A Holistic Approach to Working with Veterans and their Families

1. A Holistic Approach to Working with Veterans and their Families Tim Scala, Psy.D., C.F.C. Assistant Professor Program Director of B.S. in Recreational Therapy Nova Southeastern University

2. Current US Conflicts • Operation Iraqi Freedom (OIF) • 2003-2010 “Operation New Dawn” (OND) August 31, 2010-Present (U.S. combat mission in Iraq had ended-transitional mission to assist Iraq’s Security Forces) • Operation Enduring Freedom (OEF) • 2001-Present

3. OEF/OIF/OND Over 2 million U.S. troops have been deployed to Afghanistan and Iraq since September 2001. Tan, 2009

4. Unique to OIF/OEF Reservists and National Guard members are called to active duty at an unprecedented rate An increased number of service members are returning home with severe injuries, including Traumatic Brain Injury (TBI) More women are serving Many parents of young children are serving on active duty Institute of Medicine, 2010; Washington et al., 2010

5. Unique to OIF and OEF “The character of war is changing-it is irregular, catastrophic, disruptive, and no longer confined to the traditional battlefield”(Defense Science Board, 2007, p.1). • 360 degree battle space • Compared to linear battle field in previous conflicts • 360 degree battlespace results in maintained heightened level of arousal creating sustained high anxiety and hypervigilance outside of combat

6. Improvised Explosive Devices (IED) IEDs- highest number of amputees when compared to previous wars • Since 2001, the total number of amputations in all conflicts is 1,621 (Congressional Research Service, 2010). • Traumatic Brain Injury (TBI)

7. The Deployment Cycle

8. Multiple Deployments Frequent and lengthy deployments take their toll not only on the soldier but family members and friends as well

9. Reintegration • Service member “reintegrates” into family life and the community • Reality of homecoming may not meet expectations, need to renegotiate roles • Service member and his/her spouse reach a “new normal”

10. National Guard and Reserve • Instantly become military family-families may not be prepared • According to the Walter Reed Army Institute of Research (2007) reserve soldiers report higher rates of concern about their mental health (i.e., depression, PTSD) than do active soldiers at post-deployment • Reserves demobilize and lose day-to-day support from their peers • Often live far from VA and may face legal problems in accessing services • Adjustment with returning to civilian job after long deployment Briefing to the Defense Science Board Task Force from the Walter Reed Army Institute of Research, 2007, February

11. Impact on Family Over 700,000 children with at least one parent deployed (Rutledge, 2007) Instantly becomes one-parent household Anxiety and depression in children and spouse of deployed serviceman/woman Ambiguous Loss • Family member returns- is there but not there

12. Mental Health It has been suggested that approximately one in six servicemen and women returning from deployment in Iraq will be in need of mental health services as a result of their experiences (Robinson, 2004). According to Renshaw (2011), 33% of deployed service members have served multiple deployments, sometimes with less than a 1 year period between deployments, suggesting that members with mental health concerns are still actively serving or are likely to be deployed without proper treatment.

13. Combat Exposure • Several potential consequences to combat exposure, including : • posttraumatic stress disorder (PTSD) • depression • substance abuse • health problems/severe injuries/ Traumatic brain injury (Hoge et al., 2004)

14. Posttraumatic Stress Disorder (PTSD) • Onset may be delayed months or years following event • Those with untreated PTSD are further at risk for • alcohol and substance abuse • domestic violence • unemployment • homelessness • incarceration • suicide • health problems http://www.youtube.com/watch?v=tghYzt-nvGw&feature=player_embedded

15. Effects of PTSD on Parenting • Effects of PTSD symptoms on parenting: • Behaving in a controlling/overprotective manner • Difficulties with bonding and attachment (i.e., emotional numbing) • Affective avoidance • Many studies have indicated a link between affective avoidance of the veteran and behavioral difficulties in children (Graf, Miller, Feist, & Freeman, 2011)

16. Adjustment Concerns: Family Views • In a mixed methods study conducted by Graf, Miller, Feist & Freeman (2011), family members identified the following concerns in their combat veteran family member • Anger and aggression • Distancing and isolation • Emotional numbing • Less consideration for others in the home and negative changes in attitude towards women

17. Relationships/Couples Research has found that among Operation Enduring Freedom/Operation Iraqi Freedom (OEF/OIF) veterans diagnosed with PTSD there is an association with intimate relationship problems such as relationship distress, physical aggression, and difficulty with emotional and physical intimacy Goff, Reisbig, & Hamilton, 2007; as cited in Fredman & Monson, 2010

18. Employment Higher rates of unemployment among OIF/OEF returning veterans. According to the U.S. Bureau of Labor Statistics the unemployment rate in Florida was 11.9 % as of January 2011 and for veterans who served in the Gulf War era II unemployment rates were as high as 21.6% for veterans between the ages of 18 and 24, nationwide.

