6/7/2010

1

Understanding the Returning Veterans

Julia E. Hoffman, Psy.D.

National Center for PTSD

VA Palo Alto Health Care System

National Center for Telehealth & Technology

Defense Centers of Excellence

julia.hoffman@va.gov

The views expressed in this presentation are

those of the presenter and

do not reflect the official policy of

the Department of Veterans Affairs,

the Department of Defense

or

the United States Government

Disclaimer

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Overview

Military 101

Overview of Operation Enduring Freedom

and Operation Iraqi Freedom

Demographics of student veterans

GI Bill Update

Resources for Student Veterans

Military 101

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America’s Wars

Total U.S. Service Members

American Revolution (1775-1783) 217,000

War of 1812 (1812-1815) 286,730

Indian Wars (approx. 1817-1898) 106,000

Mexican War (1846-1848) 78,718

Civil War (1861-1865) 2,213,363

Spanish-American War (1898-1865) 306,760

World War I (1917-1918) 4,734,991

World War II (1941-1945) 16,112,566

Korean War (1950-1953) 5,720,000

Vietnam War (1964-1975) 8,744,000

Desert Shield/Desert Storm (1990-1991) 2,322,000

Global War on Terror (October 2001 - ) Approximately 1.2 million*

(U.S. Dept. of Veterans Affairs, 2010)

Military Rank Structure

Enlisted Service

Members

84%

Warrant Oficers

2% Commissioned

Oficers

14%

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Four Branches

The armed forces are comprised of four

branches each with a different function and

purpose and each with a unique culture of

its own.

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Army Structure

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Navy Structure

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Active versus Reserve Components

Active Component

• Works “full time” for the military

• Full time hours, full time benefit

• On-call 24 hrs/day, 365 days a year

• Permanent force of the military in war and peace

• Benefits:

1. Competitive salary and bonuses

2. Free healthcare for SM and family (TriCARE, VA)

3. 30 days annual leave

4. Base Privileges

5. Retirement after 20 years

6. Camaraderie and pride

Active Component Stressors

Permanent Change of Station (PCS)

Temporary Duty (TDY)

Deployment

Risk of injury or death

Behavioral expectations

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Reserve Components

Part-time duties

One weekend a month, 2 weeks a year

Can be activated to augment Active Components

There are seven reserve components of the U.S. military:

• Army Reserve

• Army National Guard

• Air Force Reserve

• Air National Guard

• Navy Reserve

• Marine Corps Reserve

• Coast Guard Reserve

Reserve versus National Guard

National Guard is “owned” by its state, while

the Reserves are “owned” by the federal

government.

NG may also be activated into military

service as needed

NG has a dual mission to serve state as well

as federal government

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Benefits and Stressors for NGR

Benefits include:

• Flexibility to serve while working on educational or occupational goals

• Pay for Drill and Annual Training

• Bonuses

• Healthcare for SM and family for a fee (TriCARE, VA)

• Base Privileges

• Pro-rated retirement pay at age 60 after completing at least 20 years of

part-time service (39 days a year).

Stressors include:

• Being “citizen soldiers”

• Mobilization and deployment

• Separation from job, family, school, etc.

• Isolation from military structure and social support

• Some limited benefits

• Training issues

Military and Veteran Treatment 101

Most Service Members will initially be treated in military

treatment facilities (MTFs)

Many return to the Continental US (CONUS) with injuries

and are treated in MTFs, VA hospitals, Vet Centers, civilian

treatment centers, or other facilities

Chaplains are the only fully confidential counseling in the

Military

Medical Boards

Service Connection

Services can be found through VA or MilitaryOneSource

All stateside DoD and VA health records while stateside are

electronic

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Profile of U.S. Veterans

65 and

older

39%

40 - 64

48%

39 or

younger

13%

Age

•Among the post 9/11

population, 73% of

Veterans are aged 39 or

younger

•This population is

expected to grow from

1.2 million to nearly 2

million by 2013.

