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Transition Home

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Painting a Moving Train Harold Kudler, M. D. VISN 6 Deployment health mental illness Research, Education and Clinical Center (MIRECC) Department of Veterans Affairs – PowerPoint PPT presentation

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Title: Transition Home


1
Painting a Moving Train Harold Kudler, M.
D. VISN 6 Deployment health mental illness
Research, Education and Clinical Center
(MIRECC) Department of Veterans Affairs
2
Introduction
When I come to feeling overwhelmedI want a
one-on-one talk with a trained psychiatrist whos
either been to war or understands war.
--Staff Sgt. Gladys Santos, who attempted suicide
after three tours in Iraq. Newsweek February 11,
2008
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3
Introduction
The most complex and dangerous conflicts, the
most harrowing operations, and the most deadly
wars, occur in the head.
(Anthony Swafford, Jarhead from PBS video
Operation Homecoming)
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4
Introduction
For the first time in American history, 90 of
wounded (soldiers) survive their injuries
A greater percentage of men and women are coming
home with TBI and severe Posttraumatic Stress.
(Alive Day Memories Home from Iraq HBO
documentary
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5
Introduction
  • How many of you are
  • A Military Member or a Veteran?
  • Spouse of a veteran ?
  • Other family member of veteran?

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6
Introduction
  • How many of you are
  • Psychiatrists, physicians?
  • Substance abuse counselors?
  • Psychologists?
  • Social workers, counselors (including schools)?
  • Psychiatric nurses or other nurses?

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7
Introduction
  • Painting a Moving Train General Magnus Analogy
  • Scope of issue why this training?

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8
Scope of the Issue
  • Length of current combat operations
  • As of November 27, 2006, war in Iraq has been
    going on longer than WWII.
  • An all volunteer force multiple deployments

8
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Scope of the Issue
  • 1 ½ million service members have served in Iraq
    and Afghanistan.
  • The war in Iraq remains very personal. Over 75
    of Soldiers and Marines surveyed reported being
    in situations where they could be seriously
    injured or killed 62-66 knew someone seriously
    injured or killed more than on third described
    an event that caused them intense fear,
    helplessness or horror.
  • --From the Office of Surgeon General Mental
    Health Advisory Team (MHAT) IV, Final Report, Nov
    06

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10
Scope of the Issue
  • The challenges are enormous and the consequences
    of non-performance are significant. Dataindicate
    that 38 of Soldiers and 31 of Marines report
    psychological symptoms. Among members of the
    National Guard, the figure rises to 49.
    Further, psychological concerns are significantly
    higher among those with repeated deployments, a
    rapidly growing cohort.
  • --Report of the DoD Task Force on Mental Health,
    June 2007

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11
Scope of the Issue
  • Psychological concerns among family members of
    deployed and returning OEF/OIF veterans, while
    yet to be fully quantified, are also an area of
    concern. Hundreds of thousands of children have
    experienced the deployment of a parent
  • --Report of the DoD Task Force on Mental Health,
    June 2007

12
Basic Training Military Culture
Understanding the nature of the military culture,
combat and the stresses of living and working in
a war zone are critical to establishing
credibility with your clients.
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13
Basic Training Military Culture
  • Army
  • Army National Guard
  • Navy
  • Marine Corps
  • Air Force
  • Air National Guard
  • Coast Guard

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14
Basic Training Military Culture
  • High standard of discipline that helps organize
    and structure the armed forces
  • Professional ethos of loyalty and self-sacrifice
    that maintains order during battle
  • Distinct set of ceremony and etiquette that
    create shared rituals and common identities
  • Emphasis on group cohesion esprit de corps that
    connect service members to each other.

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15
Basic Training Military Culture
  • A word about lingo

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16
Who VA Serves
  • Of 23.4 million veterans currently alive, nearly
    three-quarters served during a war or an official
    period of conflict
  • Women account for 8 of all veterans (roughly 1.8
    million women veterans)
  • About a quarter of the nation's population is
    potentially eligible for VA benefits and services
    because they are veterans or family members
  • VA currently provides health care to 5.5 million
    veterans (roughly 1 in 5 veterans)
  • Roughly 10 of VA users are women veterans

http//www.va.gov/
17
Care Access Points
  • 153 medical centers
  • at least one in each state, Puerto Rico and the
    District of Columbia
  • 909 ambulatory care and community-based
    outpatient clinics
  • 47 residential rehabilitation treatment programs
  • 232 Veterans Centers

