LTC Jeffrey S. Yarvis, Ph.D., MSW, M.Ed.

1
When Trauma Comes Home Reintegration of Warriors
to Families

• LTC Jeffrey S. Yarvis, Ph.D., MSW, M.Ed.
• University of Georgia School of Social Work

This briefing is unclassified and reflects the
opinion of the presenter
2
Who are we?

• Culture is always evolving and changing
• Everything that is taught is not always learned
• Technology Trauma can change culture

• Culture is learned not genetic
• Shapes behavior consciousness

3
Who we are
4
Military Services Core ValuesWhy we join?
Army Navy/Marine Corps Loyalty Honor Dut
y Courage Respect Commitment Selfless
service Honesty Integrity Personal
courage Air Force Integrity first
Courage, Honesty, Responsibility,
Accountability, Justice, Openness,
Self-respect, Humility Service before self
Rule following, Respect for others,
Discipline/Self-control, Faith in the
system Excellence in all that we do
Product/service, Personal, Community,
Resources, Operations
5
Social Work and the Military

• Why a social worker
• Understanding Culture
• Organization and Mission
• Medical Diplomacy
• Negotiation
• Community Organization
• Evidenced-Based Effects and Results
• Research

6
Social Work Skills

• Building Interpersonal Relationships
• Overcoming Bias
• Transcending Cultural Differences
• Going to where the client is.
• Communication, Negotiation and Mediation
• Conducting Needs Assessments
• Setting, Assessing and Achieving Goals
• Evidenced-Based Methods
• Mitigation

7
Cultural Competence

• Unconscious Incompetence
• Conscious Incompetence
• Conscious Competence
• Unconscious Competence

8
AD Demographics

• Enlisted Personnel
• Mean age 27 years (over 80 younger than 35)
• 14.8 female
• 32.9 racial minorities
• 49.8 married (50.9 of men 43.0 of women)
• 13.6 in dual service families
• (8.1 of married men 51.3 of married women)

Demographic statistics taken from the DoD 2004
Report Population Representation in the Military
Service
9
AD Demographics

• Officer Corps
• Mean age 34 years
• 16.0 female
• 18.3 racial minorities
• 68.1 married (71.4 of men 50.9 of women)
• 11.2 in dual service families
• (6.6 of married men 44.3 of married women)

Demographic statistics taken from the DoD 2004
Report Population Representation in the Military
Service
10
Army FamiliesPercent of Soldiers Married
11
Army FamiliesAge of AD Soldiers Spouses
Enlisted
Officers
12
Army FamiliesPercent of Soldiers with Children
13
Army FamiliesAge of Soldiers Children
14
Stressors in Military Families

• Frequent moves and separations
• PCS
• TDY
• Training
• Risk of injury and death
• Behavioral expectations
• Foreign residence
• Increased challenge if family member has special
  needs

15
Stressors Associated with Moves (PCS)
16
Army SpousesMarital Satisfaction
Marital Satisfaction (2004/2005)
Percent Agree
17
Army Spouses Impact of Demands of Military on
Family
Survey of Army Families (1995, 2001, and
2004/2005), U.S. Army
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Reserve ComponentDifferences from AD Families

• Age
• Length of marriage
• Spouse employment
• Residence
• Relocation

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Reserve ComponentDifferences from AC Families

• Age

Officers
Enlisted
20
Reserve ComponentDifferences from AC Families

• Length of marriage - Percent 6 Years

21
Reserve ComponentDifferences from AC Families

• Percent of Spouses Employed

22
Reserve ComponentDifferences from AC Families

• Time in Residence

23
PTSD A need to understand

• A mental disturbance provoking pain, excessive
  joy, hope or anxiety, where it affects its
  temper, and rate, impairing general nutrition and
  vigor
• William Harvey, 1628

24
Same or Different Today?Ex. Videos
25
The Stigma
26
Leadership Mitigates Stigmatizing Effects
27
Common Reactions to Trauma

