The War at Home:

Returning Veterans and After- Deployment Struggles August 6, 2011Samaritan Institute Annual conferenceDenver, CO

Three Learning Objectives:1. Develop treatment plans that differentiate between Combat/ Operational Stress Reaction and Post Traumatic Stress Disorder 2. Recognize how the Three Prime Directives that sustained veterans in combat contribute to emotional disconnection and difficulties in personal life and relationships. 3. Address the treatment differences between PTSD and Mild Traumatic Brain Injury and how these differences must be handled through very different therapeutic modalities.

Presenter, Jerry Powell

Licensed Marriage and Family Therapist NCLicensed Professional Counselor, NC, NCCAAMFT Clinical Member and Approved SupervisorApproved Clinical SupervisorOrdained 74

Director/Therapist at The Fayetteville Family Life Center, Fayetteville, NC; a Division of CareNet of North Carolina, part of Wake Forest Baptist Health, Department of Pastoral Care, Winston-Salem, NC.Adjunct Professor- Webster University, St. Louis, MO, Pope Air Force Campus, Fort Bragg, NC; Graduate Counseling Department.

B.S. 1975; William Jewell College, Liberty, MO.M.Div. 1978; Midwestern Baptist Theological Seminary,Kansas City, MOD.Min. 1989; -- Midwestern Baptist Theological Seminary, Kansas City, MOM.A., 1998, Community Counseling; Columbus State University, Columbus, GA.

Married to Janet Smarr of Overland Park, KS.;Three grown, married children, five grandchildren.

Our time together todayThree parts about returning vetsReturning Veterans and their familiesWhat we find works and what is not always helpfulReturning Vets with Mild Traumatic Brain InjuryReturning Vets with Post Traumatic Stress DisorderHow to respond to our Soldiers and families in distress.How to help Centers get in the mix.

Jerry PowellUS Army Chaplain 1987-2007Retired 2007 (Lieutenant Colonel)

Served in Korea, Japan, Iraq, Texas, Georgia, New York, Kansas and North Carolina.

Email:jepowell@wfubmc.edu

Deployed to Iraq in 2005 as part of the Multi-National Force-Iraq (MNFI)

Advisor to the Iraqi government on the writing of their constitution on areas of: religious freedom, rights of women & children, Non-governmental organizations

Pastor to the Embassy Chapel and Chaplain to Multi-National Security Transition Command-Iraq (MNSTCI). Provided ministry coverage to Security details and teams and multi-national forces in Baghdad.

Review of materialsHandouts and take-awaysCase PresentationVideo resourcesus.army.mil web siteWeb searches for future use

Who are you and what are you doing here?

The high price of servingPersonalFamilyMoral

Understanding the Returning VetHow the veteran views his or her life after returning from combat

How the family views the veteran after the return to the family.

How the clinician can normalize their view of their life and their changes

What is it like?Go from Hero to ZeroPTSDPost-concussive SyndromeMild TBIReadjustment difficulties

Time lines for healingHow long after the deployment to get to the New Normal?

When is the next deployment cycle?

How are Reserve and National Guard served?

They are all normal I am pleased with how well you are doing

Understanding the Returning VetEveryone in direct combat comes back different.

Different does not necessarily mean better or worse,It just means different

My husband has deployed five times and every time he comes back he is a different person than the man that I married.Wife of a soldier in counseling

Different from a therapists viewThis difference is not the normal presentation of individual or couple/family distress or dysfunction. This difference is not a developed cause and effect of relationship dynamics, but rather an imposed and unwanted intrusion in the family process that is difficult to clarify or address.

Coming home differentComing home with a level of disappointment.

We all come home to a partner with a different level of disappointment.

Why we get disappointed in warThe first bullet changes our lives.Dumb decisions get people hurt and killedInnocent people get caught up in the stupidityUndeserving people get awardedDeserving people get nothingNothing is like we expected and there is nothing we can do about it.

