Challenges in War and At Home

1. Challenges in War and At Home Steve Scruggs, Psy.D. OEF/OIF Readjustment Program Team Leader Oklahoma City VA Medical Center Volunteer Clinical Assistant Professor, OUHSC

2. Overview • Military culture • The making of a Warrior • Realities of combat • Readjustment problems • Successful transition

3. What Is Cultural Competency? • Cultural and linguistic competence is a set of congruent behaviors, attitudes, and policies that come together in a system, agency, or among professionals that enables effective work in cross-cultural situations. US Dept of Health and Human Services, Office of Minority Health

4. Culture/Competence • Culture refers to integrated patterns of human behavior that include the language, thoughts, communications, actions, customs, beliefs, values, and institutions of racial, ethnic, religious, or social groups. • Competence implies having the capacity to function effectively as an individual and an organization within the context of the cultural beliefs, behaviors, and needs presented by consumers and their communities. (Adapted from Cross, 1989).

5. What does military culture value? • Obedience • Discipline • Structure (including hierarchy) • Toughness (mental and physical) • Training/Following SOPs (standard operating procedures) • Completing the mission regardless of hardships • Up or out

6. Why do people join? Idealistic I want to serve my country. I want to defend America. I want to lead people in battle. I want to be the best I can be. I want to test myself. Practical I’m not ready for college-don’t know. what I want to do. I want college money. I want to learn a skill. I was homeless and had no where to go. I thought it would help me shape up.

7. Enlisted/Officer 85% • E-1-3 Worker • E-4 Journeyman • Non-Commissioned Officers (NCO) • E-5-6 Mid Level • E-7-8 Senior NCO • E-9 Top 1% 15% • O-1-2 Platoon • O-3 Company • O-4-5 Mid level • O-6+ Senior leader Warrant Officers 1-4

8. Preparation for war • Intention exposure to stress, in a gradual, planned way • High expectations/commitment required • Training to promote “muscle memory” • Expectation is “You are going to war" • The mission is worth risking your life for…

9. The Role of Aggression • When faced with a threat (fight/flight) • FIGHT! • Starts the first day of basic training • Used by role models (Drill Instructors, leaders) • Used to “motivate” troops • Learn to either shut up and do what you are told or get in someone’s face • Go immediately to aggression if any “push back”

10. The Development of a Warrior • Basic training • Military Occupation Specialty (MOS) training (AIT, Tech School) • Assignment to a unit • Learning the job in the “real” military • Pre-deployment training, with increased work hours and higher expectations • Deployment

11. Realities of Combat • Long hours • Constant vigilance (no battle lines to get behind) • The enemy intentionally seeks to disrupt (mortars at night, during chow) • Mission may be unclear (occupying force) • Ambiguous situations are common (friend or foe?) • Rules of Engagement (ROEs) may change arbitrarily

12. A Soldier’s Perspective • Constantly guarded, watchful and alert • Wired and tired • Increasingly gruff, impatient • Strong ties, strong dislikes • Worry about home or emotional distancing • Emotional numbing • Do your job no matter what happens • “Shut up and drive on…”

13. Realities of Combat • When a traumatic event occurs, the mission is still the priority • Processing emotions related to traumatic events is often delayed or avoided • Numbing of emotions is adaptive (short term) • Distancing from others is adaptive (short term)

14. A Soldier’s Perspective… • Often, there is a disillusionment of: • Experience • Military organization/Leadership • Self

15. Change in Outlook • Changes are life saving • Changes become “the new normal” • Changes may be celebrated • I need this to be safe • Civilians are unprepared, stupid, naïve • Reinforcing information is paid attention to or even sought out (news of drive by shooting, home invasions, robberies, mass shootings, etc.)