• Fear and anxiety
• Intrusive thoughts about the trauma
• Nightmares of the trauma
• Sleep disturbance
• Feeling jumpy and on guard
• Concentration difficulties

28
Common Reactions to Trauma

• Avoiding trauma reminders
• Feeling numb or detached
• Feeling angry, guilty, or ashamed
• Grief and depression
• Negative image of self and world
• The world is dangerous
• I am incompetent
• People can not be trusted

29
PTSD Diagnostic Criteria

• Reexperiencing (1 of 5)
• Thoughts, nightmares, flashbacks, emotional
  reactions, physiological reactions
• Avoidance (3 of 7)
• Avoid thoughts, avoid reminders,
  amnesia,detachment, numbing, anhedonia,
  forshortened future
• Arousal (2 of 5)
• Sleep disturbance, concentration problems, anger,
  hypervigilance, startle

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Is PTSD clear to you?

• A common anxiety disorder that develops after
  exposure to a terrifying event or ordeal in which
  grave physical harm occurred or was threatened.
• Confounds two distinct constructs-stress and
  mental traumatization.
• Is a retrospective construct.
• How cohesive is PTSD across different groups?
• BLUF How is PTSD related to health?

31
Problem

• PTSD is difficult to treat.
• Current Research focused on treatment and
  debunking ineffective prevention measures.
• PTSD is observed to have considerable variability
  in outcome.
• PTSD associated with considerable morbidity-most
  frequently depression substance abuse.
• Subthreshold PTSD not well studied.

32
Diagnosis of PTSD Associated Symptoms

• Guilt, shame, despair
• Hostility, aggression
• Social isolation, loss of beliefs
• Feeling constantly threatened
• Poor health

33
Stresses of Asymmetric Combat

• Immense firepower
• Improved night vision
• Obscuration
• Advanced new weaponry
• Fear of destruction and WMD
• NBC
• Locus of Control
• ROE
• OPTEMPO
• No respite
• Reintegration Leaving Again

34
The Sounds of Combat Stress
35
The Sounds of Combat Stress
36
Weather
37
Poverty
38
Passive Posture
39
First Exposure and WMD
40
Cultural Differences
41
Home-front, the Media Unit Casualties
Next slide VERY GRAPHIC
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Death of Children
43
Military-Induced Family Separation
44
Spouse Satisfaction with Army Life Associated
with Length of Separation
45
A Witness to Evil The Loudness of Silence The
Subtleties of Coming home.
How do I explain what Ive seen?
46
War is Hell, Yet

• People are shooting at you
• Friends die
• Temperatures are harsh
• Sleep deprivation is rampant
• Family Separation
• No alcohol
• No sex
• No car
• No toilets
• Lousy food
• No privacy
• BUT

47
Battle Zone to Home Zone
Mindset that keeps you Alive in Battle might be
Socially and Behaviorally Hazardous at Home
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The Combat Veterans Paradox

• Many soldiers returning home are pissed off,
  BUT happy to be home.
• Many soldiers want to return to combat, BUT are
  happy to be home.
• -Unfinished business
• -Doing what you are trained for
• -More control, life is simpler
• -Home may changed, transitions are hard

49
Adapted or Maladapted?
At Home
At War

• Cohesion
• Accountability
• Targeted Aggression
• Tactical Awareness
• Armed
• Emotional Control
• Mission Security/OPSEC
• Individual Responsibility
• Combat Driving

• Withdrawal
• Controlling
• Inappropriate Aggression
• Hypervigilance
• Locked and loaded
• Anger and Detachment
• Secretiveness
• Guilt
• Aggressive Driving
• Conflict
• Discipline/Ordering
• WRAIR, LTC Carl Castro-Adapted from Battlemind

50
War v. Home
In Combat
At Home
At home no one understands you, you avoid family
In combat no one understands like your buddies,
you trust them
51
Emotional Cycle of Deployment
52
Emotional Cycle of Deployment

• Each stage is characterized by A time frame and
  specific emotional challenges which must be
  addressed by Soldiers and families
• Early information about what to expect can assist
  in "normalizing" and coping positively with the
  deployment experience.
• Promoting understanding of the stages of
  deployment helps avert crises and decrease the
  need for command intervention and behavioral
  health care.

