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Military Culture & Treatment - 101


Military Culture & Treatment - 101 Ninety minute workshop to overview the culture of the military and its families, issues affecting treatment, and sources of support – PowerPoint PPT presentation

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Title: Military Culture & Treatment - 101

Military Culture Treatment - 101
  • Ninety minute workshop to overview the culture of
    the military and its families, issues affecting
    treatment, and sources of support

Peter McCall, Exec Dir pe 770-329-6156
Introduction and Ground Rules
  • This is not a political forum
  • Questions are encouraged for group discussion
  • Be respectful of others
  • If the discussions, material, or videos at any
    time become too disturbing feel free to leave the
    room till you feel comfortable enough to return

Sources of Materials
  • CareForTheTroops 2009/2010 Military Culture 101
  • The Fraser Counseling Center Staff, Hinesville,
  • Dr Blaine Everson, Clinical Dir, Samaritan
    Counseling Center, Athens, GA
  • Major Chris Warner, Winn Army Community
    Hospital, Fort Stewart , GA
  • Spiritual Wounds of War material
  • Kent D. Drescher, Ph.D., National Center for PTSD
    Menlo Park
  • LTC Peter E. Bauer, MS USAR, LMFT, currently at
    Ft Hood
  • Chaplain Bill Carr, D. Min., LMFT, VA Hospital,
    Atlanta, Ga
  • Alan Baroody, LMFT, Presbyterian Minister, Exec
    Dir Fraser Counseling Center
  • VA Website
  • 2010 AAMFT Annual Conference Workshop 303
  • TriWest Healthcare Alliance Help From Home DVD
  • Care For Returning Vets presentation from the
    ELCA Bureau for Federal Chaplaincies
  • Other citations on charts and handouts

Presentation Goals
  • There are 4 goals of this presentation
  • Understand the basics of themilitary culture and
    veteran issues
  • Review key issues that can impact the mental
    health of a military family
  • Provide an understanding of resources available
    and how CFTT can help
  • Ultimately, build more credibility for working
    with military families

Handout A0 Example
Opening Videos
These three movie trailers provide a good
backdrop to the Veterans Issues we are about to
discuss. Please take notes as a discussion
will be conducted after the next section. The run
time is approximately 8 minutes.
Veteran Issues
  • Multiple deployments are common causing stress
    and family attachment issues.
  • As of Oct 2008, multiple deployment breakdown
    60 1x 36 gt 2x 4 gt 4x
  • Typical Deployment Durations
  • Army and Marine 1 year (Ex Aviation and Spec
    Forces 4-6 months)
  • Navy 6-9 months
  • Air Force 6 months
  • An April 08 Rand Study reported 37 have either
    PTSD, TBI, or significant Mental Stress (5 all
    3). Some estimate gt50 return with some form of
    mental distress
  • Other mental health, marriage, and family
    problems often occur with or leading up to PTSD
    requiring attention so they dont get worse
  • In 2009, 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)
  • 43 of Service Members have children
  • Average number of children per military family is
    1.97 (AAMFT 2010 Annual Conference)
  • 42 rise in childrens visits in 2009 over 2004
    per Tricare
  • 84 of Regular Military Service Members children
    attend public school, not DoD base schools

Veteran Issues (cont.)
  • Suicide, alcoholism, drug abuse, domestic abuse
    and violent crimes rates are rising. In 2010
    military suicides exceeded civilian suicides.
  • Army and Marine have higher suicide rates than
    Navy and Air Force
  • More are occurring Stateside and many go
    unreported for insurance reasons and are
  • Female suicide rate triples when deployed
    (recent NIMH study), though still lower than
    male rate
  • In GA, per the CDC from 2006-2008, 500 suicides
    of people identified as current or former
    military . This represents 19.4 of all suicides
    during those years. The Age breakdown is as
    follows 20-29 8.4 50-59 21.2 30-39 10.8
    60-69 31.8 40-49 16.3 70 55.8
  • 18 vet suicides out of 30 attempts per day 5
    are already being treated by the VA. Women try
    more with less success than men Army Times
  • Illicit drug use in the military was 5 in 2005,
    but now nonmedical use of prescription drugs is
    the most common form of drug abuse. SPICE is
    becoming very common.
  • 24.8 reported binge drinking gt1x per week in the
    past 30 days vs 17.4 for same-age civilians
  • Military Sexual Trauma (MST) is running at
  • Includes harassment and assault
  • Almost as significant among males as among
    females (Newsweek, April 2011)
  • Mostly enlisted personnel under 25 yrs old (DOD
    2010 Annual Report)
  • Single strongest predictor of PTSD in women -
    as combat is for men (Natelson, 8/05/10).
  • 80 of assault victims fail to report the
    offense. (Natelson, 8/05/10)

