It Takes a Village to Heal Warriors- and It Takes the Warrior to - - PowerPoint PPT Presentation

It Takes a Village to Heal Warriors- and It Takes the Warrior to Teach the Village How

Understanding, Engaging and Providing Services to Our OEF/OIF Veteran Population Sherrill Valdes, LCSW, BCD

Goals and Objectives

• Increase awareness of the military culture and possible

psychiatric, medical, emotional and psychosocial challenges of the returning combat service member.

• Discuss key issues that the service member and their

family may experience during the deployment cycle.

• Raise awareness of the collateral outfall of deployment

and war on the service member, family and community

• Discuss methods of intervention and treatment

modalities that support healing of the service member, family and community.

Military Culture

“To care for him who shall have borne the battle…”

• Abraham Lincoln

• Army Soldier
• Navy Sailor
• Air Force Airman
• Marine Corps Marine
• US Coast Guard Seaman
• Reserves
• National Guard

Service Member Family Demographics

Demographic Variable DoD Active Duty Reserve and Guard (Selected Reserve)

NUMBER OF FAMILY MEMBERS 1,878,092 1,110,803 NUMBER OF SPOUSES 689,344 391,383 % WITH CHILDREN 42.8% 43.2% AVERAGE AGE AT BIRTH OF FIRST CHILD 24.9% 26.6% % OF CHILDREN AGE 0 TO 5 42.3% 42.5% NUMBER OF ADULT DEPENDENTS 10,776 1,848 % SINGLE PARENTS 5.0% 9.3%

Service M Member D Demographics

Demographic Variable DoD Active Duty Reserve and Guard (Selected Reserve)

TOTAL NUMBER 1,370,329 842,510 % WOMEN 16.4% 18.5% % MEN 85.1% 81.5% % MINORITIES 30.7% 25.1% % LOCATED IN US 87.2% 99.0% % 25 YEARS OLD OR YOUNGER 43.1% 34.2% % MARRIED 55.2% 45.9% % DUAL MILITARY MARRIAGES 6.4% 2.6%

Florida Demographics

• According to the US National Census (2012-2013):

There were 1,569,406 veterans residing in Florida and 92,575 of those live in Broward County.

• Florida (59,357) Active Duty members
• Broward County reported the second largest veteran population in

the state and Palm Beach County, the third one. Broward is home to more than 20,000 veterans between the ages of 21 and 44.

• There are many National Guard units in Broward

http:www.miltaryonesource.mil/1203//MOS/Reports/20 12-Demographic-Report.pdf

• Professional Armed Services is a career, not a job
• Operation adheres to a code of ethics
• There is structure, order and ways to behave
• Leadership and team work are essential
• Goal is to complete the mission
• Expect respect
• There is community, brotherhood , trust honesty and connection
• Support system military
• Two families
• Help others
• Don’t see themselves as a hero

Military Culture

Although I feel lost, not understood and do not fit into society, my strengths include:

– Responsibility – Dependability – Trustworthiness – Maturity & Wisdom – Deep Bonding – Warrior Capability – Appreciate Beauty – Core values of integrity, courage and pride. – Team Member – Value life, relationships and nature – Humor – Leadership

Service Mem Member S Str trengt ngths

COMBAT

• “I went to war as a young man and came

home an old man.” Marine , Vietnam

• “I was glad to be alive, I did not care about
• anything. If you kill me it is ok because I’m

already dead.” Navy Seal, Vietnam

• “My eyes have seen too much.”

Marine Sergeant, Iraq

Quotes:

Glob

• bal War on
• n

Terr rrori rism

September 11, 2001

Opera Operation E Enduri nduring F Freedo reedom (OE (OEF)

► Octob ctober 7, 7, 20 2001 01 ► Afg Afgha hani nist stan an

Opera Operation I n Ira raqi qi Freedo reedom (OI (OIF) ► March

ch 20, 20, 2 200 003 ► Iraq aq

Opera Operation n New ew Da Dawn (ON n (OND) D) ► Sep

eptem ember 1 r 1, 2010

Global War on Terrorism

MILITARY LINGO

• GWOT - Global War On Terror
• OEF - Operation Enduring Freedom
• OIF- Operation Iraqi Freedom
• SOP- Standard Operating Procedures
• ROE- Rules of Engagement
• MOS- Military Occupational Specialty
• DD214- Discharge papers
• IED- Improvised Explosive Device

Guard/Reserve

• Suspension of career/business/

education goals

• Employment problems during

and after deployment

• Financial Issues
• Child Care Issues

Active/Guard /Reserve

Active Duty Benefit of the military community Resources Support on base or community for families and service members pre and post deployment

