Preparing Our Communities To Help Our Returning Soldiers

Lanny Endicott, LCSW, D.Min.lendicott@oru.edu

http://drlannyendicott.com.tripod.comDexter Freeman, Ph.D.

Dexter.Freeman@amedd.army.mil

Some InformationSome InformationLanny EndicottLanny Endicott

• 2,200,000 service members have experienced deployment to Iraq (OIF) and Afghanistan (OEF)

• 800,000 have experienced multiple deployments• 43% of today’s fighting force is comprised of

Reserve and Guard members• 1% of the US population involved• $4 trillion expended

• Approximately 35+% return afflicted with TBI Approximately 35+% return afflicted with TBI and PTSDand PTSD

• Those who deploy more than once have 300 Those who deploy more than once have 300 % increased probability for severe mental % increased probability for severe mental health outcomeshealth outcomes

• At least 130,000 and as many as 250,000 U.S. At least 130,000 and as many as 250,000 U.S. veterans are homeless each night (over 7,000 veterans are homeless each night (over 7,000 are veterans of Iraq or Afghanistan)are veterans of Iraq or Afghanistan)

• Suicide is now the top killer of military Suicide is now the top killer of military veteransveterans

Up to 31 percent of soldiers Up to 31 percent of soldiers returning from combat in Iraq returning from combat in Iraq experience depression or post-experience depression or post-traumatic stress disorder that traumatic stress disorder that affects their jobs, relationships, or affects their jobs, relationships, or home life, according to a new study home life, according to a new study by Army researchers.by Army researchers.

81 percent of Veterans 81 percent of Veterans suffering from depression and suffering from depression and PTSD engaged in at least one PTSD engaged in at least one violent act against their partner violent act against their partner in the past year.in the past year.

One in three military women has been sexually assaulted, compared to one in six civilian , compared to one in six civilian women, according to DoDwomen, according to DoD

Active-duty female personnel make up Active-duty female personnel make up roughly 14.5 percent -- or 207,308 roughly 14.5 percent -- or 207,308 members -- of the more than 1.4 million members -- of the more than 1.4 million Armed Forces, according to the Armed Forces, according to the Department of Defense.Department of Defense.

Military and Domestic Violence: Military and Domestic Violence: Risk FactorsRisk Factors

• High percentage of military High percentage of military personnel have prior histories of personnel have prior histories of family violence.family violence.

• Among Navy recruits, 54% of women Among Navy recruits, 54% of women and 40% of men witnessed parental and 40% of men witnessed parental violence prior to enlistmentviolence prior to enlistment

Risk FactorsRisk Factors

• Military population is concentrated in Military population is concentrated in the ages of highest risk for the ages of highest risk for interpersonal violence (ages 20-40)interpersonal violence (ages 20-40)

• Constant mobility and geographic Constant mobility and geographic separation isolates victims by cutting separation isolates victims by cutting them off from family and other support them off from family and other support systemssystems

Military and Domestic Violence Risk Factors

• Higher than average unemployment rates for military spouses, leaving them economically dependent on service members

• Deployments and reunifications create unique stresses on military families

“Our military does an exceptional job of preparing soldiers, Marines, sailors and airmen for the fight – boot camp makes warriors of recruits – but we do little to ‘de-boot,’ to support that warrior and his or her family as he or she comes out of the extraordinary experience of having served in combat. A prosthetic leg, some physical therapy and a bottle of meds do not equal a homecoming plan.”

Nancy Berglass. America’s Duty: The Imperative of a New Approach to Warrior and Veteran Care. November 2010. Center for a New American Security.