Handout A1 A2 A3
Veteran Issues (cont.)
  • DoD and VA facilities are stretched the Aug
    2009 VA claims backlog was 900,000 the April
    2010 backlog was improved to 605,000
  • April 2010 back up to 756,000
  • 450,00 claims are taking over 125 days (USA
    Today, Apr 2011)
  • The U.S. Bureau of Labor Statistics reports the
    unemployment rate among post 9/11 veterans as
    15.2 in January 2011, well above the 9.6 percent
    rate for non-veterans.
  • The VA said in Dec 2010 that more than 9,000
    OIF/OEF vets were homeless (UPI) women are the
    fastest growing segment of this population.
  • 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.
    This may be one of the most significant affecting
    the future mental health impact on our
    communities and our society
  • Current numbers are in the 48 range
  • By design, approximately 33 should be Guard and
  • A large number of civilian contractors are also
    part of the deployed forces
  • Rand Study (08) estimates that PTSD and
    depression among service members will cost the
    nation up to 6.2 billion in the two years after
    deployment. Investing in proper treatment would
    actually save 2 billion within two years.

Fraser Center
  • Clients include Veterans, Active Duty Soldiers,
    and Military Dependents
  • Clients primarily from FT Stewart (3rd Infantry
    Division) and Hunter Army Airfield
  • The children of military families are often the
    first to be brought in for therapy secondary
    trauma. Is daddy going to die?
  • The length, number, and frequency of deployments
    decreases family resiliency upon re-deployment
    (returning home from a deployment).
  • The number of engagements outside the wire
    increases the likelihood of Combat Stress
    Symptoms (transient, acute, PTSD).
  • Over time, the constant threat of incoming mortar
    rounds and IED incidents increases likelihood of
    CSS and PTSD for those who remain primarily in
    green zones.
  • The primary concerns of combat troops are
    Mission First, staying safe, keeping their
    buddies safe, getting home, and what is happening
    at home with their spouse and families.

Fraser Center
  • While deployed, soldiers also fight on the
    homefront via internet and cell phone with their
    spouses. Homefront stressors may be higher than
    combat stressors.
  • Viewing internet pornography and internet sex
    chat is becoming a norm for deployment and
    effects marriages upon return.
  • Many soldiers maintain their unit bonds following
    re-deployment to the detriment of their family
  • Returning soldiers rarely talk with spouses about
    combat experiences.
  • There is a high rate of infidelity among soldiers
    and spouses during deployments. This is not
    necessarily the deal breaker that it might be
    in civilian life.
  • Illegal/prescription drugs and alcohol are
    prevalent and are used as common coping mechanism
    by soldiers (deployed and at home) and by their
  • While deployed, many soldiers are constantly
    sleep deprived and share each others medications
    (i.e. ambient, provigil). Hooked on Energy
  • The suicide rate of re-deployed) soldiers and
    spouses is on the increase.
  • Most soldiers know of at least one other soldier
    in their unit who ate his gun or was blown up
    by an IED.
  • There is a high incidence of rape and sexual
    molestation of deployed female soldiers.
  • Soldiers and spouses express a great deal of
    anger toward perceived incompetency in the chain
    of command, or in procedures, which have a direct
    negative impact upon their lives.

