Agenda

1. Returning from Combat:Understanding the Mental Health Effects of Deployment on EducationMark C. Brown, MD, MAJ, MCThanks to Roger Duda, MDMAJ, MC4th Sustainment Brigade Psychiatrist

2. Agenda • Deployment Stress • Emotional Cycle of Deployment • Post Deployment Reactions • Stressors and Combat Experiences • Recovery • PTSD and Depression • Coping with Post-Deployment Stress • Post-Deployment Growth • Resources

3. Introduction • Military families have experienced the emotional trauma of deployment on an unprecedented scale since the end of the Gulf War • Military downsizing increased likelihood each soldier will eventually participate on extended missions • Long separations are increasing concern with two-thirds of soldiers now married • Differing coping strategies are needed through five stages of deployment • Education of health care providers, military leaders, soldiers and family members to anticipate these stages is crucial to ensure the soldier's safe return and to minimize stress impacts

4. Deployment Stress • Psychological responses to deployment • Often no immediate symptoms • Reasonable immediate functioning upon return home

5. Pre-Deployment • Anticipation of loss vs denial • Train-up/long hours away • Getting affairs in order • Mental/physical distance • Arguments • Deployment • Mixed emotions/relief • Disoriented/overwhelmed • Numb, sad, alone • Sleep difficulties • Security issues Emotional Cycle of Deployment • Sustainment • New routines established • New sources of support • Feel more in control • Independence • Confidence “I can do this.” • Post-Deployment • Honeymoon period • Loss of independence • Need for “own” space • Renegotiating routines • Reintegration into family • Re-Deployment • Anticipation of homecoming • Excitement • Apprehension • Burst of energy/”nesting” • Difficulty making decisions

6. Stage 1. Pre-deployment • Stage begins with the warning order for deployment • Characteristics: • Anticipation of loss vs. denial • "You don't really have to go, do you?" • Train-up/long hours away • Getting affairs in order • Long "honey-do" lists • Mental/physical distance • Will my marriage survive?" • Arguments • "I wish you were gone already." • It is easier to be angry than confront the pain and loss of saying goodbye

7. Stage 2. Deployment • Mixed emotions/relief • Disoriented/overwhelmed • Numb, sad, alone • Sleep difficulty • Security issues at home • Positive side • Ability to communicate home is a great morale boost

8. Stage 3. Sustainment • New routines established • New sources of support • Feel more in control • Independence • Confidence • Discussing "hot topics" • Unidirectional phone calls

9. Stage 4. Re-deployment • Re-deployment • Essentially defined as the month before the soldier is scheduled to return home. • Anticipation of homecoming • “Will he (she) agree with the changes that I have made? • Will I have to give up my independence? • Will we get along?" • Excitement • Apprehension • Burst of energy • Difficulty making decisions

10. Stage 5. Post-deployment • Honeymoon period • Intimacy issues • Social, sexual, recreational, spiritual, physical, affective, intellectual • Myth of Infidelity • Loss of independence • Spouses may consider themselves to be the true heroes • Need for "own" space • "Who is this stranger in my bed?" • Renegotiating routines • Reintegrating into family • Typical period where post traumatic issues appear • Three to six months after deployment • Communicate with patience; focus on feelings, “what not who”

11. Post Deployment Effects of Deployment and Combat Experience • Cognitive (thoughts) • Emotional (feelings) • Behavioral (actions)

12. Top Deployment Stressors Uncertain Re-Deployment Date Long Deployment Length Being Separated from Family Lack of Privacy or Personal Space Boring or Repetitive Work Difficulties Communicating Back Home Not Having Right Equipment or Repair Parts Lack of time off for personal time

13. Combat Experiences

14. Combat Experiences Receiving incoming artillery, rocket, mortar Receiving small arms fire Knew someone seriously injured or killed Having a member of your own unit become a casualty Seeing dead or seriously injured Americans Handling or uncovering human remains Being directly responsible for the death of an enemy combatant IED/ booby trap exploded near you* *IED question only asked during OIF-II

15. Protective Factors • Well-functioning/supportive unit • Perceived control over events • Strong commitment to tasks • See adverse events as challenges • No prior trauma exposure • Good mental health pre-exposure • Strong social/family support

16. Risk Factors • Severity of trauma • History of previous trauma • Preexisting psychiatric disorder • Family history of psychiatric disorder • Limited support systems • Exposure to reactivating environmental events

17. Changes in Thinking • Unwanted “reliving” of combat experiences • Distressing memories • Disturbing dreams or nightmares • Flashbacks • Upset when reminded of war zone events

