Prequal

1. Prequal • http://www.youtube.com/watch?v=QAa3FjKxxOE&feature=related • 3:52……………0:10-3:35

2. Soldiers and Veterans of War The Cultural Tragedy of PTSD Rachael Dolan Wendy Seiber

3. The Basics: Culture • Social and ethnocultural responses to trauma are diverse • Process involves: • Helping the client understand the stress responses • Process the traumatic event • Develop adaptive coping mechanisms • Integrating sociocultural influences in to treatment strategies promotes restoration of homeostasis and optimal functioning

4. Many Names for One Problem • Civil War • Soldier’s Heart • WW1 • Shell Shock • WW2 • Battle Fatigue • Korean War • Gross Stress Reaction • Formally diagnosed as a disorder (PTSD) in 1980

5. http://www.military.com/NewContent/0,13190,NCO_050510_PTSD,00.htmlhttp://www.military.com/NewContent/0,13190,NCO_050510_PTSD,00.html

6. Posttraumatic Stress Disorder • Anxiety disorder that can occur after a person experiences or witnesses a violent or frightening event. • Not everyone who experiences trauma develops PTSD. • The essential feature of PTSD is the development of characteristic symptoms following exposure to traumatic events that arouse “intense fear, helplessness, or horror” (APA).

7. Etiology • May occur soon after trauma or can be delayed for more than 6 months after • When occurs right after trauma, usually gets better after 3 months • Some may have long term PTSD which can last for many years • Approximately 50% of cases remit within 1 year • Psychological, genetic, physical and social factors involved but no exact cause • Changes the body’s response to stress • There may be a personal predisposition necessary for symptoms to develop after trauma

8. General Risk Factors • Being female • Having learning disability • Physical and/or sexual abuse • Existence of mental disorder prior to event • Low education levels and poor SES • Some ethnic differences due to how pain and anxiety are expressed (Hispanics, African Americans, Native Americans) • Duration of traumatic event* • Traumatic events inflicted by a person* • Violence associated with trauma* • Negative life events* • *most likely to effect soldiers*

9. Protective Factors • Disaster Preparedness training • Firefighters, police and paramedics receive this • Strong support systems • Positive paternal relationship • Social support • Positive life events • Stress management training • Psychological preparedness • Older age at entry to war • Higher level of education • Higher SES

10. Symptoms of PTSD • Repeatedly “reliving” of the event, which disturbs day-to-day activities • Flashbacks, recurring distressing memories • Repeated dreams • Physical reactions to situations that remind of event • Avoidance • Emotional numbing, feelings of detachment • Inability to remember important parts of trauma • Lack of interest in normal activities • Less expression of moods • Staying away from anything that is a reminder • Sense of having no future • Arousal • Difficulty concentrating, sleeping difficulties • Exaggerated response when startled • Hyper vigilance • Irritability or outbursts of anger

12. Characteristics of a Soldier • Webster Definition • A soldier is loyal to his or her country, willing to fight and die. • B.R. Burg • “The complete officer must be the complete man, they believed, and to measure up each had to possess an amalgam of qualities that included patriotism, courage, honor, loyalty, absolute honesty, and elevated standards of morality” • Class? • How would YOU define a soldier in the 21st century? • War Machine?????

13. Veterans: Respectful Members of Society • Webster: • An old soldier of long service, a former member of the armed services, a person of long experience usually in some occupation or skill (political or arts usually) • From former Marine, Thomas D. Segel • “A veteran is someone, who at some point has written a check to Uncle Sam that reads: “Payable in full up to the amount of my life, if necessary, to defend our way of life.”

14. PTSD in the Media

15. PTSD in the Media • 2009 movie “Brothers” • NPR • http://www.npr.org/search/index.php?searchinput=ptsd

16. Stigma in the Military • Common Concerns • “Perceived as weak” • “being treated differently by unit leadership • “A member of my unit having less confidence of me” • In one study, soldiers felt stigmatized and abandoned after seeking help, and many had not sought help for fear of being ostracized.