18
Care Access Points
  • 88 comprehensive home-care programs
  • 4 DoD/VA Polytrauma Centers
  • My HealtheVet http//www.myhealth.va.gov/
  • 21 Veterans Integrated Service Networks (VISNs)

19
OIF/OEF Veterans and VA
  • As of the 4th Quarter, FY 2008
  • 945,423 OEF/OIF veterans eligible for VA services
  • 42 (400,304) have already sought VA care
  • Their three most common health issues
  • Musculoskeletal
  • Mental Health
  • Symptoms, Signs and Ill-Defined Conditions

20
Beyond the DoD/VA Continuum
  • Ideally such problems will be picked up somewhere
    within the DoD/VA continuum of care but
  • If only 42 of All OEF/OIF Veterans eligible for
    VA care have come to VA where are the other 58?
  • There is a silent majority of OEF/OIF veterans
    not coming to VA

21
Comparison to the National Vietnam Veterans
Readjustment Study
  • Only 20 of the Vietnam Veterans with PTSD at the
    time of the study had EVER gone to VA for Mental
    Health Care yet
  • 62 of all Vietnam Veterans with PTSD had sought
    MH care at some point
  • Kulka et al. 1990, Volume II, Table IX-2

22
Boots on the Ground Understanding the Experience
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23
Boots on the Ground Understanding the Experience
  • Theres nothing normal about war. Theres nothing
    normal about seeing people losing their limbs,
    seeing your best friend die. Theres nothing
    normal about that, and that will never become
    normal
  • Lt. Col. Paul Pasquina, MD from the movie
    "Fighting For Life"

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24
Boots on the Ground Understanding the Experience
  • In war, there are no unwounded soldiers.
  • --Jose Narosky

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  • I learned early that war forms its own culture.
    The rush of battle is a potent and often lethal
    addiction, for war is a drug, one I ingested for
    many years...
  • War exposes the capacity for evil that lurks not
    far below the surface within all of us.
  • And this is why, for many, war is so hard to
    discuss once it is over.
  • Chris Hedges, Veteran War Correspondent, War
    is a Force that Gives Us Meaning

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Post Deployment Concerns among Active and
Reserve Component Soldiers
  • Study followed 88,235 US soldiers returning from
    Iraq who completed both a Post Deployment Health
    Assessment (PDHA) and, 6 months later, a Post
    Deployment Health Reassessment (PDHRA)
  • Screening includes standard measures for
  • Posttraumatic Stress Disorder (PTSD)
  • Major Depression
  • Alcohol Abuse
  • Traumatic Brain Injury
  • Other Mental Health problems

Milliken, Auchterlonie Hoge (2007). JAMA
2982141-2148
30
Changes among Active Duty (AD) and Reserve
Component (RC) Soldiers at PDHRA
  • Roughly half of those with PTSD sx on PDHA
    improved by PDHRA yet
  • There were twice as many new cases of PTSD at
    PDHRA
  • Depression rate doubled in AD (10) and tripled
    in RC (13) at PDHRA
  • Overall, 20.3 AD and 42.4 RC were identified as
    needing MH tx post deployment

31
Changes among Active Duty (AD) and Reserve
Component (RC) Soldiers at PDHRA
  • 4-fold Increase in concern about interpersonal
    conflict
  • Alcohol abuse rate high (12AD/15RC) at PDHRA
    yet few (0.2) referred for tx
  • If this is the progression among Service Members
    over the first 6 months, what about their family
    members?

32
Why Might Reserve and Guard (RC) Members be at
Greater Risk than Active Duty (AD) Soldiers?
  • AD have ready access to healthcare but RC DoD
    health benefits (TRICARE) expire in 6 months
  • More than half of RC soldiers were beyond
    standard DoD benefit window by PDHRA
  • Special VA benefits end 24 months after
    separation so, despite the stigma, the need to
    secure ongoing VA healthcare may push RC to
    report sx on PDHRA
  • Other potential factors unique to RC may be the
    lack of day-to-day support from war comrades and
    added stress of transition back to civilian
    employment

33
Mental Health Among OIF/OEF Veterans
  • Possible mental health problems reported among
    44.6 (178,483) of the 400,304 eligible OEF/OIF
    veterans who have presented to VA
  • Provisional MH diagnoses include
  • PTSD 92,998
  • (23 of all who presented to VA)
  • Nondependent Abuse of Drugs 27,246
  • Depressive Disorder 63,009
  • Affective Psychoses 35,937
  • Neurotic Disorders 50,569
  • Alcohol Dependence 16,217
  • Drug Dependence 7,412

