Military Culture & Treatment - 101 AAPC – SE Region Kanuga Conference Date 10/24/2009

1. Military Culture & Treatment - 101AAPC – SE Region Kanuga ConferenceDate 10/24/2009 workshop to overview the culture of military families, effective treatments, and sources of support Peter McCall petemccall1@gmail.com 770-329-6156

2. Presentation Goals • There are 3 goals of this presentation: • Review the CareForTheTroops organization and understand the issues that drove the plan for the non-profit organization CareForTheTroops • Review at a high-level some of the “military culture” issues that may help in counseling military family members • Review the problems and issues faced by veterans and their families and clinical treatment issues for those who are serving and have served during periods of conflict.

3. MILITARY OATH OF ENLISTMENTrecited by all Service Members at their swearing in ceremony I, (NAME) DO SOLEMNLY SWEAR…THATI WILL SUPPORT AND DEFEND THE CONSTITUTION OF THE UNITED STATES… AGAINST ALL ENEMIES, FOREIGN AND DOMESTIC;… THAT I WILL BEAR TRUE FAITH AND ALLEGIANCE TO THE SAME;… AND THAT I WILL OBEY THE ORDERS OF THE PRESIDENT OF THE UNITED STATES… AND THE ORDERS OF THE OFFICERS APPOINTED OVER ME,… ACCORDING TO REGULATIONS AND THE UNIFORM CODE OF MILITARY JUSTICE,… SO HELP ME GOD. NOTE: 3 dots … = represents a repetition break Speaking these words has far more emotional power than these words on paper could ever convey. Anyone who has done this for real knows, in that moment, that they are agreeing to defend a principle with their very lives. It is a moment they never forget.

4. CareForTheTroops, Inc. • Who Are We – ‘Big Picture’ • CareForTheTroops is working to help the military and their extended family members receive mental health services and support from within the civilian elements of our society in the State of Georgia. • CareForTheTroops is attempting to equip the civilian support services of society e.g. pastoral counselors and congregation leadership teams, with the capacities to be helpful. • We are working toward “building a better net” to catch those that need help before they fall too far and reach moments of desperation.

5. Organization 501c3 status has already been approved by the IRS Current Board of Directors: President Rev Robert Certain, Rector, Episcopal Church of St Peter and St Paul (USAF) Exec Director Peter McCall (USArmy) Member Bill Harrison, Partner, Mozley, Finlayson & Loggins LLP (USAF) Member William Matson, Exec Director, Pathways Community Network, Atlanta, GA Member Alan Baroody, Exec Director, Fraser Counseling Center, Hinesville, GA Member Joseph Krygiel, CEO of Catholic Charities, Archdiocese of Atlanta (US Navy) Current Partners: The Georgia Association for Marriage and Family Therapy (GAMFT) The EMDR Network of Clinicians in Georgia Pathways Community Network, Inc Fraser Counseling Center, Hinesville, Georgia (nearby Fort Stewart) Episcopal Diocese of Atlanta Presbytery of Atlanta and the Presbyterian Women of Atlanta Catholic Charities and the Archdiocese of Atlanta

6. Causes for Concern Multiple deployments are common causing stress and family attachment issues An April ‘08 Rand Study reported 37% have either PTSD, TBI, or significant Mental Stress (5% all 3). Some estimate >50% return with some form of mental distress Suicide, alcoholism, domestic abuse and violent crimes rates are rising. Suicide is 33% higher in ‘07 over ’06, 50% higher in ‘08, and almost equal to ‘08 by May of ’09 Military Sexual Trauma (MST) is running at 16%-23% In 2008, military children and teens sought outpatient mental health care 2 million times, a 20% increase from ‘08 and double from the start of the Iraq war (‘03) DoD and VA facilities are stretched … the Aug 2009 VA claims backlog is 900,000 Many more Reservists & Guard than previous wars (54% as of mid ‘08) and they and families are more distant from DoD and VA support facilities Other mental health, marriage, and family problems often occur with or leading up to PTSD requiring attention so they don’t get worse Rand Study estimates that PTSD and depression among service members will cost the nation up to $6.2 billion in the two years after deployment. The study concludes that investing in proper treatment would actually save $2 billion within two years