(U.S. Dept. of Veterans Affairs, 2007)

Race and Ethnicity

All U.S. Veterans Veterans Age 39 or Younger

Non-

Hispanic

White

68%

African

American

16%

Hispanic/

Latino

10%

Other

6%

White

85%

African

American

10%

Asian

American

1%Other

4%

(U.S. Dept. of Veterans Affairs, 2007)

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Gender Distribution

1980 2006

Male

93%

Female

7%

Male

96%

Female

4%

(U.S. Dept. of Veterans Affairs, 2007)

Male

93%

Female

7%

Operation Enduring Freedom and

Operation Iraqi Freedom

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KIA and WIA

OFFICIAL DoD COUNT OF:

Troops Killed in Iraq: 4,391

Troops Killed in Afghanistan: 1,199

Wounded in Action in Iraq: 3,1839

Wounded in Action in Afghanistan: 6,141

(DoD, May 2010)

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Operation Enduring Freedom (OEF) and Operation

Iraqi Freedom (OIF)

Previously referred to as the Global War on Terror

(GWOT)

Afghanistan: mountainous with distinct seasons

(9/11 Attacks)

Iraq: desert with incredible heat (WMD)

Urban guerilla warfare, no front lines (and no safe

Military Occupational Specialties), difficult to

identify enemy

Frequent encounters with explosives (IEDs, RPGs,

etc.), which can be triggered with common devices

(e.g. key fob or mobile phone)

Experience of OEF/OIF Veterans

Career military with 53% doing multiple tours

Contact can be made with families at home using email,

cell phone, Skype, or other services

Generally daily (and/or nightly) missions, leave Green Zone

and then return at night

Frequent boredom and downtime is most unexpected

unpleasant experience

Driving challenges specific to these conflicts

Friendly with some Iraqi and Afghani civilians

No specific sleep schedule; use of caffeine drinks

Infrequent substance abuse comparatively

Carrying heavy materials constantly

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Exposure to war-zone stressors in OIF

Combat stressors:

• 51% reported they had been in serious danger of being injured or killed on at least several occasions during the deployment

Non-combat stressors: “high/very high trouble or concern”

• 87% uncertain redeployment

• 71% long deployment length

• 55% lack of privacy or personal space

• 54% boring or repetitive work

78% reported seeing destroyed homes and villages

67% (95%) reported seeing dead bodies or human remains

65% reported having hostile reactions from civilians

63% (93%) reported receiving small arms fire

61% (89%) reported being attacked or ambushed

59% (86%) reported knowing someone who was seriously injured or killed

37% reported engaging in a firefight

19% (48%) reported being directly responsible for death of enemy combatant

(14%) reported being responsible for death of non-combatant

(22%) reported having buddy shot or hit who was near you

11% (22%) reported engaging in hand-to-hand combat

10% (14%) reported being wounded/injured

*Reported during deployment (reported after deployment)

War-Zone Stressors (OIF)

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Military Sexual Trauma (MST)

23% of female VA patients reported experiencing at

least one sexual assault while in military

• < 1% of male VA patients???

Rates are higher in wartime

• Persian Gulf War

Sexual assault (7%)

Physical sexual harassment (33%)

Verbal sexual harassment (66%)

What’s Keeping the New Veterans from Seeking Care?

Practical Concerns

22%: I don’t know where to get help

18%: I don’t have adequate transportation

45%: It’s difficult to schedule an appointment

55%: Difficulty getting time off work

25%: Costs too much money (Hoge et al. 2004,

NEJM)

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What Else?

Stigma! 50%: It would harm my career

59%: Members of my unit might have less confidence in me

63%: Unit leadership might treat me differently

51%: Leaders would blame me for the problem

65%: I would be seen as weak

41%: It would be too embarrassing

38%: I don’t trust mental health professionals

25%: Mental health care doesn’t work

How Can We Reach the Newest Veteran?

Most appear to acknowledge having a problem• Army Iraq War returnees: 78% of those who screened positive for MDD,

GAD, or PTSD

Interest in receiving help, however, is much lower• Only 43% of positive screens

GAO 2006 Report on DD 2796• 5% of returnees screened positive for PTSD

• Only 22% of positive screens were referred for mental health evaluations

35% of returnees accessed mental health services in the year after returning home (Hoge et al., 2006)

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Mental Health Diagnoses for New Veterans in VA Care

13%

12%

9%

8%

5%

2%1%

0%

5%

10%

15%

PTSD

Drug abuse

Depression

Neurotic disorders

Affective psychoses

Alcohol dependence

Drug dependence

Problematic Drinking After Deployment (Hoge, 2004)

17%

13%

25%

18%

24%21%

35%

29%

0

0.05

0.1

0.15

0.2

0.25

0.3

0.35

0.4

Have you used alcohol more

than you meant to?

Have you felt you wanted or

needed to cut down on your

drinking?

Pre-Deployment Army Afghanistan Army Iraq Marine Iraq

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New Veterans May Minimize Substance Use

Problems….

