Veterans Today

Denise Lukowski LCSW, CASACVeterans Justice Outreach Coordinator

VA New York Harbor Healthcare System

Modified from a presentation by Dr. Male, et.al.

Objectives

• Identify adaptations individuals make to a combat environment that may impact behavior in a civilian setting

• Differentiate between normative post-deployment readjustment and PTSD with TBI considerations

• Treatment modalities available for Veterans in the VA system

Current Conflicts

Global War on Terrorism (GWOT):

• Operation Enduring Freedom (OEF)– Afghanistan - Since October 2001

• Operation Iraqi Freedom (OIF)– Iraq -Since March 20, 2003

• Operation New Dawn (OND)– Afghanistan – Since Summer, 2010

Age Distribution

Data as of July, 2010

Combat and Operational Stress

• No real safe area

• Unpredictable

threat level

• Periodic

unpredictable

re-exposure to

high stress

moments

Combat and Operational Stress

• Adaptation to dangerous

environment• Exposure to actual

threats/trauma• Cumulative stress:

– moderate stress for

extended period– loss of resiliency

Job Stress

• Long Hours

• Newly formed units

• High operational tempo

• No Privacy

• Individual and unit functioning changes

Women in the Military

• Vietnam – 7500 women in country

• Currently – over 200,000 women in country

• Same duties as men

• Military sexual trauma

• Sexual Harassment

• 2006 - Congress Sexual Assault Coordinator

For every command

Relationship Stress

• Long and/or multiple deployments

• Rushed marriages/pregnancies

• Irritability & numbing

• New communication styles

• Pre-existing strains

• Helpless to assist with crises

• “Dear Jane/John”

General Situational Stress

• Financial problems• Guard and Reserve with employment &

business problems• General case of helplessness and/or

hopelessness• Disconnect from established support

systems, faith communities• Physical/environmental conditions

Environmental Conditions

How Many Times Matters

• Many military members have deployed more than once

• Some have deployed 3+ times

• More deployments = more likelihood for clinically significant impairment

Trauma Exposure Matters

Successful Adaptation: A Balance between Stress, Coping, Resilience

Homecoming

Readjustment

• Accustomed to relating to unit personnel rather than to loved ones

• Not used to being around children

• Forgotten that family problems are often not as easy to solve as military problems

• May feel more important/prominent than civilian peers

Relationships

• Unrealistic Expectations re: Homecoming

• Emotional Distance– Communication Problems– Isolation

• Detachment

• Angry outbursts

• Increased substance use

• Intimacy problems

Returning to Work

• Many co-workers/supervisors may not relate to combat experiences

• Some will not even realize the soldier was deployed!

• Co-workers may resent soldier’s absence• Re-frame co-workers’ reactions in terms of

their frame of reference• Those left behind may have worked extremely

hard as well

Screening and Assessment

Six conditions to screen for:

• Suicide

• Post Traumatic Stress Disorder (PTSD)

• Military Sexual Trauma (MST)

• Substance Use Disorders (SUD)

• Traumatic Brain Injury (TBI)

• Depression

Post Traumatic Stress Disorder

TRAUMA

• Overwhelms ability to cope

• Trauma is in the perception of the experiencer

STRESS• Fight: Attack the threat• Flight: Run from the

threat • Freeze: Not be seen by

the threat• Response to real and/or

perceived threat

Anxiety & Physiological Arousal

• We like to think of ourselves as a big dominant predator type.

• Our biological wiring is more consistent• to that of a prey species than a predator

species.

Example of Stress Example of Stress ResponseResponse

Soldiers drive down the middle of the road at full speed, being very aware of parked cars, debris, overpasses, etc.

Driving = Danger

Long after deployment, Veterans experience driving-related stress, fear, rage, or a need for speed.