Workshop ObjectivesWorkshop Objectives

• Articulate how military culture can both help or Articulate how military culture can both help or hinder community re-integrationhinder community re-integration

• Describe 2 evidence-based treatment modalities for Describe 2 evidence-based treatment modalities for treating service members with PTSDtreating service members with PTSD

• Introduce “traumatic brain injury”Introduce “traumatic brain injury”• Address the concept of “soul or moral injury” Address the concept of “soul or moral injury”

affecting our service members and discuss ways affecting our service members and discuss ways social workers of faith can address the issuesocial workers of faith can address the issue

3,300 Members of the 3,300 Members of the Oklahoma National Guard have Oklahoma National Guard have

returned home from returned home from Afghanistan/KuwaitAfghanistan/Kuwait

A New ParadigmA New Paradigm• Despite their best intentions DOD and VA are Despite their best intentions DOD and VA are

overwhelmedoverwhelmed• Less that 50% of veterans access services of Less that 50% of veterans access services of

the VA - particularly “mental health’the VA - particularly “mental health’• Private sector partners (non-profits and for-Private sector partners (non-profits and for-

profits) can provide important services – but profits) can provide important services – but need assistance with funding and training to need assistance with funding and training to address the needs of veteransaddress the needs of veterans

• A key is that personalized care for our A key is that personalized care for our veteran warriors includes the VA and veteran warriors includes the VA and community partners working togethercommunity partners working together

Community PartnersCommunity PartnersEngage coordinated and informed community planning effortsEngage coordinated and informed community planning efforts

VA + CommunityVA + Community• Community-based social service providersCommunity-based social service providers• Educational institutions (universities, colleges, Educational institutions (universities, colleges,

tech schools)tech schools)• Faith communities (churches, synagogues, etc.)Faith communities (churches, synagogues, etc.)• Court systems (Veterans Court)Court systems (Veterans Court)• EmployersEmployers• Veterans AdministrationVeterans Administration• Military support organizations (Wounded Military support organizations (Wounded

Warriors, Folds of Honor, Blueprint, Give an Warriors, Folds of Honor, Blueprint, Give an Hour)Hour)

Veterans Initiative Veterans Initiative Community Service Council (Tulsa) Community Service Council (Tulsa)

• Bring agencies/organizations together to Bring agencies/organizations together to discuss what they dodiscuss what they do

• Discover gaps/needs in services to veteransDiscover gaps/needs in services to veterans– Preparation of therapists to accommodate Preparation of therapists to accommodate

veteran clientele: veteran clientele: • military culture military culture • evidenced based treatment for PTSDevidenced based treatment for PTSD

– Develop a “go-to-provider” in each agency: one Develop a “go-to-provider” in each agency: one trained who functions as trainer for otherstrained who functions as trainer for others

Wounded Warriors’ GrantWounded Warriors’ Grant

• Community Service Council (Veterans Community Service Council (Veterans Initiative)Initiative)

• Three parts: Three parts: – Military CultureMilitary Culture– Cognitive Processing Therapy (Duke and TU)Cognitive Processing Therapy (Duke and TU)– Create a “learning community” for application Create a “learning community” for application

and feedback of CPTand feedback of CPT

• Goal: train 60 therapistsGoal: train 60 therapists

ID Veterans and FamiliesID Veterans and Families

• Identification of veterans and their families at Identification of veterans and their families at social services, doctors offices, employers, social services, doctors offices, employers, educational institutions, etc.educational institutions, etc.Add a question on veteran status in intake formsAdd a question on veteran status in intake forms

Veterans CourtsVeterans Courts

Promote establishment of Veterans CourtsPromote establishment of Veterans Courts Tulsa has Veterans Courts on both County and Tulsa has Veterans Courts on both County and

City levelCity level Modeled after the “drug court”Modeled after the “drug court” 2-year program: treatment, case management, 2-year program: treatment, case management,

mentorsmentors

Preparing Educational InstitutionsPreparing Educational Institutions

• Educational institutions should have: Educational institutions should have: Go-to person to work with veteransGo-to person to work with veteransVeteran organizationVeteran organizationVeterans Lounge (private meeting place)Veterans Lounge (private meeting place)Training of faculty and staff for working with veteransTraining of faculty and staff for working with veteransReferral network for assisting veterans and their Referral network for assisting veterans and their

familiesfamiliesSee SVA Toolkit: www.vetfriendlytoolkit.orgSee SVA Toolkit: www.vetfriendlytoolkit.org

University of Denver Study

• Of 800,000 veterans who attended college• 88% dropped out after the first year• 3% graduated from college