34
Traumatic Events in OEF/OIF A Sampler
  • Multi-casualty incidents (Suicide Bombers,
    VB/IEDs, ambushes)
  • Seeing the aftermath of battle
  • Handling human remains
  • Friendly fire
  • Witnessed or committed atrocities

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Traumatic Events in OEF/OIF A Sampler
  • Witnessing death/injury of close friend/favored
    leader
  • Death/injury of women children
  • Feeling/being helpless to defend or
    counter-attack
  • Being unable to protect/save a colleague or
    leader

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Traumatic Events in OEF/OIF A Sampler
  • Killing at close range
  • Killing civilians/avoidable casualties or deaths

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Barriers To Treatment
  • Treatment beliefs not addressed
  • Fears of failure and fears of success
  • Labels and stereotypes
  • Avoidance
  • Realistic concerns

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Identifying/Treating Post Deployment Mental
Health Problems Among New Combat Veterans and
their Families
  • OEF/OIF veterans often seek care outside DoD/VA
  • Family members are also dealing with
    deployment-related stress and look for help in
    the community
  • Is your practice prepared to identify or treat
    post deployment problems?

39
If You Dont Take the Temperature, You Cant Find
the Fever
  • Know something about our nations military
    history and about our present military conflicts
  • Know something about DoD and VA
  • Ask each patient if he/she is a Service
    Member/veteran or a family member/ significant
    other of a service member or veteran?
  • Know something about the different Service
    Branches and respect the difference!

40
Our Focus
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Posttraumatic Stress Disorder (PTSD)
  • Characterized by a constellation of symptoms that
    follow exposure to an extreme traumatic event
    which involves actual or threatened death or
    serious injury
  • The response to the event must include intense
    fear, helplessness or horror and symptoms that
    persist more one month, including
  • re-experiencing the traumatic event through
    intrusive recollections, dreams or nightmares
  • avoidance of trauma-associated stimuli, such as
    people, situations, or noises and
  • persistent symptoms of increased arousal, which
    may include sleep disturbance, hypervigilance,
    irritability or an exaggerated startle response

42
Posttraumatic Stress Disorder (PTSD)
  • PTSD diagnosis must also be accompanied by
    clinically significant distress or impairment in
    social, occupational or other important areas of
    function
  • Problems must persist at least one month after
    the event

43
Traumatic Brain Injury (TBI)
  • Problems with memory, concentration, emotional
    lability or irritability may also suggest TBI
  • Screen with the 3-Question Screening Tool
    developed by the Defense and Veterans Brain
    Injury Center (DVBIC)

44
Traumatic Brain Injury (TBI)
  • Proximity to explosions, thrown from a vehicle,
    lost consciousness (knocked out or down) and for
    how long, having symptoms of concussion
    (dizziness, headache, irritability, etc.)
    afterwards the blast
  • Current symptoms headaches, dizziness, memory
    problems, balance problems, ringing in the ears,
    irritability, sleep problems, change in ability
    to smell or taste, sensitivity to sound or light,
    irritability, fatigue, trouble with
    concentration, attention, thinking.

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Combat/Operational Stress Reactions/Injuries
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A Combat Stress Injury
  • Happens to a person (not chosen)
  • Involves loss of normal integrity
  • Causes loss of function at least temporarily
  • Provokes predictable self-protective or healing
    symptoms
  • Cannot be undone (though it usually heals)
  • --Capt. Bill Nash in Combat Stress Injury

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Combat Stress Injury/Trauma
  • Participant in/witness to event(s) involving
    horror, feelings that you or someone close to you
    will die, helpless, powerless

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48
Combat Stress Injury Discomfort/Fatigue
  • Accumulation of stress over time, environmental
    hardships

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Combat Stress Injury Grief
  • Loss of people who are cared about both in Iraq
    and at home

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Tricare
51
Beyond Diagnosis
  • Many problems faced by returning combat veterans
    and their families are not so much clinical and
    they are functional
  • Work Stress/Unemployment
  • Educational/Training Needs
  • Housing Needs
  • Is your patient homeless or perhaps functionally
    homeless?
  • Financial and/or Legal Problems)
  • Family Issues
  • Lack of Social Support
  • Estrangement
  • Family Breakup
  • Kids in trouble