19. Military Sexual Trauma According to the DoD Annual Report on Sexual Assault in the Military (2011), in FY10, there were a total of 3,158 reports of sexual assault involving Service members. Mount, 2010; Graf, Miller, Feist, & Freeman (2011)

20. Homelessness • It is estimated that 26% of all homeless adults are veterans. Particularly among female veterans, rates of homelessness are concerning. Washington et. al, (2010) reported that women in the military are three to four times more likely than civilian women to become homeless. • Researchers found barriers to VA health care use to be among the risk factors associated with becoming homeless and the results of their study found that unemployment was one of the strongest predictors of homelessness for women (Institute of Medicine, 2010). Washington et al, 2010; Institute of Medicine, 2010

21. Suicide Nationwide statistics show that veterans comprise about 20 percent of the 30,000 to 32,000 U.S. deaths each year from suicide (Miles, 2010) http://www.youtube.com/watch?v=RzceLmVnj6A

22. Programmatic Needs • The Department of Defense (DoD) has adopted several programs to assist with adjustment following deployment, such as: • Courage to Care • Military One Source • Military HOMEFRONT • Project DE-STRESS (Delivery of Self Training and Education for Stressful Situations) • Transition Assistance Program • National Center for Telehealth and Technology • PTSD Coach • Life Armor

23. DoDTotal Force Fitness Four “mind” domains Four “body” domains • Psychological Fitness • Behavioral Fitness • Social and Family Fitness • Spiritual Fitness • Physical • Environmental • Medical • Nutritional

24. Treatment of Returning Veterans • The current system of care provided by the VA is built on the principles of social work, with the goal of rehabilitating overall health. • A wraparound model that is recovery-oriented is beneficial in helping to connect veterans to needed services and to provide as much outreach to these individuals as possible. Admur et al., 2011

25. Recovery Oriented Mental Health Services • 10 components: • Self-Direction • Nonlinear • Individualized and Person-Centered • Strength-Based • Holistic • Focus on Empowerment • Respect • Responsibility • Peer Support • Hope Makin-Byrd, Gifford, McCutcheon, & Glynn, 2011

26. Wraparound and Holistic Approach • Treatment focuses on these areas: • Case Management • Mental Health Services • Job Training/Job Placement • Education Support and Benefits • Legal Assistance • Health and Wellness • Outreach with Other Supportive Services

27. VA Treatment Resources/Programs to be Familiar With Case managers VA Liaisons for healthcare Polytrauma system of care Federal Recovery Coordination Program Caregiver support VET Centers Seven Touches of Outreach Amdur et al., 2011

28. Seven Touches of Outreach Demobilization Initiative (briefings) Reserve National Guard Yellow Ribbon Reintegration Program Support Initiative (enrolling in healthcare) VA’s partnership with National Guard Bureau’s Transition Assistance Advisors (TAA’s) Initiative Combat Veteran Call Center Initiative (contacting those not enrolled) Reserve and National Guard Post-Deployment Health Reassessment Support Initiative (healthcare screenings) Individual Ready Reserve (IRR) Muster Initiative (reaching out to those that didn’t attend briefings) Internet Webpage for OEF/OIF Veterans (one stop) Amdur et al., 2011

29. Therapeutic Skills to Consider When Working with Returning Veterans • Connecting with the returning veteran and creating a trusting environment : • Validation of the veteran’s experiences and concerns will be crucial. • Discussion of “warzone,” not “combat,” stress may be warranted because some traumatic stressors may not involve war fighting as such. • Work from a client-centered perspective, and take care to find out the current concerns of the patient. • Connect veterans with each other: • VA and Vet Center clinicians are great at bringing veterans together. Department of Veterans Affairs, 2004

30. Therapeutic Skills to Consider When Working with Returning Veterans • Offer practical help with specific problems: • Returning veterans are likely to feel overwhelmed with problems related to the workplace, family and friends, finances, physical health, and so on. • These problems will be distracting, often interfering with the tasks of therapy and resolution of symptoms. • Rather than treating these issues as distractions clinicians can help veterans identify, prioritize, and execute action steps to address their specific problems. Department of Veterans Affairs, 2004

31. Therapeutic Skills to Consider When Working with Returning Veterans • Attend to broad needs of the person (Wolfe, Keane, and Young, 1996): • The impact of both pre-military and post-military stressors on adjustment. • Recognition and referral for assessment of the broad range of physical health concerns and complaints that may be reported by returning veterans is important. Department of Veterans Affairs, 2004

