEF • not homogenous---heterogeneous • Active duty • Reservists/Guard- • joined for variety of reasons • likely did not expect to be deployed • Large number of civilian contractors • wide age range: 18-60+ • married • parenting/grand-parenting job/career • financial responsibilities (e.g. mortgage, family) • multiple deployments with unknown duration are typical • instant communication • more indirect combat e.g. IEDs and suicide bombers, constant threat • wounded/killed ratio 15:1 Korea and World War II ???

29. The Veteran Experience Demographics From 2010 AAMFT Annual Conference Workshop #303 Handout – D2 D3

30. The Veteran Experience Realizing the bridge is down… “Home—the place many think is the safe haven to find relief from the stress of war—may initially be a letdown. When a loved one asks, ‘What was it like?’ and you look into eyes that have not seen what yours have, you suddenly realize that home is farther away than you ever imagined.” Down Range: From Iraq and Back, by Cantrell & Dean, 2005 Handout – E1

31. Video – Signs of Stress Scenes from these movies depict the stress points that occur between couples upon re-deployment . These are also intended to set up the following charts that cover the deployment life cycle and key points on the cycle’s timeline. Again, please take notes as a discussion will be conducted following these clips. Run time approximately 10 minutes.

32. Deployment CycleChris 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.

33. Deployment Cycle • Pre-deployment - Period of training and equipping prior to deployment (30-90 days). • Deployment- Combat and Humanitarian missions anywhere in the world (3-18 months). • Redeployment - Return from operations to home base (30 days). (For Reserve and National Guard components this includes demobilization and return to civilian life).

34. Family readjusts - Consequences for behavior The Military Deployment Cycle … or The Military Family Life Cycle Pre-deployment Conflict & Previous Stressor pile-up Revitalize Relationships and “honeymoon” Pre-deployment Stress – anxiety and concern Reunion and homecoming – joy and anticipation Soldier Deployment Pre-reunion Stress – anxiety and worry about behavior away Separation Stress – Depression & Anxiety Family Adjustment w/o Soldier in Home – Out-of-Ordinary Behaviors

35. Military Family Life Cycle(…Career View) <May be 1st deployment for both partners> <Missed 1st year of marriage> New family begins in absentia -Courting -Pregnant -Marriage Parental adj & young children Resume normal routines Deploy Mid-tour leave Return & Reunion <Divorce & remarriages w/ kids for previous relationships are common – complex stepfamily> Families w/ teens & possibly steps Return & Reunion Family w/ school agers ETS or Retire Re-deploy Relocation Transitions are often marked by crisis points in the family life cycle.

36. Deployment CycleMilitary Family At-Risk Factors Frequent Relocation 3.3 years average Previous Deployments 87% Longer Separations 7.3 month average Larger Families 42% ≥ 3 children Younger Mothers 26.5 median age Blended Families 31% step-parents Education 21% w/o HS diploma Working Outside Home 44% Median Income < $30,000 (34%) Quality of Life Among U.S. Army Spouses During OIF, Dissertation, 2005, Dr. Blaine Everson

37. Interviewed Guard Couple Due to time limitations, it is likely that we will skip this during the allotted time. If time and logistics permit after the allotted time, I will be happy to stay for those that care to listen. Interviews from TriWest’s “Help From Home” DVD Again, please take notes as a discussion will be conducted following these clips. Run time approximately 17 minutes. http://www.youtube.com/results?suggested_categories=27&search_query=triwest+help+from+home%2C+channel

38. ChildrenMental Health Overview • Currently, there are about 230,000 American children and teenagers with an active duty mother or father at war. Another 320,000 from Reserve/Guard families. (550K total) Nearly half of all troops deployed in support of the recent wars are parents — many of whom are on their second or subsequent deployments. (Aug ‘09) • In 2008, military children and teens sought outpatient mental health care 2 million times, which was double the number at the start of the Iraq war (2003), according to an internal Pentagon document obtained by The Associated Press. • An article published by the Associated Press (August 9, 2009) notes a Pentagon report indicating a 20 percent increase in the number of active duty dependent children hospitalized for mental health needs between 2007 and 2008. • The document revealed there was also a spike in the number of service members' children hospitalized for mental health reasons. • http://www.msnbc.msn.com/id/32585278/ns/health-kids_and_parenting/ http://cbs3.com/wireapnewspa/Camp.for.military.2.1147685.html

39. ChildrenWhat Impacts Are Seen • Disruption of Routines • Boundary Issues & Parental Roles • Fear for Safety of Military Parent • Mimicry of Parental Responses • Sleep Disturbances and Phobias • Increase in Number of Physical Ailments • Secondary and Vicarious Traumatization

40. ChildrenDevelopmental Issues • Toddlers (3-5) - Separation Anxiety, Self-Comforting Behavior, Regression,Refusal to Eating and Sleep • Elementary (5-10) - Anxiety, Withdrawal, Regression, Fear, Uncontrolled Acting Out, Behavioral Contagion • Middle School (10-13) + Fighting, Isolation Behavior, Emotional Contagion, Difficulties with Concentration • Teenagers (13-18) + Rule Testing, Substance Use, Assaults, Use of External Systems for Support

41. ChildrenItems to Remember • Children have individual reactions • Children take their emotional and behavioral cues from parents • Children are generally egocentric and see themselves as responsible for everything • Children may need an invitation to talk • Children need people to listen to them and their stories

42. ChildrenReserve and National Guard Family Concerns • Families are not as experienced with deployment and extended absences • Family members are less familiar with military support agencies • Live in local communities with less access to military support systems • Face integration back into civilian job or may need job assistance.

43. Interviewed Teenagers Interviews from TriWest’s “Help From Home” DVD Again, please take notes as a discussion will be conducted following these clips. Run time approximately 12 minutes. http://www.youtube.com/results?suggested_categories=27&search_query=triwest+help+from+home%2C+channel

44. Military CouplesDeployment Related Stressors for Spouses Warner CH, Appenzeller GN, Warner CM, Grieger T. “Psychological Effects of Deployments on Military Families” Psychiatric Annals 2009; 14: 56-62.

45. Military CouplesAssessment and Treatment Issues • Dangerousness to self / others • Suicide / Homicide • Domestic violence • Child abuse • Individual issues • PTSD, TBI • Medication abuse • Alcohol and drug use 2010 AAMFT Annual Conference Workshop #303

46. Military CouplesStressors Specific to the Couple Relationship • Level of Commitment and Maturity • Deployment Cycle / Adaptability • Roles / Power issues • Sexual Issues • Infidelity • Disabilities / Chronic illness • Financial Issues • Parenting • Additional for Reserve/Guard Families • “Citizen Soldier” • Mobilization and Deployment • Separation from School, Jobs, etc • Demobilization 2010 AAMFT Annual Conference Workshop #303

47. Interviewed Spouses Interviews from TriWest’s “Help From Home” DVD Again, please take notes as a discussion will be conducted following these clips. Run time approximately 18 minutes. http://www.youtube.com/results?suggested_categories=27&search_query=triwest+help+from+home%2C+channel

48. 10 Minute Break After a “Light” Clip The Evil Eye !

49. The next few charts cover Trauma, PTSD, TBI and the Spiritual Wounds of War that are related to the OEFand OIF veteran.

50. The Trauma Continuum “The past is never dead. It is not even past.” …William Faulkner “Not everyone has PTSD. It is not the only diagnosis.” …me ASR COSR PTSD