16. Return/Reunion • Honeymoon phase • Disappointment due to problems or unmet expectations • Others expect the soldier to quickly return to “normal” • Frustration builds • Expression of anger is more intense and not acceptable (like it was in theater of combat)

17. Common Readjustment Issues • Problems getting and staying asleep • Occasional nightmares • Constantly alert and guarded • Uncomfortable in crowded places • More gruff, irritable • More goal oriented (have problems relaxing) • Thinking about combat experiences (even when you don’t want to)

18. Why do sleep problems develop after combat and trauma? (Dr Rob Braese) • Unhealthy or erratic sleep patterns • Night shift, long missions • Reinforcement • Poor sleep is often rewarded (when you are alert and sleep light you feel safer) • Good, sound sleep is often punished (attacks at night often make people feel vulnerable)

19. Why do sleep problems develop after combat and trauma? • New sleep habits • More caffeine, drinking to fall asleep • Physical changes following deployment • Pain and injuries make it hard to sleep   • Mental changes following deployment • Feeling "on edge“ • Have to do a perimeter check if woken

20. Transition Difficulties • Continuously training for war • Routine/Structure • Constant vigilance • Constantly “hitting the gas” • When faced with fight/flight-FIGHT • Little training for peace • No routine, no external structure • Increased perception of threat • No strategies to “hit the brakes” • Reactions scare others

21. Differences with members of National Guard & Reservists • Many have established families and careers (that get disrupted by deployment) • Families do not live on military bases (with support) • Do not have regular contact with fellow soldiers after return (limited support system)

22. Substance AbuseSeal et al. (2011) Drug and Alcohol Dependence • About 1 in 10 had an alcohol use disorder and 1 in 20 had a drug use disorder • Risk Factors: Male sex, age under 25, never-married or divorced status, and greater combat exposure • Almost 3/4 also received a diagnosis of PTSD or depression. • Those with PTSD or depression were about 4x more likely to have a drug or alcohol problem. • Close to those seen in Vietnam Veterans.

23. Family ProblemsSayers, Farrow, Ross & Olsin, 2009Journal of Clinical Psychiatry • 40.7% feeling like a guest in their house • 25.0% children are not warm toward them or are afraid of them • 37.2% not sure of their family role Among separated partners • 53.7% shouting, pushing or shoving • 27.6% partner is afraid of them N=199

24. Military Mindset/Academic Mindset • Functional • Practical-Get er’ Done • Subject Expert • Minimize Debate • Overcome Obstacles • Accomplish the Mission • Abstract • Thoughts and Ideas • Everyone’s opinion • Invite Discussion • Discussion Enhances • Embrace the Journey

25. WAR ZONE SKILLS Vigilance/Distrust Chain of command Mission Orientation Act, then think Numb or control emotions Avoid closeness HOME SKILLS Trust Cooperation Juggling Multiple Responsibilities Think, then act Express feelings Create intimacy War Zones Require a Unique Set of Skills & Behaviors James Monroe, Ed.D. Boston VA

26. Stress Injuries Occur When Stress Is Too Intense or Lasts Too LongCAPT W. Nash, USN • Injury • May be more abrupt • A derailment, change in self • Individual loses control • Irreversible (though can heal) • Adaptation • A gradual process • Can be traced over time • Individual remains in control • Reversible

27. COMBAT / OPERATIONAL STRESS TRAUMA FATIGUE GRIEF • An impact injury • Due to events involving terror, horror, or helplessness • A loss injury • Due to the loss of people who are cared about • A wear-and-tear injury • Due to the accumulation of stress over time Three Mechanisms of Stress Injury

28. Operational Stress Injuries Correlate with DSM-IV Diagnoses Prepared by Capt. William Nash, MC, USN HQ, Marine Corps Combat / Operational Stress TRAUMA FATIGUE GRIEF PTSD Depression Anger Anxiety Drugs Alcohol

29. Combat Stress PTSDTypical Reactions Mild/Moderate/Severe to Combat Experiences

30. What Causes PTSD?Risk Factors • Intensity of trauma exposure • Frequency of trauma exposure • Killing • Prior traumatic events • Combat verses Combat Support • Poor Leadership • Lack of support (family, friends, etc.) • Context/Meaning • Transition (military to civilian life) • Avoidance of trauma related thoughts, memories or activities

31. What Causes PTSD?Protective Factors • Training • Experience (Habituation) • Unit cohesion/ leadership • Expectations • Sense of purpose in suffering of self and/or fellow service members • Support on return • Resilience

32. DSM-IV Criteria for Post Traumatic Stress Disorder (PTSD)? • Life threatening situation(s) • Strong psychological reaction, e.g. intense fear, helplessness, or horror • About 2/3 of combat veterans have at least one situation that was very frightening, about 10-20% have PTSD