32. PTSD • Those with untreated PTSD are further at risk for • alcohol and substance abuse • domestic violence • unemployment • homelessness • incarceration • suicide • health problems

33. Preventing PTSD in Returning Veterans • Pharmacological Prevention: • Propranolol (Inderal) most promising, but need more research • Psychological Approaches • Little support for psychological debriefing in preventing PTSD. May in fact be detrimental • CBT techniques more beneficial as a preventative strategy only for symptomatic clients Sharpless & Barber, 2011

34. Treating PTSD in Returning Veterans • Psychopharmacology: • First line choices: • Selective Serotonin Reuptake Inhibitors: Paroxetine (Paxil) and Sertraline (Zoloft) • Serotonin Norepinehprine Reuptake Inhibitor: Venlafaxine (Effexor) • Second line choices: • Tricycllic Antidepressants: Elavil and Tofranil • Monoamine Oxidase Inhibitors: Nardil • Antidepressants: Remeron and Serzone • Adjunctive agents: • Prazosin – Reducing nightmares and sleep difficulties • D-cyloserine – Cognitive enhancer in Anxiety D/Os • Atypical Antipsychotics Sharpless & Barber, 2011

35. Treating PTSD in Returning Veterans • Psychotherapies: • Prolonged Exposure (PE), Cognitive Processing Therapy (CPT), and Eye Movement Desensitization and Reprocessing (EMDR) are the most empirically validated treatments for PTSD in returning veterans. • Other promising and less researched treatments: • Stress Inoculation Training (SIT) • Exposure therapy using virtual reality (VR) • Relaxation Training • Cognitive Behavioral Group Therapy • Psychodynamic Psychotherapy • Interpersonal Psychotherapy (IPT) • Dialectical Behavior Therapy (DBT) • Hypnosis Sharpless & Barber, 2011

36. Family and Couples Treatment with Returning Veterans • Statistics: • Approximately half of service members are married and one-fourth have children (DOD Task Force, 2007) • More dependence on National Guard members and longer deployment periods without traditional military communities and resources • Frequent relocation (average of every 2-3 years) • Warfare and guerilla tactics lead to significant injuries • Experiential avoidance (EA) has been associated with lower relationship adjustment for men and an association has been found between men’s EA and their partner’s relationship adjustment, and greater EA among women was associated with poorer partner relationship adjustment (Reddy, Meis, Erbes, Polusny, and Compton, 2011) Makin-Byrd, Gifford, McCutcheon, & Glynn, 2011

37. Family and Couples Treatment with Returning Veterans • Effects of deployment on families: • Partners experience loneliness, anxiety, and depression • Loss of income • Child care challenges • Changes in health insurance • Child behavior problems while parent is deployed Makin-Byrd, Gifford, McCutcheon, & Glynn, 2011

38. Family and Couples Treatment with Returning Veterans • Effects of service member’s return on families: • Difficulty adjusting to different environment, daily schedule, and set of relationships • Positive and negative emotions stemming from integrating service member back into the family • TBI, PTSD, and depression have been linked to divorce (Tanielian & Jaycox, 2008) • Relocation due to service member injuries to receive appropriate healthcare • Partner/Domestic violence and family conflict • Substance abuse Makin-Byrd, Gifford, McCutcheon, & Glynn, 2011

39. VHA Policies and Initiatives on Evidenced-Based Practices for Veterans and Families Family involvement has become a national priority (VHA Directive 2006-041) In 2003 President’s New Freedom Commission called for family-centered services VA Secretary’s New Mental Health Strategic Plan (2004)-Family Care that is Recovery Oriented, high quality, and maximizes the delivery of evidenced-based practices. VHA Handbook 1160.01 Uniform Mental Health Services in VA Medical Centers and Clinics (2008) – Must provide family consultation, family education, and family psychoeducation. Makin-Byrd, Gifford, McCutcheon, & Glynn, 2011

40. Suicide in Combat Veterans • Statistics: • Recent study demonstrated suicide risk has increased in former active duty veterans who served in Iraq and Afghanistan war zones, especially with those diagnosed with mental disorders • Department of Veterans Affairs published data indicating that suicide rates among veterans increased 26% between 2005 and 2007 • Rates are much higher than in the general population • Common causes of death among veterans which are suspected to be suicides: • Vehicle accidents • Motorcycle Accidents • Drug Overdoses Sher & Yehuda, 2011

41. Suicide in Combat Veterans • Things to consider: • No longer being part of military culture can lead to feelings of failed belongingness or emotional distress • Feelings of hopelessness are prominent in post-military life • Preventing suicide in veterans: • Little research on effective techniques • More research needs to be done in the areas of identifying biological and psychological risk factors • Take suicidal statements by veterans very seriously • Provide a trusting and safe therapeutic environment to allow expression of thoughts and emotions • Include family and social support as much as possible Sher & Yehuda, 2011

