Another Kind of Valor:Another Kind of Valor:

A Day of Learning How to Better Serve Veterans

and Their Families

IntroductionIntroduction“…and they shall beat their swords into

plowshares, and their spears into pruning hooks: nation shall not lift up sword against nation, neither shall they learn war any more.” Is.2:4

OverviewOverview• What am I going to learn?

– The effects of war on returning Veterans and their families

– The effects of war and differences among those who served in all military branches, and in services available to Veterans and their families

– How to engage, talk to, work with Veterans and their families

– Resources for Veterans and their families

Today’s Returning VeteransToday’s Returning Veterans• Who are returning vets?

– Over 1.6 million soldiers have been deployed to Iraq or Afghanistan.

– Over 1/3 of those soldiers have been deployed multiple times.

– Global War on Terror (GWOT): 799,791 veterans are currently separated from the military.

– As of January 2008, there were 299,585 GWOT Veterans who have sought health care through the VA.

– Over 100,00 veterans have returned to California.

• OEF: Operation Enduring Freedom

• OIF: Operation Iraqi Freedom

• GWOT: Global War on Terror

• DOD: Department of Defense

• VA: Veterans Administration

• VBA: Veteran Benefits Administration

• VHA: Veteran Health Administration

Alphabet Soup: Veteran Key TermsAlphabet Soup: Veteran Key Terms

Major Issues for Combat VeteransMajor Issues for Combat Veterans• Major Depression• Post-Traumatic

Stress Disorder (PTSD)

• Traumatic Brain Injury (TBI)

• Military Sexual Trauma (MST)

• Substance Abuse

• Suicide• Job loss• Family dissolution• Homelessness• Violence towards

self and others• Incarceration

Population: Regular ForcesPopulation: Regular Forces• What are concerns for those who served in

active duty in the Army, Navy, Air Force, Marines and Coast Guard as well as the National Guard & Reserves?

• 46.6% of regular forces are under 25 years old.

• Many entered as teenagers and left home for the first time.

• They may return to an already unstable home environment with added stress from combat.

Population: National Guard & Population: National Guard & ReservesReserves

• What are the concerns among National Guard and Reservist Veterans?– The average age of Guard and Reservists is

35.8 years old. – Many Guard and Reservists are forced to

leave jobs at or near the peak of their career.– These “volunteer” soldier veterans are half as

likely to file VA claims as their regular forces counterparts, and half as likely to have their claims approved.

Population: Women Military Population: Women Military in the Militaryin the Military

• What are concerns among soldiers and Veterans who are women?– More women are engaging in combat roles in Iraq.– To date there are between 155,000- 180,000 women

who have served in OIF/OEF.– Women are 2 to 4 times more likely than non-Veteran

women to be homeless.– Preliminary research shows that women in war have

much higher exposure to traumatic experiences than women in the community.

Population: Veteran FamiliesPopulation: Veteran Families• What are some of the issues facing Veteran

families?– PTSD frequently has a debilitating effect on Veterans’ ability to

maintain employment and family relationships.– 50-60% of spouses of brain injured Veterans reported having

depression. – A drastic increase in the rate of child abuse and neglect in

military families has been reported since 2002. – Resources for Spouses and children of Guard and Reservists

lose all benefits 90 days after their soldier returns from war

Meeting and GreetingMeeting and Greeting Veterans & Families Veterans & Families

• Be quick to listen and slow to speak.• When discussing combat experiences,

ALWAYS avoid making character judgments.• Never say anything as stupid and insensitive

as: – So, did you kill anyone?– My mom told me not to date a vet.– Did your (son, daughter, spouse) come back crazy?– What do you think about the war?

Talking With Veterans & FamiliesTalking With Veterans & Families• How should I talk to

Veterans or their families about their experience? – With respect, compassion

and patience. Talking about combat can be an awkward conversation.

• Ask factual, logistical questions like:– How long have you been

home?– What did you do in the

military?– How are you transitioning?

• Be honest and direct in order to earn their trust and build rapport..– Welcome home. How can I

help you? Thank you for your service.

Getting Help: Getting Help: Support and ResourcesSupport and Resources

• Where can Veterans and their families go to get help?– Veterans Administration.– Vet Centers.– Community Organizations like:

• Coming Home Project• Swords to Plowshares

– YOU. – What are helpful resources that you would

recommend?

Resource: Veterans Affairs (VA)Resource: Veterans Affairs (VA)

The Department of Veterans Affairs

Veteran’s Health Administration

Veterans Benefits Administration

Vet Centers

• Can’t all veterans go to the VA?