52
Beyond PTSD and TBI
  • Psychological trauma may
  • Surface indirectly as an exacerbation of chronic
    physical ailments (shortness of breath in an
    asthmatic, increased pain in a person with war
    wounds) or
  • Be expressed in new somatic symptoms (headaches,
    abdominal pain) or
  • Present as new or exacerbated substance abuse or
  • Lie veiled behind vague complaints of poor
    energy, poor sleep or malaise

53
Common themes Presenting Problems
  • Marriage, relationship problems
  • Medical issues
  • Financial hardships
  • Endless questions from family and friends
  • Guilt, shame, anger
  • Lack of structure

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Common themes Presenting Problems
  • Feelings of isolation
  • Nightmares, sleeplessness
  • Lack of motivation
  • Forgetfulness
  • Anger
  • Feeling irritable, anxious, on edge

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Impact of Deployments and Combat Stress On the
Family
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Emotional Stages of Deployment
  • Pre-deployment
  • Deployment
  • Sustainment
  • Re-deployment
  • Post-deployment

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How does combat/operational stress affect family
members?
  • Avoidance
  • Guilt Shame
  • Anger
  • Drug and Alcohol Abuse
  • Health Problems
  • Sympathy
  • Depression
  • Grief
  • Fear Worry
  • Loss of Sleep

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What to expect of children when service member
comes home
  • o Preschoolers Feel guilty for making parent go
    away, need time to warm-up to returning parent,
    intense anger, act out to get attention, be
    demanding.
  • o School Age Excitement, joy, talk constantly to
    bring the returning parent up to date, boast
    about the returning parent, guilt about not doing
    enough or being good enough.

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What to expect of children when service member
comes home
  • o Teenagers Excitement, guilt about not living
    up to standards, concern about rules and
    responsibilities, feel too old or unwilling to
    change plans to meet or spend extended time with
    the returning parent.

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Positive Aspects of Deployments
  • Foster maturity
  • Encourage independence
  • Strengthen family bonds

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Assessment Questions
  • Why did you join the Marine Corps, Army, Navy,
    etc.? What did you hope to accomplish?
  • Combat tours when, location, MOS, job in
    Iraq
  • Satisfaction with training preparation
  • Satisfaction with leadership and equipment
  • How do family members feel about the military?
    About the separations?

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Assessment Frames
  • Deployment Cycle
  • Nature of Deployment
  • Stages of Change

63
Assessment - Deployment Cycle
  • Pre-Deployment
  • Deployment
  • Post-Deployment

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Assessment - Deployment Cycle
  • Pre-deployment
  • Deployment orders can change/be revised
  • Worry about safety of loved ones/themselves
  • Activities of Daily Living finances, health
    care, child care, pets
  • Single Parents
  • Reservists - jobs, houses, family members
  • Preparing not to come home

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Assessment - Deployment Cycle
  • Deployment - stresses from in theater and
    home, e-mails/news coverage/internet

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Assessment - Deployment Cycle
  • Post Deployment-Garrison life adjustment to lack
    of control, family life, pressures of daily
    living, broader focus, turning in weapons,
    personal protective gear

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Assessment Nature of Deployment
  • Low intensity fear of death or injury is less
    imminent but chronically present.

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Assessment Nature of Deployment
  • High intensity firing rounds at enemy, combat
    patrols, long duty hours, lack of sleep, whos
    the enemy, altered rules of engagement

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Assessment Nature of Deployment
  • Highest Intensity - Terrorist activities,
    guerilla warfare tactics VBIEDs, IEDs, mortar
    attacks, chronic strain anxiety
  • Friends, comrades killed/injured
  • Split second decisions may be second guessed.
  • Friendly fire

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Assessment stages of change
  • Pre-contemplation Problem? What problem?
  • Contemplation Do I need to change?
  • Preparation Can I change?
  • Action How do I change?
  • Maintenance How do I keep on doing what Ive
    been doing thats working?

