Coming Home Current Concerns Facing Our Returning Veterans and Their Families

Coming Home – Current concerns facing our returning veterans and their families. Michele Lukacik, MA, LPC, LMHC, Veteran

Terms • OIF • Active • Dependant • Service • OEF Duty • Retired Connected Disability • TDY • Guard • DD-214 • Vet • Deploymen • Reserve t • Discharged • Vet Center

Deployment • 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 Preparing for Telling the Saying Good Bye Distance Deployment Children

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%) • Being responsible for the death of a • Shooting or directing fire at the non-combatant (14%) enemy (77%) • Seeing dead bodies or human remains • Being responsible for the death of an (95%) enemy combatant (48%)

The Family Left Behind • Stress of Deployment • Financial Concerns • Changes in Communication • Becoming Primary Parent • Changes in Routine • Children Acting Out • Head of Household

The Homecoming • Couples Communication • Changes in Routine • Family Interactions • Adjustment to Visible and Invisible • Roles Injuries

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". • 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. • 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 • 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 • Anger Management • Help Couples & Families Reconnect / • Coping with injury Communicate • Driving aggressively to avoid debris in • Prevention the road • Adjust to life after Deployment • Feeling anxious in crowds • Reorientation to Civilian life • Difficulty readjusting to family roles • Depression • Difficulty sleeping • Anxiety • Difficulty keeping your focus • PTSD

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. Common examples include: • Serious accident or injury • Sudden or unexpected death • Physical assault • Natural disaster • Rape / Sexual Abuse • Military Combat • Robbery - 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 simply means that the natural healing process from the trauma has been blocked or hampered in some way.

PTSD Symptoms - Symptoms come in 3 Groups

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.

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 • Motor vehicle-traffic crashes • Falls • 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 • Concentration problems • Sleep problems • Dizziness • Forgetting things (memory • Balance problems • Excessive fatigue problems) • Ringing in the ears (tiredness) • Irritability • 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 • slurred speech go away • weakness or numbness in the • repeated vomiting or nausea extremities • convulsions or seizures • loss of coordination • an inability to awaken from sleep • increased confusion, restlessness, or • dilation of one or both pupils of the agitation eyes

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 A feeling of worry, nervousness or unease generally out of proportion to actual threat.

Anxiety Symptoms Physical • Racing heart • Tightness or pain in chest • Irritability • Shortness of breath • Anger • Headache • Poor memory • Tingling in finger tips • Difficulty concentrating • Muscle pains • Fear of madness • Muscle weakness • Fear of impending death • Dizziness • Feelings of being outside yourself • Difficulty in swallowing • Feelings of being cut off from reality • Abdominal discomfort • Diarrhea • Chills or hot flashes Emotional

Depression • Persistent sad, anxious, or “empty” • Sudden change in appetite mood • Major changes in sleep pattern • Feelings of guilt, hopelessness or (insomnia or hypersomnia) worthlessness • Difficulty concentrating or making • Fatigue or lethargy – being “slowed decisions down” • Thoughts of suicide or death • Loss of interest in previously • Persistent physical symptoms that enjoyable activities don’t respond to treatment • Irritability, restlessness • Low self-esteem

Causes of Shame or Guilt in Traumatic Stress Injuries Surviving when others did not Failing to act Failing to save or protect others Loss of control Killing or injuring others Even just having stress symptoms of any kind Helplessness

Stress Physical Emotional • Headaches • Anger • Upset Stomach • Irritability • Frequent colds • Loss of hope • Lack of energy • Feeling powerless • Sleep problems • Poor concentration • Forgetfulness • Trouble making decisions • Clumsiness • Sadness • Feelings of emptiness

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.