17. Recent study by the APA showed: • 60% feared that seeking out mental health care could have negative consequence on their career • More than 50% reported they believe others would think less of them if they sought out counseling • Most said they have rarely or never spoken even to family and friends about mental health issues • 12% reported their spouse would resent them if they sought help

18. Stigma in the Military • NPR: http://www.npr.org/templates/story/story.php?storyId=128489706 • “Reducing the stigma associated with PTSD is the first step”—Ron Capps • CBS news story: need to reduce stigma in the military • http://www.cbsnews.com/video/watch/?id=7049763n&tag=related;photovideo

19. Reducing Stigma • A policy shift in 2008 that no longer requires military personnel applying for security clearance to disclose psychiatric counseling. • Department of Defense • Seeking to reduce the psychological toll of deployment and stigma of seeking mental health treatment • Resiliency Training • Peer support programs • Integrated mental health and primary providers

20. Real Warriors Campaign: • Encourages use of mental health services and stigma reduction via community outreach, partnership with military organizations and NGOs, printed material, media outlets, interactive website and social networking. “Reaching out is a sign of strength”

21. Impact on Soldiers • Difficulty fitting into the society they went to war to defend • Hard to turn off some of the reactions that saved life in combat • May lead to grief in bar • No drug addictions, alcoholism, or criminal behavior until after war • War assignments basically 14months of testosterone build-up

22. Suicide Factors • Common risk factors • Male gender, older age, diminished SES (homelessness and unmarried status especially), availability and knowledge of firearms, and the prevalence of medical and psychiatric conditions associated with suicide • Efforts under way to emphasize ambulatory care and decrease the VA culture of reliance on impatient treatment heightens the need for accurate suicide assessment

23. Suicide, a Tragic Asssociate • Data released by Army • September • Active Duty: 19 potential: 6 confirmed, 13 under investigation • Reserves: 10 total: 4 confirmed, 6 pending investigation • October • Active Duty: 9 potential: 2 confirmed, 7 under investigation • Reserves: 16 potential • Suicide Prevention Lifeline • 1-800-273-TALK • Wounded Soldiers and Family Hotline • 1-800-984-8523

24. Impact on Families of Soldiers • Abuse • Tension • Marital strain • Violence • Secondary PTSD for wives

25. Secondary PTSD • Spouses married to husbands with PTSD • Higher levels of burden ad distress • Suffered more somatization symptoms ,obsessive-compulsive problems, depression, anxiety, paranoid ideation, and psychoticism • Reported more anger, suspicion, anxiety and blame towards their spouse • Interpersonal problems: • Coping with the veteran’s ptsd symptoms, unmet needs, violence, and emotional cutoff • Effective types of treatment: • Family psychoeducation, support groups for both partners and veterans, concurrent individual treatment, and couple or family therapy

26. Domestic Violence Study • Michelle D. Sherman (2006) • Veterans with PTSD have higher rates than the general population of abuse • 17 couples seeking therapy were studied • PTSD and depression diagnosed Veterans perpetrated more violence • Much higher than found in previous research • 81% engaged in at least one act of violence toward their partner in a year • > than 6x the general population

27. Cost on Society • Increased crime rates • Lost lives • Risk of suicide and/or homicide • High medical costs • Costs of untreated trauma, related alcohol/drug abuse about $160 Billion/yr • Legal woes • Criminal Behavior • Poor work performance • Lost jobs-US loses $3 Billion every year due to work place problems caused by PTSD • Family troubles

28. Helping Soldiers Return to Society • Growing need to facilitate their reintegration into communities, families and jobs • 3 factors • Tour of duty, level of danger, and lack of linkage to the civilian culture will compound the adjustment difficulties experienced by returning veterans • Strategies for reintegration include: • Identification of effective strategies • National communication initiatives • Screening and strategic service plans • Local veteran support collaborative • Internet communication • Addressing disability • Coping with the loss of a veteran

29. Smith College for Social Work: Heeding the call of the veteran's needs • 1918 • Established to respond to the mental health needs of “shell shocked veterans” • 2008 • Sponsored a 3-day conference aimed at preparing social workers to respond to the new and complex needs of veterans returning from the Iraq and Afghanistan Wars • A joint planning process effectively developed a program that helped military and civilian social workers gain insight into the impact of multiple deployment, traumatic brain disorder, PTSD, and other factors present in today’s new military culture

30. What Support is Offered • Exposure Therapy (ET) • Foster emotional and cognitive processing of trauma by helping patients systematically overcome their avoidance of trauma-related stimuli and memories. • Veterans Health Administration: Virtual Reality Exposure Therapy • http://www.youtube.com/watch?v=z4rnpmJeN5Q • The most effective treatments involve understanding and overcoming avoidance behavior

31. The Response of the VA • Funded a nationwide effort to spread the use of evidence-based exposure-oriented treatments for PTSD. Mandated that such treatments be available in each VA medical center • Has placed evidence based psychotherapy coordinators at every VAMC to help promote the use of effective treatments, created a PTSD mentoring program • Incorporated the use of “Telehealth”“

32. Pet Therapy • http://www.time.com/time/video/player/0,32068,671301612001_2030797,00.html • P2V http://p2v.org/ • Paws for Purple Hearts: Veterans Helping Veterans • Combat veterans with PTSD train dogs • In dozens of interviews, veterans and their therapists reported drastic reductions in P.T.S.D. symptoms and in reliance on medication after receiving a service dog

