Veterans, Families, & Communities Under Fire

Clinical and Ethical Guidelines for Treating the Effects of War

R. Blaine Everson, Ph.D.

Marriage & Family Therapist

Samaritan Counseling Center

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Learning Objectives

Learn a systems based approach to common problems seen with vets and families

Better understand military culture & language upon practice & broader culture

Ethics of assessing, evaluating, & treating vets & their families from a systemic perspective

Utilize knowledge of in-depth ethics associated with interventions where needs of vets & families may diverge.

Learn more about seeking & providing supervision for working with vets & their families.

Identify ways of become a more veteran friendly therapist and attracting clients.

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Military CultureMilitary Culture

Sociologists define culture as …Sociologists define culture as …

• LanguageLanguage - nomenclature; acronyms, abbr. - nomenclature; acronyms, abbr.• BeliefsBeliefs – defenders of Democracy – defenders of Democracy• Value systemsValue systems – leave no one behind – leave no one behind• Norms & rulesNorms & rules – formal & informal conduct – formal & informal conduct• Material productsMaterial products – weapons systems – weapons systems

Associated with a social system & unique to a given Associated with a social system & unique to a given system.system.

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Language Barriers for CiviliansLanguage Barriers for Civilians

MOSMOS BNOCBNOC NTCNTC PCSPCS DCUDCU AWOLAWOL LTCLTC NCONCO BAHBAH ETSETS FOBFOB

Type of UniformType of Uniform Preparation Encampment Preparation Encampment Desert Warfare TrainingDesert Warfare Training MovingMoving SergeantSergeant Staff Sergeant’s SchoolStaff Sergeant’s School Rent MoneyRent Money Leaving Without PermissionLeaving Without Permission Leiutenant ColonelLeiutenant Colonel Job in the MilitaryJob in the Military Separation from ServiceSeparation from Service

Military Cultural Influences on Society

Military systems and its participants have influenced our society at-large in various ways – politics, business, etc.

Language – “snafu”, “whole 9 yards”, “son of a gun”, “dressed to the 9’s”, etc.

Behaviors – smoking cigarettes becomes fashionable for males after WWI b/c common in rations.

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A Warrior CasteA Warrior Caste

Military is a Military is a castecaste system into which marines, soldiers, system into which marines, soldiers, sailors, & airmen are reborn as recruits via basic training sailors, & airmen are reborn as recruits via basic training & re-socialized into specific roles within the military & re-socialized into specific roles within the military system.system.

Total institutions where many aspects of life are dictated Total institutions where many aspects of life are dictated and contrived via rules & regs.and contrived via rules & regs.

Then they are ritualistically baptized by combat & set Then they are ritualistically baptized by combat & set apart from the rest of society for remainder of their lives apart from the rest of society for remainder of their lives due to these extraordinary experiences.due to these extraordinary experiences.

A “warrior” from that point in time onward.A “warrior” from that point in time onward.

Creeds and Mottos of Military

USMC Rifleman’s Creed

This is my rifle. There are many like it, but this one is mine. It is my life. I must master it as I master my life. Without me, my rifle is useless. Without my rifle, I am useless. I must fire my rifle true…Before God I swear this creed. My rifle and I are the defenders of my country…and there is no enemy.

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Military Families As Embedded SystemsMilitary Families As Embedded Systems

National DefenseSystem

Local Community

Military Installation

Service Unit/Support

Military Family

Service Member

Understanding How Military Families Influence (and Are Influenced by) Multiple Systems Is A Must for Practitioners Working With this Clientele

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Military Family Life Cycle

-Courting

-Pregnant

-Marriage

Deploy Mid-tour

leave

New family begins in absentia

Parental adj & young

children

Transitions are often marked by crisis points in the family life cycle.