Drugs and 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 REFERRAL RESOURCE LIST FOR VETERANS AND FAMILIES

 After Deployment: www.afterdeployment.org/index.php  Air Force-Wounded Warrior http://www.woundedwarrior.af.mil/  Army Families Online - 1-800-833-6622 - One stop center to address questions of families that lost a soldier - information on benefits etc. http://www.armywell-being.org/  America's Heroes at Work A U.S. Department of Labor project that addresses the employment challenges of returning service members living with brain injury or Post-Traumatic Stress Disorder . http://www.americasheroesatwork.gov/  American Legion http://www.legion.org/  Army Post-Deployment Health Reassessment Program http://www.armyg1.army.mil/HR/pdhra/faq_overview.asp  Blue Star Moms Have children serving now. http://www.bluestarmothers.org  Defense Centers of Excellence in Psychological Health and Traumatic Brain Injury http://www.dcoe.health.mil/default.aspx  Defense and Veterans Brain Injury Center Serve active duty military, their dependents and veterans with traumatic brain injury through state-of-the-art medical care, innovative clinical research initiatives and educational programs. http://www.dvbic.org/  Department of Labor http://www.dol.gov/vets/  Department of Veterans Affairs http://www.va.gov/  Deployment Health Clinical Center http://www.pdhealth.mil/  Deployment Guide For Families of Deploying Soldiers. Separation and Reunion Handbook www.hooah4health.com/deployment/familymatters/reunion.htm#  DisabilityInfo.Gov http://www.disability.gov/education/veterans_&_military  Disabled American Veterans https://www.dav.org  DOD Deployment Health Clinical Center -- A Soldier and Family Guide to Redeploying. www.apgea.army.mil/deployment/FamilyReunionTrifold19Dec03.pdf  Free Attorney to veterans and family members http://www.vetsprobono.org/  Getting Home: All the Way Home. Free downloadable DVD created by TriWest (TRICARE Contractor) for soldiers & their families. www.triwest.com/triwest/default.html?/triwest/unauth/newContent/newBehavioralHealth/videostream.asp  GI Rights Hotline, 800-395-9544 Provides advice to members of the military seeking information about discharges, grievance and complaint procedures and other civil rights. http://www.objector.org/girights/  Give an Hour Non-profit providing free mental health services nation wide http://www.giveanhour.org  Gold Star Moms Mom's military children died on duty. http://www.goldstarmoms.com/  Gold Star Siblings - Brings together brothers & sisters. http://www.goldstarsiblingsinc.org/  Gold Star Wives - 1-888-751-6350 - Military Widows where spouse died on duty. http://www.goldstarwives.org/  Grief Support http://griefnet.org/resources/veterans.html  Hope For Heroes Free counseling for OIF/OEF Vets in central Texas www.hopeforheroestexas.org  Hope 4 Heroes Counseling Resources for Veterans http://www.hope4heroes.org/  Horses for Heroes Nation wide therapeutic riding programs for veterans http://www.narha.org/Horses%20For %20Heroes/NARHAHorsesforHeroes.asp  Iraq & Afghan Vets of America - 212-982-9699 - Group dedicated to support Iraq and Afghan troops. http://iava.org/.  Lawyers Serving Warriors A project of National Veterans Legal Services Program that provides free legal services to U.S. military personnel and veterans who served in OIF or OEF, and who need help with disability, discharge, or veterans benefits cases.www.LawyersServingWarriors.org  Marines-Wounded Warrior Regiment www.woundedwarriorregiment.org  Medline Plus: Veterans http://www.nlm.nih.gov/medlineplus/veteransandmilitaryhealth.html  Military Treatment Facility Locator http://www.tricare.mil/mtf/  Military Mental Health Screening - online self screening for all branches. https://www.militarymentalhealth.org/Welcome.aspx  Military Widows - 1-800-842-3451 - Helps women who’s husband died on active duty or were disabled. http://www.militarywidows.org/  Mental Health Self-Assessment Program (DOD sponsored mental health / alcohol screening and referral program offered to families and service members affected by deployment) www.MilitaryMentalHealth.org  Military One Source (1-800-342-9647). www.militaryonesource.com  Military HOMEFRONT (Official DoD site). www.militaryhomefront.dod.mil  Benefits Facts Sheets, US Department of Veterans Affairs: www.vba.va.gov/benefit_facts/index.htm  National