VETERANS HEALTH ALLIANCE

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• VETERANS HEALTH ALLIANCE
• OF LONG ISLAND
• John A. Javis
• Director of Special Projects
• (MHA Nassau County)
• PHONE [phone] ext. 1101
• E-MAIL jjavis_at_mhanc.org

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• WELCOME
• HOME!
• THANK YOU
• FOR
• YOUR SERVICE!

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• PERSONAL
• BACKGROUND

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PURPOSE OF PRESENTATION

• (1) To provide an overview of the military
  culture in regards to substances
• (a) Public perception of substance
  abuse / mental health issues
• (b) Accurate / Inaccurate media
  portrayals of alcohol use and the military
• (2) To discuss readjustment issues
• (3) To discuss addictions and resources

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• WHATS THE FIRST THOUGHT OR IMAGE THAT COMES INTO
  YOUR MIND WHEN YOU THINK ABOUT MENTAL HEALTH OR
  SUBSTANCE ABUSE ISSUES? (IN GENERAL)

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• If this briefing does not apply to you at the
  present time You may be able to use this
  information to help a buddy, or a soldier you are
  responsible for.

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COMMUNTY RESPONSE TO RETURNING VETERANS

• First reports of unusually high levels of PTSD
  began hitting the media in mid-late 2006.
• Media publicity surrounding the Walter Reed and
  VA scandals in the Winter of 2007 resulted in a
  flood of reporting and studies.

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• INTRODUCTION OF THE ALLIANCE
• The Veterans Health Alliance is a collaborative
  effort of over 70 mental health and substance
  abuse providers, county and state mental health
  and substance abuse oversight bodies, the VA, VET
  Centers, county Veterans Service Agencies,
  veterans organizations, elected officials and
  other stakeholders.

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MISSION OF THE ALLIANCE

• To promote the health and well-being of Veterans
  and their Families through advocacy, and a broad
  array of services

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VISION OF THE ALLIANCE

• YOU SERVED YOUR COUNTRY, NOW LET YOUR COMMUNITY
  SUPPORT YOU

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• New York is home to over 1,000,000 veterans and
  has the 4th largest number of veterans in the
  U.S.
• The Long Island area is 2nd only to San Diego in
  the percentage of veterans among its citizens.
  (Suffolk is 1 in terms of numbers of veterans.)
• Over 18,000 New Yorkers have returned home from
  service on OEF / OIF

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• HAVE YOU SEEN YOUR COUNTY VETERANS SERVICE
  AGENCY?
• HAVE YOU REGISTERED WITH THE VA?
• NEW YORK STATE DIVISION OF VETERANS AFFAIRS
  (http//veterans.state.ny.us)

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BASIC PRINCIPLES

• It is normal for one to have trouble after the
  experience of combat. It would be abnormal not to
  have trouble. Colonel George Patrin (SAMHSA
  Conference August 2008)

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But Not Everyone Will Require Services

• Of OEF / OIF Veterans seeking help from the VA
• 38 were diagnosed with a mental health
  condition
• 17 had substance abuse issues
• 11 had a Traumatic Brain Injury

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• RECOVERY FROM COMBAT RELATED TRAUMA AND SUBSTANCE
  ABUSE ISSUES IS POSSIBLE.

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SUBSTANCES AND THE MILITARY CULTURE

• WORLD WAR II (Crash of Ruin, Peter Schrijvers)
• In Europe water shortages formed the perfect
  excuse for GIs to justify drinking alcohol
• A soldier in Germany in 1945 wrote home to tell
  his parents he couldnt access good drinking
  water, so he says he, Wet my whistle with wine
  and champagne. (p. 166)

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WORLD WAR II (Continued)

• Cartoonist Bill Mauldin remarked, Drinking was a
  big thing in a dogfaces life. (p. 166)
• Surgeons of the 326 Airborne Medical Company
  during the invasion of Normandy carried with them
  92 quarts of whiskey. (p. 166)
• During the siege of Bastogne, General McAuliffe
  said to give the wounded, Booze for comfort.
  (p.166)

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WORLD WAR II (Continued)