Return & Reunion

Resume normal

routines

<Missed 1st year of marriage>

Re-deploy

<May be 1st deployment for both partners>

Family w/ school agers

Return & ReunionRelocation

Families w/ teens & possibly

steps

ETS or Retire

<Divorce & remarriages w/ kids for previous relationships are common – complex stepfamily>

A Dynamic Family Systems Model for

Understanding Military Family Problems

Emerging Features

(Symptoms)

Changing External

Environment

“Therapy”

Changing External

Environment

“Withdrawal”

Changing External

Environment

“Misbehavior”

Changing External

Environment

“Re-deployment”Complex Adaptive Behaviors

Info In

Info In

Info Out

Info Out

(+) feedback

(-) feedback

Reactive Relational Dynamics

Amplifying Dampening

e.g. “secrets”e.g. “cut-offs”

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Basic Emotional Triangulation between Military Families and the Military System

military

service member

spouse

children

Uninjured or unimpaired, but with familial problems.

Physically injured seen with familial problems.

Psychologically injured with familial problems.

Physical & psychological injuries impacting families.

Returning Warriors: Your Practice

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Part II

Ethical Understanding of Treatment Options & Interventions

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Veterans And Families Under Fire

A Systemic Orientation

Family Structure Boundaries Family Roles & Rules Triangles Birth Order Ecosystems

Family Development Lifespan Development Resilience & Vulnerability Crisis in Families Belief Systems

Family Process Emotional Regression Differentiation &

Separation Multigenerational

Influences Paradoxical Situations Family Secrets Family Rituals Sibling Relationships

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Assessing Problems & Systems Treatment – Part I

History taking Clinical interview Life span stage Scales & indices Genograms Mindset during

assessment: willing to include military service in history taking.

Multiple life cycle phases experienced simultaneously & may conflict w/ phase progression.

Disruptions frequently erupt in a crisis state & must be managed by therapist.

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Assessing Problems & Systems Treatment – Part II

Genogramming Complexity!!! Unit members may be

2nd order family. Time consuming b/c of

complexity Helpful for teasing out

systemic issues related to step-family, FOO, etc.

m. 99 – d. 03m. 04

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Assessing Problems & Systems Treatment – Part III

Ecomapping is a graphical representation showing all of the systems at play in an individual's life

Sometimes more helpful to focus on extra-family connections

Helps understand stressors stemming from embedded nature of families

Son (5)Mom

Dad Step-son (8)

ScoutsUnit

Church

Systems Oriented Therapy

Should not view the family problems as simply vet’s readjustment issues (context)

Family problems may have existed prior to ETS or last deployment (history)

Presenting px should be viewed within larger focus of recent service (events)

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Systems-Based Diagnosis of Common Operational Maladies

Traumatic Brain Injury Combat Stress Injury Post Traumatic Stress Disorder Generalized Anxiety Disorder Panic Disorder Depressive Disorders

TBI & CSI in a Systemic Context

Traumatic Brain Injury Ranges from mild to

severe – concussions to major intracranial trauma

Concussive episodes – IED, RPG, etc.

Sx include: of memory loss, poor concentration, sleep px, body aches, pain, high BP, fatigue

R/O b/w mTBI & PTSD

Combat Stress Injury Exposure to deployment

related stressors & operations

Physical, emotional & cognitive impact

Sx may morph into major clinical syndrome

Combat Exposure Scale is valid & reliable for assessment of CSI

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PTSD & CSI PTSD: three symptom sets

Hyperarousal – startles easily & hyper-vigilance Intrusions – flashbacks & nightmares (terrors) Constriction of affect – numbing or dissociation

Combat Stress Injury: Physical hardships >noise, blasts, dirty, malnourished Cognitive > +/- information, mission ambiguity, lack of

contextualizing Emotional > fear of injury or death of comrades, shame/guilt,

helplessness, killing Social > social support vs. privacy issues; public opinion Spiritual > forgiving; self-forgiveness; loss of faith

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Systemic Considerations in Stress Disorders

Allostasis vs. homeostasis – equilibrium restored by shifting set point - w/ allostasis the fulcrum is moved in a particular direction disallowing the return to previous functioning

Neurotransmitter-receptor hypothesis – changes due to stress & predispositions may be irreversible due to depletion of NE & 5-H serotonin in the CNS

New modalities for treating stress disorders are emerging or improvement in existing methods in response to more severe & tx resistant disorders