33. Case Study • http://content.usatoday.com/communities/pawprintpost/post/2010/01/dog-helps-iraq-vet-with-ptsd-my-little-marine/1 • Chris Goehner from Wenatchee Valley WA • Suffers from PTSD since serving 2 tours in Iraq with the Marines • Since receiving his dog, Pele, he reports he has slept better than he had in 3 years., that he can go into a crowded place with less fear that he is going to be attacked or shot at. Not as unnerved by loud noises that remind him of shellfire, and he isn’t constantly filled with anger and ready for a fight

34. What Support is Offered Dr. Craig Bryan: Assistant Professor of Psychology at the University of Texas Health Center http://www.npr.org/templates/story/story.php?storyId=131096642 “Unfortunately, in the vast majority of cases, when a veteran comes forward for help, it's usually when they're in extremely bad shape.” --Dr. Craig Bryan (4:30-7:45) Techniques he uses: Classic Talk Therapy: Relates to many aspects of military life. Helps service members understand that they do have a choice and can exercise free will.

35. Clinical Implications: Why Important Obstacles to Intervention (Such as Exposure Therapy) • Lack of therapist training in exposure techniques • Myths about the tolerability and safety of exposing their fears • Therapist beliefs about the lack of applicability of research outcome trials to real-world settings • Gap between science and practice

36. Other Barriers to Treatment • Location of VA medical centers • Simply seeking treatment and talking about the trauma are obstacles to care • Those who are most symptomatic are also the least likely to seek help • Lack of access to empirically-supported therapies and multiple barriers to care have resulted in only a minority of returning veterans with PTSD receiving state-of-the-art treatment

37. Clinical Implications • Need to be aware of and understand the stigma and barriers to treatment • There is a big need to “train both military and civilian psychologists and other mental health professionals to provide high quality deployment-related behavioral health services to military personnel and their families (Teurk 2009)” • Terrorism is a psychological warfare against society as a whole so intervention must be approached from a societal as well as individual clinical perspective.

38. Study (de Jong 2002) defines four levels of intervention: • Societal • Community • Family • Individual Studies have shown that interventions to bolster psychological resilience and post deployment social support may help reduce the severity of traumatic stress and depressive symptoms

39. More Treatment Options • Cognitive Behavior Therapy and EMDR • Eye movement desensitization and reprocessing • Exposure Therapy • Medication Management

40. Future Considerations • Increase research concerning neurobiological, psychological and physical health implications • Clinical considerations • Examination on the impact of the family • Advocacy within criminal justice system • Screening improvements • Expanded treatment options • Networking among service providers • Increased community outreach • Ongoing learning

41. Case Study and Class Activity Client: Dan Jones • 28-year-old single Caucasian male who is a National guardsman with 4 years reserve service Presenting Problem: • Was called to active duty in Baghdad. Describes his deployment as “high intensity,” saying that he witnessed an explosion that killed three of his friends. Witnessed dead and injured civilians and Iraqi soldiers on multiple occasions Involved in an attack that left him with shrapnel in his neck, chronic pain, reports feeling anger since the incident. • Began to develop insomnia, hyper vigilance and a startle response • Reports dreams which are intense and frequent, as well as intrusive thoughts and flashbacks • Since returning home, he has withdrawn from his peer group, reports feeling detached from others. Avoids going out where there will be crowds or loud noises, has a lack of interest in the things he enjoyed before deployment. Current Functioning: • Cl. demonstrates difficulty completing daily tasks, being in public, maintaining relationships. Avoids conversations about past traumatic events with friends and family. • Cl. Would like to begin school again but wants to address these symptoms as he readjusts to civilian life. No mental health history Diagnosis: • Post Traumatic Stress Disorder.

42. Possible Treatment Plan • One-on-one talk therapy, CBT • Virtual Reality Exposure Therapy to help relieve the traumatic experiences, re-learn panic responses • Connection with a social network or support group

43. Resources Available • Screening for mental health: military pathways • http://www.mentalhealthscreening.org/military/index.aspx • National Center for PTSD • http://www.ptsd.va.gov/ • PTSD Resources • http://www.patss.com • Iraq War Clinician Guide • http://www.ptsd.va.gov/professional/manuals/iraq-war-clinician-guide.asp