Resource Directory: www.nationalresourcedirectory.org  National Center for PTSD. www.ncptsd.org  National Coalition for Homeless Veterans http://www.nchv.org/  National Lawyers Guild, Military Law Task Force Assists those working on military law issues as well as military law counselors working directly with GIs. 415-566-3732 http://www.nlgmltf.org/  National Guard Post-Deployment Health Reassessment Program http://www.virtualarmory.com/mobiledeploy/PDHRA/  National Gulf War Resource Center 1-866-531-7183 - International service provides information and support to those affected from Gulf war. http://www.ngwrc.org/  National Mental Health Association. www.nmha.org/reunions  National Native American Vet Association - Assists Native Americans without regard to tribal affiliation on veterans benefits and rights. http://www.nnava.org/  Post-Deployment Stress: What Families Should Know, What Families Can Do. http://rand.org/pubs/corporate_pubs/CP535-2008-03/  Post-Deployment Stress: What You Should Know, What You Can Do. http://rand.org/pubs/corporate_pubs/2008/RAND_CP534-2008-03.pdf  PTSD Support Services - Resources and other information for Post Traumatic Stress Disorder (PTSD), particularly related to military service. http://www.ptsdsupport.net/  S.A.F.E. Program, Support And Family Education: Mental Health Facts for Families. An 18-session curriculum for people who care about someone who has a mental illness / PTSD. w3.ouhsc.edu/safeprogram  Safe Harbor Program-Navy http://www.npc.navy.mil/CommandSupport/SafeHarbor  Service Dogs for Veterans http://www.hero-dogs.org/veterans.html or http://www.neads.org/services_new/military_dog.shtml  Silver Star Families - 1-812-847-7030 - Assists the wounded vets and their families. http://www.silverstarfamilies.org/  Substance Abuse http://findtreatment.samhsa.gov/  Swords to Plowshares Provides counseling and case management, employment and training, housing, and legal assistance to homeless and low-income veterans. www.stp-sf.org  Sons & Daughters In Touch - 1-800-984-9994 - Locates, unites, and supports son&daughters of vietnam vets http://www.sdit.org/  Strategic Outreach to Families of All Reservists: www.sofarusa.org  State Departments of Veterans Affairs: www.nasdva.com  Surviving Deployment: Resources for Military Families. www.survivingdeployment.com  Transition Assistance Program http://www.turbotap.org/portal/transition/resources/About_Us  TexVet: Partners Across Texas Partners Across Texas is the collaborative effort of federal, state and local organizations, that focuses on bringing our military members and those that care about them a wealth of resources. The resources identified through TexVet are meant for anyone who is serving or has served in any branch of the military, as well as the others who care about a service member. http://texvet.com  Tricare (South) http://www.humana-military.com/  US Department of Veterans Affairs: www.va.gov and www.oefoif.va.gov  Vet Centers: Free Counseling for Combat Veterans and their families www.vetcenter.va.gov  United Warrior Survivor Foundation - 1-877-804-8973 - Committed to the spouses surviving Special Operations personnel killed in the line of duty. http://www.frogfriends.com  Veterans for America http://www.veteransforamerica.org/  Veterans Asbestos Exposure Focuses on military asbestos exposure with a listing of veteran-specific hospitals and medical centers and a database of medical & legal resources for veterans. http://www.mesothelioma.com/veteran_asbestos_exposure.htm  Veterans of Foreign Wars http://www.vfw.org/  Welcome Home: How to make a difference in the lives of returning war zone veterans (includes Dr. James Munroe’s “Eight Battlefield Skills that Make Life in the Civilian World Challenging”). Washington Family Policy Council. www.fpc.wa.gov/Welcome%20Home.pdf  Veterans Benefits Manual (Legal) http://www.nvlsp.org/Publications/Bookstore/Manuals/vetbenefitmanual.htm  Veterans’ Widows/ers International Network - 303-756-8920 - Veterans’ Widows/ers (Survivors), reaching out to Vet's Widows/ers Statewide & overseas. http://www.vetsurvivors.com/  Vietnam Veterans of America 1-800-VVA-1316 - Helps Vietnam vets with all their issues. http://www.vva.org/  Vietnow - 1-800-837-VNOW - Works on veterans issues affecting them now. http://www.vietnow.com  Wounded Warrior Project https://www.woundedwarriorproject.org/