• At that time, Europe was more liberal with
  alcohol consumption than the U.S.
• It was indeed quite a sensation for GIs who
  were attached to British Troops in North Africa
  to line up for the rum rations in the morning.
  (p.167)

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Character of CPT. Lewis Nixon Pending divorce at
home Guilt for not having fired his weapon in
combat drove his alcohol habit.
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KOREAN WAR

• Korean War, Paul Edwards
• Cigarettes were provided in C Rations.
• Army Manuals urged leaders to encourage the
  soldiers to smoke.
• When unavailable, it lead to whole platoons of
  men going through withdrawal. (p.155)

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Continued

• Beer was provided rather routinely for the
  enlisted men, along with candy and cigarettes.
  (p.155)
• Issue with drinking was not so much drinking to
  excess on a regular basis, but binge drinking
  during periods of RR. (Rest and Relaxation)

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MASH
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CARL STINER (Shadow Warriors, with Tom Clancy)

• When reporting to his Special Forces assignment
• The last thing you need to know is we get
  together every Friday afternoon at four oclock
  for happy hour. Youre expected to bring your
  wife, and your expected to have a 3rd Special
  Forces Group mug which I just happen to sell
  for three dollarsThis little ritual of happy
  hours and mugs might jar people in these
  politically correct times, but that was the way
  the Army was back then. (p. 130)

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• The social culture in the Army as a whole was
  far less structured than it is nowSocializing
  tended to focus on gatherings where everyone
  drank Friday afternoon happy hours were the
  norm. (p. 130)
• Remember that were talking about only a few
  years after the end of the Korean War. Or
  example, in those days commanders were not nearly
  as involved in the training of soldiers or in the
  taking care of families. That culture did not
  really begin evolving until the draft was done
  away with and we became a volunteer force.
  (p.131)

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• Instead Commanders tend to host dinner parties
  at home for the officers and their spouses. Its
  relatively relaxed and informal, and drinking is
  limited. There are pluses and minuses in all
  this. We probably dont have as much spontaneity
  in todays Army as we did back then, and thats a
  loss but fewer people make fools of themselves,
  and thats a gain.

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VIETNAM WAR

• GENERAL NORMAN SCHWARZKOPF (Vietnam)
• Upon Taking Command of His Battalion
• The outgoing battalion commandersought me
  outCome back to my hooch, he said. I need to
  talk to you a little. On the table sat a bottle
  of Johnnie Walker Black label scotch. This is
  for you, he said. Youre gonna need it. (It
  Doesnt Take a Hero, p. 175)

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• I was expecting a two or three hour discussion
  of the battalion, its officers, its NCOs, its
  mission but he only said, Well I hope you do
  better than I didthis is a lousy battalion. Its
  got lousy morale. Its got a lousy mission. Good
  luck to you. With that he shook my hand and
  walked out. (It Doesnt Take a Hero, p. 175)

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AFTER THE BATTLE OF IA DRANG VALLEY

• Pleiku The Dawn of Helicopter Warfare in Vietnam
  (J.D. Coleman)
• When they walked up to the bar the bartender
  told them he couldnt serve them because Moore
  was too dirtyMoore patiently explained that they
  had just come out of the field and would really
  appreciate a drink.
• The bartender refused to serve them and told them
  to leave.

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• So Moore unslung his M-16 and laid it on the
  bar. Mills and Crandall solemnly following suit
  with their .38s. Moore than said, Youve got
  exactly thirty seconds to get some drinks on the
  bar or Im going to clear house. The bartender
  got smart and served the drinks. By this time the
  club officer had arrived. He had heard all about
  the fight in the valleyso did most of the
  customers in the club. From then on the trio
  couldnt buy a drink.

