Military Culture

1
Military Culture Treatment - 101GAMFT
Chapter Workshop

• three hour workshop to overview the culture of
  military families, effective treatments, and
  sources of support

Blaine Everson doceverson_at_gmail.com
706-369-7911

• Alan Baroody
• na4nb_at_yahoo.com
• 912-369-7777

Peter McCall petemccall1_at_gmail.com 770-329-6156
2
Presentation Goals

• There are 5 goals of this presentation
• Better understand the basics of themilitary
  culture to build credibility while working with
  military families
• 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
• Review where clinical support material can be
  found via CFTT
• Learn what the GAMFT initiative is with the
  CareForTheTroops.org organization

3
Agenda
Handout A0 ..an Example
4
MILITARY OATH OF ENLISTMENTrecited by all
Service Members at their swearing in ceremony
NOTE the 3 dots its a break point, repeat
after me.

• I, (NAME)
• DO SOLEMNLY SWEAR
• THAT I WILL SUPPORT AND DEFEND THE
• CONSTITUTION OF THE UNITED STATES
• AGAINST ALL ENEMIES, FOREIGN AND DOMESTIC
• THAT I WILL BEAR TRUE FAITH AND ALLEGIANCE TO THE
  SAME
• AND THAT I WILL OBEY THE ORDERS OF THE PRESIDENT
  OF THE UNITED STATES
• AND THE ORDERS OF THE OFFICERS APPOINTED OVER
  ME,
• ACCORDING TO REGULATIONS AND THE UNIFORM CODE OF
  MILITARY JUSTICE,
• SO HELP ME GOD.
• Speaking these words has far more emotional power
  than these words on paper
• could ever convey. Anyone who has done this for
  real knows, in that moment,
• that they are agreeing to defend a principle with
  their very lives.
• It is a moment they never forget.

Handout A1
5
Agenda
6
CareForTheTroops, Inc.

• Who Are We Big Picture
• CareForTheTroops is working to help the military
  and their extended family members receive mental
  health services and support from within the
  civilian elements of our society in the State of
  Georgia.
• CareForTheTroops is attempting to equip the
  civilian support services of society e.g.
  clinicians, with the capacities to be helpful.
• We are working toward building a better net to
  catch those that need help before they fall too
  far and reach moments of desperation.

7
Organization
501c3 status has already been approved by the IRS
Current Board of Directors President Rev
Robert Certain, Rector, Episcopal Church of St
Peter and St Paul (USAF) Exec Director Peter
McCall (USArmy) Member Bill Harrison, Partner,
Mozley, Finlayson Loggins LLP
(USAF) Member William Matson, Exec Director,
Pathways Community Network, Atlanta,
GA Member Alan Baroody, Exec Director, Fraser
Counseling Center, Hinesville, GA Member Joseph
Krygiel, CEO of Catholic Charities, Archdiocese
of Atlanta (US Navy) Current Partners The
Georgia Association for Marriage and Family
Therapy (GAMFT) The EMDR Network of Clinicians in
Georgia Pathways Community Network, Inc Fraser
Counseling Center, Hinesville, Georgia Catholic
Archdiocese of Atlanta Cooperative Baptist
Fellowship (CBF) of Georgia Episcopal Diocese of
Atlanta Presbytery of Greater Atlanta/Presbyterian
Women
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Causes for Concern

• Multiple deployments are common causing stress
  and family attachment issues
• An April 08 Rand Study reported 37 have either
  PTSD, TBI, or significant Mental Stress (5 all
  3). Some estimate gt50 return with some form of
  mental distress
• Suicide, alcoholism, domestic abuse and violent
  crimes rates are rising. Suicide is 33 higher
  in 07 over 06, 50 higher in 08, and almost
  equal to 08 by May of 09
• Military Sexual Trauma (MST) is running at
  16-23
• In 2008, 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)
• DoD and VA facilities are stretched the Aug
  2009 VA claims backlog is 900,000
• 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
• Other mental health, marriage, and family
  problems often occur with or leading up to PTSD
  requiring attention so they dont get worse
• 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. The study concludes that investing in
  proper treatment would actually save 2 billion
  within two years