7. Mission of CareForTheTroops.org • Work to improve the ability of the civilian mental health infrastructure in the State of Georgia, then nationally, to work with military family members • Facilitate connecting military families to providers of spiritual and psychological services familiar with the military culture and trauma • Focus on addressing combat stress recovery as well as other spiritual and mental health related problems impacting the marriages and families of military veterans • Educate and train clinicians, congregation and community leaders, extended family, and civilian groups about the military culture and trauma associated with military deployments in order to better assess and treat mental health symptoms, and provide more effective referrals and care • Provide opportunities for additional trauma treatment training to clinicians • Operate in an interfaith, non-political manner, focusing on the humanitarian interest that benefits the veterans and their extended family members

8. Approach Affected Systems Extended Family Members Person in need of support Children Church Employers Spouse Parents Military Member Siblings Grandparents Community

9. ISSUE RESPONSE RAND study says over 33% of returning military have some form of mental distress CareForTheTroops Operations Overview CFTT will improve the overall mental health infrastructure to better support military families ISSUE ISSUE ISSUE ISSUE ISSUE How can families know where trained support is available How do we expect to overcome the stigma of mental health help Private Sector MH providers have limited military experience How can CFTT assure that word of mouth spread all over the GA How to help referral sources know better when & where to refer RESPONSE Use congregations to create a grassroots info distribution channel RESPONSE RESPONSE RESPONSE Target info for friends & family “surrounding” the military member CFTT website shows info usable by therapists & referrals CFTT website lists therapists trained in the military culture RESPONSE CFTT will provide training opportunities, including remote areas ISSUE 54% of those deployed are R/NG. GA is 6th largest R/NG RESPONSE Improve support even in remote areas of the state

10. The next set of charts provide a simulation of using the www.CareForTheTroops.org website with pastoral counselors in mind

11. This is the top of the Home Page

12. This is the bottom of the Home Page Highlights, New Items And Reports

13. Back to the top of the Home Page

14. Home Page The drop-down menu for Mental Health Professional is opened up. In this case, selecting the Enroll with CFTT page Note the other options available

15. Top of the Enrollment Page The info asked is completely voluntary. We do not ask you to volunteer time and any financial info is left between you and the client. We are looking for people with background, training, and experience.

16. Home Page The menu for Congregation Leaders is opened up. In this case, selecting the About Congregation Programs page

17. Top of the About Congregation Programs Page Click on the picture and this presentation is available

18. Moving down the same page gets you to the Guide Book info we have introduced in this presentation. It also shows the TOC and the Intro Letter in the document Clicking on the picture of the book will let you download it.

19. Military Ministry Programs

20. Back to the top of the Home Page A key piece of the web site is the Resource Library with the 4 selections shown. This material is updated periodically. The reference material is weekly.

21. Home Page Another key section is the gathered in the “Stuff” You Should Know Section. Our goal here is to provide plenty of info on these topics and also refer you to the top 3-5 sites on these topics.

22. Home Page Finally, an important aspect of our mission is to connect you to others that can help. The Find a Therapist menu item discusses how one might choose a therapist and then allows you to search many ways.

23. This shows the first 4 search results for Fulton County in the database. This is intended for use by congregation sources, clinicians, and people in need searching for a therapist who wants to work with military families.

24. Training is key. This shows the training events we are aware of. Both from CFTT and from other organizations. Please visit it periodically and also let us know of training you hear about to share with others.

