Preparing Our Communities To Help Our Returning Soldiers

1. Preparing Our Communities To Help Our Returning Soldiers Lanny Endicott, LCSW, D.Min. lendicott@oru.edu http://drlannyendicott.com.tripod.com Dexter Freeman, Ph.D. Dexter.Freeman@amedd.army.mil

2. Some InformationLanny Endicott • 2,200,000 service members have experienced deployment to Iraq (OIF) and Afghanistan (OEF) • 800,000 have experienced multiple deployments • 43% of today’s fighting force is comprised of Reserve and Guard members • 1% of the US population involved • $4 trillion expended

3. Approximately 35+% return afflicted with TBI and PTSD • Those who deploy more than once have 300 % increased probability for severe mental health outcomes • At least 130,000 and as many as 250,000 U.S. veterans are homeless each night (over 7,000 are veterans of Iraq or Afghanistan) • Suicide is now the top killer of military veterans

4. Up to 31 percent of soldiers returning from combat in Iraq experience depression or post-traumatic stress disorder that affects their jobs, relationships, or home life, according to a new study by Army researchers.

5. 81 percent of Veterans suffering from depression and PTSD engaged in at least one violent act against their partner in the past year.

6. Active-duty female personnel make up roughly 14.5 percent -- or 207,308 members -- of the more than 1.4 million Armed Forces, according to the Department of Defense. One in three military women has been sexually assaulted, compared to one in six civilian women, according to DoD

7. Military and Domestic Violence: Risk Factors • High percentage of military personnel have prior histories of family violence. • Among Navy recruits, 54% of women and 40% of men witnessed parental violence prior to enlistment

8. Risk Factors • Military population is concentrated in the ages of highest risk for interpersonal violence (ages 20-40) • Constant mobility and geographic separation isolates victims by cutting them off from family and other support systems

9. Military and Domestic Violence Risk Factors • Higher than average unemployment rates for military spouses, leaving them economically dependent on service members • Deployments and reunifications create unique stresses on military families

10. “Our military does an exceptional job of preparing soldiers, Marines, sailors and airmen for the fight – boot camp makes warriors of recruits – but we do little to ‘de-boot,’ to support that warrior and his or her family as he or she comes out of the extraordinary experience of having served in combat. A prosthetic leg, some physical therapy and a bottle of meds do not equal a homecoming plan.” Nancy Berglass. America’s Duty: The Imperative of a New Approach to Warrior and Veteran Care. November 2010. Center for a New American Security.

11. Workshop Objectives • Articulate how military culture can both help or hinder community re-integration • Describe 2 evidence-based treatment modalities for treating service members with PTSD • Introduce “traumatic brain injury” • Address the concept of “soul or moral injury” affecting our service members and discuss ways social workers of faith can address the issue

12. 3,300 Members of the Oklahoma National Guard have returned home from Afghanistan/Kuwait

13. A New Paradigm • Despite their best intentions DOD and VA are overwhelmed • Less that 50% of veterans access services of the VA - particularly “mental health’ • Private sector partners (non-profits and for-profits) can provide important services – but need assistance with funding and training to address the needs of veterans • A key is that personalized care for our veteran warriors includes the VA and community partners working together

14. Community PartnersEngage coordinated and informed community planning effortsVA + Community • Community-based social service providers • Educational institutions (universities, colleges, tech schools) • Faith communities (churches, synagogues, etc.) • Court systems (Veterans Court) • Employers • Veterans Administration • Military support organizations (Wounded Warriors, Folds of Honor, Blueprint, Give an Hour)

15. Veterans Initiative Community Service Council (Tulsa) • Bring agencies/organizations together to discuss what they do • Discover gaps/needs in services to veterans • Preparation of therapists to accommodate veteran clientele: • military culture • evidenced based treatment for PTSD • Develop a “go-to-provider” in each agency: one trained who functions as trainer for others

