Post Traumatic Stress Disorder and The Military Veteran Student

1. Post Traumatic Stress Disorder and The Military Veteran Student

2. Autonomy The organism possess a certain degree of freedom… It acts according to its own inherent nature, which is based on intrinsic forces, and is not under the compulsion of outside influences

3. Autonomy Characteristics: • Self Governing • Self Determination • Self Understanding • Intrinsic Forces • “Self” is known • “The World” is understood • “Shattered Assumptions”

4. Autonomy Assumptions about “Self” and the World SELF • Personal Empowerment • Sense of Personal Efficacy • Efficiently Manage Self and Decisions • Sense of Personal Power and Self Control • Capable of interacting effectively with others WORLD • The World is a Safe Place • Some Personal Control over the Environment • Efficiently interacts with the Environment & Others • Empowered to Keep Oneself & Loved Ones Safe in the World

5. Autonomy: Once Assumptions are Shattered • Failure to Maintain Sense of Personal Power • Question Ability to Self Manage • Question Efficiency and Effectiveness of Choices • Fear of Losing Control of Self and Uncertainty about the Future • Questions Safety of World • Questions Self and ability to control any Aspect of Life. • Questions Efficiency of Being and Interacting in the World • Questions Personal Ability to keep Loved Ones and Self out of Harms Way Crisis with the SELF World VIEW

6. Why Self and World View are Changed • The Crisis Event Rendered the Person “HELPLESS” • Crisis events Cause a Person to Question Their SELF (Decision Making) • The Event is Incongruent with Beliefs about Self (Abilities and Strengths) • The Event is Incongruent with Belief about Safety of World. • An overpowering sense of failure, inadequacy, abandonment and/or rejection will often set in due to this incongruence.

7. DANGER As A Profession • Military Veterans • Police Officers • Emergency Medical Technicians • Fire Fighters • Emergency Room Personnel • FBI, ATF, other dangerous professions

8. Danger Powerful vs. Powerless Mild danger vs. extreme

9. Danger Impact of Traumatic Events Self is Changed • Beliefs • Self Esteem • Personality Shift • Biological • Fear • Spiritual Crisis

10. Danger • Shatters one’s perception about themselves and their place in the world. • Shatters one’s sense of safety & security • Most Devastating effect: Autonomous ability to relax Ego Defenses – (isolation, anger, guilt, anxiety, depression)

11. Danger Other Ego Defenses develop: • Inability to Trust • Inability to Establish or Re-Establish Intimacy • Emotional Numbing • Hyper-Sensitivity TowardInjustice • Pervasive Sense of Feeling Damaged

12. Symptoms (P.C.E.B.S.)Physical, Cognitive, Emotional, Behavioral, Spiritual

13. P.C.E.B.S. • Agitation • Fatigue • Headaches • Vision Problems • Hyper-arousal • Exhaustion • Chest Pain • Muscle Tremors • Grinding of Teeth • Intrusive Thoughts • Memory/Concentration • Confusion • Preoccupation • Uncertainty • Feeling Overwhelmed • Poor Problem Solving • Poor Abstract thinking • Intrusive Images Physical Cognitive

14. P.C.E.B.S. (Cont’d) • Anxiety • Depression • Hopelessness • Despair • Rapid Mood Swings • Unpredictable Mood • Denial • Agitation • Intense Anger • Hyper-vigilance • Sleep Problems • Substance Abuse • Self Mutilation • Cry easily • Antisocial Acts • Defiance of Authority • Inability to Rest • Erratic Movements • Loss of Appetite Emotional Behavioral

15. P.C.E.B.S. (Cont’d) • Questioning Good and Evil • Attempting to Make Sense of Senselessness • Searching for the Meaning of the Experience • Struggling with Understanding Why • Questioning God/Faith Spiritual

16. Human Toll: Depth of Change • First Responders and Horrific Scenes • Violent Law Enforcement Action • Katrina & Natural Disasters • Virginia Tech Carnage • Oklahoma City Bombing • Columbine • 9/11 • Military Combat

17. Readjustment After Combat: What the Soldier Brings Home “No one comes back unchanged” COL (Dr.) Tom Burke,Department of Defense,Director of Mental Health Policy

18. Life on the Front To understand what the soldier brings home, one needs to look at how the environment of war gets inside the mind.

19. What the Soldier Brings Home • 86% received artillery fire. • 93% were shot at with small arms. • 77% fired at the enemy. • 95% saw dead bodies or remains. • 89% were attacked or ambushed. • 86% know a troop injured or killed. • 65% saw dead or injured American. • 69% saw injured women/children and were unable to help. • -- These numbers correspond in part to a study in the New England Journal of Medicine and pertain to service members in Iraq.