9
Mission of CareForTheTroops.org

• Work to improve the ability of the civilian
  mental health infrastructure in the State of
  Georgia, then nationally, to work with military
  family members
• Facilitate connecting military families to
  providers of spiritual and psychological services
  familiar with the military culture and trauma
• Focus on addressing combat stress recovery as
  well as other spiritual and mental health related
  problems impacting the marriages and families of
  military veterans
• Educate and train clinicians, congregation and
  community leaders, extended family, and civilian
  groups about the military culture and trauma
  associated with military deployments in order to
  better assess and treat mental health symptoms,
  and provide more effective referrals and care
• Provide opportunities for additional trauma
  treatment training to clinicians
• Operate in an interfaith, non-political manner,
  focusing on the humanitarian interest that
  benefits the veterans and their extended family
  members

10
Approach
Military Member
11

The next set of charts provide a simulation of
using the www.CareForTheTroops.org website with
clinicians in mind
12
This is the top of the Home Page
13
Home Page The drop-down menu for Mental Health
Professional is opened up. In this case,
selecting the Enroll with CFTT page Note the
other options available
14
This focus is on the Top Menu In particular
this shows the Mental Health Professional
options. The Menu that drops down shows the
tasks most often used by the Mental Health
Professionals.
15
Top of the Enrollment Page The info asked is
completely voluntary. We do not ask you to
volunteer time and any financial info is left
between you and the client. We are looking for
people with background, training, and experience.
16
Moving down the same page. Info about your
office , license, language, and education.
HANDOUT
17
Moving further down the same page. Info about
your insurance, specialties, and training Text
boxes are there for free-form input ref insurance
and specialties
HANDOUT
18
Moving to the end of the form. Info about your
experience, unique background. This is also
where you enter your ID and password.
HANDOUT
19
Back to the top of the Home Page A key piece
of the web site is the Resource Library with the
4 selections shown. This material is updated
periodically. The reference material is weekly.
20
Back to the top of the Home Page A key piece
of the web site is the Resource Library with the
4 selections shown. This material is updated
periodically. The reference material is weekly.
21
This shows the first 4 search results for Fulton
County in the database. This is intended for
use by congregation sources, clinicians, and
people in need searching for a therapist who
wants to work with military families.
22
Training is key. This shows the training
events we are aware of. Both from CFTT and from
other organizations. Please visit it
periodically and also let us know of training you
hear about to share with others.
23
Training is key. We have just added OnLine
Training from 2 sources Alliant Univ. The
VA Much of the training is free, a wide
selection of courses, and some is eligible for
CEUs with a nominal fee attached.
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The EMDR HAP (Humanitarian Assistance Program)
Training organization (www.emdrhap.org ) will
conduct Weekend 1 (Part I) training Friday
through Sunday, Jan 15th to 17th in Athens,
Georgia. The training facilities used in Athens
are at Milledge Avenue Baptist Church, 598 South
Milledge Avenue, Athens, GA 30605. Weekend 2
(Part II) training will be scheduled 3-6 months
later with details TBA. This training is jointly
sponsored by the The Samaritan Counseling Center
of Northeast Georgia (www.samaritannega.org ),
GAMFT-The Georgia Association for Marriage and
Family Therapy (www.gamft.org ), and The
CareForTheTroops, Inc. non-profit organization
(www.CareForTheTroops.org ). AUDIENCE This
training is for licensed (and some licensable)
counselors working in a non-profit environment.
Specific details are available at the following
web location www.emdrhap.org/training/ . COST
350 for each weekend. Lodging and meals are the
responsibility of the participant. SCHOLARSHIPS
A limited number are available to cover the full
HAP Fee for Weekend 2 (Part II) for those that
meet the criteria below. So please apply early
if one is needed. ENROLLMENT TRAINING Enroll
for the HAP Part I training is done on-line
through the HAP website www.emdrhap.org/training/
toregister/listEvents.php. Look for this events
description on the web page. SCHOLARSHIPS Apply
for the CareForTheTroops scholarship at
www.careforthetroops.org/emdrevent.php .
Download the Application Document, complete and
email or mail it to the address shown on the
document. Additional information about this
weekend such as schedule, lodging, restaurants,
etc. can be found at the following web location
www.CareForTheTroops.org/emdrevent.php .
HAP Participant Requirements EMDR PART I AND
PART II are available for licensed mental health
clinicians at the masters degree level or above,
or for masters level clinicians on a licensure
track, with permission of their licensed clinical
supervisor. In keeping with its mission, HAP
normally trains only clinicians working 30 or
more hours per week in community based,
non-profit settings. Exceptions have been made
for private practice clinicians who have made a
substantial commitment to pro bono service in the
community.

