Facilitating culture-centered communication between health care providers and veterans transitioning

from military deployment to civilian life

Christopher J. KoenigShira Maguen, Jose Monroy, Lindsay Mayott,

Karen Seal

August 16, 2014SSSP San Francisco, CA

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Background

Veterans returning from Afghanistan and Iraq–↑ PTSD, depression, & SUD–↓ MH service utilization–↑ PC service utilization– Little known about the cultural and social

aspects of re-integration

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Background

Military culture–Distinct population & community– Switch between cultures–Health vulnerable b/c of deployment• Medical (Chronic pain, TBI)• Psychological (PTSD, moral contamination)• Social (Isolation)

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Background

DisengagementFrom military

Re-Entry intoCivilian Life

Re-integrationInto Civilian Life

Model of Veteran Re-Entry to Civilian life

Faulkner & McGaw (1977)

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Study Aims

• To describe veterans’ transition experience from military to civilian life

• To develop a theoretical model of veteran readjustment

• To promote culturally sensitive interactions between providers & veterans after while readjusting to civilian life

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Data & MethodsData• 31 qualitative in-depth, semi-structured IVs– Purposeful sample – 17 male, 14 female veterans– Interview as conversation model– Audio-recorded & transcribed verbatim• ~65 minutes, 1,156 double-spaced pages

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Data & MethodsMethods• Grounded Practical Theory– Meta-theoretical framework• To make values and social practices available for critical

evaluation• To construct a normative model useful for practice &

reflection

– Blends analyses• Discourse Analysis (language use = evidence)• Grounded Theory Method (constant comparison)

Grounded Practical Theory

Philosophical level

Problem level

Technical level

Craig & Tracy, 1995

Grounded Practical Theory

Philosophical level

Problem level

Technical level

Craig & Tracy, 1995

Situated ideals

Practical values

Techniques

Readjustment ExperiencePHILOSOPHICAL

PROBLEMCivilianIdentity

MilitaryIdentity

Theoretical Model

Readjustment Experience

MilitaryIdentity

PHILOSOPHICAL

PROBLEMCivilianIdentity

Challenges AdviceTECHNICAL

Theoretical Model

Readjustment Experience

MilitaryIdentity

PHILOSOPHICAL

PROBLEM

CULTURALDOMAINS

CivilianIdentity

Intra-Personal

Professional/Educational

Inter-Personal

TECHNICAL Challenges Advice

Theoretical Model

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Intrapersonal Challenges

Extract 1. [29:4] Army, Female, Hispanic, 26–30 years old

IVR: What was it like transitioning back to civilian life after being deployed?

VET: It was weird. JUST DRIVING, IT WAS JUST CRAZY BECAUSE WHEN YOU GO TO SWITCH LANES, YOU JUST SEE SOMETHING ON THE STREET THAT I THINK IS AN IED [IMPROVISED EXPLOSIVE DEVICE]. So it’s like, I was always alert even when I came back. The neighbor down stairs slammed the door one night, and I thought it was a bomb and I started looking for an IBA [Interceptor Body Armor], my weapon.

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Intrapersonal Challenges

Extract 1. [29:4] Army, Female, Hispanic, 26–30 years old

IVR: What was it like transitioning back to civilian life after being deployed?

VET: It was weird. Just driving, it was just crazy because when you go to switch lanes, you just see something on the street that I think is an IED [improvised explosive device]. So it’s like, I was always alert even when I came back. THE NEIGHBOR DOWN STAIRS SLAMMED THE DOOR ONE NIGHT, AND I THOUGHT IT WAS A BOMB AND I STARTED LOOKING FOR AN IBA [INTERCEPTOR BODY ARMOR], MY WEAPON.

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Professional/Educational Challenges

Extract 2. [26:3] Army, Female, Caucasian, 31–35 years old

IVR: What were some of the major challenges that you faced when you came back?

VET: Boredom. YOU KNOW, [DURING DEPLOYMENT] YOU FUNCTION AT SUCH A HIGH LEVEL OF LIKE, ‘‘WHAT’S GONNA HAPPEN? WHAT’S GONNA HAPPEN?’’ EVEN THOUGH WE WERE TOTALLY BURNED [OUT] AND EXHAUSTED FROM THE AMOUNT OF HOURS AND TIME THAT WE WORKED. . .But when I went back to my old job, working on the maternity floor, I found it hard to even like stay awake at work ((laughter)). I didn’t feel like I had any job satisfaction. I didn’t feel like we had any camaraderie.

Readjustment Experience

MilitaryIdentity

PHILOSOPHICAL

PROBLEM

CULTURALDOMAINS

CivilianIdentity

Intra-Personal

Professional/Educational

Inter-Personal

TECHNICAL Challenges Advice

Theoretical Model

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Intrapersonal Advice

Extract 5. [12:1] Army Reserve, Multiracial, Male, 31–35 years old

IVR Do you have advice for somebody still deployed who is about to come home?

VET Don’t go home and sit around and dwell on negative things about what happened or, you know, negative aspects of life. Even if you don’t feel like it, force yourself to go back and get involved with your normal life. Do the things you used to enjoy doing, and see people you used to associate with. If you’re religious, definitely make sure you go to church.

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Professional/Educational Advice

Extract 4. [6:1] Marines, Male, Multiracial, 20–25 years old

IVR: Let’s say that you have a buddy about to come home, what advice would you give?

VET: You have to be proactive about everything you do. Nobody is going to help you out. Nobody knows exactly all the information to give you. Nobody can answer your exact question. You have to find that on your own.

Readjustment ExperiencePHILOSOPHICAL

PROBLEM

CULTURALDOMAINS

CivilianIdentity

Intra-Personal

Professional/Educational

Inter-Personal

TECHNICAL

MilitaryIdentity

Challenges Advice

Theoretical Model

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Communication Techniques

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Implications

• Reverse culture shock– Social identities change @ context– Readjustment difficulty based on living in distinct

cultures • Attention to communication– When articulating challenges, many participants

volunteered advice– Not all participants gave advice in all domains, all

participants gave advice for at least one domain– Veterans develop strategies for resilience

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Limitations

• 31 US veterans from Afghanistan & Iraq– At least 1 MH diagnosis/screen– Enlisted personnel (64.5%)– Most served 1 deployment (58.1%)

• Qualitative, semi-structured interviews• Interpretive theoretical framework

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Acknowledgements

• Department of Defense award W81XWH-08-2-0106

• VAMC Clinic providers• Veterans who served in OEF/OIF/OND