16. Wounded Warriors’ Grant • Community Service Council (Veterans Initiative) • Three parts: • Military Culture • Cognitive Processing Therapy (Duke and TU) • Create a “learning community” for application and feedback of CPT • Goal: train 60 therapists

17. ID Veterans and Families • Identification of veterans and their families at social services, doctors offices, employers, educational institutions, etc. • Add a question on veteran status in intake forms

18. Veterans Courts • Promote establishment of Veterans Courts • Tulsa has Veterans Courts on both County and City level • Modeled after the “drug court” • 2-year program: treatment, case management, mentors

19. Preparing Educational Institutions • Educational institutions should have: • Go-to person to work with veterans • Veteran organization • Veterans Lounge (private meeting place) • Training of faculty and staff for working with veterans • Referral network for assisting veterans and their families See SVA Toolkit: www.vetfriendlytoolkit.org

20. University of Denver Study • Of 800,000 veterans who attended college • 88% dropped out after the first year • 3% graduated from college

21. Coffee Bunker • Tulsa is a large community without a military instillation nearby • Coffee Bunker is an evening drop-in center for veterans of all services • Volunteers are trained in QPR • Recent grants from Wounded Warriors and United Way (Venture Grant) will help expand program to its own site

22. Summary In general, prepare and educate the community for veteran reintegration • Remember the 1% • $4 trillion of borrowed money • Lack of sacrifice from the community in general • Old news becomes less newsworthy

23. A Matter of National Defense “The willingness with which our young people are likely to serve in any war, no matter how justified, shall be directly proportional to how they perceive the Veterans of earlier wars were treated and appreciated by their nation.” President George Washington

24. Military Culture

25. When You Think of the Military(Unique Facets) • Frequent separations • Regular household relocations • Mission comes first • Early retirements • Loss • Detachment • System security • Rank focused

26. The Deployment cycle(Emotional factors) • Predeployment – “Gearing up” • Anticipation, detachment, sadness, restless • Deployment – “Boots on the ground” • Emotional disorganization, sleep disturbance • New patterns, psychological presence • Postdeployment (Redeployment) • Relief, boundary ambiguity • New normal, prepping to gear up

27. Coping with deployment(awaiting spouse’s concerns) • Safety of Deployer (49%) • Loneliness (47%) • Anxiety or depression (36%) • Difficulty sleeping (36%) • Sole parent concerns (32%) • Inaccurate information (31%) • Household duties/repairs (28% • Job/education demands (26%) Data from 2008 survey of active duty spouses, defense manpower data center (2009)

28. Military Culture: “Paint a Moving Train” (Kudlar) http://www.mirecc.va.gov/visn6/paint-moving-train.asp For introduction to treatment of PTSD (Cognitive Processing Therapy): http://www.ptsd.va.gov/professional/ptsd101/ptsd-101.asp http://cpt.musc.edu “Psychological First Aid” http://www.ptsd.va.gov/professional/manuals/psych-first-aid.asp What we know about Army Families: 2007 update http://www.army.mil/cfsc/research.htm For training in military culture

29. PTSD • Think of PTSD as inability to recover from a traumatic event • In normal recovery, intrusions and emotions decrease over time and no longer trigger each other • In those not recovering, strong negative emotion leads to escape and avoidance

30. Symptoms of PTSD Three Categories: • “Reliving” the event: • Flashbacks • repeated upsetting memories of the event • repeated nightmares • strong uncomfortable reactions to situations that remind one of the event

31. “Avoidance” or emotional numbing or feeling one doesn’t care about anything • Feeling detached • Being unable to remember important aspects of event • Having lack of interest in normal activities • Avoiding reminders of event: places, people, thoughts • Showing less of one’s moods • Feeling like one has no future