Avoidance

• Tries to avoid any discussion related to trauma

• Avoids places, activities, etc. related to trauma

• Cannot recall details of trauma

• Alcohol, drugs

War Changes People

• Major Areas of Impact:

–Changes in Thinking

–Changes in Emotions

–Changes in Physiology and Behavior

Changes in Thinking• Miss excitement of combat,

urges to return• Confused about direction and

meaning in life• Blaming self for actions in war

zone• Loss of “innocence” and belief

in former values • Existential/Spiritual crisis

• Unwanted “re-living” of the trauma

• Distressing memories • Disturbing dreams or

nightmares• Upset when reminded of

traumatic event• Changes in Attitude and

Outlook• Preoccupation with news

about the war• Worry about friends still

deployed overseas

Changes

Emotions• Feeling unsafe, on guard• Irritability and outbursts of anger• Feelings of Guilt or Shame• Feeling alienated from others and

society (“I don’t fit in anymore!”)• Loss of interest and enjoyment in

life• Down, depressed, hopeless• Shutting down and emotional

numbness• Anxious, apprehensive, panicky,

stressed out

Physiology and Behavior• Trouble with Sleep

• Easily startled & jumpy

• Overly controlling and worried about safety

• Physical symptoms and health problems

• Problems with concentration and attention

• Increased use of alcohol or drugs

• Withdrawn, sullen, uncommunicative

• Increased avoidance

Substance Use Disorders

• It has been estimated that as many as 20% of returning Veterans meet criteria for SUD

Traumatic Brain Injury Causes of War Zone TBI

• Blast or Explosion IED (improvised explosive device), RPG (rocket propelled grenade), Land Mine, Grenade, etc.

• Vehicular accident/crash (any vehicle, including aircraft)

• Often sustain multiple blast injuries within close temporal proximity

• Much less is known about these injuries

• Fragment wound or bullet wound above the shoulders

• Fall

• Blow to head (head hit by falling/flying object, head hit by another person, head hit against something, etc.)

• Other injury to head

Mild TBI May Go Undiagnosed

• Common to “get your bell rung”

• Explosion did not result in obvious serious injury in the field

• Multiple exposures common

• Overlap of TBI symptoms and mental health symptoms

• Reluctance/inability to seek care

TBI Immediate Symptoms

• Losing consciousness/"knocked out"

• Being dazed, confused or "seeing stars“

• Not remembering the event

• Concussion

• Head injury

Enduring Effects of Mild TBI

• Memory problems or lapses

• Balance problems or dizziness

• Sensitivity to bright light

• Irritability

• Headaches

• Sleep problems

*alcohol/drugs don’t help these things

Mild TBI: Course of Recovery

• Most effects resolve within weeks or months

• Possible improvement up to 1-2 years

• Improvement after 2 years more likely to be psychological coping

Depression

• Screen ALL veterans• Ask ALL veterans about suicidal ideation• Ask about weapons – if concern re:

safety, ask them to give to someone else to hold

• If won’t give them up, ask them to lock weapons separate from ammunition

• Provide Emergency Resources

Suicide

• Vietnam Veterans – more suicides after war than actual war casualties

• Suicide rates are 4 to 5 times higher for OEF/OIF veterans• Veteran’s Suicide Hotline:

1-800-273-8255 or 1-800-273-TALK

Reasons for Not Seeking Help

• Would be seen as weak• Unit leaders might treat differently• Loss of confidence by peers• Difficult to get time off for treatment• Harm career• Difficult to schedule an appointment

Strategies for Positive Outcomes

• Prepare Veteran by explaining the process and what to expect at their court appearance

• If possible, reduce environmental stimulation (first app/arraign docket) by having them wait outside until they are called

• Assign cognitive tasks to keep them grounded in the present

• Allow Soldier/Veteran as much control as possible

• Be GENUINE

VA’s Response

• Increase in mental health providers with focus in dual diagnosis (PTSD/SUD)

• Increase in providers to treat and rehabilitate TBI

• Women’s Health Program

• Develop screening for Intimate Partner Violence

Top 5 Things NOT to Say to or Ask a Returning Soldier

Top 5 Things NOT to Say to or Ask a Returning Soldier

2. “Just get over it.”

3. “What’s the worst thing you saw/did over there?”

4. “What do you think of George W. Bush?”

5. “Wow—back so soon? It hardly seems that you’ve been gone.”

Top 5 Things NOT to Say to or Ask a Returning Soldier

“Did you kill anyone?”

Top 5 Things TO Say to or Ask a Returning Soldier

Top 5 Things TO Say to or Ask a Returning Soldier

2. “What do you want to tell me about it?”

3. “It matters to me that you’re back.”

4. “No, really—I meant it: Thank you for your service.”

5. “Thank you for your service.”

Top 5 Things TO Say to or Ask a Returning Soldier

“Welcome Home.”

Questions?

DENISE LUKOWSKI LCSW, CASAC, BCD DENISE.LUKOWSKI@VA.GOV