Fraser Center
  • Home is no longer a safe place to live. Many now
    carry weapons when not on military installations
    at home.
  • The vast majority of returning troops are filled
    with undifferentiated anger and a short fuse.
  • There is a statistically verifiable increase in
    domestic violence and child abuse among military
    families. Child abuse increases as the
    stressors increase in the life of the
    non-deployed spouse.
  • A primary therapeutic issue is the soldiers
    inability to re-connect emotionally with spouse
    and children. (exacerbated by anger and lack of
  • Chaplains are the mental and spiritual health
    first responders at home and in the combat
  • Special attention needs to be given to National
    Guard and Reserve Chaplains. There is a high
    incidence of their leaving the ministry.
  • Both spouse and soldier recognize that the
    soldier is changed by combat deployment.
  • Important family milestones and transitions have
    been missed.
  • Soldiers may pursue activities which replicate
    the adrenaline rush of combat and sometimes
    re-enlist without spousal consultation in order
    to maintain the rush.
  • Spousal dissatisfaction and resentment power
    control issues upon redeployment. I didnt sign
    up for this. The military spouse sacrifices
    education and career
  • With increased monetary incentives and a lowering
    of recruitment standards the quality of the
    troops has been increasingly lowered no GED
    necessary, accepting recruits with DSM-IV
    diagnosable conditions and on meds, increase of
    gangs in the army.

Fraser Center
  • Due to young age, immaturity, and low educational
    levels, many soldiers and spouses have poor life
    skills money management, parenting,
    communication, etc.
  • Some soldiers return to empty bank accounts and
  • The military has greatly increased mental health
    support resources at home and abroad. The Army
    recognizes that it is still not adequate.
  • The military is going out of their way to
    encourage soldiers to seek out mental health
    treatment, yet the stigma against seeking help
    continues to exist.
  • Spirituality is an important tool in the healing
    process as it is an important issue among those
    who have been in combat. It may not be express
    in typical religious language.


The next few charts cover the Military Culture
and organizational background to help you better
understand the client, where he/she was
positioned, and to better interpret the
information and stories they might tell during
their therapy
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
  • Material Products weapons systems

Culture is associated with a social system and
unique to a given system.
Handout B1
Military CultureBranches of the Military
Georgias Military presence is dominated by
Marine and Army units, though Air Force and Navy
are well represented too. Georgias National
Guard also has a large number of transportation
units subject to IEDs on roads and highways. It
was ill-prepared when first deployed in
2003. Georgia is 6th largest National Guard
State. With the current base closing plan
(BRAC), GA will be one of the 5 largest military
states along with TX, CA, NC, VA NOTE Coast
Guard is now under Homeland Security
Handout B2
Military CultureMilitary Branch Structures -
Example U.S. Army
Services Army, Navy, Marines, AF, CG Components
- Active, Guard, Reserve
Handout B3
Military CultureLanguage - Glossary of Military
Terms / Acronyms
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. Operation New Dawn post OIF
operations USAR United States Army Reserve
(Federal) USANG United States Army National
Guard (State) 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 Gunnie A Marine
First Sergeant NCO Non-Commissioned Officer,
ranks E6 through E9 IEDs Improvised Explosive
Devices FOB Forward Operating Base 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
Army Soldier Navy Sailor Marine Marine Air
Force Airmen
Handout C1 C2 C3 C4 C5
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

Military CultureKey Descriptors
  • Structured
  • Standardized
  • Authoritarian
  • Esprit de Corps
  • Focused on Mission
  • Disciplined
  • Service Before Self
  • Political
  • Mobile
  • Family Secondary
  • Technical
  • Education

Military CultureRegular/Active Duty vs
Reserve/Guard Units
Reserve / Guard
Regular / Active
  • 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,
  • Likely to work within local communities
  • Cant relocate easily when activated
  • Lack of military related health services
  • Need to make use of family or local supports
    (church, etc.) though FRGs are very helpful
  • Units are based at major military
  • 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
  • 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 soldiers unit

Handout D1
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


The next few charts cover the Veteran Experiences
and Stressors that are part of the military
culture of OEF and OIF veterans families. It
applies in manyways to other veterans and
their families also.
Handout D2 D3 D4
The Veteran ExperienceWhy 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
  • Deliberately targeting our moral code
  • COMMUNICATION! Internet, cell phones, etc.
  • IEDs, RPGs (TBI, hearing loss, neuro-chemical
  • Advancement in medical treatments
  • Nation-building activities and interactions with
    local leaders