25. Back to the top of the Home Page

26. EMDR TRAINING Weekend 1 (Part I) January 15-17, 2010 Athens, Georgia Weekend 2 (Part II) - TBA • The EMDR HAP (Humanitarian Assistance Program) Training organization (www.emdrhap.org ) will conduct Weekend 1 (Part I) training Friday through Sunday, Jan 15th to 17th in Athens, Georgia. The training facilities used in Athens are at Milledge Avenue Baptist Church, 598 South Milledge Avenue, Athens, GA 30605. • Weekend 2 (Part II) training will be scheduled 3-6 months later with details TBA. • This training is jointly sponsored by the The Samaritan Counseling Center of Northeast Georgia (www.samaritannega.org ), GAMFT-The Georgia Association for Marriage and Family Therapy (www.gamft.org ), and The CareForTheTroops, Inc. non-profit organization (www.CareForTheTroops.org ). • AUDIENCE: This training is for licensed (and some licensable) counselors working in a non-profit environment. Specific details are available at the following web location: www.emdrhap.org/training/ . • COST: $350 for each weekend. Lodging and meals are the responsibility of the participant. • SCHOLARSHIPS: A limited number are available to cover the full HAP Fee for Weekend 2 (Part II) for those that meet the criteria below. So please apply early if one is needed. • ENROLLMENT: • TRAINING: Enroll for the HAP Part I training is done on-line through the HAP website: www.emdrhap.org/training/toregister/listEvents.php. Look for this events’ description on the web page. • SCHOLARSHIPS: Apply for the CareForTheTroops scholarship at www.careforthetroops.org/emdrevent.php . Download the Application Document, complete and email or mail it to the address shown on the document. • Additional information about this weekend such as schedule, lodging, restaurants, etc. can be found at the following web location: www.CareForTheTroops.org/emdrevent.php . HAP Participant Requirements EMDR PART I AND PART II are available for licensed mental health clinicians at the masters degree level or above, or for masters level clinicians on a licensure track, with permission of their licensed clinical supervisor. In keeping with its mission, HAP normally trains only clinicians working 30 or more hours per week in community based, non-profit settings. Exceptions have been made for private practice clinicians who have made a substantial commitment to pro bono service in the community. CareForTheTroops(CFTT) Scholarship Criteria It is the intent of CFTT to incent attendance of both EMDR Training Weekends (Part I and Part II) in order to increase the number of fully qualified EMDR Therapists to treat trauma in Georgia. Participants must: Practice in Georgia Attend and successfully complete both Part I and Part II EMDR training by HAP Enroll in the CareForTheTroops Therapist Database at the completion of Weekend 1 and stay enrolled at least 2 years. More Info about this is available at www.careforthetroops.org/clinician_cftt_enroll.php Be willing to work with military clients and their extended family members Pay the HAP Training Fee for Part I. CareForTheTroops will pay the HAP Training Fee for Part II which means you must attend a Part II by HAP Attend and complete Part II within 12 months of completing Part I Be responsible for all other costs, fees, and expenses associated with the training weekends.

27. Chapter WorkshopsMilitary Culture 101-Clinical Treatment Issues NOTE: Check with your local GAMFT Chapter and also with the www.CareForTheTroops.org web site for changes and updates.

28. Final Comments Ref CareForTheTroops • Help For You • Use the web site as a resource • Information and reference material • Training • Referrals • Use you involvement with CFTT to help market your practice and or help your congregations • Help for Us • Enroll in the CFTT database if you qualify • Publicize CFTT to community and congregations • Would you consider being a Trainer using material similar to what you see today?

29. The next charts information about the military culture

30. Military Culture Sociologists define culture as … • Language - nomenclature; acronyms, abbr. • Beliefs – defenders of Democracy • Value Systems – leave no one behind • Norms & Rules – formal & informal conduct Culture is associated with a social system and unique to a given system.

31. Language Barriers for CiviliansGlossary of Military Terms and AcronymsMilitary Cultural Competence OEF Operation Enduring Freedom – it is a multinational military operation aimed at dismantling terrorist groups, mostly in Afghanistan. It officially commenced on Oct. 7, 2001 in response to the September 11th terrorist attacks. OIF Operation Iraqi Freedom - also known as the Iraq War; began on 3/20/2003. USAR United States Army Reserve USANG United States Army National Guard E1-E9; O1-O10 Enlisted Ranks; Officer Ranks SPC Specialist, rank of E4, often referred to a “Spec 4” First SGT First Sergeant, rank of E7, lead enlisted person in a company. It and SSG, Staff Sergeant are key leadership ranks with lots of job pressures NCO Non-Commissioned Officer, ranks E6 through E9 IEDs Improvised Explosive Devices Sandbox Iraq and Afghanistan Down Range Deployed to anyplace where there is shooting. Outside the Wire Leave the safety of the “enclosed” military base (FOB) Taking the Pack Off Leaving mentally and physically from combat Top Cover Making sure the boss looks good www.rivervet.com/oif_glossary.htm