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ALCOHOL / DRUG USE IN VIETNAM

• From American Psychiatry After World War II,
  Menninger and Case
• Of 610 soldiers treated by 1 psychiatrist in
  country, 113 had an alcohol problem.
• In 1970 an anonymous questionnaire indicated that
  29 admitted to using marijuana in country. (p.23)

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(Continued)

• Between 1969 1971, 9 10 of lower enlisted
  soldiers reported daily marijuana use.
• By 1970, 90 96 pure heroin became readily
  available. By 1971, 44 of lower enlisted had
  used heroin.
• By 1971 there were more evacuations due to drugs
  than to combat wounds. (p. 24)
• There were 75 confirmed or suspected opiate
  deaths from Aug. 1 Oct. 1970. (p. 23)

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PLATOON
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New York Times Article (March 13, 2007) For US
Troops at War, Liquor is Spur to Crime

• Commanders have not always regarded drinking as
  a problem. The Army was a culture in the 1970s
  that encouraged drinking, said a retired Army
  colonel. Youd go out drinking together and
  youd find your buddy hugging the toilet at the
  officers club and think nothing of it.

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CONSEQUENCES

• In 2007 NYS OASAS (Office of Alcoholism and
  Substance Abuse Services) served nearly 14,000
  veterans
• 14 under age 35, 19 over 55 years of age.
• 59 seen for alcohol
• 17 Crack / Cocaine
• 17 Heroin / Opiates
• 5 Marijuana / Hash

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CONSEQUENCES (Continued)

• 22 Were Employed
• 30 Unemployed
• 48 Report Not in Labor Force
• 31 had Criminal Justice involvement
• 24 Homeless
• 40 had also been treated at some point for a
  mental health issue

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NY Times Article (Continued)

• Command tolerance for such behavior began
  changing in the 1980s and by the 1990s. If you
  had more than a couple of drinks at the club,
  people started looking at you strange, the
  retired colonel said.

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NY Times Article, After the Battle, Fighting the
Bottle at Home (July 8, 2008)

• In recent years the military has worked to
  transform a culture that once indulged heavy
  drinking as part of its warrior ethos into one
  that discourages it and encourages service
  members to seek help.

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WARRIOR PRIDE MESSAGES

• Maintain your Warrior Pride Dont Drink and
  Drive!
• Dont leave a Soldier behind on the battlefield,
  in a bar or at a party.
• I am a Warrior - I am Drug Free.
• Warrior Pride 0-0-1 Warriors have ZERO DUIs,
  ZERO underage drinking incidents, and dont drink
  more than ONE drink per hour

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Continued (Fort Drum)

• In late 2007 soldiers from the 10th Mountain
  Division returned after 15 months in Iraq. Some
  had served 3 and 4 tours.
• Many also did what generations of homecoming
  soldiers have done they salved their wounds in
  local bars. With drinking off-limits in Iraq, at
  least openly, they were that much more likely to
  binge, that much less able to tolerate it.

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(Continued) FORT DRUM, NY

• A 23 year old soldier at Ft. Drum, New York,
  interviewed by Reuters said, The first month
  back, everybody got drunk, pretty much.Youve
  been gone 15 months and thats what everybody
  wants to do.

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(Continued) FORT DRUM

• The base commander, MAJ. GEN. Michael Oates
  ordered post newspaper to publish names and
  photographs of all soldiers charged with drunken
  driving 116 appeared
• Im not a teetotaler. Im not against people
  drinking. Im against misconduct.

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(Continued) HEAVY DRINKING

• 2005 Army Survey found that nearly 25 of
  soldiers described themselves as heavy drinkers
  (i.e. Having 5 drinks at 1 sitting once a week)
• 18 25 year old Soldiers and Marines are 2X as
  likely to be heavy drinkers than their civilian
  counterparts.

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(Continued) Lack of Substance Abuse Treatment

• New Jersey National Guard
• 37 had problem drinking
• 55 for those with PTSD
• Of those reporting both, 41 received mental
  health treatment only 9 received help for
  substance abuse.

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HOMECOMING / TRANSITION (Dan Taslitz, One
Freedom, SAMHSA August 08)

• In combat, life is Either Or
• Either Im Safe OR Im in danger kill
• Civilian world is not Either Or (ex. Being
  insulted by someone is not a life threatening
  experience
• Sleeping is dangerous in combat zone - how to
  sleep when home?

