Michele Lukacik, MA, LMHC, LPC, NCC, CCHT, Veteran

Coming Home – Current concerns facing our returning veterans and their families.

Alliance of Information and Referral Systems (AIRS)

I&R Training and Education Conference May 23rd – May 26th, 2010

Rochester, New York

Terms

•OIF•OEF•TDY•Deployment•Active Duty•Guard•Reserve•Discharged

•Dependant

•Retired

•DD-214

•Service Connected Disability

•Vet

•Vet Center

Deployment NumbersChallenge with finding those we serve and calculating how

many in any given area because:• Guard/reserve issue• Separated and returned to area• Family members who live in service area but loved

one could be stationed anywhere.

Deployment Numbers Cont.• Over 2 Million Soldiers have deployed OIF/OEF and over

500,000 of those have served 2 or more tours.• 1 in 10 serving in Iraq or Afghanistan are women.• Total Service members (Worldwide) (as of Sep. 30,

2009) 1,471,008• Deployed to Iraq (as of Sep. 30, 2009) 164,100• Deployed to Afghanistan (as of Sep. 30, 2009) 66,400• Battle Deaths (as of March 10, 2010) 4,201• Other Deaths (In Theater) (as of March 10, 2010) 1,175• Non-mortal Woundings (as of March 10, 2010) 36,906

Impact On The Community• Increased need for Resources

• Increased need for specialized care• It is estimated that 6.5 to 9.5 million Americans are likely

to know someone who has been killed or injured in the war in Iraq and Afghanistan

Pre-Deployment• Emotional Distance• Preparing for Deployment Training Packing Preparing Family Living Arrangements

• Telling the Children• Saying Good Bye

During Deployment

• Adjusting to Life in a Combat Zone• Frustration at serving in combat without having any idea

of when they’ll be able to come home.• Worry over leaving loved ones behind.

• Anger that civilian contractors get paid three times more for similar jobs and have superior gear.

• Guard and Reserves fear losing civilian jobs or businesses while in combat.

• Survivors Guilt• Shifts in Values and Belief Systems.

• Stress Related to Combat Experiences.

Common OIF/OEF Experiences

According to an article by The New England Journal of Medicine in 2004

soldiers surveyed reported:

• Being attacked or ambushed (89%)• Receiving incoming artillery, rocket

or mortar fire (86%)• Being shot at (93%)

• Shooting or directing fire at the enemy (77%)

• Being responsible for the death of an enemy combatant (48%)

• Being responsible for the death of a non-combatant (14%)

• Seeing dead bodies or human remains (95%)

•Seeing dead or seriously injured Americans (65%)

• Knowing someone seriously injured or killed (86%)

• Seeing ill or injured women and children they were unable to help

(69%)• Wounded or Injured themselves

(14%)• Had a close call, but protective gear

saved them (8%)• Had a buddy shot near them (22%)•Engaged in hand-to-hand combat

(22%)

The Family Left Behind• Stress of Deployment

• Changes in Communication

• Changes in Routine

• Head of Household

• Financial Concerns

• Becoming Primary Parent

• Children Acting Out

The Homecoming

• Couples Communication Case Example

• Family Interactions Case Example

• Roles

• Changes in Routine

• Adjustment to Visible and Invisible Injuries Case Example

Understanding the Returning Soldier

• The soldier is returning from a life of danger to a life of uncertainty.

• In combat the military guided and provided. • In civilian life the soldier will have to live by a complex

code. • In combat the soldier bonded with a few, in civilian life

the soldier will be expected to interact with a myriad of networks of people; family, friends, co-workers, relatives, etc…

• In combat the soldier was "safe" within the confines of the forward operating base and the company, squad or team.

• At home the soldier will often feel vulnerable, not sure where he/she is "safe and secure".

Understanding the Returning Soldier

• The soldier may feel alienation because of the unique experiences (both good and bad) of combat and the inability to adequately express those experiences to those who haven't been there.

• The soldier may feel that friends and co-workers have "leapt ahead" while he/she was "frozen in time". Others have gone to school, married, been promoted, learned new skills and advanced in their careers and the soldier is faced with trying to "catch up" in a world that the combat veteran may feel he/she is out of synch with.

The Returning Soldier

• Don't overwhelm the soldier and his/her family with attention, but at the same time don't ignore them.

• Listen and support but don't condemn. Accepting the soldier does not mean you need to be in support of foreign policy.

• Be alert for signs of distress. • Don’t expect them to step right back into life like

it was when they left. They will have questions. Being in a life or death situation like war will raise these questions.

The Stigma of Mental Health

• Stigma • Security Clearance application (Question 21) As of April

18, 2008 applicants no longer have to acknowledge they received counseling if it was related to service in a military combat zone (or non-court ordered family,

marital, or grief counseling (unless related to violence).• Post Deployment Health Reassessments

• VA increasing number of OIF/OEF Veteran Counselors

These are all great steps in the right direction, but the stigma is ingrained and it will take time for change to happen.