44. References (Wendy's) • Antai-otung, D. (2002). Culture and Traumatic Events. Journal of the American Psychiatric Nurse Association 8(6): 203-208. • APA, (2009). PTSD facts and statistics. Retrieved November 20, 2010 from APA help Center http://www.apa.org/topics/topicsptsd/html • Army (2010, Nov 19). Army Released October Suicide Data. Retrieved November 20, 2010 from Army G1: www.armyg1.army.mil/hr/suicide/defauult.asp • Arzi, Ben, Solomon, Zahava, and Dekel, R. (2000). Secondary Traumatization among Wives of PTSD and Post-concussive casualties: Distress, Caregiver Burden, and Psychological Separation. Brain Injury 14(8): 725-736. • Basoglo, M. (1997). Psychological preparedness for traumas a protective factor in survivors of torture. Psychological Medicine 27: 1421-1433. • Burg, B.R. (2002). Officers, Gentlemen, “Man-Talk” and Group Sex in the “Old Navy”. Journal of the History of Sexuality 11 (3): 439-456. • Lambert, M.T. and Fowler, D.R. (1997). Suicide Risk Among Veterans: Risk Management in the Changing Culture of Department of Veteran Affairs. Journal of Mental Health Administration 24(3): 350-358. • LaPierre, C.B. (2007). Posttraumatic stress and depression symptoms in soldiers returning from combat operations in Iraq and Afghanistan. Journal of Traumatic Stress 20: 933-943 • Manderscheid, R.W. (2007). Helping Veterans Return: Community, Family, and Job. Archives of Psychiatric Nursing 21(2): 122-124. • Martin, I.R. (2009). Warriors and Healers: Preparing for Returning Veterans. Smith College Studies in Social Work 79(3): 464-470. • NCPTSD, (2007, Aug 2). PTSD Information Center. Retrieved November 20, 2010, from National Center for PTSD http://ncptsd.va.gov/ncmain/index.jsp • Nelson, Brian and Wright, D.W. (1996). Understanding and Treating PTSD Symptoms in Female Partners of Veterans with PTSD. Journal of Marital and Family Therapy 22(4): 455-467. • Sherman, M.D. (2006). Domestic Violence in veterans with PTSD who seek couples therapy. Journal of Marital and Family Therapy 32: 479-490. • Segel, T.D. (2009, Nov. 9). Everyday is Really Veterans Day. Retrieved November, 20, 2010, from American Daily http://americandaily.com/index.php/article/2519 • Solomon, Zahava. (1990). Life events and combat related PTSD; the intervening role of locus of control and social support. Military Psychology 2: 241-256. • Solomon, Zahava. (1988). Negative life events, coping response and combat-related psychopathology: A prospective study. Journal of Abnormal Psychology 97: 302-307

45. References (Rachael's) • http://content.usatoday.com/communities/pawprintpost/post/2010/01/dog-helps-iraq-vet-with-ptsd-my-little-marine/1 USA Today • Armstrong, Thomas (2009). PTSD in the Media: A Critical Analysis of the Portrayal of Controversial Issues. The Scientific Review of Mental Health Practice 7(1) • Brailey, Kevin (2007). PTSD Symptoms: Life Events, and Unit Cohesion in U.S. Soldiers: Baseline Findings from the Neurocognition Deployment Health Study. Journal of Traumatic Stress, 20(4), 495-503. • Burke, Hillary (2009). A New Disability for Rehabilitation Counselors. Journal of Rehabilitation, 75(3). 5-14 • Freidman, Matthew (2005). Toward a Public Mental Health Approach for Survivors of Terrorism. Obtained from http://www.haworthpress.com/web/JAMT • Gould, Matthew. (2007). Stigma and the Military: Evaluation of a PTSD Psychoeducational Program. Journal of Traumatic Stress, 20(4), 505-515. • McLay, Robert N. (2010). Insomnia is the Most Commonly Reported Symptom and Predicts other Symptoms of PTSD. Military Medicine, 175. • Pietrzak, Robert H. (2009). Psychological Resilience and Postdeployment Social Support. Depression and Anxiety, 26, 745-751. • Price, Lawrence H. (2010). Morphine shows protective effect against future. Pharmacology Update, 21(4). • Reger, Greg M. (2008). Virtual Reality Therapy for Active Duty Soldiers. Journal of Clinical Pshcyology: Insession. 64(8). 940-946 • Shen, Yu-Chu (2010). Effects of Iraq/ Afghanistan Deployments on PTSD Disagnoses for Still Active Personnel in All Four Services. Military Medicine, 175,10. • Sundin, N.T. (2010). PTSD after deployment to Iraq: conflicting rates, conflicting claims. Psychological Medicine,40, 367-382. • Tuerk, Peter (2009). Combat-Related PTSD: Scope of the Current Problem, Understanding Effective Treatment, and barriers to Care. Journal of Traumatic Stress, 21(3), 301-308.