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BOREDOM

• Deployment / Combat is an adrenaline high.
• Reintegration
• Less Excitement
• Normal Responsibilities (i.e. Take out the
  trash!)
• Boring Job
• May seek out thrills Driving fast / Spending
  recklessly / Risky Sex / Use substances

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HOMECOMING ISSUES (MAJ. DAVINA FRENCH, SAMHSA
CONF. AUG. 08)

• While deployed, Cant wait to get home and see
  my kids.It will be great. While deployed in
  Iraq may have spent a lot of time being around
  children
• When home, veteran may feel smothered by their
  child and pull away Veteran may be distracted
  by thoughts of their comrades who are still
  deployed.

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MAJ. French (Continued) HOMECOMING

• WHO IS THE HERO?
• Returning veterans may be treated to parades,
  parties, banners etc. but may not feel heroic.
• May feel that those killed are the true heroes.

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Capella University Study (June, 2008) FAMILY
PREPAREDNESS

• Returning Servicemembers to Community Heres
  How You Can Help
• Only 3 of servicemembers felt the typical
  military family was very prepared to help them
  transition from combat duty.
• More than 50 felt that families were not at all
  prepared to help with the transition.

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RELUCTANCE TO SEEK HELP (Capella Study)

• (1) Concern about negative impact on military
  career.
• (2) No help was offered me.
• (3) No one with combat experience available to
  help me.
• (4) Concern loved ones would lose respect for
  me.
• (5) Not enough access to community mental health
  resources.

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BATTLEMIND Alcohol Transition

• www.battlemind.army.mil
• Alcohol Transition In Combat access to alcohol
  is limited At Home access is plentiful

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HOMECOMING

• HOLIDAYS
• FAMILY FUNCTIONS
• SEE OLD FRIENDS
• GO OUT
• INCREASE ACCESS TO ALCOHOL / DRUGS

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ALCOHOL TOLERANCE

• When you first started drinking you may have
  felt drunk after 2 beers.
• When you build up alcohol tolerance it may have
  taken you a six-pack to feel that way.
• Body can be fooled into getting a DUI because
  you dont feel drunk.
• Since you have been away from alcohol while
  deployed, your tolerance may be back down to 2
  3 beers again before you show signs of
  intoxication.

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BLOOD ALCOHOL CONCENTRATION (HOT TOPICS Current
Issues for Army Leaders Volume 7, No. 1 2005
p.5)

• The amount of alcohol in the bloodstream,
  measured in percentage. Actual effect on
  performance and judgement is different for every
  person.
• .02 No loss of coordination, slight euphoria
• .05 Legal limit for military personnel on duty
• .08 Judgement, self-control, caution and reason
  impaired Legal limit in most states
• .15 Difficulty standing, walking and talking
• .40 Loss of consciousness
• .50 Death

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• WHAT ARE SIGNS
• OF PROBLEM
• DRINKING?

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SIGNS OF PROBLEM DRINKING CAGE Questions

• C Have you ever felt that you should Cut down
  on your drinking?
• A Have people Annoyed you by criticizing your
  drinking?
• G Have you ever felt bad or Guilty about your
  drinking?
• E Have you ever had a drink first thing in the
  morning to steady your nerves or get rid of a
  hangover (i.e. as an Eye-Opener)?

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CAGE QUESTIONS (Iraq War Clinicians Guide)

• SCORE of 3 or 4 most likely indicates alcohol
  dependence
• SCORE of 1 or 2 may indicate alcohol abuse

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SHORT TERM EFFECTS OF HEAVY DRINKING(Hot Topics,
p.8)

• Affects vision
• Black-outs
• Loss of coordination
• Altered perception emotions
• Impaired judgement
• Stomach irritation
• Increased urination

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EFFECTS OF LONG TERM DRINKING

• Loss of appetite, weight loss
• Ulcer
• Cancer of liver, throat
• Heart Disease
• Sexual Impotence
• Personality changes

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OTHER SIGNS OF PROBLEM DRINKING

• Unable to stop drinking
• Causing trouble at home
• Missing work due to drinking
• Blackouts
• DUI Arrest
• Vomiting
• Fighting
• Financial Problems

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PROBLEM DRINKING (Continued)

• Spouse / Child Abuse
• Injury
• Decreased performance at work
• Loss of Control Doing Stupid things
• Unprotected sex / Unwanted Sex
• Unexpected guest for breakfast