• Heavy drinking is socially validated among young adults

• 37% of men under age 25 binge drink (drops to 20% in men age 45-64)

• Drinking to mask problems is less stigmatizing than admitting to PTSD or depression

• Admitting to drug use may have negative consequences

• Younger veterans often have not yet had enough time to encounter negative consequences of substance use (have not “hit bottom”)

Student Veterans

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Definitions

Military Students/

Student Veterans

Nonmilitary

Nontraditional

Students

Nonmilitary

Traditional

Students

Percentage Distribution of Undergraduates

Undergraduates by Military Status

Veterans (3.1%)

Military: Active Duty (0.6%)

Military: Reserves (0.4%)

Non Vet or Military Undergrads (95.8%)

Military Undergraduates by Current Service

Veterans,

75%

Active

Duty,

16%

Reserves

, 9%

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Demographics of Student Veterans: Age

0.5 0.9

18.115 13.6

81.9

31.4 37.2

0

28.226.5

0

24.9 21.9

0

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Military Nonmilitary

Nontraditional

Traditional

40 or older

30-39

24-29

19-23

18 or younger

Radford & Wun (2009)

Demographics of Student Veterans: Gender

26.9

64.852.9

73.1

35.247.1

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Military Nonmilitary

Nontraditional

Traditional

Male

Female

Radford & Wun (2009)

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Demographics of Student Veterans: Race/Ethnicity

60.1 5765.8

18.318.1

10.3

12.8 15.1 13.5

3.2 5.6 4.35.7 4.3 4.1

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Military Nonmilitary

Nontraditional

Traditional

Other

Asian American

Hispanic

African American

White

Radford & Wun (2009)

Demographics of Student Veterans: Dependency and

Marital Status

Dependent, 3%

Unmarried, no

dependents,

35%

Married, no

dependents,

15%

Married

parents, 33%

Single parent,

14%

Radford & Wun (2009)

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Military Experience (CSCMH data)

No

72%

Yes

28%

Did your military

experiences include any

traumatic or highly

stressful experiences

which continue to

bother you?

No

98%

Yes

2%

Have you ever been

enlisted in any branch of

the US military (active

duty, veteran, national

guard, or reserves?)

Difficulties of Student Vets with Trauma Exposure

0%

5%

10%

15%

20%

25%

30%

35%

40%

45%

I get angry

easily

I have difficulty

controlling my

temper

I have spells of

panic or terror

I have

unwanted

thoughts I

cannot control

I am afraid I

may lose

control and act

violently

I have no one

who

understands

me

The percentage of students who strongly endorsed

specific CCAPS items

Military with trauma Military without trauma Non-military

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Functional and Social Issues for Student Veterans

Liberal bias of professors

Feeling out of place due to differing

demographics and developmental mismatch

with peers

High marriage rate means student veterans

have more commitments

Military sexual trauma can lead to

relationship problems and medical refusal

Driving problems

Half of Us

4

8

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Factors of Graduation Success for Student

Veterans

GI Bill and

Financial Aid

Successul

Transition from

the Military

Support from

Academic

Institution

Physical and

Mental Health

Support

Employability

Following

Graduation

Sense of

Belonging on

Campus

(Student Veterans of America 2010 Legislative Agenda www.studentveterans.org )

GI Bill Update

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History of the G.I. Bill

19

40

19

50

19

60

19

70

19

80

19

90

20

00

20

10

Veterans’

Educational

Assistance Act

of 1984 (the

Montgomery

GI Bill)

Veterans’

Readjustment

Benefits Act of

1966

Veterans’

Readjustment

Assistance Act

of 1952 (the

Korean GI Bill)

1944

Servicemen’s

Readjustment

Act

Post-

Vietnam Era

Veterans’

Educational

Assistance

Act of 1977

Post-9/11

Veterans

Educational

Assistance

Act of 2008

Basic Eligibility Requirements or Benefits of the New GI Bill

Military service members and vets may be eligible for benefits under the new GI Bill if:

Served at least 90 aggregate days on active duty after September 10, 2001 and meet one of the 5 requirements:

1. Currently active duty

2. Honorably discharged from active duty

3. Honorably released from active duty and placed on the retired list or temporary disability retired list

4. Honorably released from active duty and transferred to the Fleet Reserve or Fleet Marine Corps Reserve

5. Honorably released from active duty for further service in a reserve component of the Armed Forces

OR served 30 continuous days after September 10, 2001 if honorably discharged from active duty for a service-connected disability)

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Type of Institution by Student Type