Coffee Bunker

• Tulsa is a large community without a military instillation nearby

• Coffee Bunker is an evening drop-in center for veterans of all services

• Volunteers are trained in QPR • Recent grants from Wounded Warriors and

United Way (Venture Grant) will help expand program to its own site

SummarySummary

In general, prepare and educate the community In general, prepare and educate the community for veteran reintegrationfor veteran reintegration• Remember the 1% Remember the 1% • $4 trillion of borrowed money$4 trillion of borrowed money• Lack of sacrifice from the community in generalLack of sacrifice from the community in general• Old news becomes less newsworthyOld news becomes less newsworthy

A Matter of National Defense

“The willingness with which our young people are likely to serve in any war, no matter how justified, shall be directly proportional to how they perceive the Veterans of earlier wars were treated and appreciated by their nation.”

President George Washington

MILITA

RY CULT

URE

WHEN YOU THINK OF THE MILITARY(UNIQUE FACETS)• Frequent separations• Regular household relocations• Mission comes first • Early retirements• Loss• Detachment• System security• Rank focused

THE DEPLOYMENT CYCLE(EMOTIONAL FACTORS)• Predeployment – “Gearing up”

•Anticipation, detachment, sadness, restless

• Deployment – “Boots on the ground”•Emotional disorganization, sleep disturbance

•New patterns, psychological presence• Postdeployment (Redeployment)

•Relief, boundary ambiguity•New normal, prepping to gear up

COPING WITH DEPLOYMENT(AWAITING SPOUSE’S CONCERNS)• Safety of Deployer (49%)• Loneliness (47%)• Anxiety or depression (36%)• Difficulty sleeping (36%)• Sole parent concerns (32%)• Inaccurate information (31%)• Household duties/repairs (28%• Job/education demands (26%)

DATA FROM 2008 SURVEY OF ACTIVE DUTY SPOUSES, DEFENSE MANPOWER DATA CENTER (2009)

For training in military cultureFor training in military culture

Military Culture: “Paint a Moving Train” (Kudlar)Military Culture: “Paint a Moving Train” (Kudlar)http://www.mirecc.va.gov/visn6/paint-moving-http://www.mirecc.va.gov/visn6/paint-moving-

train.asp train.asp

For introduction to treatment of PTSD (Cognitive For introduction to treatment of PTSD (Cognitive Processing Therapy):Processing Therapy):http://www.ptsd.va.gov/professional/ptsd101/ptsd-http://www.ptsd.va.gov/professional/ptsd101/ptsd-101.asp101.asp

http://cpt.musc.eduhttp://cpt.musc.edu““Psychological First Aid”Psychological First Aid”

http://www.ptsd.va.gov/professional/manuals/psych-http://www.ptsd.va.gov/professional/manuals/psych-first-aid.aspfirst-aid.asp

What we know about Army Families: 2007 updateWhat we know about Army Families: 2007 updatehttp://www.army.mil/cfsc/research.htm http://www.army.mil/cfsc/research.htm

PTSDPTSD

• Think of PTSD as inability to recover from a Think of PTSD as inability to recover from a traumatic eventtraumatic event

• In normal recovery, intrusions and emotions In normal recovery, intrusions and emotions decrease over time and no longer trigger decrease over time and no longer trigger each othereach other

• In those not recovering, strong negative In those not recovering, strong negative emotion leads to escape and avoidanceemotion leads to escape and avoidance

Symptoms of PTSDSymptoms of PTSD

Three Categories:Three Categories:1.1. ““Reliving” the event: Reliving” the event:

• FlashbacksFlashbacks• repeated upsetting memories of the eventrepeated upsetting memories of the event• repeated nightmaresrepeated nightmares• strong uncomfortable reactions to situations strong uncomfortable reactions to situations

that remind one of the eventthat remind one of the event

2.2. ““Avoidance” or emotional numbing or feeling one Avoidance” or emotional numbing or feeling one doesn’t care about anythingdoesn’t care about anything