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Assessment Measures
  • Primary Care PTSD Screen (PC-PTSD)
  • Combat Exposure Scale (CES)
  • PTSD Checklist Civilian Version (PCL-C)
  • Trauma Symptom Checklist - 40 (TSC-40)
  • 3 Question DVBIC TBI Screening Tool
  • Other measures as appropriate

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Clinical Practice Guidelines and Treatment
73
Post Deployment MH Problems Now that You Found
Them
  • The key is to develop a supportive and
    collaborative therapeutic alliance with the
    patient and with his/her significant others
  • Other steps/options include
  • Early recognition of PTSD and other post
    deployment MH problems
  • PTSD-related education
  • Pharmacotherapy
  • Psychotherapy/Supportive counseling
  • Identifying resources
  • Regular follow-up and monitoring of symptoms

74
Treatment
  • VA/DoD Clinical Practice Guidelines

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Clinical Practice Guidelines
  • Assist clinicians in learning about available
    treatments, reviewing their evidence base and
    making practical, patient-specific choices among
    them
  • Provide clinical algorithms that walk clinicians
    through the necessary steps from screening and
    initial assessment through treatment and
    re-assessment
  • Most relevant among these is the VA/DoD Clinical
    Practice Guideline for the Management of
    Posttraumatic Stress

76
VA/DoD Clinical Practice Guideline for the
Management of Posttraumatic Stress
  • Created by a working group of VA and DoD
    clinicians and researchers
  • Separate algorithms defined for primary care
    providers and mental health professionals
  • Evidence tables provided for each recommendation
    and a substantial literature review included
  • Available at www.oqp.med.va.gov/cpg/PTSD/PTSD_Base
    .htm
  • In the public domain

77
Clinical Practice Guidelines
  • The American Psychiatric Association has
    published a Practice Guideline for Patients with
    Acute Stress Disorder and Posttraumatic Stress
    Disorder
  • The International Society for Traumatic Stress
    Studies, the worlds largest international
    multidisciplinary professional organization
    working in the field of psychological trauma,
    provided a comprehensive set of treatment
    guidelines in 2000 with a new edition expected in
    2008
  • Both guidelines provide a thoughtful introduction
    to available therapies, significant background
    information and evidence-based treatment
    recommendations.

78
Triaging TBI
  • Consider consultation
  • Rehabilitative Medical Specialist
  • Neurologist
  • Speech Pathologist
  • Audiologist
  • Vision Assessment

79
A Point of Caution
  • Little evidence to support the use of Critical
    Incident Debriefing in the prevention of PTSD
  • Debriefing in heterogeneous groups may actually
    increase the risk of PTSD by re-traumatizing
    survivors who are not prepared to be re-exposed
    to horrific memories

80
Treatment Options Cognitive Therapy (CT)
  • Identify and clarify patterns of thinking
  • Identify distressing trauma-related thoughts
  • Convert these thought patterns into more accurate
    thoughts
  • Address core beliefs about self, others, larger
    world

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Treatment Options Exposure Therapy (ET)
  • Reduce the fear associated with traumatic
    experience through repetitive, therapist-guided
    confrontation of feared places, situations,
    memories, thoughts, and feelings
  • Exposure can be imaginal or in vivo
  • Reduced intensity of emotional and physiological
    response is achieved through habituation.

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Treatment Options Stress Inoculation Training
(SIT)
  • Anxiety management is among the most useful
    psychotherapeutic treatments for PTSD clients
    (Expert Consensus Guideline Series)
  • SIT can be thought of as a set of skills for
    managing stress and anxiety
  • Breathing control, Deep Muscle Relaxation,
    Assertiveness Training, Role Playing, Covert
    Modeling, Thought Stopping, Positive Thinking,
    Self Talk

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Treatment Options Eye Movement Desensitization
and Reprocessing (EMDR)
  • Accessing and processing traumatic memories to
    bring these to resolution.
  • The client focuses on emotionally disturbing
    material while at the same time focusing on an
    external stimulus (usually therapist directed
    bilateral eye movements, hand tapping, sounds)

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Pharmacotherapy
  • Specific serotonin reuptake inhibitors (SSRIs)
    and venlafaxine have the strongest evidence
  • While many drugs from a wide range of classes
    have been studied in PTSD, there is little
    evidence for their use except as adjunctive tx
  • Antipsychotics often prescribed in military
    settings
  • Available research suggests that prazosin
    reduces the frequency and intensity of
    posttraumatic nightmares and may be effective in
    managing other symptoms of PTSD but it cannot yet
    be recommended as stand-alone tx
  • Benzodiazepines are not effective as first line
    agents in the treatment of PTSD
  • Because of potential for dependence and abuse,
    their use as single agents is strongly
    discouraged

85
Battlemind
  • Developed by Walter Reed Army Institute of
    Research
  • A motivational intervention that makes ignoring
    readjustment issues feel like a mistake
  • Training, NOT Treatment
  • Emphasis on adaptive change and the capacity for
    continued change

86
Battlemind Defined
  • Key Message Combat skills and Battle mindset
    sustained your survival in the war-zone
  • Battlemind is the Soldiers inner strength to
    face fear and adversity in combat with courage
  • But Battlemind may be hazardous to your social
    and behavioral health on the home front if it
    isnt transitioned
  • In other words Battlemind represents a Soldiers
    successful adaptation to combat but Dont try
    this at home!

