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Challenges in War and At Home


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 – PowerPoint PPT presentation

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Title: Challenges in War and At Home

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

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

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

  • 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).

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

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
  • Im not ready for college-dont 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.

  • 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

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

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 someones face
  • Go immediately to aggression if any push back

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

Realities of Combat
  • Long hours
  • Constant vigilance (no battle lines to get
  • 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

A Soldiers 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

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)

A Soldiers Perspective
  • Often, there is a disillusionment of
  • Experience
  • Military organization/Leadership
  • Self

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.)

  • Honeymoon phase
  • Disappointment due to problems or unmet
  • Others expect the soldier to quickly return to
  • Frustration builds
  • Expression of anger is more intense and not
    acceptable (like it was in theater of combat)

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
    dont want to)

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)

Why do sleep problems develop after combat and
  • 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

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

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

Substance Abuse Seal 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
  • Those with PTSD or depression were about 4x more
    likely to have a drug or alcohol problem.
  • Close to those seen in Vietnam Veterans.

Family Problems Sayers, Farrow, Ross Olsin,
2009 Journal 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
  • N199

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

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

Stress Injuries Occur When Stress Is Too Intense
or Lasts Too Long CAPT 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

Three Mechanisms of Stress Injury
Operational Stress Injuries Correlate with DSM-IV
Prepared by Capt. William Nash, MC, USN HQ,
Marine Corps
Combat / Operational Stress
Combat Stress PTSD
Typical Reactions
Mild/Moderate/Severe to Combat

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

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

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

DSM-IV Criteria for PTSD
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

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

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
  • Note Criterion 4A does not apply to exposure
    through electronic media, television, movies, or
    pictures, unless this exposure is work-related)

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

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

Avoidance Symptoms
  • Avoidance refers to intentionally pushing out of
    ones mind
  • Distressing memories
  • Thoughts
  • Feelings
  • Avoiding external reminders of the trauma.

Negative Thinking and Mood
  • Negative cognitions and mood represents myriad
  • 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

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

Mild TBI - PTSD Overlapping Symptoms
  • Postconcussion Syndrome (PCS)
  • Insomnia
  • Memory Problems
  • Poor concentration
  • Depression
  • Anxiety
  • Irritability
  • Fatigue
  • Noise/light intolerance
  • Dizziness
  • Headache
  • PTSD
  • Insomnia
  • Memory problems
  • Poor concentration
  • Depression
  • Anxiety
  • Irritability
  • Re-experiencing
  • Avoidance
  • Emotional numbing

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

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

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

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

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

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.
  • Trauma Focused
  • Research strongly indicates best choice for
    improvement (with Evidenced-Based
  • Systematic
  • Time limited (usually 12-15 sessions)

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

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

Learning Alternative Ways to Respond
  • Respond rather than react
  • Changing muscle memory
  • Learn assertive versus passive or aggressive

What makes reactions better or worse?
  • Worse
  • Looking at situations as if you are still in war
  • Insisting immediate improvement
  • Assuming that all alarming reactions are true
  • Becoming a hermit
  • Better
  • Reminding yourself you are not in a war zone
  • Staying in situations long enough to allow the
    alarm reaction to go down
  • Being around people even though it may feel
    awkward at first

Evidence-Based Therapies
  •  Prolonged Exposure (PE) and Cognitive Processing
    Therapy (CPT) are treatments endorsed by the
    Veterans Administration as evidence-based
    treatments for PTSD.
  • EMDR is a promising treatment for PTSD.

A Qualification (Hoge-2010)
  • Effect sizes
  • Meds (59 recovery versus 39 placebo)
  • Psychotherapy (41 Exposure Therapy versus 29
    Supportive (no specific)
  • CPT 3 versus 40
  • Partial versus Complete Recovery from PTSD may be
    the case for many veterans

Prolonged Exposure (PE)
  • PE is a 10-15 session program that is done in 90
    minute individual sessions. There is also
    considerable out of session homework involved.
  • 15 Randomized Controlled Trials/Many
    Effectiveness studies
  • The Veteran monitors symptoms by completing a
    symptom checklist (PCL-M).

Prolonged Exposure (PE)
  • PE is a treatment that helps survivors of trauma
    to emotionally process their experiences.
  • Veterans are helped to confront their trauma
    memory. This is done to decrease their fear and
    anxiety. An example of this is the rider that is
    encouraged to get back on the horse after being
    thrown off. The rider overcomes the fear of being
    thrown again. This also prevents the fear from
    affecting other areas of his life.