20. VA HEALTHCARE UTILIZATION Total who served in Iraq (OIF) and Afghanistan (OEF) 2.3+ million* OIF and OEF war veterans separated from militaryand eligible for civilian care 1.4 million* • 766,081 (~55%) Former Active Duty troops • 630,396 (~45%) Reserve and National Guard * FY 2002 to Dec 2011. Office of Public Health, Veterans Health Administration, Department of Veterans Affairs

21. Total Deployed by State- Active Duty +Guard/ Reservesince June 2010 8,761 10,725 65,497 11,554 4,622 25,557 5,531 21,249 83,027 25,568 56,444 12,022 5,325 11,562 28,482 17,243 184,721 18,245 7,108 13,764 63,550 81,898 76,846 39,940 12,071 15,772 26,413 13,044 32,969 24,218 55,274 18,453 37,748 19,396 48,690 20,893 63,192 9,866 25,744 31,935 29,410 33,360 12,678 52,440 23,914 36,303 267,720 29,209 206,699 SERV Proprietary and Confidential CTS deployment File Jan 2010

22. VA HEALTHCARE UTILIZATION OIF/OEF veterans seen by VA Health Care: • Over 742,000 OIF/OEF era veterans have sought VA Healthcare since 2002 (mostly outpatients). • Reflects ~ 8% of ALL patients treated at VAMC’s (6 million). • No. of newest veterans seeking help has doubled in 2 yrs. • Ages: ~ 45% = 19-29; 28%=30-39; 28% = 40+. • Gender: ~ 12% females.

23. VA HEALTHCARE UTILIZATION • Over 52% (385,700+) of all OIF/OEF veterans seeking VA care have presented with a mental health problem. • Approx 35% have utilized MH services at least once. • Approx 18% diagnosed with psychiatric problem. • Over 3.2% (~24,000) OIF/OEF veterans are being seen at Ohio VA’s (VISN10).

24. Frequency of Possible Mental DisordersOIF/OEF Veterans since 20021 1 The total will be higher than all unique patients who received a diagnosis of a possible mental health disorder. A Veteran may have more than one mental health disorder diagnosis and each diagnosis is entered separately in this table.

25. What the Soldier Brings Home The PTSD Syndrome (12-16% of soldiers) • Intrusive thoughts/memories • Nightmares • Avoidance/isolation • Anger/angry outbursts • Hyper-startle response • Flashbacks • Hyper vigilance • Feelings of grief, guilt, & loss

26. What the Soldier Brings Home It’s not just about PTSD • Disillusionment with “civilian life” & activities. • Irritability & anger towardnon-military. • Profound feeling of alienation. • Social isolation. • Self-blame or guilt for acts of war. • Physical health problems

27. What the Soldier Brings Home Alcohol and Drug Abuse • Work as way to cope with post-trauma internal distress. • Quick way to alleviate anxiety symptoms. • Allows social interaction without emotion inhibitions. • Dulls memories; creates fast moving, transientemotional states • Helps maintain status quo.   • Helps develop and reinforce “safe” social alienation.

28. What the Soldier Brings Home Most veterans with traumatic stress symptoms get better over time even without professional help or with minimal (2-3 session) interventions.

29. What the Soldier Brings Home The soldier does not have energy or time to process events until after leaving the battlefield. It is only on return that many incidents begin to impinge on his or her daily life.

30. What the Soldier Brings Home Prolonged exposure to combat stress • Most soldiers exposed to multiple terrorism or life threatening events. • Some may have participated in atrocities. • Witness to or participantin atrocities creates senseof alienation from “civilians”.

31. What the Soldier Brings Home • In Iraq & Afghanistan, there is a sense of danger all the time. • Constant fear & stress over long period of time creates distrust of any new environment. • Adaptation to combat violenceas “norm” generates tendencyto get overly aroused physically in arguments. • Often develop a mindset of“act immediately, debate later”In the class room they may have difficulty with debates.

32. What the Soldier Brings Home They often have experienced deathof close friends or comradesthat still bothers them greatly. For many, a comrade’sdeath is an overwhelmingexperience, often leadingto prolonged unresolvedmourning and anger.

33. What They Say Are Problems (from Focus Groups) Wanting to be left alone - Social avoidance/isolation Sensitivity to loud noises and jumpiness – hyper-arousal Anger, lack of patience - irritability Chronic joint pain, generally ankle, knee and back pain Memory problems or "lapses“ - trouble concentrating Drinking or smoking too much Personality changes, emotionally distressed Body image issues: scars, weight changes, etc. What the Soldier Brings Home

34. Coming Home: Life, Work, Learning Difficulties with Public Interactions • Soldier may be tense about the “politics” of war. • Public may not always know what to do or say. • Veteran unsure who he/she can talk to. Questions can arise about:What will they want me to talk about? What can I talk about? How will they react to a story or event?

35. Coming Home: Life, Work, Learning Difficulties Reconnecting • Some found violence scary and exhilarating. Many say combatwas the most exciting andimportant thing they haveever done. They are often boredwith classroom experience. • Difficult for soldier to discuss this with “civilians” who do not understand military or combat (will gravitate toward veterans).

36. Coming Home: Life, Work, Learning Learning Environment Problems • Internal chaos (intrusive images and memories) may intrude on ability to concentrate, pay attention. • Hyper-arousal (on guard), in crowds, among new persons, changing environments (new classroom each course), may create tension, irritability, anxiety. • Veteran may feel students behave differently toward him/her. • Tendency toward social isolation leads to difficulty seeking help for studies, working with other students.