87
Key Signs of Battlemind
  • Buddies vs. Withdrawal
  • Accountability vs. Control
  • Targeted vs. Inappropriate Aggression
  • Tactical Awareness vs. Hypervigilance
  • Lethally Armed vs. Unarmed
  • Emotional control vs. Anger or Detachment
  • Mission OPSEC vs. Secretiveness
  • Individual Responsibility vs. Guilt
  • Non-Defensive (Combat) Driving vs. Aggressive
    Driving
  • Discipline Ordering vs. Conflict

88
A Sample of Battlemind Training
89
The Face of the New Veteran
  • Developed as an all employee training for VA and
    other healthcare personnel
  • Keyed to a set of Resource Guides
  • Guide for providers
  • Guide for Veterans and their Significant Others

90
Call to Action
91
Public Health Model
  • Most war fighters/veterans will not develop a
    mental illness but all war fighters/veterans and
    their families face important readjustment issues
  • This population-based approach is less about
    making diagnoses than about helping individuals
    and families retain a healthy balance despite the
    stress of deployment

92
Public Health Model
  • Incorporates the Recovery Model and other
    principles of the Presidents New Freedom
    Commission on Mental Health
  • There is a difference between having a problem
    and being disabled
  • The public health approach requires a
    progressively engaging, phase-appropriate
    integration of services

93
Public Health Model
  • This program must
  • Be driven by the needs of the Service Member/
    veteran and his/her family rather than by DoD and
    VA traditions
  • Meet prospective users where they live rather
    than wait for them to find their way to the right
    mix of our services
  • Increase access and reduce stigma

94
Beyond the DoD/VA Continuum Partnering with
States and Communities
DoD/VA/State and Community Partnerships Are
Already Under Way or in planning in
  • Upstate New York
  • Washington State
  • Ohio
  • Alabama
  • Vermont
  • Rhode Island
  • New Mexico
  • Oregon
  • Minnesota
  • Texas
  • Missouri
  • Virginia
  • Maryland
  • Other states?

95
Advantages of Working at State and Community
Levels
  • May enhance access for Service Members, veterans
    and family members concerned about seeking help
    within the DoD/VA continuum
  • May enhance the quality of services veterans and
    family members receive in the community

96
Advantages of Working at State and Community
Levels
  • National Guard programs are organized by state
  • Each state has its own veterans outreach program
  • Builds a system of interagency communication and
    coordination that may serve well at times of
    disaster

97
The North Carolina Governors Summit on Returning
Veterans and their Families
  • On September 27, 2006, key leaders of North
    Carolina State Government, VA, and DoD met with
    representatives of state and community provider
    and consumer groups 
  • Governor Michael Easley charged Summit
    participants to develop new ideas that would help
    veterans succeed in getting back to their
    families, their jobs and their communities
  • The Summit was only the start of a process, not
    its end!

98
Summit Goals
  • Exchange information about respective agencies
    assets and goals
  • Identify strategic partnerships
  • Articulate an integrated continuum of care that
    emphasizes access, quality, effectiveness,
    efficiency, and compassion

99
Summit Goals
  • Emphasize principles of resilience, prevention,
    and recovery
  • Optimize access to information, support, and,
    when necessary, clinical services across systems
    as part of a balanced public health approach

100
Next Steps
  • Governors Letter to Veterans and Families
  • A strong and clear Thank you
  • A toll free number from the State Department of
    Health and Human Services (1-800-662-7030)
  • Access to health, educational, and vocational
    services for Service Members/veterans and their
    family members
  • A new mission for veterans and their families
  • Build stronger careers, families and communities
    for the good of all the people of North Carolina

101
Goals
  • Enhance outreach
  • Increase appropriate referrals
  • Reduce stigma
  • Promote healthy outcomes/Resilience/Recovery
  • Strengthen families
  • Decrease military attrition
  • Decrease disability
  • Increase consumer and provider satisfaction
  • Transform the post deployment health system

102
The Bottom Line
  • There should be No Wrong Door to which OIF/OEF
    veterans or their families can come for help

103
QUESTIONS?
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