• 1. Pre-deployment, 2. Deployment,
• 3.Sustainment, 4. Re-deployment
• and 5. Post-deployment.

53
Family Systems Moving Through Time

• Families comprise people who have a shared
  history and a shared future. -Betty Carter and
  Monica McGoldrick
• Boundaries shift
• Psychological Distance Changes
• Roles are constantly redefined
• In general, defining what normal family
  patterns look is becoming more difficult
• Values driven
• Trajectories change and Family Development altered

54
Transitioning Skills

• Spouses/Partners
• Children
• -Infants
• -Toddlers
• -Young children
• -Teens
• Caregivers
• Grandparents
• Environmental differences or changes
• Preventing intergenerational trauma

55
Risk Factors for Soldiers

• Trauma History
• Gender
• Number of Deployments
• Age
• What about
• Subthreshold Presentations (Yarvis et al., 2005
  Yarvis and Schiess, 2008, Yarvis, 2008)
• Stress induced Resilience (Stoic Warrior-MAJ
  Thomas Jarrett)
• TBI (Hogue et al., 2007)

56
Trauma and The Social Environment

• Part II

57
Relation Between PTSD and Social Support

• One of the strongest predictors of recovery
  following trauma is social support
• Perceived social support (PSS)
• Received social support (RSS)
• Interaction is complicated
• PSS is often negatively related to trauma
  severity
• RSS is often positively related to trauma
  severity
• Deterioration of perceived social support over
  time may contribute to increased symptoms

58
PTSD Symptoms Impact onSocial Support

• PTSD and associated problems can reduce available
  social support
• Emotional numbing
• Detachment
• Hostility and Aggression
• Distrust of others
• Social problem solving deficits
• In addition, as symptoms persist individuals may
  tire of providing support or exhaust resources

59
PTSD and Anger

• PTSD has been repeatedly associated with higher
  levels of anger/hostility
• (see Orth Wieland, 2006 for a review)
• Anger/Hostility more associated with PTSD in
  samples of combat veterans than in other trauma
  exposed samples
• (Orth Wieland, 2006)
• Veterans with PTSD respond with more hostility in
  non-provoking interpersonal interactions
• (Beckham et al., 1996)
• Veterans with PTSD experience more anger in
  response to trauma cues
• (Pitman et al., 1987 Taft et al., 2006)

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Anger in Response to Trauma Cues

Taft et al., 2006
61
Interpersonal Problems Associated with PTSD in VN
Veterans


Roberts et al., 1982
62
PTSD and Social Problem-Solving Deficits
Riggs et al., 2006
63
Social Problem-Solving Deficits Associated with
PTSD in VN Veterans



Nezu Carnevale, 1987
64
Social Support
Initial Reactions
Trauma
PTSD Symptoms
65
The Role of Families

• In general, families provide a primary source of
  social support.
• Spouses and intimate partners are typically
  identified as the chief source of social support.
• Approximately 50 of service members deployed to
  OEF/OIF are married at the time of deployment.