• CareForTheTroops(CFTT) Scholarship Criteria
• It is the intent of CFTT to incent attendance of
  both EMDR Training Weekends (Part I and Part II)
  in order to increase the number of fully
  qualified EMDR Therapists to treat trauma in
  Georgia. Participants must
• Practice in Georgia
• Attend and successfully complete both Part I and
  Part II EMDR training by HAP
• Enroll in the CareForTheTroops Therapist Database
  at the completion of Weekend 1 and stay enrolled
  at least 2 years. More Info about this is
  available at www.careforthetroops.org/clinician_cf
  tt_enroll.php
• Be willing to work with military clients and
  their extended family members
• Pay the HAP Training Fee for Part I.
  CareForTheTroops will pay the HAP Training Fee
  for Part II which means you must attend a Part II
  by HAP
• Attend and complete Part II within 12 months of
  completing Part I
• Be responsible for all other costs, fees, and
  expenses associated with the training weekends.

25
Chapter WorkshopsMilitary Culture 101-Clinical
Treatment Issues
NOTE Check with your local GAMFT Chapter and
also with the www.CareForTheTroops.org web site
for changes and updates.
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Final Comments

• Help For You
• Use the web site as a resource
• Information and reference material
• Training
• Referrals
• Use you involvement with CFTT to help market your
  practice
• Help for Us
• Enroll in the CFTT database
• Publicize CFTT to community and congregations
• Would you consider being a Trainer using material
  like you see today?

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Agenda
28
Brothers At War Film Cliphttp//www.brothersatwar
movie.com/
29
Fraser Center ExperienceFilm Clip Comments
THERAPEUTIC ISSUES OBSERVED IN THE CLIPS FROM
BROTHERS AT WAR

• The adrenaline high, or adrenaline addiction
  Its like the best!
• Personality changes. No one returns the same
  from combat or lengthy deployments.
• Generalized and undifferentiated anger short
  fuse, loss of patience, (increase in domestic
  violence and child abuse). Now when he gets
  mad, he just screams.
• Grief over absence during important life
  transitions (also, resentment by spouse at
  soldiers absence). When I come home I just want
  to hug her, but she may not let me because she
  wont know who I am.
• Intense bonding during deployment competes with
  and sometimes trumps marital and family bonds.
  My friends here are closer than any Ive had.
  These guys take you on as a brother.
• Survivor guilt and loss It hurts a lot to lose
  fellow soldiers.
• Family of origin issues I want to make my Dad
  proud.
• Fantasy verses reality. (living on dreams and
  through TV series)
• Emotional numbing He used to be sensitive.
  Now, he shows no emotion and wants me to be the
  same way.
• The ramifications of sacrificing for family
  and the sacrifices made by families.

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Fraser Center Experiencewww.frasercenter.com
HANDOUT

• 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.

31
Fraser Center Experiencewww.frasercenter.com
HANDOUT

• 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.

32
Fraser Center Experiencewww.frasercenter.com
HANDOUT

• 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 soldiers
  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 didnt 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.

33
Fraser Center Experiencewww.frasercenter.com
HANDOUT

• 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.

34
Chris Warners Sources of Stress
---?gtgt Number of Months
Warner CH, Breitbach JE, Appenzeller GN, et.al.
Division Mental Health Its Role in the New
Brigade Combat Team Structure Part I
Pre-Deployment and Deployment Journal of
Military Medicine 2007 172 907-11.
35
Agenda
36
Intake Scenario

• Your New Client
• 20 year old male
• SPC in USANG, 4month Post-Deployment from OIF
• Gunner from 1st BCT 3ID
• on edge, pissed off, difficulty Sleeping
• First SGT concerned over his irritability
• Anger towards leadership for decisions made
  downrange
• Married with 2 children, lt4 yrs old, one born
  during his deployment
• Marital discord
• Wants to deploy again ASAP

37
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 A2
38
Language Barriers for CiviliansGlossary of
Military Terms and AcronymsMilitary Cultural
Competence
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. USAR
United States Army Reserve USANG United
States Army National Guard 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 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
Handout A3_1, A3_2, A3_3, A3_4
39

The next few charts cover organizational
background to help understand the client, where
he/she was positioned, and to better interpret
the information and stories they might tell
during their therapy
40
Branches of the Military
Georgias Military is dominated by Marine and
Army units, though Air Force and Navy are
represented as well. Georgias National Guard
also has a large number of transportation units
subject to IEDs on roads and highways. NOTE
Coast Guard is now under Homeland Security
Handout A4
41
Military Branch StructuresExample U.S. Army
Handout B1, B2, B3
42
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

43
Reserve and National Guard Units vs Regular Army
Reserve / Guard
Regular

• 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
• Cant relocate easily when activated
• Lack of military related health services - PCP
  not Tricare approved
• Make use of family or local supports (church,
  etc.)