9 8 9

12 154

13 916

43 49

32

21 19

38

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Military Nontraditional

nonmilitary

Traditional

Public four-year

Public two-year

Private not-for-profit four-

year

Private for-profit

Others or attended more

than one institution

Attendance by Student Type

37 37

13

23 29

17

1614

14

23 20

56

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Military Nontraditional

nonmilitary

Traditional

Full time / full year

Full time / part year

Part time / full year

Part time / part year

Radford & Wun

(2009)

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Financial Aid (Including VEB) by Student and

Institution Type

66%

81%85%

98%

48%

67%

82%

97%

45%

73%

86%

95%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Public two-year Public four-year Private not-for-

profit our-year

Private for-profit

Military Nonmilitary nontraditional Traditional

Reasons for Choosing Institutions by Student

Type

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

Location Program/

Coursework

Cost Personal or

Family

Reputation Other

Military Nonmilitary Nontraditional Traditional

Radford & Wun (2009)

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Top 10 Schools Enrolling Students with GI Bill

Benefits

Institution Students using GI

Bill

1 U. Of Phoenix-Online Campus 17,714

2 American Inter-Continental U. 3,698

3 American Public U. System 3,668

4 U. Of Maryland U. College 3,359

5 Central Texas College 3,024

6 Colorado Technical U. 2,738

7 Saint Leo U. 2,688

8 Kaplan U. 2,460

9 Strayer U. 2,348

10 U. Of Maryland at College Park 2,260

U.S. Department of Veterans Affairs (2008)

Resources for Student Veterans and

Health Care Providers

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5

9

http://www.mentalhealth.va.gov/College/

Student Veterans of America www.studentveterans.org

Three primary missions:

•Develop student veteran groups on

college and university campuses and

coordinate by region between existing

groups.

•Connect student groups with

resources.

•Advocate on behalf of student veterans

at the state and national level.

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6

1

3-Tier Access Model:

• Visitors

• Registrants

• In-Person Authenticated (IPA)

Users

www.myhealth.va.gov

March 2010:

• Over 38.6 Million visits

• Over 976,000 registered users

(75% are VA patients)

• Over 186,000 users have an IPA

account

• Over 14.5 Million VA prescription

refills since August 2005

My HealtheVet Overview

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My HealtheVet Features Today

• Personal information (contacts, providers, etc.)

• Personal, family, and military health history

• Personal health summary

• HealtheLogs (blood pressure, weight etc.)

• Medications (over the counter drugs, herbals, etc.)

• Allergies and immunizations

• Medical events

• Food and activity journals

• Online VA prescription refills, VA prescription history

• My Complete Medications (printable summary)

• Wallet health information card

• Health calendar

• Trusted health education information

• Self-assessment tools, VA Wellness Reminders

• Mental health resources (including online courses)

• Secure Messaging (currently at 8 VA sites)

Considering Professional Help

Open-access,

30-minute

course with 5

topics

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Do I need help?

Take a quick self-check

For example: “I have been

feeling sad or depressed

almost all of the time for

more than one week.”

What is stopping me?

Includes known

barriers to help-

seeking

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What can I expect?

Actor videos of

transcripts of

Veterans who

have had to

overcome

concerns and

challenges

before

seeking helpDescription of types

of care that may be

available:

•Counseling

(Individual, group,

residential)

•Medication

Who can help me?

Provides

descriptions

of various

professionals

who can help

and what they

do

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Where can I find help?

Directories for

Veterans, including:

•Sites for returning

Veterans, facility

locator (VA and RCS),

etc. (and NCPTSD)

•Descriptions of

these links

Directories for

everyone,

including:

•APA,

physician

finder, ABCT,

ACA, AAPC,

etc.

•Descriptions

of these links

Afterdeployment.org

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Contents for Each Topic

Validated assessments

on related areas of

functioning (e.g. PCL;

PHQ-9)

Multi-session

interactive workshops

E-library

Links & books

Forums

Personal stories from

real veterans and

service members

http://store.pamphleteerpress.com/06.html

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Military Competence

Center for Deployment Psychology www.deploymentpsych.org

Operation S.A.V.E.

Operation S.A.V.E training will help you act with care and compassion if you encounter a person who is suicidal. The acronym summarizes the steps needed to take an active and valuable role in suicide prevention.•Signs of suicidal thinking •Ask questions •Validate the person’s experience •Encourage treatment and Expedite getting Help

7

4

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Questions?

National VA Hotline for Benefits and General Info:

1-800-827-1000

Julia E. Hoffman, Psy.D.

julia.hoffman@va.gov