How Counseling Can Help

• Reintegration• Help Couples & Families Reconnect / Communicate• Prevention• Adjust to life after Deployment• Reorientation to Civilian life• Depression• Anxiety• Anger Management• Coping with injury• Driving aggressively to avoid debris in the road

How Counseling Can Help Cont.

• Feeling anxious in crowds• Difficulty readjusting to family roles• Difficulty sleeping• Difficulty keeping your focus• PTSD (20 to 30 % depending on the report) - A large study by the Rand

Corporation in January found nearly one out of three service members reported a mental health problem or symptoms of traumatic brain injury. And only half of them sought help.  That study also found that many of the returning troops thought seeking treatment would have a negative impact on their security clearance and their careers.

Counseling Some “gaps” in counseling services

• Military mental health and the VA cannot see family members without military person present.

• Family members during deployment.

• Veterans who are no longer in the military

• Extended family members who are coping with the deployment of a loved one.

• Some military personnel fear utilizing traditional resources because of the stigma of accessing mental health services or fear of it affecting their career.

• Fearing their family members going to counseling could affect their career.

• Outreach for those who were wounded and unable to get to services.

Post Traumatic Stress Disorder

It has gone by different names throughout history• 1800’s – Exhaustion

• WWI – Combat Fatigue• WWII – Shell Shock or Soldiers Heart

• Vietnam – Battle Fatigue• Gulf War - PTSD

What is Trauma?

Trauma is a profoundly threatening experience,

usually involving and immediate or perceived

threat to someone’s life. In trauma one’s ability to cope

is overwhelmed by circumstances out of ones

control.

Trauma

Common examples include:

•Serious accident or injury•Physical assault•Rape / Sexual Abuse•Robbery•Sudden or unexpected death•Natural disaster•Military Combat

An event can be just as devastating if:

•The event is witnessed•It occurred to a love one•One feels responsible in some way

PTSD

Anyone may have trouble recovering from a traumatic event.

• 8% of Americans will develop PTSD at some point in their lives

• 50% of those who spent time in a war zone will develop PTSD

When a traumatic event occurs, the body kicks into action, prepared for fight or flight. One may shut down to

function in the moment.

PTSD

After the trauma event repressed thoughts and feelings begin to emerge.

• If one is able to receive them for what they are, emotion is released, and the mind gains perspective.

• Most important element in recovery is a sense of safety.

• Getting in touch with traumatic emotions can be very unsettling.

PTSD

• PTSD simply means that the natural healing process from the trauma has been blocked or hampered in some way.

• People may feel embarrassed, ashamed, weak, crazy, or guilty.

For the majority of people, especially military,

it is easier to accept and understand a

physical injury than a psychological one

PTSD Symptoms

Symptoms come in 3 Groups

• Re-living the Event• Avoiding Reminders of the

Event• Being on Guard (hyper-alert)

Re-living the Event

• Recurrent and intrusive, distressing recollections of the event, including images, thoughts or perceptions

• Nightmares or Flashbacks• Strong reactions when reminded of the trauma• A sense of reliving the experience through

illusions, hallucinations and active flashbacks• Sudden fear or nervousness• Physical reactions such as chills, panic or

nausea• Sudden urge to run or hide

Avoiding Reminders of the Event

• Not being able to talk about the trauma.• Difficulty recalling details of the trauma.• Avoiding people, places, thoughts and activities that remind you of

the event.• Feeling “scattered” and unable to focus on work or daily activities.• Having difficulty making decisions.• Feeling emotionally “numb”, “withdrawn”, or disconnected.• Losing interest in everyday activities, or family and friends.• Crying without reason, feeling a sense or despair and

hopelessness.• Feeling depressed or sad, having low energy.

Being on Guard (Hyper-alert)

• Being overly alert at all times, or easily startled (jumpy).

• Feeling irritable, easily agitated, or angry and resentful.

• Having trouble sleeping or concentrating.• Irritability or outbursts of anger.• Feeling extremely protective and worried about

the safety of loved ones.

PTSD Cont.

•PTSD patients are 6 times more likely to attempts suicide than the general population

•PTSD is NOT a character flaw or sign of weakness- Fear that they will be seen as

“damaged” or emotionally unstable.

TBI

What is a traumatic brain injury?• A traumatic brain injury (TBI) is a blow or jolt to the head

or a penetrating head injury that disrupts the function of the brain.

• Not all blows or jolts to the head result in a TBI. • The severity of such an injury may range from “mild,” —

a brief change in mental status or consciousness—to “severe”, an extended period of unconsciousness or

amnesia after the injury. • A TBI can result in short or long-term problems with

independent function.

TBI Cont.

What causes TBI?

The leading causes of TBI are:

• Bullets, fragments, blasts

• Falls

• Motor vehicle-traffic crashes

• Assaults

Blasts are a leading cause of TBI for active duty military personnel in war zones.