32. Military CultureBelief and Value Systems; Norms and Rules • Beliefs: Defenders of Democracy Trust in the leadership Role clarity Distrust of civilians • Value Systems: Leave no one behind “The Group” practically becomes a ‘family system’ Top Cover-defend and support the boss Violence :many have a history of violence which often plays a role • Norms & Rules: Formal and informal conduct Stigma of mental health and PTSD Cover of the boss (Top Cover) Back-logging trauma

33. Reserve and National Guard Units vs Regular Army Reserve / Guard Regular • Units are small & based in local communities. • Part-time soldiers, often working with local police, fire, and EMS. • Families may be left in a town with little or no support services. • Mostly support units in Georgia (transport, MP, etc) • Likely to work within local communities • Can’t relocate easily when activated • Lack of military related health services - PCP not Tricare approved • Make use of family or local supports (church, etc.) • Units are based at major military installations. • Full-time soldiers who expect to be deployed . • Families are left at their post where a variety of support is in place both on-post & in communities. • Are part of a larger fighting force including 1/5 combat units. • Live on-post or nearby; other family support • Less need to relocate when deployed • Access to a variety of health, welfare, & educational services • Support groups in-place through soldier’s unit

34. The next few charts provide some background of this war that might help you better understand your client or congregation member and their presenting story and issues

35. Why is this war different? • Volunteer vs. draft • Multiple deployments • Type of suicide bombings • Never any safety, no real recovery time • Use of civilians as shields and decoys by the enemy • Deliberately targeting our moral code • COMMUNICATION! Internet, cell phones, etc. • IEDs, RPGs (TBI, hearing loss, neuro-chemical effects) • Advancement in medical treatments

36. OIF/OEF - Statistics • As of 12/1/2008 • 1.7M troops deployed • 4207 US Military killed in Iraq (excludes civilians) • 627 US Military killed in Afghanistan (excludes civilians) • 65,000+ US Military wounded • 54% deployed are Reserve / Guard (4/08) • 1% of US population is directly touched by military service; more if you consider civilian contractors • Deployed as of 09/2009:~ 130K troops in Iraq~ 160K civilian contractors in Iraq~ 65K troops in Afghanistan (more are being sought as of Oct 2009)

37. OIF/OEF - Profile • All-Volunteer military • Many did not expect deployment(reminder: GA is 6th largest NG state) • Multiple deployments is the norm • 2008 Rand Study indicates: • 53% of those that need treatment sought Mental Health treatment in ‘08 • 16-23% have experienced MSTMST = Military Sexual Trauma • 2yr post-deployment cost $6.2B • OIF vs OEF – VA indicates a OIF vet is 2x likely to seek help than a OEF vet • As of 04/08, 120K mental health dx’s, 50% were diagnosed w PTSD • “Homecoming Concept” = alienation, detachment, isolation, avoidance, boredom

38. OIF/OEF - More Statistics • 15 wounded for every 1 fatality (Vietnam was 3 for 1) • VA predicts that it will treat 263,000 OIF/OEF vets in 2008 and 330,000 in 2009 • Current backlog of veterans is 400,000 (as of 2008) • Claims backlog is over 900,000 (as of Aug 2009) • Heaviest of that backlog is mental health (Ex: Virginia VA community mental health services has a waiting list of 5,700 as of early 2008) • 550,000 school age children of active duty Service Members (Reg/Res/NG) • 52,000 children of Reserve and National Guard Service Members affected • 84% of Regular Military Service Members’ children attend public school, not DoD base schools • Georgia has over 750K veterans