32. Arousal • Difficulty concentrating • Startling easily • Exaggerated response to things that startle • Feeling more aware (hypervigilance) • Feeling irritable or having outbursts of anger • Having trouble falling or staying asleep • Feeling guilt about the events (“survivor guilt) • Symptoms typical of anxiety, stress, tension: • Agitation or excitability, dizziness, fainting, feeling heart beat in one’s chest, headache

33. PTSD Treatment VA recognizes two therapies with best evidence: • Cognitive Processing Therapy (CPT) • Prolong Exposure Therapy (PET)

34. VA website for Cognitive Processing Therapy http://www.ptsd.va.gov/public/pages/cognitive_processing_therapy.asp VA website promoting Mobile App: PTSD Coach http://www.ptsd.va.gov/public/pages/PTSDCoach.asp Mobile App: PE Coach

35. Traumatic Brain Injury (TBI) Symptoms of Mild TBI • Brief loss of consciousness (seconds to minutes) • Headache • Vomiting • Nausea • Lack of motor coordination • Dizziness • Difficulty balancing • Lightheadedness

36. Blurred vision or tired eyes • Ringing in the ears • Bad taste in the mouth • Fatigue or lethargy • Changes in sleep patterns • Behavioral or mood changes • Confusion • Trouble with memory, concentration, attention, or thinking

37. Moral Injury • Is a suspected contributor to soldier suicide • Is not PTSD: an injury of trauma leading to suppression of fear and lack of integration of feelings with coherent memory – leading to symptoms including flashbacks, nightmares, dissociative episodes and hyper-vigilance

39. Moral injury is a negative self-judgment based on having violated core moral beliefs and values or feeling betrayed by one in authority • It includes loss or destruction of moral identity and loss of meaning • Its symptoms include shame, survivor guilt, depression, despair, addiction, distrust, anger, a need to make amends and the loss of desire to live

40. A Consequence of Training • “Mission first” training – can contribute to resiliency in soldier’s mission (including survival) while ignoring empathy for others and deep moral values • Soldiers taught to see events in a neutral light, not labeling them as good or bad, and to focus on those things that are positive

41. A soldier could experience the incomprehensible while on mission: killing a family, including women and children, after kicking down the door of suspected insurgent; losing a close friend; or torturing detainees? • Will the soldier see as neutral or positive?

42. Person of faith • Many soldiers seek the help of clergy: • To avoid a negative psychological record • To seek help with religious meaning, moral issues, and matters of conscience • Social workers of faith can also provide caring and empathetic help through careful listening and understanding as soldiers may seek community professionals to avoid mental health labeling

43. Treatment • Moral injury is not a clinical condition that can be medicated or cured by psychology • Requires the reconstruction of a moral identity and meaning in life with the support of a caring, nonjudgmental community (chaplain, pastor, therapist, social worker) that can provide a way for the veteran to learn to forgive

44. PTSD Treatment Cognitive Processing Therapy • Address event(s) – thinking – feelings connection • Writing about detailed trauma event(s) & reading them to the therapist • Utilizing worksheet assignments Prolonged Exposure • Teach relaxation • Expose person to discussing/experiencing traumatic event (invivo – imaginal)

45. Moral Injury • Two types of violations: co-mission or omission • Violation of moral, cultural, religious and/or other deeply held beliefs • Military training emphasizes mission with suppression of individual beliefs • Moral Injury does not come from a specific traumatic event

46. Treatment of Moral Injury • Shame: the consequence • Forgiveness, repentance: the treatment via help from community therapists, clergy, chaplains, or trusted moral authority • Honor: community events, ceremonies celebrating and honoring returning soldiers “Honor is the antidote of shame”

47. Grief • The soldier may be experiencing “grief” from loss (i.e., death of colleague, separation from unit & mission, leaving of spouse) • The treatment is an application of “grief therapy”: talk through the loss while recognizing that people process grief differently

48. Resources for Moral Injury http://www.ptsd.va.gov/professional/pages/moral_injury_at_war.asp http://www.commondreams.org/view/2012/06/29-8

49. Questions/Comments