– No. Generally, veterans must have an honorable discharge, have served 24 continuous months, demonstrate financial need, and/or have a service connected disability.

– OIF/OEF Veterans who served in combat are eligible for 5 years of free health care and may be eligible for 90 days of dental care after separation.

– Veterans must apply separately to the VHA and the VBA.

– Vet Centers are designed to serve combat veterans, their surviving family members and victims of military sexual trauma (MST).

– Provide marital and family counseling with counselors who are a Veteran as a conduit for care.

Barriers to AssistanceBarriers to Assistance• I sent a veteran to the VA for help, so they

should be okay, right?– Hopefully. Veterans do not always receive immediate

assistance.– The backlog in Veteran benefit claims has risen to

600,000.– As of June 2007, there were 202,705 GWOT

Veterans filing claims for the first time. – The AVERAGE WAIT TIME for an initial decision on a

claim 183 days!– The time frame for a claim decision, including

appeals, can exceed 10 years

What can I do to Help Veterans and What can I do to Help Veterans and Their Families?Their Families?

• Learn– About military culture, experiences of soldiers,and the needs of military, Veterans and their families.

• Give– Them some of your time and energy, your

appreciation, and your resources.

• Be an Advocate– For military, Veterans, and their families

• Talk – To them with respect and honor, listening with

compassion and patience.

Engagement SkillsEngagement Skills• Practicing empathy

• Providing choice

• Removing barriers

• Providing feedback

• Clarifying goals

PTSD: Combat StressorsPTSD: Combat Stressors• Being in constant alert for an IED/‘Booby

trap’ or other life threatening dangers.• Feeling responsible for the death of an

enemy and fellow human.• Seeing or experiencing the death or injury of

a friend or fellow soldier.• Being shot at or exposed to other dangers.• Sexual trauma.

Symptom ResponseSymptom Response• Acute stress reaction – immediate

• Acute stress disorder – up to 1 month

• Acute PTSD – 1 to 3 months

• Chronic PTSD – 3 months and beyond

PTSD: Diagnostic CriteriaPTSD: Diagnostic Criteria• Re-experiencing: thoughts, nightmares,

flashbacks, emotional reactions, physiological reactions.

• Avoidance: Avoid thoughts, reminders, amnesia; detachment, numbing, anhedonia.

• Arousal, sleep disturbance, concentration problems, anger, hypervigilance, hyper startle response.

PTSD: Impact on FamiliesPTSD: Impact on Families• Intimate relationships:

– Directly effect the relationship: Anger responses, withdrawal of affection, unpredictable responses

– Indirect affect on relationship skills e.g. impaired communication skills, avoidance, numbing, etc.

– Perception of the relationship: satisfaction with relationship reduced

PTSD: Impact on FamiliesPTSD: Impact on Families• Spouse/partner

• Direct impact of PTSD symptoms• Indirect: added stress, lack of intimacy• Domestic violence

• Secondary trauma: “Contagious” PTSD

• Compassion fatigue

• Caregiver burden

PTSD: Impact on ChildrenPTSD: Impact on Children• Direct effects: developmental milestones

delayed, adjustment issues, frightened of parent

• Indirect effects: parenting skills/role changes, compromised e.g. hypervigilance, avoidance/withdrawal, anger/aggression

• Child at risk: increased risk taking, neglect, violence, substance abuse

Stages of Recovery and TreatmentStages of Recovery and Treatment

OhioSpaniol, Gagne,

et alProchaska & DiClemente

Stage of Treatment

Treatment Focus

Dependentunaware

Overwhelmed by disability

Pre-contemplation

Engagement

• outreach • practical help• crisis intervention• relationship building

Dependent aware

Struggling with disability

Contemplation/preparation

Persuasion• psycho-education• set goals• build awareness

Independent aware

Living with disability Action

Active Treatment

• counseling• skills training• self-help groups

Inter-dependentaware

Living beyond disability Maintenance

Relapse Prevention

• prevention plan• skills training• expand recovery

Motivational InterviewingMotivational Interviewing• asking open-ended questions

• listening reflectively

• affirming change-related participant statements

• encouraging self-motivational statements

• handling resistance without direct confrontation

What HelpsWhat Helps• Cognitive Behavioral Therapy (CBT)• Eye Movement Desensitization and

Reprocessing (EMDR)• Brainspotting• Support Groups• Assistance with daily living support as

needed.• Spiritual and Social supports.• What have you found to be helpful in serving

returning Veterans and their families?