• Feeling detachedFeeling detached• Being unable to remember important aspects of Being unable to remember important aspects of

eventevent• Having lack of interest in normal activitiesHaving lack of interest in normal activities• Avoiding reminders of event: places, people, Avoiding reminders of event: places, people,

thoughtsthoughts• Showing less of one’s moodsShowing less of one’s moods• Feeling like one has no futureFeeling like one has no future

3.3. ArousalArousal• Difficulty concentratingDifficulty concentrating• Startling easilyStartling easily• Exaggerated response to things that startleExaggerated response to things that startle• Feeling more aware (hypervigilance)Feeling more aware (hypervigilance)• Feeling irritable or having outbursts of angerFeeling irritable or having outbursts of anger• Having trouble falling or staying asleepHaving trouble falling or staying asleep• Feeling guilt about the events (“survivor guilt)Feeling guilt about the events (“survivor guilt)• Symptoms typical of anxiety, stress, tension:Symptoms typical of anxiety, stress, tension:

o Agitation or excitability, dizziness, fainting, Agitation or excitability, dizziness, fainting, feeling heart beat in one’s chest, headachefeeling heart beat in one’s chest, headache

PTSD TreatmentPTSD Treatment

VA recognizes two therapies with best VA recognizes two therapies with best evidence:evidence:– Cognitive Processing Therapy (CPT)Cognitive Processing Therapy (CPT)– Prolong Exposure Therapy (PET)Prolong Exposure Therapy (PET)

VA website for Cognitive Processing TherapyVA website for Cognitive Processing Therapyhttp://www.ptsd.va.gov/public/pages/http://www.ptsd.va.gov/public/pages/

cognitive_processing_therapy.aspcognitive_processing_therapy.asp

VA website promoting Mobile App: PTSD CoachVA website promoting Mobile App: PTSD Coachhttp://www.ptsd.va.gov/public/pages/PTSDCoach.asp http://www.ptsd.va.gov/public/pages/PTSDCoach.asp

Mobile App: PE CoachMobile App: PE Coach

Traumatic Brain Injury (TBI)Traumatic Brain Injury (TBI)Symptoms of Mild TBISymptoms of Mild TBI• Brief loss of consciousness (seconds to minutes)Brief loss of consciousness (seconds to minutes)• HeadacheHeadache• VomitingVomiting• NauseaNausea• Lack of motor coordinationLack of motor coordination• Dizziness Dizziness • Difficulty balancingDifficulty balancing• Lightheadedness Lightheadedness

• Blurred vision or tired eyesBlurred vision or tired eyes• Ringing in the earsRinging in the ears• Bad taste in the mouthBad taste in the mouth• Fatigue or lethargyFatigue or lethargy• Changes in sleep patternsChanges in sleep patterns• Behavioral or mood changesBehavioral or mood changes• ConfusionConfusion• Trouble with memory, concentration, attention, or Trouble with memory, concentration, attention, or

thinkingthinking

Moral InjuryMoral Injury

• Is a suspected contributor to soldier suicideIs a suspected contributor to soldier suicide• Is not PTSD: an injury of trauma leading to Is not PTSD: an injury of trauma leading to

suppression of fear and lack of integration of suppression of fear and lack of integration of feelings with coherent memory – leading to feelings with coherent memory – leading to symptoms including flashbacks, nightmares, symptoms including flashbacks, nightmares, dissociative episodes and hyper-vigilancedissociative episodes and hyper-vigilance

• Moral injury is a negative self-judgment Moral injury is a negative self-judgment based on having violated core moral beliefs based on having violated core moral beliefs and values or feeling betrayed by one in and values or feeling betrayed by one in authorityauthority

• It includes loss or destruction of moral It includes loss or destruction of moral identity and loss of meaningidentity and loss of meaning

• Its symptoms include shame, survivor guilt, Its symptoms include shame, survivor guilt, depression, despair, addiction, distrust, depression, despair, addiction, distrust, anger, a need to make amends and the loss anger, a need to make amends and the loss of desire to liveof desire to live

A Consequence of TrainingA Consequence of Training• ““Mission first” training – can contribute to Mission first” training – can contribute to

resiliency in soldier’s mission (including resiliency in soldier’s mission (including survival) while ignoring empathy for others survival) while ignoring empathy for others and deep moral valuesand deep moral values