The Veteran ExperienceProfile of Differences by
  • Vietnam
  • military cohorts
  • relatively homogenous
  • enlisted and drafted
  • fewer Reservists/Guard
  • fewer civilian contractors
  • average age 18-22
  • not married
  • no children
  • no career developed
  • adolescents early stages of development
  • one tour (12-13 mos) were typical
  • communications via phone, mail
  • wounded/killed ratio 31
  • OIF / OEF
  • not homogenous---heterogeneous
  • Active duty
  • Reservists/Guard-
  • joined for variety of reasons
  • likely did not expect to be deployed
  • Large number of civilian contractors
  • wide age range 18-60
  • married
  • parenting/grand-parenting job/career
  • financial responsibilities (e.g. mortgage,
  • multiple deployments with unknown duration are
  • instant communication
  • more indirect combat e.g. IEDs and suicide
    bombers, constant threat
  • wounded/killed ratio 151

Korea and World War II ???
The Veteran ExperienceWith a Focus On Negative
  • Fear of Death
  • Killing
  • Survivor Guilt
  • Unreality
  • Strong Bonds
  • About Face
  • Unfinished Business
  • Seared Memory
  • Multiple Losses
  • Teamwork
  • Survival Mindset
  • Cautious of People
  • Soul Searching
  • Lack of Understanding

The Veteran Experience Realizing the bridge is
  • Homethe place many think is the safe haven to
    find relief from the stress of warmay initially
    be a letdown. When a loved one asks, What was
    it like? and you look into eyes that have not
    seen what yours have, you suddenly realize that
    home is farther away than you ever imagined.
  • Down Range From Iraq and Back, by Cantrell
    Dean, 2005

Handout E1
Video Signs of Stress
Scenes from these movies depict the stress points
that occur between couples upon re-deployment .
These are also intended to set up the following
charts that cover the deployment life cycle and
key points on the cycles timeline. Again,
please take notes as a discussion will be
conducted following these clips. Run time
approximately 5 1/2 minutes.
Deployment CycleChris Warners Sources of Stress
---?gtgt Number of Months
Warner CH, Breitbach JE, Appenzeller GN,
Division Mental Health Its Role in the New
Brigade Combat Team Structure Part I
Pre-Deployment and Deployment Journal of
Military Medicine 2007 172 907-11.
Deployment Cycle
  • Pre-deployment - Period of training and equipping
    prior to deployment (30-90 days).
  • Deployment - Combat and Humanitarian missions
    anywhere in the world (3-18 months).
  • Redeployment - Return from operations to home
    base (30 days). (For Reserve and National Guard
    components this includes demobilization and
    return to civilian life).

The Military Deployment Cycle or The Military
Family Life Cycle
Military Family Life Cycle(Career View)
ltMissed 1st year of marriagegt
ltMay be 1st deployment for both partnersgt
ltDivorce remarriages w/ kids for previous
relationships are common complex stepfamilygt
Transitions are often marked by crisis points in
the family life cycle.
Deployment CycleMilitary 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 lt 30,000 (34)

Quality of Life Among U.S. Army Spouses During
OIF, Dissertation, 2005, Dr. Blaine Everson
Military CouplesDeployment Related Stressors for
Warner CH, Appenzeller GN, Warner CM, Grieger T.
Psychological Effects of Deployments on Military
Families Psychiatric Annals 2009 14 56-62.
Military CouplesAssessment and Treatment Issues
  • Dangerousness to self / others
  • Suicide / Homicide
  • Domestic violence
  • Child abuse
  • Individual issues
  • Medication abuse
  • Alcohol and drug use

2010 AAMFT Annual Conference Workshop 303
Military CouplesStressors Specific to the Couple
  • Level of Commitment and Maturity
  • Deployment Cycle / Adaptability
  • Roles / Power issues
  • Sexual Issues
  • Infidelity
  • Disabilities / Chronic illness
  • Financial Issues
  • Parenting
  • Additional for Reserve/Guard Families
  • Citizen Soldier
  • Mobilization and Deployment
  • Separation from School, Jobs, etc
  • Demobilization

2010 AAMFT Annual Conference Workshop 303
ChildrenWhat Impacts Are Seen
  • Disruption of Routines
  • Boundary Issues Parental Roles
  • Fear for Safety of Military Parent
  • Mimicry of Parental Responses
  • Sleep Disturbances and Phobias
  • Increase in Number of Physical Ailments
  • Secondary and Vicarious Traumatization

