INTRODUCTION: REUNION FOR FAMILIES FOLLOWING DEPLOYMENT

1. COMING HOME: REFUGE OR A NEW COMBAT ZONE?Kathryn Karusaitis Basham, PhD, LICSW June 26, 2008

3. INTRODUCTION: REUNION FOR FAMILIES FOLLOWING DEPLOYMENT LESSONS LEARNED • What are the challenges, stressors and rewards of coming home for soldiers and their families? • How does research inform our understanding of the effects of combat on soldiers and their families?

4. Focus • Effects of deployment on attachments for soldiers, their partners and families? • Protective and risk factors, including gender, race and ethnicity? • Relationship patterns expressed by traumatized couples? • Practice methods that facilitate renewed attachments, improved affect regulation and re-connection.

5. After The Parade

6. RESPONSES OF FAMILIES • Positives Enhanced self esteem Pride and mastery Sense of duty and honor • Return to civilian life: shifts in roles work, reintegration to community • Caregiving

7. RESPONSES OF FAMILIES • Secondary trauma (Stamm, 1999) with PTSD-like symptoms of hyperarousal, avoidance and numbing) • Marital conflict, attachment ruptures and divorce (Jensen et al. 1995; Jordan et al. 1992) • Intimate partner violence (Clark & Messer, 2005; McCarroll et al. 2000) • Parenting issues and attachment adjustments (Samper et al. 2004) • Effects on children (Rosenheck & Fontana, 1998; Marshall et al. 2005)

8. “What’s this they say, Billy, about a new, more virulent strain of teen-ager?”

9. Victim-Victimizer-Bystander Scenario • Central relationship pattern with survivors of trauma (Staub, 1989, 2003; Herman, 1992) • Victim (person who is victimized), the victimizer (offender) and a bystander (who often remains detached) relate in this scenario. • Trauma survivor experiences victimization in the “here and now” AND internalizes the victim-victimizer-bystander relationship template that guides her world view.

10. “I’ll abandon my medium- and shorter range missiles if you abandon yours.”

11. COUNTERTRANSFERENCE TRAPS WITH TRAUMATIZED FAMILIES PASSIVE INDIFFERENCE HELPLESS VICTIMIZATION RESCUER ENACTMENT AGGRESSION REACTION FORMATION

12. RACE, ETHNICITY AND DEPLOYMENT • Lessons learned from Vietnam re. experiences for African American, Hispanic and American Indian veterans (Hoge et al. 2002) • Current demographics for OEF/IEF • New immigrants and non-citizen residents

13. WOMEN AND COMBAT • Wide range of duties with greater exposure to combat (Vogt et al. 2005) • Role adjustment as single mothers and caregivers (Kang, 1995) • Military sexual assault (Goldzweig et al. 2006)

15. MENTAL HEALTH EFFECTS • Acute Stress Response • Post Traumatic Stress Disorder (Seal et al. 2007) • Depression (Fiedler et al. 2002) • Suicide (Toomey et al. 2007) • Panic disorder • Somatic complaints • Substance use disorder (Jordan et al. 1991) • Disability (Physical, Cognitive and Mental Health) • Traumatic brain injury

16. GUIDING PRINCIPLES :CLINICAL SOCIAL WORK PRACTICE • Relationship and connection • Resilience • Empowerment • Cultural responsiveness

18. Role of Psychodynamic Theory • Strengths and vulnerabilities established in childhood that influence experiences of self and relationship with others • Power of unconscious/conscious phenomena • Realm of symbolic meaning • Unique meaning of narrative of individual • Transference/CT

19. ATTACHMENT PATTERNS SECURE ATTACHMENT (i.e. mutual, reciprocal and sustainable relationships) INSECURE ATTACHMENT Dismissing—fears of intimacy, intense self –reliance and aloofness Preoccupied-ambivalence, rage when disappointed and “keeping score” Disorganized/Disoriented-extremes of rigidity and inflexibility, emotional chaos, potential violence

20. TRAUMATIC STRESS RESPONSE AND AFFECT DYSREGULATION • Attachment injuries and affect dysregulation (chronic repetition of traumatic stress response) • “Rage storms” • Interference with mentalization (i.e. a capacity to regulate affect where there is a level of consciousness of the affect within oneself as well as within another person (Fonagy et al. 2002). • Interruption of : attachment (careseeking or proximity seeking) caregiving (offering a safe haven) and exploration (curiosity and initiative)

21. PRACTICE APPROACHES • Individual treatment for veteran -Relationship-based psychodynamic - Cognitive-Behavioral (CBT) • Exposure therapy Cognitive-Behavioral (CBT) Cognitive Processing Treatment (CPT) - EMDR, Somatic Experiencing, neural relaxation • Couple and family therapy -Phase oriented with relationship-base and psychoeducational focus • Group therapy and re-building through community

22. What helps soldiers, families and clinicians? BATTLEMIND SKILLS • Buddies (Social Support) • Adding/subtracting family roles • Taking control • Talking it out • Loyalty and commitment • Emotional balance • Mental health and readiness • Independence • Navigating the Army System • Denial of self (self-sacrifice)

24. RATIONALE FOR COUPLE/FAMILY THERAPY PROMOTE SECURE ATTACHMENTS REDUCE MENTAL HEALTH SYMPTOMATOLOGY MINIMIZE SECONDARY TRAUMATIZATION INCREASE KNOWLEDGE RELATED TO TRAUMA-RELATED EFFECTS RESTORE A SENSE OF RE-CONNECTION AND SOCIALVINDICATION

25. PHASE ORIENTED COUPLE/FAMILY THERAPY PRACTICE • Biopsychosocial Assessment • Phase I: Safety, stabilization and establishing a context for change • Phase II: Reflection of trauma narratives • Phase III: Consolidation of new perspectives, attitudes and behaviors

26. PHASE ONESAFETY, SELF-CARE AND STABILIZATION • Establishing safety • Self-care • physical health • mental health • sleep, nutrition and exercise • substance use, abuse and/or addiction • bio-behavioral behavioral strategies for stress reduction, self-soothing and affect regulation. • Support systems (e.g. spirituality/religion, family, work and community). • Assessment of stability of family