• Soldiers taught to see events in a neutral Soldiers taught to see events in a neutral light, not labeling them as good or bad, and light, not labeling them as good or bad, and to focus on those things that are positiveto focus on those things that are positive

• A soldier could experience the A soldier could experience the incomprehensible while on mission: killing a incomprehensible while on mission: killing a family, including women and children, after family, including women and children, after kicking down the door of suspected kicking down the door of suspected insurgent; losing a close friend; or torturing insurgent; losing a close friend; or torturing detainees? detainees?

• Will the soldier see as neutral or positive?Will the soldier see as neutral or positive?

Person of faithPerson of faith

• Many soldiers seek the help of clergy:Many soldiers seek the help of clergy:– To avoid a negative psychological recordTo avoid a negative psychological record– To seek help with religious meaning, moral To seek help with religious meaning, moral

issues, and matters of conscienceissues, and matters of conscience

• Social workers of faith can also provide Social workers of faith can also provide caring and empathetic help through careful caring and empathetic help through careful listening and understanding as soldiers may listening and understanding as soldiers may seek community professionals to avoid seek community professionals to avoid mental health labelingmental health labeling

TreatmentTreatment

• Moral injury is not a clinical condition that Moral injury is not a clinical condition that can be medicated or cured by psychologycan be medicated or cured by psychology

• Requires the reconstruction of a moral Requires the reconstruction of a moral identity and meaning in life with the support identity and meaning in life with the support of a caring, nonjudgmental community of a caring, nonjudgmental community (chaplain, pastor, therapist, social worker) (chaplain, pastor, therapist, social worker) that can provide a way for the veteran to that can provide a way for the veteran to learn to learn to forgiveforgive

PTSD TreatmentPTSD Treatment

Cognitive Processing TherapyCognitive Processing Therapy• Address event(s) – thinking – feelings Address event(s) – thinking – feelings

connectionconnection• Writing about detailed trauma event(s) & Writing about detailed trauma event(s) &

reading them to the therapistreading them to the therapist• Utilizing worksheet assignmentsUtilizing worksheet assignmentsProlonged ExposureProlonged Exposure• Teach relaxationTeach relaxation• Expose person to discussing/experiencing Expose person to discussing/experiencing

traumatic event (invivo – imaginal)traumatic event (invivo – imaginal)

Moral InjuryMoral Injury

• Two types of violations: co-mission or Two types of violations: co-mission or omissionomission

• Violation of moral, cultural, religious and/or Violation of moral, cultural, religious and/or other deeply held beliefsother deeply held beliefs

• Military training emphasizes mission with Military training emphasizes mission with suppression of individual beliefssuppression of individual beliefs

• Moral Injury Moral Injury does not does not come from a specific come from a specific traumatic eventtraumatic event

Treatment of Moral InjuryTreatment of Moral Injury

• Shame: Shame: the consequencethe consequence• Forgiveness, repentance: Forgiveness, repentance: the treatment via help the treatment via help

from community therapists, clergy, chaplains, or from community therapists, clergy, chaplains, or trusted moral authoritytrusted moral authority

• Honor: Honor: community events, ceremonies community events, ceremonies celebrating and honoring returning soldierscelebrating and honoring returning soldiers

““Honor is the antidote of shame”Honor is the antidote of shame”

GriefGrief

• The soldier may be experiencing “grief” from The soldier may be experiencing “grief” from loss (i.e., death of colleague, separation from loss (i.e., death of colleague, separation from unit & mission, leaving of spouse)unit & mission, leaving of spouse)

• The treatment is an application of “grief The treatment is an application of “grief therapy”: talk through the loss while therapy”: talk through the loss while recognizing that people process grief recognizing that people process grief differentlydifferently

Resources for Moral InjuryResources for Moral Injury

http://www.ptsd.va.gov/professional/pages/moral_injury_at_war.asp

http://www.commondreams.org/view/2012/06/29-8

Questions/CommentsQuestions/Comments