ChildrenDevelopmental Issues
  • Toddlers (3-5) - Separation Anxiety,
    Self-Comforting Behavior, Regression,Refusal to
    Eating and Sleep
  • Elementary (5-10) - Anxiety, Withdrawal,
    Regression, Fear, Uncontrolled Acting Out,
    Behavioral Contagion
  • Middle School (10-13) Fighting, Isolation
    Behavior, Emotional Contagion, Difficulties with
  • Teenagers (13-18) Rule Testing, Substance Use,
    Assaults, Use of External Systems for Support

ChildrenReserve and National Guard Family
  • Families are not as experienced with deployment
    and extended absences
  • Family members are less familiar with military
    support agencies
  • Live in local communities with less access to
    military support systems
  • Face integration back into civilian job or may
    need job assistance.


The next few charts cover Trauma, PTSD, TBI and
the Spiritual Wounds of War that are related to
the OEFand OIF veteran.
The Trauma Continuum
The past is never dead. It is not even
past. William Faulkner
Not everyone has PTSD. It is not the only
diagnosis. me
Trauma ContinuumASR to COSR to PTSD
  • ASR (acute stress reaction) produces
    biological, psychological, and behavioral
    changes. ASD means it has become disruptive
    and destructive.
  • COSR(combat and operational stress) is
    expected, common, and occurs throughout
    deployment to some degree. Pretty much everyone
    comes home with some version of combat and
    operational stress.
  • PTSD(post traumatic stress disorder) becomes
    classified if COSR symptoms are daily, interfere,
    and last longer than 1 month

Trauma ContinuumHuman Stress Response
Trauma Continuum Signs / Symptoms Of (Combat)
  • HYPER-AROUSAL Fight/Flight/Freeze, Angry,
    poor sleep, argumentative, impatient, on alert,
    tense (hyper-vigilant), intense startle response,
    speeding tickets (once home), and other risky
  • NUMBING/AVOIDANCE Withdrawn, secretive,
    detached, controlling, removes all reminders,
    avoids similar situations, ends relationships
    with people associated with trauma, etc.
  • RE-EXPERIENCING Nightmares, flashbacks,
    intrusive thoughts

Dont Forget Inter-Generational PTSD
Handout F1 F2 F3 F4 F5
Trauma ContinuumTBI Traumatic Brain Injury
  • Signature Injury of OIF/OEF
  • Explosions account for 3 of 4 combat-related
  • VA reports 61,285 OIF/OEF vets had preliminary
    screen, 11,804 were positive (20)
  • Improvements in war zone medical treatment
    hasdecreased fatalities but may have impacted
    rise in TBI
  • Prevalence is possibly still underestimated
  • Soldiers are returning home with poly-trauma
  • TBI may hinder or cause good therapy to be
    ineffective. A TBI assessment may be
  • Symptoms headaches, tinnitus, dizziness,
    balance problems, sleep problems, persistent
    fatigue, speech, hearing and vision impairment,
    sensitivity to light and sounds, heightened or
    lessened senses, impairments in attention and
    concentration, memory problems more like dementia
    than amnesia, poor impulse and anger control

The Spiritual Wounds of War
Veteran Quotes of Spiritual Injuries
  • I was totally alone
  • I was not myself
  • I saw myself dead
  • I lost my innocence, sanity and faith
  • Time stopped
  • Did I die there?
  • I became mean and cold
  • I was afraid
  • I never talked about it
  • I reject religion
  • Nothing prepared me

Handout G1 G2
Support Resources
The next few charts cover Support Resources for
veterans and those who come in contact with a
veteran in need of support
VA Hospital Contacts in Georgia
Handout H1
All the material used in this presentation (PPT
and PDF), except for the videos themselves, is
available on the CareForTheTroops website.Here
is the link http//
Military Member
A Comprehensive Web Site Feeds and Supports Our
Clinicians / Therapists
Congregations / Clergy
Military Culture 101 Conference Workshops EMDR
Weekends 1 2 On-Line Training Training
Calendar Information Resources Articles / Reports
/ Presentations Therapist Database
Information Workshops Military Ministry
Programs -Veteran Friendly Congregation -Lead
Congregation -Program Guidebook Clergy/Lay Leader
Training - Signs of Trauma and Spiritual
Wounds - Referral Source Information
This is the top of the Home Page
Handout H2
In Closing
Why its all worth learning about how to work
with military families. Run time is 4
minutes Remember