How we deal with the differenceAdrenaline junkieTakes a higher jolt to get our attentionFaster bike/car; more alcohol; sexIgnoring mortalityRefusing to heed higher HQs guidance.

What is different?No sense of urgency/importance.No way to make up for what was missed.Low emotional/conversational energy levelPreference to stay with other vetsHome life:DrinkingAvoiding family membersLimited decision making

Brothers at WarBy Metanioa FilmsProduced by Gary Sinese

3 prime directivesduring combatStay aliveStay safeTake care of your buddies

Anything outside of the 3 Directives will appear irrelevant. This can seem to indicate lack of interest or energy in the relationship.

Is anybody angry here?Everyone who deploys returns with some level of anger after the deploymentEveryone who deploys returns to someone with a level of anger after the deployment.

He just screamsNo question on her part of commitment, but no way to counter his anger.

He used to be sensitive, but that wore away

He wants me to be tough like he has to be tough, and to show no emotion.

Diagnosis and AssessmentPTSD or redeployment issues?Anxiety or Depression?

Readjustment or Axis II?

Low energy or chronic depression?

Use of medication

MTBIMild Traumatic Brain InjuryWhat it is and what we do with it

[Hint: Cant find it in DSM]

STRETCHED TO THE LIMIT: SHOCK WAVES CAN DAMAGE HEALTHY BRAIN CELLS. [LEFT] SOMETIMES JUST LIGHTLY TWISTING THE CELL IS ENOUGH TO DO THE JOB. THE DOWNWARD SPIRAL: THE SHEARING NOT ONLY CAUSES PHYSICAL DAMAGE TO CELLS BUT CAN ALSO UNLEASH A BIOCHEMICAL CASCADE THAT EVENTUALLY CAUSES CELLS TO SELF-DESTRUCT [RIGHT].MEDI-MATION

Mild TBI vs.

Moderate TBISevere TBI

Characteristics of MTBISame as PTSDLosing the filter on their mouth (Filter between the brain and mouth is out of adjustment)Losing higher level rationale and behavior.Unable to recognize when they are out of control.

Brain damage in frontal cortex

PTSDHow do we recognize it?How do we treat it?Everyone with PTSD has the characteristics of MTBI; But everyone with MTBI does not have PTSD

List of medsWellbutrin/75 mgXanax (alzrazolam)/.5mgAlbuterol-inhalerSingulair (montelukast)/10mgDilaudid (hydromorphone)2mgAmbien (zolpidem)/10mgTrazadone/50 mgVitamin B12 injectionVitamin D3/400IUAnxiety2x dayAnxiety1-2 3x dayshortness of breath1-2xallergies1x daypainas neededto sleep1x dayto stay asleep1x day1x mo5 tab/day

Presenting for treatmentHow long after deployment do the concerns start surfacing?

Couples present for help with marriage, but what is the issue?

Individuals often have trouble presenting by themselves.

Treatment modalitiesDeveloping Treatment PlansPurpose and choice of modalitiesExposure therapyCognitive/behavioral therapyBehavior modification therapyEMDRSpiritual dimensionValue of holding placeHow long will treatment take?

Permanent White WaterThe goal:Stay in the boat

Who has the energy for the relationship?

What will we do with their anxiety?

Coping skillsHow much does the client want help? Is the help being accepted or resented by them when offered by family members?

How can we help with the anxiety during the time of healing?

How will we shape our sessions with them?

Clinician/theologianHow does treating combat vets affect you as a clinician?

How does a clinician take care of ones self?

How do we help our teammates?

Theological ImplicationsCombat and traumaJust War and supporting vetsTheology of combat and killing

Implications for our community

Community/Congregational SupportHow do we recognize and honor our vets?Do they feel welcomed and received?How do we manage their differences?

Review of MaterialsWeb sitesHandoutsReferences

Discussion time

email:

jepowell@wfubmc.edu