Family Empowerment Therapy:Five Phase Model

Beginning & Exploration of Problems Framing Problems & Balancing Ind

Needs: Optimizing Therapy Environs Retelling of Events: PTSD & STS

related Reframing, Altering Structure, & Healing

Narrative Closure & Follow-up (p. 198-203 FUF)

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Injury-Extent of Injury-Limitations

Φ – physicalaspects

Ψ – emotional impact

Soldier

Spouse

Children

CoupleRelational Dynamic

Parent-ChildRelational Dynamic

Parent-ChildRelational Dynamic

Parent-Child Disability Dynamic-reduced interaction-estrangement-negative reactions (stage dependent)-# of children

Spousal Disability Dynamic-reduced intimacy-disengagement-poor communication

Secondary Disability Dynamic

-Δ in communication-w/h negative info?-parentified child?

The entire family dynamic changes from this point forward in time as the family attempts to accommodate the injury and adapts to new situations as they arise.Physical rehab & psychotherapy must balance emotional and physical aspects of injury with family support, while maintaining focus on the value of the family as a healing environment and attending to family member’s emotional needs to that end – all must heal together.

Key:Solid – represent overt interactional patternDashed - represent covert interactional pattern

The Healing Journey- accounts for changes & transitions in family dynamics across time, situations, & stages of life (ETS, PCS, etc.)

A Paradigm for Understanding Post-War Healing Within Veteran Families

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PTSD & Secondary Trauma: Case Illustration – Sgt. Love

37 42 46

10 22 7

m. 96 – d. 2002m. 2006

-PTSD

-Affair

-ETOH Abuse

1) Lived parallel lives since Afghan Deployment. 2) Lost Battle Buddy in IED blast – injured himself. 3) Working as a foreman at a metal fabricator. 4) Difficulty talking to one another.

-Depression

-Secondary stress

-Withdrawal

-Presenting problem?

- Diagnosis?

- Treatment plan?

- Strengths?

-Referrals?

Genogram circa 2011

Ethical Issues Associated with Treating Veterans & Families

Must balance needs of family and veteran needs simultaneously

Consultation with other healthcare professionals may be needed

Ethics associated with labeling vets & stigma attached to labels

Working with VA resources & systems can be frustrating for private providers

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Systems Based Supervision & Being a Veteran Friendly Therapist

Veterans And Families Under Fire

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Part III

Supervision Issues

Sometimes difficult to see multiple layers of systems

Orient to family lifespan develop-ment perspective

Differentiate relational diagnoses from individual axes

Help supervisee understand triangle b/w themselves & family

Help integrate systems based knowledge into ongoing treatment

Videotape & audiotape in place of live supervision

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Levels of Systemic Supervision

1. Learning basics of systems theory & concepts within military scope

2. Integrating systemic theory in light of interactions with military families & organizing of formal assessment

3. Integrating assessment into an informed selection of effective clinical intervention

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Goals for Systemic Supervision With Vet Friendly Therapists

Deepen understanding of family process & theory as applied to vet families

Increase sensitivity to dynamic processes & recognize in systems of vet families

Help with systemic assessments, formulations of treatment goals, & selection of interventions

Help to step back and learn from successes & failures, while instilling confidence to try new & creative approaches

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Veteran Family Friendly Therapist

Tricare/Value Options paneled; others are BCBS, UBHS, Magellan

Partner with VA to provide ongoing services that they don’t provide, specialty groups, family therapy, spousal support, etc.

MFT & LPC are eligible for jobs in the Dept of Defense and the VA

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References in Brief Beder, J. (Ed.) (2012) Advances in Social Work Practice

with Military Families. Routledge. Everson, R. & C. Figley (Eds.) (2011) Families Under Fire.

Routledge. Figley, C. & W. Nash (Eds.) (2007) Combat Stress Injury.

Routledge. Hall, L. (2008) Counseling Military Families. Routledge. Hoge, C. W. (2010) Once A Warrior… Guilford. Lee, R. & C. Everett. (2004). The Integrative Family

Therapy Supervisor. Routledge.

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