66
PTSD and Difficulties in Families
67
Impact of PTSD on Families

• PTSD can impact directly on intimate
  relationships
• Direct effects impact on relationship
• Indirect effects impact on relationship skills
• Impact of PTSD on perception of relationship
• PTSD can impact the spouse/partner
• Direct effects impact of PTSD symptoms
• Indirect effects impact of added stress
• PTSD can impact on children
• Direct effects impact on child
  development/adjustment
• Indirect effects impact on parenting skills

68
PTSD and Intimate Relationships
69
PTSD and Relationship Quality



Carroll et al., 1982
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PTSD and Relationship Quality




Riggs et al., 1998
Jordan et al., 1992
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PTSD and Relationship SkillsVietnam Veterans




Riggs et al., 1998
72
PTSD and Relationship SkillsWW II and Korean
War POWs



Cook et al., 2004
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PTSD and Relationship SkillsVietnam Veterans



Carroll et al., 1982
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Partners of People with PTSD
75
Distress Among Partners of Veterans With PTSD





Calhoun et al., 2002
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Distress Among Partners of Veterans With PTSD







Dekel Solomon, 2006
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Distress Among Partners of Veterans With PTSD






Westerink Giarratano, 1999
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Distress Among Partners of People with PTSD

• Secondary Trauma
• Contagious PTSD
• Cycle of Trauma
• Lessons Learned
• Compassion Fatigue
• Emotionally Drained
• Exhaustion
• Caregiver Burden
• Crisis Symptom Management
• Isolation
• Family Stress

79
Children of People with PTSD
80
Intergenerational Trauma-Holocaust
81
Vietnam
82
Parental PTSD and Childrens Distress

• Children of Vietnam veterans with PTSD, compared
  to children of veterans without PTSD, are more
  likely to experience symptoms
• 36 vs. 14 indicated symptoms severe enough to
  cause distress on GHQ (Westerink Giarratano,
  1999)
• more and more severe behavior problems reported
  (Kulka et al., 1988)
• 23 vs. 0 had received psychiatric treatment
  (Davidson et al., 1989)

83
Parental PTSD and Childrens Distress
Davidson Mellor, 2001
Caselli Motta, 1999
84
PTSD and Parenting Skills

• Clinical descriptions have characterized
  parenting by veterans with PTSD as
• Overprotective (or potentially avoidant) (Haley,
  1984)
• Controlling, overprotective, demanding (Harkness,
  1993)
• Enmeshed (Jurich, 1983 Rosenheck, 1986)
• Highly emotional (Rosenheck, 1986)
• Children of PTSD veterans describe families as
• More conflicted (Westerink Giarratano, 1999)
• Less Cohesive (Westerink Giarratano, 1999)
• Veterans with PTSD are more likely than those
  without PTSD to endorse severe parenting problems
• 54.7 vs. 17.3 (Jordan et al., 1992)

85
PTSD and Parenting Skills






AI Affective Involvement AR Affective
Responding BC Behavior Control C
Communication PS Problem Solving R - Roles
Davidson Mellor, 2001
86
PTSD and Parenting Relationships
PTSD Scores Total Reexp Avoid Aro
usal Parenting -.27 -.17 -.30
-.17 Satisfactiona Child .27 -.01
.35 .33 Misbehaviorb Positive -.31
-.10 -.46 -.25 Sharingb Child Critical
.28 .22 .30 .25 Of
Fatherb Relationship -.55 -.39 -.63
-.48 Qualityb
a Samper et a., 2004 b Ruscio et al., 2002
87
A Model for Understanding the Impact of PTSD on
Families
88
Understanding Childrens Reactions to War
Deployment

• Children are affected by their parents traumatic
  experiences as well as their own
• Little scientific information about impact of
  parental combat exposure on children
• Equally dangerous to assume uniform resilience or
  uniform problems as a result of war exposure
• A real accounting of the trauma and its effects
  is an opportunity to honor the service and
  sacrifice
• War trauma is a primary source of difficulty for
  all military family members

89
Childrens Reactions to Deployment
Percent reported with Moderate to Very
serious problems
Source 2004/2005 Survey of Army Families, U.S
Army Community and Family Support Center (CFSC)
90
Children Coping with Deployment
Source 2004/2005 Survey of Army Families, U.S
Army Community and Family Support Center (CFSC)
91
How Parents can support children during deployment

• Maintain routines, discipline
• Monitor television viewing
• Listen
• Discuss your feelings
• Answer questions honestly and dispel rumors give
  age-appropriate explanations
• Encourage communication, let child talk