37. Coming Home: Life, Work, Learning Learning Environment Problems • Veteran and classroom expectations may conflict. • Homework assignments (group assignments may be difficult) • Subject matter or presentation may arouse anger, irritation, isolating response (politics, history, social sciences are especially red flags). • Has difficulty with “vague” subject matter or mixed conclusions. Need for concrete outcomes, “usable” learning.

38. Coming Home: Life, Work, Learning Learning Environment Problems Aftereffects of mild Traumatic Brain Injuries (mTBI) or multiple extreme concussions may create short term cognitive deficits. • Physical Issues: Headaches, ears ringing, dizziness, visual blurring • Assignment Overload: May not beable to focus on single subject forlong periods of time. • difficulty with remembering details,memorization, etc. • Not write as well, move as quickly as others.

39. Welcome To College Developing a Welcoming Environment Information, Information, Information • How to park, where to park, who to see about what. • E-mail a map if possible (Website Information helps) • Work with other veterans who are willing to be “buddies” Orientation • Provide a personal walk through • Show major important areas (with a fellow vet if possible)

40. Welcome To College First Engagements: Veterans Orientation Event • Try to have a group orientation for veterans only • Find Instructors who are veterans willing to be mentors • Invite local Vet Reps who will provide free services: • Dept of Veteran Affairs- • Veterans Benefits (BVA) Reps • Veterans Healthcare Reps if possible - Local Vet Center - Community Based Outpatient Clinics • State or County Veterans Reps (Veteran Service Commission) • Community Veteran Organizations • AMVETS, VFW, Local Service Officers

41. Welcome To College Setting A Path of Matriculation • Assign a Veterans Benefits Administrator job at University. • Able to guide them on paperwork, timelines, • Give them a list of what is needed from them for benefits. • Discuss unexpected costs, especially books • Discuss cost of living allowance delays Won’t get first check until 6-8 weeks after 1st day

42. Welcome To College Mentoring and Counseling • Encourage tutors on first day of school • They won’t want to at first : Sign of weakness • Try to find student veteran tutors • Develop Veteran Lounge/Centeron campus (Support) Provides a gathering placefor the veterans (support) • Train a counselor on militaryculture and veteran MH issues.

43. Welcome To College Classroom Strategies Orient Professors on how to be veteran friendly • Do not point veterans out as “victims” of War or feel sorry for them. • Do not belittle, demean lapses in completing assignments or failures to grasp material. • Allow them to leave classroom if necessary. • Allow them to sit in back of class. • Professors who do not agree with decision to serve should be discreet. • Be aware of subject matter drifting to volatile topics. • Be open to requests to change classes.

44. Tailoring the Learning Environment for Success Roger Buck, Ph.D.

45. Fifteen Environmental Cues That May Trigger Increased Symptoms Cues that May Cause Agitation, Anxiety, Panic,Intense Anger, Apprehension, Sadness: • Inefficient Support Services • Non-Compassionate Attitude of Staff Members • Waiting in Long Lines for Services • Getting the “run-around” about Administrative Paperwork • Immoral or Unethical Practices by Staff, Faculty or Students • Lack of Clear “Chain of Command” to resolve problems or concerns

46. Environmental Cues (Cont’d) • Lack of Respect for & Acknowledgment of Veteran and Their Service • Lack of Respect by Faculty or Staff for Sacrifice of Veteran’s Friends Killed and Injured in War • Childish Behavior by “Traditional Teenage Students” (Loud Music after lights out – Dorm life) • Roll Call • Overall Lack of effective and efficient leadership at the college • Timeliness of GI Bill Processing and Other Financial Supports • Large, Loud and Crowded Classrooms • Classrooms Where Veteran Cannot Sit With Back to the Wall • Chaotic Classroom – Instructor Not in Charge

47. Sensory Triggers to Consider Visual • Use of Laser Pointer • Emergency Light Flashing • Middle Eastern Student/Clothing • Human Suffering • Dry/Arid Environment

48. Sensory Triggers to Consider Other Senses • Loud Noises • Helicopter Blades • Smells (Raw Sewage) • Smells (Sweat) • Oppressive Heat • Taste/Smell of Middle Eastern Foods • Sitting in uncomfortable chairs with back pain, knee injuries other chronic medical concerns

49. Twelve Administrative Action Items • Ask the Vets • Special Supports During Registration for Rapid Enrollment • Veteran Task Force • Encourage and Develop Peer Support Organization (Student Veterans of America)www.studentveterans.org • Host Veteran Recognition and Welcoming Activities • Specific College Policy and Procedures addressing action if student deployed. • Institution Admin consistency: GI Bill, course credit for military schooling, Financial Aid, etc.

50. Administrative Action (Cont’d) • Present “Veteran Awareness and Sensitivity” training for all Staff & Faculty • Create a Veteran Resource Center & Devote Office Space • Register as Service Member Opportunity College (SOC) • Develop a Veteran Foundation Account to Assist Student Veterans with Tuition, Books, Fees and Household Emergencies • Presidential and Senior Leadership Support