• 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.
• Are part of a larger fighting force including 1/5
  combat units.
• 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 soldiers unit

Handout C1
44

The next few charts provide some background of
this war that might help you better understand
your client and their presenting story and issues
45
Why 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

46
OIF/OEF - Statistics

• As of 12/1/2008
• 1.7M troops deployed
• 4207 US Military killed in Iraq (excludes
  civilians)
• 627 US Military killed in Afghanistan (excludes
  civilians)
• 65,000 US Military wounded
• 54 deployed are Reserve / Guard (4/08)
• 1 of US population is directly touched by
  military service more if you consider civilian
  contractors
• Deployed as of 09/2009 130K troops in Iraq
  160K civilian contractors in Iraq 65K troops
  in Afghanistan (more are being sought as of Oct
  2009)

47
OIF/OEF - Profile

• NG and Reserve did not expect deployment(reminder
  GA is 6th largest NG state)
• Multiple deployments is the norm
• 2008 Rand Study indicates
• 53 of those that need treatment sought Mental
  Health treatment in 08
• 16-23 have experienced MSTMST Military Sexual
  Trauma
• 2yr post-deployment cost 6.2B
• OIF vs OEF VA indicates a OIF vet is 2x likely
  to seek help than a OEF vet
• As of 04/08, 120K mental health dxs, 50 were
  diagnosed w PTSD
• Homecoming Concept alienation, detachment,
  isolation, avoidance, boredom

Handout C2
48
OIF/OEF - More Statistics

• 15 wounded for every 1 fatality (Vietnam was3
  for 1)
• VA predicts that it will treat 263,000 OIF/OEF
  vets in 2008 and 330,000 in 2009
• Current backlog of veterans is 400,000 (as of
  2008)
• Claims backlog is over 900,000 (as of Aug 2009)
• Heaviest of that backlog is mental health (Ex
  Virginia VA community mental health services has
  a waiting list of 5,700 as of early 2008)
• 550,000 school age children of active duty
  Service Members (Reg/Res/NG)
• 52,000 children of Reserve and National Guard
  Service Members affected
• 84 of Regular Military Service Members children
  attend public school, not DoD base schools
• Georgia has over 750K veterans

Handout C3
49
OIF/OEF and some more Statistics

• According to a new American Journal of Public
  Health study on veterans' mental health diagnoses
• Of the 289,328 veterans who entered VA care in
  2008, nearly 37 had mental health problems,
  including post traumatic stress disorder (about
  22) and depression (roughly 17). (ref
  http//www.ajph.org/cgi/content/abstract/AJPH.2008
  .150284v1 )
• "Weekend warriors" over 30 years old in the
  national guard and reserves who left stable
  family, work and community environments for
  combat zones were especially susceptible to
  mental health problems. 2008 American Journal of
  Public Health study
• A recent (July, 2009) US government
  accountability office report found that nearly
  20 of women veterans suffer from PTSD (ref
  http//www.gao.gov/new.items/d09899t.pdf )

50
OEF / OIF Experience - Summary

• Indirect threats not so much direct assaults
  and attacks
• IEDs, car bombs
• RPG, snipers
• Suicide bombings
• Powerlessness
• threat is indiscriminate
• not dependent upon skill or mastery
• relationship between loss of control and PTSD
• This generations war
• 1st Internet War (Vietnam was the TV War)
• Blogs, email, cell phone (cameras) 24 hr new
  sites
• New versions of the Dear John/Jane letter
• Home trouble as a leading stressor (financial,
  intimate partner)
• Reservists/Guard repeated, unpredictable
  separations from family/job

51

The next several charts will cover life within
the military family and clinical treatment
considerations
52
The Military Deployment Cycle or The Military
Family Life Cycle (Original View)
53
Military Family Life Cycle(Multiple Deployment
View)
ltMissed 1st year of marriagegt
ltMay be 1st deployment for both partnersgt
ltDivorce remarriages w/ kids for previous
relationships are common complex stepfamilygt
Transitions are often marked by crisis points in
the family life cycle.
54
Military 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 lt 30,000 (34)

Quality of Life Among U.S. Army Spouses During
OIF, Dissertation, 2005, Dr. Blaine Everson
55
Separation
HANDOUT

• Resulting from deployments, relocation, or
  training range from a few to many months
  disrupts life cycle transitions.
• Emotional ambiguity stemming from physical loss,
  but expect maintenance of closeness.
• Child family ties/problems within the larger
  community.
• Heightening difficulties are the threat of death
  or injury of service member.