92
How parents can support children during deployment

• Be reassuring
• Show on a map where the parent is
• Have child communicate with deployed parent
• Have deployed parent send separate letters to
  each child
• Help child find ways to handle stress

93
Infants.

• Irritability
• Difficulties with comforting by caregiver
• Difficulties with self-comforting
• Sleep difficulties
• Eating disturbances

94
Dad brings in 7 month old baby

• Just doesnt know how to handle the baby crying
  all the time, feeding difficulties
• Mom has deployed in the past month
• Dad has never had to fully care for the baby
  alone, past psychiatric history
• Mom is the glue that held everything together
• Sometimes dad feels like he could lose it when
  baby cries

95
Preschool and Kindergarten

• Clinging to people or favorite toy or blanket
• Unexplained crying or tearfulness
• Choosing adults over same-age friends
• Increased violence toward people or things
• Shrinking away from people, more quiet
• Eating, sleep difficulties
• Regression in behaviorsbedwetting

96
Mom brings in 3 year old for

• New onset biting other children in the CDC, they
  are threatening to kick him out
• Daddy has just deployed in past month
• Seems anxious, irritable at home
• Hitting little sister
• Clinging, leaving him at the CDC requires extra
  time to reassure him that he will be o.k.

97
School-aged Children

• Any of the signs noted previously
• Rise in complaints of stomach aches, head aches,
  or other illness
• More irritable or crabby
• Increase in school problems-drop in grades,
  school avoidance, fights
• Other changes in behavior

98
Mom brings in 7 year old for

• New onset stomach aches with increased school
  absence
• Patient lives on post
• Recent tragedy in dads unit
• Several service members injured/killed
• Everyone is talking about it
• The little girl hears her mother and friends
  talking
• Will her daddy be o.k.what if something happens
  while she is at school?

99
Adolescents

• Any of the signs noted previously
• Acting out behaviors (getting into trouble at
  school, at home, or with the law)
• Low self-esteem and self-criticism
• Misdirected anger (lots of anger over small
  incidents)
• Depression, anxiety

100
Mom brings in 16 year old son

• Worried because he seems down, not concentrating
  at school, not engaged in his usual activities
• Patient very close to dad
• Dad has been deployed
• Patient worried about dad

101
Child Maltreatment and Deployment

• Rentz ED, Marshall SW, Loomis D, et al. Am J
  Epidem 2007
• McCarroll JE, Fan Z, Newby JH, et al., Child
  Abuse Rev, in press
• Rate of military family maltreatment twice as
  high in period after October 2002 compared to
  prior period versus no change in nonmilitary
  family population during similar period
• Greatest rise in maltreatment appears to be
  attributed to child neglect in younger children
• Rates of child neglect appear highest in junior
  enlisted population

102
US ARMY CHILD NEGLECT RATES 1989-2004 1-2 YEAR
OLDS
McCarroll J et al, 2005
103
Factors Affecting Family Adjustment During
Deployment

• Families at increased vulnerability
• Families in transition
• Young families
• Families with problems prior to deployment
• Pregnant spouses
• Families with multiple needs

104
Cycle of Deployment

• Pre-deployment
• Notification
• Preparation

Return from Deployment Reunion Reintegration
Deployment Departure Sustainment Combat and
conflict
105
Typical course of reintegration

• Family resilience is the rule, not the exception
• Usual for families to return to the normal
  routine
• Common to incorporate changes without disability
  in family functioning
• HOWEVERWe dont always want to reintegrate.
  What does that mean?