PE 2 main components
  • Imaginal exposure Client recounts their worst
    traumatic event in detail repeatedly in session
    (and daily listens to tapes of themselves out of
  • In-vivo exposure Client develops a hierarchy of
    avoided situations and exposes themselves to
    these situations for 30-45 minutes daily
    (starting with situations that are 30 on a 0-100

Resources for Therapist and Patient
  • Prolonged Exposure Therapy for PTSD Emotional
    Processing of Traumatic Experiences Therapist
    Guide (Treatments That Work) Edna Foa, Elizabeth
    Hembree, Barbara Olaslov Rothbaum
  • Reclaiming Your Life from a Traumatic Experience
    A Prolonged Exposure Treatment Program Workbook
    (Treatments That Work) Barbara Rothbaum, Edna
    Foa, Elizabeth Hembree
  • PE app (

Center for Deployment Psychology Course 113
(Online) Cognitive Processing Therapy (CPT) for
PTSD in Veterans and Military Personnel
National Center for PTSD The Course Cognitive
Behavioral Psychotherapies for PTSD outlines the
components and empirical support for two
evidence-based treatments Prolonged Exposure
(PE) and Cognitive Processing Therapy (CPT).
Cognitive Processing Therapy (CPT)
  • 12 Session structured psychotherapy approach
  • 7 Randomized Controlled Trials/Many
    Effectiveness studies
  • Based on a social cognitive theory of PTSD that
    focuses on how the traumatic event(s) is
    construed and coped with by a person who is
    trying to regain a sense of mastery and control
    in his/her life
  • Based on the Cognitive Therapy Model developed by
    Aaron Beck, M.D.
  • Also utilizes therapeutic writing strategies
    developed by James Pennebaker, Ph.D.

Cognitive Processing Therapy
  • CPT is a 12 session program that can be done in
    individual (much research basis) or group
    sessions (emerging research basis).
  • There is also some out of session homework
    involved-writing about the trauma and writing
    about ones thoughts and emotions. This is
    reviewed with the therapist in session.

Cognitive Processing Therapy (CPT)
  • CPT begins with education about trauma. It looks
    at the normal reactions to the trauma. The
    therapy then moves to look at and evaluate your
    thinking and beliefs about the events. You are
    finally asked to "talk" about your experiences by
    writing about them. You read them to the
    therapist (and/or group members).

  • Reading about your trauma is followed by a
    discussion of "stuck points." Stuck points are
    memories or thoughts you have been unable to move
    past. They continue to impact on your ability to
    live a full life. The Veteran monitors symptoms
    by completing a check list (PCL-M).

Treatment Model Cognitive Processing Therapy
  • Focus on the content of cognitions and the effect
    that distorted cognitions have upon emotional
    responses and behavior
  • Sees PTSD as a disruption or stalling out of a
    normal recovery process and works to determined
    what interfered with normal recovery

Eye Movement Desensitization and Reprocessing
  • EMDR is a treatment for traumatic memories that
    involves elements of exposure therapy and
    cognitive behavioral therapy, combined with
    techniques like eye movements or hand taps that
    cause the patients attention to alternate back
    and forth across the midline.

EMDR Outcome Studies
  • EMDR has been shown to be more effective than
    placebo wait list, psychodynamic, relaxation, or
    supportive therapies. However, research comparing
    EMDR to other CBT therapies shows significantly
    better results have been maintained with CBT than
    EMDR, particularly over time.

  • Many veterans will benefit from ongoing support
  • This can be community based or may be part of a
    formal mental health treatment program

OEF/OIF/OND Readjustment Program (405) 456-2855
  • Carly Hobbs, Program Support Assistant
  • Yan Feng, M.D., Medical Director
  • Gina Pierce, M.D., Psychiatrist
  • Shannon Thomas, M.D., Psychiatrist
  • Steve Scruggs, Psy.D., Team Leader
  • Susan Shead, LCSW, Social Worker
  • Amber Ward, LCSW, Social Worker
  • Rob Braese, Ph.D., Staff Psychologist
  • Anna Colston, PA-C, Physician Assistant
  • Regan Settles, Ph.D., Postdoctoral Fellow