THE EMOTIONAL CYCLE OF DEPLOYMENT

On Ongoi going a and E Evol

• lving S

Str tress essors s th that t Challen enge th ge the e Veter Veteran a and th thei eir Fami mily

• Medical
• Psychiatric
• Relationships
• Employment
• Education
• Financial
• Spiritual
• Legal/Judicial
• Housing
• Citizenship
• Redeployment

Remember the Children

Break the silence

Our most valuable gift is the gift from the heart

Global War on Terrorism Signature Wounds

• 2,000,000 service members have deployed to Iraq or

Afghanistan

• Amputations: 19.6 per month in 2011 vs.16.3 per month

in 2010

• PTSD: Mental health evacuations outpacing medical

evacuations for OIF/OND since 2007

• Traumatic Brain Injury: 647.4 a month in 2011
• Spinal Cord Injuries

• Musculoskeletal

Ailments

• Traumatic Brain

Injury

• Dermatology
• Amputations
• Digestive

Disorders

• Dental Injury
• Audiology &

Speech

Most Common Medical Problems

• Acute Stress Disorder
• Generalized Anxiety

Disorder

• Panic Disorder
• Major Depressive

Disorder

• Post Traumatic Stress

Disorder

• Substance

Abuse/Dependence

• Adjustment Disorder
• Complicated Grief

Most Common Psychiatric Problems

PTSD is a psychiatric disorder that can develop after the direct, personal experiencing or witnessing of a traumatic event, often life threatening to self or others. Essential Cluster of Symptoms:  Persistent Re-experiencing- (e.g. flashbacks, nightmares)  Persistent Avoidance or Numbing  Hyper arousal

Source: American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders dsm-iv-tr fourth edition

Posttraumatic Stress Disorder (PTSD)

Center for Military Health Policy Research

“Since October 2001, approximately 1.64 million U.S. troops have been deployed for Operations Enduring Freedom and Iraqi Freedom (OEF/OIF) in Afghanistan and Iraq. Early evidence suggests that the psychological toll of these deployments—many involving prolonged exposure to combat- related stress over multiple rotations—may be disproportionately high compared with the physical injuries of combat. Unlike the physical wounds of war, these conditions are often invisible to the eye, remaining invisible to other service members, family members, and society in general.”

Most Common OEF/OIF Traumatic Event

Received small arms fire 94% Knew someone injured or killed 86% Saw dead or seriously injured 68% Handled or uncovered remains 51% Shot or directed fire at enemy 77% Responsible for death for noncombat 48%

• Who am I now ?
• Where was God ?
• What is my purpose?

Healing the Wounds of the Heart, Mind, Body and Spirit

“The people that come home (from war) are dying inside day by day. The ones that died (in war) have freedom.”

• US Marine, Iraq

• Profound loss
• Reactive distress to the death
• Social/identity disruption
• Traumatic bereavement
• Differential Diagnosis
• Major depressive disorder
• Major depressive disorder with mixed features
• Bipolar 1 disorder
• Cyclothymic disorder

DSM Conditions for Further Study Complex Bereavement Disorder

What Kept Them Alive Then Keeps Them From Living Now

• Denial
• Anger/ Rage
• Trust Issue
• Isolation/Withdrawal
• Control of Self, Situation and Weapons
• Avoidance of triggers
• Numbing/Detachment
• Alcohol/Drugs

Hyper-arousal symptoms

• Hyper-vigilance
• Startled response
• Decreased sleep
• Perimeter checking
• Persecutory feelings
• Irritability
• Explosive/Labile mood

Re-experiencing of the traumatic event in the form of:

Intrusive thoughts Nightmares Flashbacks Hypnogogic Hallucinations Combat Images Paranoid Ideation or false perception of danger

Behavioral Manifestations to Recognize:

• Need to control

“When I was in Iraq everything was normal and I was in

control…I know what I’m capable of doing…I’m a killing machine…”

• Feeling out of control

“If I loose control I will die and so will my buddies…If I loose

control that means I’m crazy…”

• Maintaining control

“Nothing must change…” Approach/Avoidance Behaviors

Authority figures Significant others Community Government Religion

Trust Issues

Possible Triggers

• Perceived threats (verbal/physical)
• Perceived misuse of power
• Perceived conflict
• Particular smells
• Loud noises
• Fast/hidden movements
• Crowds/confusion
• Alcohol/Drug use
• Telling them to get over it
• Regrets/Guilt

Assessment

Stressors:

• Global War on Terrorism
• Active duty/ reserves, multiple deployments
• Emotional cycle of deployment
• Challenges of the family
• Readjustment issues (crisis, job, etc…)
• Medical and psychiatric concerns
• What is happening to me , who am I now , how

do I put meaning to this

• Profound loss and grief

• Build a therapeutic relationship
• Crisis/Stabilization
• Medication
• Assessment: on-going
• Psycho education
• Support system
• Resources and referrals
• Grief and mourning from profound loss are not

usually the presenting problem

Where to Begin

Assessments Complex Grief/PTSD Treatment

Crisis and Stabilization

Therapist Responsibility

• Assess for safety, weapons, substance abuse
• Assess for immediate needs: physical,

medical, psychiatric, and medication

• Identify strengths, defense mechanisms
• Cultural influences
• Support system
• Collaborate with patient to develop crisis

intervention plan

Antidepressants Mood stabilizers Sleep agents Anti-anxiety agents Antipsychotics

MEDICATIONS

Role of Therapist

• Self-care is on going
• Be willing to explore self issues
• Be vulnerable and have self compassion and

empathy

• Be willing to sit in a place of deep human

connection of pain with some one

• Find a support system
• Self-soothing skills/practices

Self Care: You Are Important

• Sound clinical knowledge
• Comprehensive assessment skills
• Ability to collaborate with patient in treatment planning

process

• Provide treatment in a respectful manner
• Education is on going: Sometimes teacher/sometime

student (empower and give a map for the healing journey)

• Be honest: “Say what you mean and do what you say.”
• Be willing to explore self issues
• Knowledge of grief and mourning and other issues of loss

Requirements of the Therapist

• Relationship begins at first contact
• Connection is primary
• Therapeutic tone gentle and caring
• Listen and witness without judgment
• Vulnerability: sometimes teacher and sometimes

student

• Provide safe and sacred space
• Display dignity and respect for patient
• You are the medicine

Relationship Presence

• Know that in our profession, we plant seeds and do not always know how

the gardens grows

• Our presence for profound loss include: Empathy, compassion, trust, and

non-judgmental attitudes

• Provide a safe environment as the service member addresses internal and

external stressors

• Be open to hear the needs of survivor and family, this role exists in all

uncomplicated and complicated grief

• We must remain in touch with the human experience to be effective and

to realize that we can not prevent pain and we can not make things easy for people

• Little kind deeds and emotional support means a lot
• Be a fellow sojourner, confidant, witness and spiritual companion in issues
• f profound loss, purpose and meaning

Role of Therapist Relationship

• Stabilize situation
• Address presenting problems
• Physical and mental health
• Psychosocial issues
• Relationships
• Internal and external fears
• Grief and mourning
• Identifying treatment modalities
• Participate in treatment
• Self identity
• Empower and provide hope

Treatment Issues

• Beginning treatment and ongoing treatment
• Crisis therapy
• Evidence based therapy
• Psycho-education
• Psychotherapy
• Group therapy
• Grief counseling
• Medication

Treatment Modalities

• A comprehensive assessment is needed for possible diagnosis and

treatment direction of complex cases. This is on-going.

Therapist Responsibility

• Assess for safety, weapons, substance abuse
• Assess for immediate needs: physical, medical psychiatric
• Identify strengths, Defense Mechanisms
• Cultural Influences
• Support System
• Collaborate with Patient to develop Crisis Intervention Plan

Complex Grief/PTSD Treatment Crisis and Stabilization

• Explanation of impact of trauma

– Experience on physical body – Relationships – Psychological functioning – Spirituality

• Understanding and coping with symptoms

– Constricted affect – Hyper arousal – Dissociative states flashbacks – Re-experiencing traumatic events – Avoidance symptoms

• Give map of treatment

Psycho Education

• Evidenced-Based

– Cognitive Behavioral Therapies (CBT)

• Treatment typically includes a number of components

including psycho education, anxiety management, exposure, and cognitive restructuring

• Prolonged Exposure
• Cognitive Processing Therapy

– Eye Movement Desensitization and Reprocessing (EMDR) – Acceptance and Commitment Therapy (ACT)

Overview of Psychotherapy for PTSD (Complicated Grief)

• Other Approaches:

– Group Therapy – Psychodynamic Therapy – Hypnotherapy – Supportive Therapy – Mindfulness – Life Span Integration

Overview of Psychotherapy for PTSD (Complicated Grief)

– Acupuncture – Yoga – Meditation – Reiki – Guided Imagery – Tai Chi

Sherrill Valdes, LCSW, BCD, ACSW Individual and Couples Therapy Conscious Breath Work Life Span Integration Therapy Reiki III Master sherrillvaldes@gmail.com 954-465-5630