106
Post Deployment Reunion and Reintegration

• Reunion can be very stressful for service members
  and families
• Expectations
• Changed roles/responsibilities
• Lack of time
• Deployment vs. Home
• Extended family
• Health/Mental health problems
• Transition of caregivers and loss

107
Post Deployment Adjustment Difficulties
Source 2004/2005 Survey of Army Families, U.S
Army Community and Family Support Center (CFSC)
108
Reserve ComponentStress Following Deployment

• Return to civilian life
• Job may no longer be available
• May experience a reduction in income
• Transition of health care or loss of health
  coverage
• Loss of unit/military support system for the
  family
• Lack of follow up/observation by unit commanders
  to assess needs

109
Social Information Processing
110
BattleMind Training

• Battlemind skills helped you survive in combat,
  but may cause you problems if not adapted when
  you get home.

Buddies (cohesion) vs. Withdrawal Accountability
vs. Controlling Targeted Aggression vs.
Inappropriate Aggression Tactical Awareness vs.
Hypervigilance Lethally Armed vs. Locked and
Loaded at Home Emotional Control vs.
Anger/Detachment Mission OPSEC vs.
Secretiveness Individual Responsibility vs.
Guilt Non-Defensive Driving vs. Aggressive
Driving Discipline and Ordering vs. Conflict
111
Cued Traumatic Responses
External Trauma Cues Sights Sounds Smells Situati
ons
Internal Trauma Cues Emotional State Physical
State Thoughts
Traumatic Reactions Emotions Thoughts Arousal
112
Impact of Trauma Memory on Social Information
Processing
113
Summary of Research on Families During Deployment

• In general, military families appear robust and
  healthy
• Deployment can have negative impact some families
• Rarely reaches clinical levels
• Usually resolves post-deployment
• Pre-deployment functioning related to functioning
  during and post deployment
• Unique aspects of OIF/OEF have not been studied
  with respect to families

114
Military Family ChallengesAssociated with
Deployment

• Deployment
• transient stress
• modify family roles/function
• temporary accommodation
• reunion adjustment
• military community maintained
• probable sense of growth and accomplishment

Psychiatric/ Physical Injury Transient vs.
permanent stress modify family
roles/function Temporary vs. permanent
accommodation military community jeopardized
Death permanent stress modify
family roles/function permanent
accommodation grief and mourning military
community lost
115
Reintegration Injured Parent

• Notification of injury initiates intense activity
  for family (Cozza et al, 2005)
• Spouse often joins injured member at MTF distant
  from home
• Children left under supervision of others or
  brought along to hospital
• School absences
• New environment not conducive with meeting
  childrens needs
• Children must be properly prepared before
  reunited with injured service member
• Information must be developmentally appropriate
• Not too much or too little

116
Impact of the Injury on the Family

• Remember The injured service member is part of a
  family
• Recovery will happen in the context of that
  family
• Family offers support
• Family must adjust to injury
• Injury may cause disruptions in family
• May require the family moving with associated
  changes in neighborhoods, schools and peer/social
  groups
• May cause changes in family constellation and
  roles
• Possible loss of AD military status and/or
  military community
• Injury can cause disruptions in parenting
• change in disciplinary style, emotional support
  or availability
• change in personality or cognitive ability
• Should monitor ALL family members for changes in
  functional status over time

117
Impact of Parental Injury on Children

• The meaning of the injury to the child
• Childs developmental limitations of
  understanding
• Time of parental distraction and preoccupation
  with injury
• Child must modify the internal image of his
  injured parent
• Health requires developing an integrated and
  reality based acceptance of parental changes

118
Helping the Injured Family

• Facilitate the family in reconnecting
• Acknowledge the integral and essential role of
  parenting in the service members life
• Collaborate with other clinicians (e.g., OT, PT)
  to promote rehabilitation with a focus on
  parenting
• Recognize the childs complex and stressful
  experience and promote mastery
• Focus parent on childs developmental needs
• Explore new activities and play that allows
  parent and child to try new ways of relating

119
Questions Comments

• 301-295-9853
• Jeffrey.Yarvis_at_us.army.mil
• LTC Jeffrey S. Yarvis, Ph.D.
• Director of Social Work Asst. Professor
• USUHS