18. Changes in Thinking (cont.) Changes in Attitude and Outlook: • Preoccupation with news about the war • Worry about friends still deployed overseas • Miss excitement of combat, urges to return • Confused about direction and meaning in life • Blaming self for actions in war zone • Loss of “innocence” and belief in former values

19. Changes in Emotion • Feeling unsafe, on guard • Irritability and outbursts of anger • Anxious, apprehensive, panicky, stressed out • Guilt, shame • Feeling alienated from others and society (“I don’t fit in any more!”) • Loss of interest and enjoyment in life • Down, depressed, hopeless • Shutting down and emotional numbness

20. Changes in Behavior • Trouble falling asleep and/or staying asleep • Easily startled, jumpy • Physical symptoms and health problems • Problems with concentration and attention • Avoiding people, places, or things that are reminiscent of military duty • Increased use of alcohol or drugs • Isolated, withdrawn, sullen, uncommunicative • Overly controlling and worried about safety

21. Recovery • Understanding and the support of others helps stress reactions pass more quickly • Structure your time with normal activities – keep busy with a normal schedule • Don’t label – this is a normal reaction to an abnormal event • Talk to people – it is the most healing medicine

22. Recovery • Get plenty of rest • Eat healthy – even if you don’t feel like it • Daily exercise • Spend time with others • Share your feelings • Do things that feel good • Don’t make any big life changes

23. Mental Health Awareness: Returning Soldiers are at Risk for: • Domestic Violence • Substance Abuse • Depression • Anxiety disorders • Post-Traumatic Stress Disorder (PTSD)

24. Current Statistics • Depression • 8-10% in post-deployment • PTSD • OIF 15-20% of returning soldiers • OEF 10-15% of returning soldiers • Substance Misuse • Up to 30% of returning soldiers

25. Effects of Witnessing Traumatic Events • It is quite normal for people to experience emotional or physical reactions after a traumatic event • They can occur immediately after the event, or may take hours, days, weeks or months to appear • They are normal and for most will resolve or not have significant impact on life

26. Risk Factors for PTSD • Nature of the trauma: prolonged, severe • History of prior trauma • Family history of anxiety disorders • Personal history of mood disorder, anxiety disorder

27. Suggested Coping Skills for Dealing with Post-Deployment Stress • Unwanted distressing memories, images or thoughts • Remind yourself that they are just that—memories • Talk to someone you trust about them • Sudden feelings of anxiety or panic. • Slowing down your breathing may help. • Learn to “ride the wave” • Depression • Talk about losses, changes and gaps between what you dream and what you have • Monitor and disrupt negative self-talk • See the doctor if it last longer than a month

28. Suggested Coping Skills for Dealing with Post-Deployment Stress (cont.) • Feeling like the trauma is happening again (“Flashbacks”) • Keep your eyes open. Look around you and notice where you are. Tell yourself, “I am at ___” • Call someone you trust and tell them what’s been happening. • Trauma-related dreams and nightmares • If you awaken from a nightmare in a “panic,” remind yourself that you are reacting to a dream • Talk to someone or your doctor about your nightmares; certain medications can be helpful.

29. Suggested Coping Skills for Dealing with Post-Deployment Stress (cont.) • Difficulty concentrating • Write things down. Making “to do” lists may be helpful • Break task down into small do-able “chunks” • Having difficulty feeling or expressing positive emotions • Ensure regular participation in activities you enjoy or used to enjoy. • Take steps to communicate caring to loved-ones in little ways: “pleasers,” write a card, leave a small gift, phone and say hello

30. Suggested Coping Skills for Dealing with Post-Deployment Stress (cont.) • Difficulty falling or staying asleep • Avoid using your sleeping area for anything other than sleeping or sexual intimacies. • Do not lie in bed thinking or worrying. Get up and enjoy something soothing or pleasant; • Irritability, anger, and rage • Take a “time out” to cool off or to think things over • Talk to someone about the triggers to the anger and irritability

31. Helping A Person Affected By Combat Experiences • Listen carefully • Spend time with them • Reassure them they are safe • Help with everyday tasks • Allow some private time • Don’t take their anger or other feelings personally • Ask how you can assist them

32. Post-Deployment Growth • Improved sense of own vulnerability • Sense of increased competence and self-reliance • Increased gratitude for relationships with significant others • More compassion and empathy for others • Greater efforts directed at improving relationships • Greater appreciation for life • Positive changes in one's priorities • Stronger religious/spiritual beliefs

33. Resources • WBAMC OPS 569-2801 • El Paso Child Guidance Center Grant • TRICARE • Military One Source • Army Behavioral Health web site: • www.behavioralhealth.army.mil