39. OIF/OEF – and some more Statistics According to a new American Journal of Public Health study on veterans' mental health diagnoses • Of the 289,328 veterans who entered VA care in 2008, nearly 37% had mental health problems, including post traumatic stress disorder (about 22%) and depression (roughly 17%). (ref: http://www.ajph.org/cgi/content/abstract/AJPH.2008.150284v1 ) • "Weekend warriors" over 30 years old in the national guard and reserves who left stable family, work and community environments for combat zones were especially susceptible to mental health problems. A recent (July, 2009) US government accountability office report found that nearly 20% of women veterans suffer from PTSD (ref: http://www.gao.gov/new.items/d09899t.pdf )

40. OEF / OIF Experience - Summary • Indirect threats – not so much direct assaults and attacks • IEDs, car bombs • RPG, snipers • Suicide bombings • Powerlessness • threat is indiscriminate • not dependent upon skill or mastery • relationship between loss of control and PTSD • This generation’s war • 1st Internet War (Vietnam was the TV War) • Blogs, email, cell phone (cameras) 24 hr new sites • New versions of the “Dear John/Jane” letter • Home trouble as a leading stressor (financial, intimate partner) • Reservists/Guard: repeated, unpredictable separations from family/job

41. The next several charts will cover life within the military family and clinical treatment considerations

42. Family readjusts - Consequences for behavior The Military Deployment Cycle … or The Military Family Life Cycle Pre-deployment Conflict & Previous Stressor pile-up Revitalize Relationships and “honeymoon” Pre-deployment Stress – anxiety and concern Reunion and homecoming – joy and anticipation Soldier Deployment Pre-reunion Stress – anxiety and worry about behavior away Separation Stress – Depression & Anxiety Family Adjustment w/o Soldier in Home – Out-of-Ordinary Behaviors

43. Military Family At-Risk Factors Frequent Relocation 3.3 years average Previous Deployments 87% Longer Separations 7.3 month average Larger Families 42% ≥ 3 children Younger Mothers 26.5 median age Blended Families 31% step-parents Education 21% w/o HS diploma Working Outside Home 44% Median Income < $30,000 (34%)

44. Separation • Resulting from deployments, relocation, or training – range from a few to many months – disrupts life cycle transitions. • Emotional ambiguity stemming from physical loss, but expect maintenance of closeness. • Child & family ties/problems within the larger community. • Heightening difficulties are the threat of death or injury of service member.

45. Reunification • Stressful because of adjustment required – family functioning may have been enhanced in absentia. • Presence of service member alters household rule, role, time, & routine structure. • Expect to return to normal functioning after long term separation ~ what is normal? • Reckoning for misdeeds during service member’s absence (school failure, affairs, etc.)

46. Relocation • Families in the military (U.S. Army in particular) relocate every three to five years. • Inconsistency of services b/w the installations (schools @ Ft. Hood vs. Ft. Stewart). • Requires readjustment for family members who may lag behind service member both physically & emotionally

47. Deployment Related Stressors for Spouses Warner CH, Appenzeller GN, Warner CM, Grieger T. “Psychological Effects of Deployments on Military Families” Psychiatric Annals 2009; 14: 56-62.

48. …a closing thought on the Military Culture “The capacity of Soldiers for absorbing punishment and enduring privations is almost inexhaustible so long as they believe they are getting a square deal, that their commanders are looking out for them, and that their own accomplishments are understood and appreciated.” GENERAL Dwight Eisenhower, 1944

49. Demographics - AGE Enlisted Officers

50. Demographics - Young Adults in the Military • 46.6% of all service members are <= 25 yrs old • 53% of enlisted members are <= 25 yrs old • 24.8% reported binge drinking >1x per week in the past 30 days vs 17.4% for same-age civilians • Higher smoking rates (40% vs. 35.4%) than same-age civilians • Illicit drug use in the military was 5% in 2005, but nonmedical use of painkillers is the most common form of drug abuse. Source: Military Family Research Institute at Purdue University.(2005). 2005 demographics report. Arlington, VA: Office of the Deputy Under Secretary of Defense, Military Community and Family Policy. Retrieved January 7, 2009, from www.cfs.purdue.edu/mfri/pages/military/2005_Demographics_Report.pdf