56
Reunification
HANDOUT

• Stressful because of adjustment required family
  functioning may have been enhanced in absentia.
• Presence of service member alters household rule,
  role, time, routine structure.
• Expect to return to normal functioning after long
  term separation what is normal?
• Reckoning for misdeeds during service members
  absence (school failure, affairs, etc.)

Handout D1
57
Relocation
HANDOUT

• Families in the military (U.S. Army in
  particular) relocate every three to five years.
• Inconsistency of services b/w the installations
  (schools _at_ Ft. Hood vs. Ft. Stewart).
• Requires readjustment for family members who may
  lag behind service member both physically
  emotionally

58
Deployment Related Stressors for Spouses
HANDOUT
59
Deployment 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.
60
Summary of Stressors

• For Active Component Families
• Permanent Change of Station (PCS)
• Temporary Duty (TDY)
• Deployment
• Foreign Residence
• Risk of Injury or Death
• Behavioral Expectations
• Additional for Reserve/Guard Component Families
• Citizen Soldier
• Mobilization and Deployment
• Separation from School, Jobs, etc
• Demobilization

61
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

62
Agenda
63
Demographics - AGE
Enlisted
Officers
64
Demographics - Young Adults in the Military

• 46.6 of all service members are lt 25 yrs old
• 53 of enlisted members are lt 25 yrs old
• 24.8 reported binge drinking gt1x per week in
  the past 30 days vs 17.4 for same-age civilians
• Higher smoking rates (40 vs. 35.4) than
  same-age civilians
• Illicit drug use in the military was 5 in 2005,
  but nonmedical use of painkillers is the most
  common form of drug abuse.

Source Military Family Research Institute at
Purdue University.(2005). 2005 demographics
report. Arlington, VA Office of the Deputy Under
Secretary of Defense, Military Community and
Family Policy. Retrieved January 7, 2009, from
www.cfs.purdue.edu/mfri/pages/military/2005_Demog
raphics_Report.pdf
Handout D2
65
Demographics GENDER AND RANK
Women represent approximately 15 of the military
force. Representation of women is slightly
lower for Senior Enlisted and General Officers.
66
Demographics MARITAL STATUS
Divorce Trends
Marital Status
ACActive Duty RCReserves/Guard
67
Demographics Suicide

• Two dominant factors
• Financial Stress
• Concerns with Intimate Partners
• The 2008 overall Army rate was 24/100K, a 33
  increase
• 70 increase reported from 2005 to 2008

Handout E1
68
Psychological Injury ContinuumASR to COSR to
PTSD

• ASR (acute stress reaction) produces
  biological, psychological, and behavioral
  changes. ASD means it has become disruptive
  and destructive.
• COSR(combat and operational stress) is
  expected, common, and occurs throughout
  deployment to some degree. Pretty much everyone
  comes home with some version of combat and
  operational stress.
• PTSD(post traumatic stress disorder) becomes
  classified if COSR symptoms are daily, interfere,
  and last longer than 1 month

69
SIGNS / SYMPTOMS OF (COMBAT) PTSD

• HYPER-AROUSAL Fight/Flight/Freeze, Angry,
  poor sleep, argumentative, impatient, on alert,
  tense (hyper-vigilant), intense startle response,
  speeding tickets (once home) and other risky
  behavior.
• NUMBING/AVOIDANCE Withdrawn, secretive,
  detached, controlling, removes all reminders,
  avoids similar situations, ends relationships
  with people associated with trauma, etc.
• RE-EXPERIENCING Nightmares, flashbacks,
  intrusive thoughts

70
PTSD Cues or Triggers

• Think full body memories are laid down in all
  sensory spheres (smell, sound, vibrations,
  colors, etc)
• Terrain desert, urban
• Weather heat wind, humidity
• Songs
• Smells
• Driving signature trigger for OIF/OEF vets
  (assess driving safety !)
• Nature of war in Iraq and Afghanistan
• Need for high speeds, evasive maneuvers
• Importance of a driving assessment
• People automatic response to persons who appear
  Middle Eastern, children
• Situational mimic loss of control powerlessness
  (e.g. dentist chair, anesthesia, OB-GYN exam,
  endoscopy, etc)