• Males are about 1.5 times as likely as females to sustain a TBI

• Military duties increase the risk of sustaining a TBI

Symptoms of mild TBI• Headaches • Dizziness

• Excessive fatigue (tiredness)• Concentration problems

• Forgetting things (memory problems)• Irritability

• Sleep problems• Balance problems• Ringing in the ears

• Vision change

Symptoms Often Overlap With PTSD

Recovery (mild) is expected within 4-12 weeks however, some symptoms may linger for months to years

Post-Concussion Syndrome

Symptoms immediately post in jury may include:

– Memory, attention, concentration deficits– Fatigue, poor sleep, dizziness, headaches,

irritability, depression.– Anxiety – most common: free floating

anxiety, fearfulness, intense worry, generalized uneasiness, social withdrawal, heightened sensitivity, related dreams.

Moderate or Severe TBI Symptoms

A person with a moderate or severe TBI may show these same symptoms as mild TBI, but may also have:

• a headache that gets worse or does not go away• repeated vomiting or nausea• convulsions or seizures• an inability to awaken from sleep• dilation of one or both pupils of the eyes• slurred speech• weakness or numbness in the extremities• loss of coordination• increased confusion, restlessness, or agitation

PTSD vs. TBI

The overlap between classic symptoms of post-traumatic

stress disorder and those of mild traumatic brain injury is

substantial. Even those who appear to have no external

damage from explosions can suffer lasting brain injury that causes behavioral and other

symptoms.

Other Trauma Related Reactions

• Anxiety•Depression

• Shame/Guilt

• Stress• Alcohol

Anxiety

• A feeling of worry, nervousness or unease

generally out of proportion to actual

threat.•Can be both physical

or emotional

Anxiety Symptoms

Physical• Racing heart• Tightness or pain in chest• Shortness of breath• Headache• Tingling in finger tips• Muscle pains• Muscle weakness• Dizziness• Difficulty in swallowing • Abdominal discomfort• Diarrhea• Chills or hot flashes

Emotional• Irritability• Anger• Poor memory• Difficulty

concentrating• Fear of madness• Fear of impending

death• Feelings of being

outside yourself• Feelings of being

cut off from reality

Depression

• Persistent sad, anxious, or “empty” mood• Feelings of guilt, hopelessness or worthlessness• Fatigue or lethargy – being “slowed down”• Loss of interest in previously enjoyable activities• Irritability, restlessness• Sudden change in appetite• Major changes in sleep pattern (insomnia or

hypersomnia)• Difficulty concentrating or making decisions• Thoughts of suicide or death• Persistent physical symptoms that don’t respond to

treatment• Low self-esteem

Causes of Shame or Guilt in Traumatic Stress Injuries

•Surviving when others did not•Failing to save or protect others

• Killing or injuring others• Helplessness• Failing to act

• Loss of control• Even just having stress

symptoms of any kind

Stress

Physical•Headaches•Upset Stomach•Frequent colds•Lack of energy•Sleep problems•Forgetfulness•Clumsiness

Emotional•Anger•Irritability•Loss of hope•Feeling powerless•Poor concentration•Trouble making decisions•Sadness•Feelings of emptiness

Combat Stress

Combat Stress: A state of mental or emotional strain or tension resulting

from adverse or very demanding circumstances related to combat

operations.Combat Operational Stress Reaction

(COSR): A variety of physical and emotional signs related to an

overwhelmingly traumatic event, or a result of ongoing combat and non-

combat related stresses.

Ways to reduce Stress

•Surround yourself with friendly, positive people•Take some time everyday to be still and quiet•Eat a well-balanced diet – avoid caffeine & sugar•Set realistic limits on what you expect of yourself•Get plenty of sleep, and sleep regular hours•Break up big jobs into smaller, easier steps•Spend time doing simple things •Avoid excessive noise, crowded areas, and clutter

•Take a whole day sometime just to relax•Talk to someone about what you want or enjoy•Let yourself cry, even if you don’t know why•Laugh as often as possible•Avoid excessive alcohol or drugs•Stretch regularly throughout your day•Practice slow, deep breathing•Know you deserve to relax!!

Drugs and Alcohol• Drugs• Alcohol

• About 12 percent of active-duty soldiers and 15 percent of reservists had signs of alcoholism six months after returning

from combat, but few were referred to treatment. It's not unusual for a soldier's body to be revved up after returning from war, so it's not unusual to self-medicate with alcohol.

• 43 percent of active-duty military personnel reported binge drinking. Returning veterans of the Iraq and Afghan wars are

at especially high risk of binge drinking and suffering alcohol-related harm.

• More than 25 percent of Guardsmen and Reservists began binge drinking after experiencing exposure to combat, 8.8

percent started drinking heavily, and 7.1 percent developed alcohol problems

Referrals and Resources

See handout

HOPE for HEROES Serving those who serve and their families

Questions/ Discussion

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