REFERRAL RESOURCE LIST FOR CHILDREN AND PARENTS

 10 Things Military Kids Want You to Know www.nmfa.org/site/DocServer/TOOLKIT_8.5x11_proof6.pdf? docID=15601&JServSessionIdr008=zo7xh43fx1.app1a  Army Reserve Child and Youth Service’s Online Teen Deployment Class www.arfp.org/skins/cys/display.aspx  Building Resilient Kids. A course for school personnel focused on building resilience among students from military families. Johns Hopkins Bloomberg School of Public Health’s Military Child Initiative. http://jhsph.edu/mci/training_course  Coming Home: Adjustments For Military Families and Families In The Military.American Academy of Child and Adolescent Psychiatry. www.aacap.org/cs/root/facts_for_families/coming_home_adjustments_for_military_families & http://www.aacap.org/cs/root/facts_for_families/families_in_the_military  Department of Veterans Affairs http://www4.va.gov/kids/  DOD’s Military Student Program: The Military Child in Transition and Deployment www.militarystudent.dod.mil  Military Child Education Coalition http://www.militarychild.org/  Military Kids Bill of Rights http://www.nmfa.org/site/DocServer/Military_Child_Bill_of_Rights5-08.pdf? docID=13201  My Life: A Kid’s Journal (for during deployment- by Health Net Federal Services) https://www.hnfs.net/res/tricare/beneficiary/common/pdf/-1542306275/Kids_jrn_bw_coloringbook_12_07.pdf  National Child Traumatic Stress Network’s Military Children and Youth Resource Page. http://nctsn.org/nccts/nav.do?pid=ctr_top_military  National Guard Family Program / Guard Family Youth Website www.guardfamily.org // www.guardfamilyyouth.org  National Military Family Association / Operation Purple Camp. www.nmfa.org  Operation Child Care (for National Guard and Reservists). www.childcareaware.org/en/operationchildcare  Salute Our Services A Thousand Thanks to Military Kids Program (sends free personalized card to military child): http://www.saluteourservices.org/skins/sos/display.aspx?mode=user&ModuleId=8cde2e88- 3052-448c893d-d0b4b14b31c4&action=display_page&ObjectID=f2cbe28f-381c-475a-a2aa-175371eed89d  Sesame Workshop http://archive.sesameworkshop.org/tlc/  Tackling Tough Topics: An Educator’s Guide to Working with Military Kids. Washington State Office of Superintendent of Public Instruction. https://www.operationmilitarykids.org/resources/ToughTopics %20BookletFINAL.pdf  Talk, Listen, Connect: Deployments, Homecomings, Changes. Sesame Street DVDs for families with youth ages 2-5. Available for free through Military OneSource (1-800-342-9647) OR www.sesameworkshop.org/tlc  The Price of Peace. Song by two military teens about deployment. www.thepriceofpeace.org  Tragedy Assistance Program for Survivors http://www.taps.org/  VA Kids: www.va.gov/kids  When Parents Are Deployed (with Cuba Gooding, Jr). Sesame Street video. Available to view at: http://www.sesameworkshop.org/wpad/  Young Children on the Homefront, ZERO TO THREE. Military families share their unique deployment experiences and professionals offer tips and strategies for dealing with difficult issues such as grief and loss from deployment and the challenges that often arise upon reunification. Available to view at: http://www.zerotothree.org/site/PageServer?pagename=key_military  Young Heroes: Military Deployment Through the Eyes of Youth. 18 minute video created by teens of the New Jersey Operation Military Kids’ Speak out for Military Kids Program explaining the deployment cycle: http://www.operationmilitarykids.org/public/somk.aspx  Youth Coping With Military Deployment: "Promoting Resilience in Your Family" and “Mr. Poe and Friends.” American Academy of Pediatrics. Video from Operation Purple summer camp with interviews by kids. Available: www.aap.org/sections/uniformedservices/deployment/index.html  Zero to Three http://main.zerotothree.org