71
PTSD non-DSM

• What does PTSD feel like What do you hear in
  therapy
• Sense of immediacy (happening right now)
• Re-experiencing of original memories and sensory
  impressions
• Involuntary
• Guilt
• Rational or irrational
• Understanding atrocities
• Survivor Guilt, also guilt for leaving, being
  intact
• Grief
• Multiple losses without time to grieve
• Affective numbing, anger/revenge
• Impact of pre-war losses, post-war losses
• Deaths of loved ones during deployment
• Other Feelings
• Anger at Government
• Mistrust of Authority
• Desire to return to the war zone
• Damage to spirituality

Handout F1, F2
72
TBI Traumatic Brain Injury

• Signature Injury of OIF/OEF
• Prevalence hard to estimate
• Approximately 2100 Afghanistan troops diagnosed
  since 2001 as of 08/2007
• VA reports 61,285 OIF/OEF vets had preliminary
  screen, 11,804 were positive (20)
• Prevalence has probably been underestimated so
  far
• Explosions account for 3 of 4 combat-related
  injuries
• Improvements in war zone medical treatment
  decreases fatalities but may impact rise in TBI
• Soldier return home with poly-trauma
• Symptoms headaches, tinnitus, dizziness,
  balance problems, sleep problems, persistent
  fatigue, speech, hearing and vision impairment,
  sensitivity to light and sounds, heightened or
  lessened senses, impairments in attention and
  concentration, memory problems more like dementia
  than amnesia, poor impulse and anger control

73
MST Military Sexual Trauma

• 2008 Rand Study reported 16 - 23 experienced
  MST
• Reported MST were 1,700 in 2004 and 2,947 in 2006
• VA indicates that 1 in 4 female veterans using
  the VA reported at least one MST
• The VA Day Hospital Program estimates 3-5 female
  referrals have MST
• Treatment Considerations
• May be compounded by combat trauma
• Frequently unreported
• Trauma occurs in context of where the solder
  lives and works (comparable to incest)
• Military Culture emphasizes cohesion
• Males victims as well as female
• Female perpetrators as well as male
• Largely male population in the VA where female
  veterans go for help

Handout C2
74
PTSD Treatments

• Cognitive Therapy (CT)
• Exposure Therapy (ET)
• Stress Inoculation Training (SIT)
• Eye Movement Desensitization Reprocessing
  (EMDR)
• Generally individually oriented
• and systemically focused One
• size does not fit all

Handout G1, H1
75
A Extra Word About The Children

• 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 most 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-kid
  s_and_parenting/ http//cbs3.com/wireapnewspa/Cam
  p.for.military.2.1147685.html

76
Realizing the bridge is down

• Homethe place many think is the safe haven to
  find relief from the stress of warmay 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 H2
77
Intake Scenario Revisit and Review
78
Agenda
79
TriCare - Ceridian

• TriCare
• MFTs are eligible for TriCare
• LPCs need supervision by an M.D.
• 90-120 days application process
• Application in handout
• More confidential less need to exchange info
  for decisions
• Preference is to use the spouses contract
• Ceridian
• 5 yr clinical experience required
• Fax the application
• 12 sessions (raised sessions allowed lowered
  fees)
• Must use Ceridian forms and notes
• Less confidential requires more client info for
  decisions
• Good place for EMDR because of limited sessions
• Easier access

Handout I1, J1, J2, K1
80
Agenda
81
What This Presentation WAS About

• There were 5 goals of this presentation
• Better understand the basics of the military
  culture to build credibility while working with
  military families
• 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
• Review where clinical support material can be
  found
• Learn what the GAMFT initiative is with the
  CareForTheTroops.org organization

82
In ClosingConsider These Next Steps

• Look for more training opportunity to learn
  about treating the military. Visit
  www.CareForTheTroops.org
• If not yet trained in a trauma treatment
  technique, consider getting that training, e. g.
  EMDR (Jan 15-17 Weekend I in Athens)
• If you are willing to work with military
  families, enroll in the CareForTheTroops database
• Consider being a trainer to outreach to
  community organizations, congregations, and other
  counselors
• to participate in the CFTT initiative
• to market your practice

Handout L1, M1