42. Substance Abuse Treatment with Veterans • The National Survey on Drug Use and Health (2007) reported that 60% of veterans have reported recent alcohol use and 7.4% reported heavy use. • Recent data indicates that approximately 40% of active duty soldiers and veterans had positive responses to screenings for alcohol use, including heavy, binge, or harmful drinking (Stahre et al., 2009). • Risk factors for substance abuse in general: • Depression • Anxiety • PTSD • Personality Disorders • Physical Health Problems Skidmore & Roy, 2011

43. Substance Abuse Treatment with Veterans • Theories of substance use disorders: • Hereditary Factors • Social Learning and Cognitive-Behavioral Models • Self-Medication • Military Factors • Stress alternating with periods of down time • Long tours of duty • Loss of friends or forming new strong bonds • Specific substances to area of combat (Afghanistan produces opium) • Dependence related to medicating injuries Skidmore & Roy, 2011

44. Substance Abuse Treatment with Veterans • Clinical Considerations: • Substance use in women: • Pressure performing in a male dominated environment • Depressive states • Physical, sexual, combat-related trauma • Cultural Background and Age • Certain cultures may condone use of substance in coping with difficulties • Studies have shown African Americans experience greater drug problems and less alcohol and psychiatric problems • Younger individuals are likely more amenable to changing habits that are not as longstanding, as with older individuals • Homelessness • Implications for attendance at treatment and lower follow through • Poor ability to communicate with providers • Stress associated with finding housing Skidmore & Roy, 2011

45. Substance Abuse Treatment with Veterans • Basic Assessment: • Screening measures like Alcohol Use Disorders Identification Test (AUDIT), the Drug Abuse Screening Test (DAST), or the Alcohol, Smoking, and Substance Involvement Screening Test (ASSIST) • Urinalysis and breathalyzers • Interview and History • Pre-Military, Military, and Post-Military • Strengths and Skills • Assessment of Risk Skidmore & Roy, 2011

46. Substance Abuse Treatment with Veterans • Levels of Care: (Should be individualized, evidenced-based, and least restrictive) • Self-Help • Outpatient • Inpatient • Modalities of Treatment: • Group therapy is most widely used with veterans • Support • Awareness of triggers • Skill acquisition • Teaching healthy relationships • Increases honesty about substance use Skidmore & Roy, 2011

47. Substance Abuse Treatment with Veterans • Modalities of Treatment: • Marital and Family Therapy: • Daily sobriety contract • Targets larger systemic issues • Increases communication between family members • Case Management • Strength-based approaches work best • Linking up with appropriate services • Pharmacotherapy Skidmore & Roy, 2011

48. Substance Abuse Treatment with Veterans • Clinical Interventions: • Motivational Interviewing and Motivational Enhancement Therapy have been proven effective with veterans (Miller and Rollnick, 2002) • Empathetic listening • Rolling with resistance • Supporting client self-efficacy • Providing feedback • Encouraging client responsibility • 12-Step and CBT have also been frequently used • Acceptance and Commitment Therapy (ACT) and Dialectical Behavior Therapy (DBT) are newer methods of intervention that are gaining popularity. Skidmore & Roy, 2011

49. Treatment of TBI in Veterans • Posttraumatic stress disorder was strongly associated with TBI • 44% of the soldiers who had injuries with loss of consciousness met criteria for PTSD; about 27% with alteration of consciousness; about 16% with other types of injuries, and about 9% with no other injuries. • Those soldiers who reported TBI, especially with loss of consciousness, were more likely to report poor general health, missed workdays, medical visits, and a higher number of somatic and post-concussive symptoms than reported by soldiers with other injuries. • However, after adjustment for PTSD and depression, the occurrence of TBI was no longer significantly associated with these physical concerns (except for headache). • This study underscored the important relationship between somatic and psychological symptoms French & Parkinson, 2008

50. Treatment of TBI in Veterans French & Parkinson, 2008 In August 2003, the Walter Reed Army Medical Center commander issued a mandate that required TBI screening of all medically evacuated service members with high-risk injury histories. Careful review of the transit medical records of all casualties arriving. This is followed by clinical interview of the patient (if possible), interviews with family members or witnesses to the incident (if possible), and review of records. CT, MRI, and Cognitive Status Assessments [Repeatable Battery for the Assessment of Neuropsychological Status (RBANS) ] Following discharge to an outpatient status, the service member continues to receive care as needed. This is coordinated by a series of care managers and is centered through the TBI clinic at the hospital. That clinic is staffed by neurologists, psychiatrists, neuropsychologists, and psychologists.