33. DSM-IV Criteria for PTSD

34. DSM-5 Criteria A • Exposure to actual or threatened death, serious injury or sexual violation. The exposure to actual or threatened death, serious injury or sexual violence in one or more of the ways:

35. DSM-5 Criterion A • Directly experiencing the traumatic event • Witnessing, in person, the event(s) as it occurred to others • Learning that the traumatic event occurred to a close family member or close friend. In cases of actual or threatened death of a family member or friend, the event(s) must have been violent or accidental

36. DSM-5 Criterion A 4. Experiences repeated or extreme exposure to aversive details of the traumatic event(s) (e.g. first responders collecting human remains; police officers repeatedly exposed to details of child abuse) • Note: Criterion 4A does not apply to exposure through electronic media, television, movies, or pictures, unless this exposure is work-related)

37. DSM-5 Criteria for PTSD • Four distinct diagnostic symptom clusters • Re-experiencing • Avoidance • Negative cognitions and mood • Arousal

38. Re-experiencing symptoms • Spontaneous memories of the traumatic event • Recurrent dreams related to it • Flashbacks or other intense or prolonged psychological distress

39. Avoidance Symptoms • Avoidance refers to intentionally pushing out of one’s mind: • Distressing memories • Thoughts • Feelings • Avoiding external reminders of the trauma.

40. Negative Thinking and Mood • Negative cognitions and mood represents myriad feelings: • Persistent and distorted sense of blame of self or others • Estrangement from others • Markedly diminished interest in activities • (Less common) An inability to remember key aspects of the event

41. Arousal Symptoms • Arousal is marked by: • Aggressive, reckless or self-destructive behavior • Sleep disturbances • Hyper-vigilance or related problems. • Both “fight” and “flight” reactions

42. Postconcussion Syndrome (PCS) Insomnia Memory Problems Poor concentration Depression Anxiety Irritability Fatigue Noise/lightintolerance Dizziness Headache PTSD Insomnia Memory problems Poor concentration Depression Anxiety Irritability Re-experiencing Avoidance Emotional numbing Mild TBI - PTSD: Overlapping Symptoms Scholten/Collins

43. Successful Recovery • Overcoming barriers to treatment • Assessing the problem • Normalizing reactions • Engaging in/Completing Treatment • Aftercare, if needed

44. Barriers to treatment • Stigma • Worry about impact on military or civilian career • Worry about being seen as “crazy” or “paranoid” • Finding resources • Negotiating bureaucracies • Getting to treatment (low wage jobs, no paid time off)

45. Assessing the problem • Sometimes well meaning, caring people can push a combat veteran to talk… • Triggers either fear and distance or overexposure and feeling overwhelmed • “I thought talking about it was going to make me feel better, but instead…”

46. Normalizing reactions • You are not crazy • It makes sense to be watchful, guarded and alert (You are not paranoid) • You developed skills to help you adapt to a difficult and dangerous environment • These skills saved your life in war zone, so may seem essential to keep • These skills may not be working so well for you now

47. Engaging in treatment • This is often a big step • Outcome research for substance abuse shows equal improvement whether self referred or “a nudge from the judge” • Matching the person with a treatment that is acceptable to them is key

48. Treatment Options Symptom Management • More acceptable to many veterans • Easy to “try out” • Gives practical, “how to” skills and fast relief (e.g. with meds) • Best approach for limited symptoms (e.g. nightmares) Trauma Focused • Research strongly indicates best choice for improvement (with Evidenced-Based Psychotherapies) • Systematic • Time limited (usually 12-15 sessions)

49. Avoidance and Treatment • Since avoidance is a symptom of PTSD, the person will be tempted to cancel or not show for sessions • Completing treatment is difficult, especially if engaged in trauma focused treatment

50. Free Self Help Treatment Options • Afterdeployment.org • Put together by the Dept of Defense and offers help for sleep, anger, PTSD, family issues, etc. • Maketheconnection.net • Developed by the VA to help veterans connect with other veterans from the same era with similar issues. • Mobile App: PTSD Coach ncptsd.gov