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Problem Drinking

• Cant remember how much they drank
• Drinking alone
• Drink prior to social event or drink to excess at
  events
• Pass out after drinking
• Drink to cope with stressful situations

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ALCOHOL DEPENDENCY (HOT TOPICS, p.11)

• Physiological Tolerance Need to drink more to
  get a buzz
• Physical Dependence Need to drink to feel OK
• Addiction
• Withdrawal feel depressed, have hallucinations
  or delusions when one stops drinking

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BEHAVIOR CHANGES (HOT Topics, p.9)

• Separation / distance from family
• Borrowing of
• Stealing
• Drinking in Secret
• Neglect personal appearance
• Revolve life around alcohol events

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Signs of Drug Abuse Problems

• In addition to many of the same issues with
  problem drinking
• Purposely misusing prescription medications
• Blackouts or Flashbacks
• Engaged in illegal activities to obtain drugs
• Withdrawal symptoms
• Medical problems due to drug use

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HALT (Never Drink if You are) (HOT TOPICS, p.6)

• H ungry
• A ngry
• L onely
• T ired

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EFFECTS ON THE FAMILY

• FAMILY SYSTEMS THERAPY
• Prior approaches used a remove and replace
  approach. (i.e. Remove the substance abuser
  (detox / rehab), fix them and return them to
  the family)
• Family systems therapy looks at family as a
  childs mobile (i.e. If you shake one part,
  the whole mobile shakes seeks a balance.)

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CHILDREN OF DYSFUNCTIONAL FAMILIES

• Applies to both the children of the current user,
  as well as to the current user if he / she grew
  up in a home with a substance abuser.
• 4 Common Roles

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• (1) HERO
• Takes over the Parental Role
• Gives families Self-worth
• Good Students / Sports stars
• Usually the oldest child
• As adult may be controlling or judgemental
• As adult may achieve success on outside but may
  be cut off from inner emotions

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• (2) ACTING OUT CHILD
• Family is ashamed of them
• Acts out the tension in the family
• Get into trouble at school
• May resent the hero
• Self-hatred / destructive
• May be the addicted / arrested teen
• As adult may turn to drugs / alcohol

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• (3) CLOWN / MASCOT
• Divert families pain through humor
• Focus on others
• Give love, unable to receive love
• Usually the youngest child

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• (4) LOST / WITHDRAWN CHILD
• Invisible
• Lose selves in Fantasy / Books / TV
• Deny feelings
• Afraid of intimacy
• May turn to overeating or Drugs / Alcohol

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ADULT CHILDREN OF ALCOHOLICS

• Brought up in an alcoholic or other dysfunctional
  households.
• We became people pleasers
• We either became alcoholics ourselves, married
  them, or both. Failing that, we found other
  compulsive personalities, such as a workaholic,
  to fulfill our sick need for abandonment.

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• We lived live from the standpoint of victims.
• (Co-Dependency) We were dependent personalities,
  terrified of abandonment, willing to do almost
  anything to hold on to a relationship in order
  not to be abandoned.
• We often confused love with pity, tending to love
  those we could rescue.
• Even more self-defeating, we became addicted to
  excitement in all our affairs, preferring
  constant upset to workable solutions.

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• TYPES
• OF
• SERVICES

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INPATIENT PROGRAM

• DETOXIFICATION Medically supervised
  detoxification from alcohol and / or other drugs.
  Detox is short term (3 5 Days)
• REHABILITATION Structured environment to begin
  the process of sobriety. Workshops, educational
  and counseling sessions are offered. Rehab is
  usually a few weeks in length.

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OUTPATIENT TREATMENT

• Person participates in any combination of
  services which could include
• Group therapy
• Individual sessions
• Family conferences

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12 STEP GROUPS

• ALCOHOLICS ANONYMOUS
• NARCOTICS ANONYMOUS
• GAMBLERS ANONYMOUS

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• VARIOUS
• APPROACHES TO
• RECOVERY

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ABSTINENCE

• Traditional 12 Step Groups use an Abstinence
  (i.e. Not using) approach.
• One Day at a Time.
• People, Places and Things That Get You Into
  Trouble.
• 90 in 90.

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Confrontational Approaches

• Argues that the person has a problem and needs to
  change.
• Worker is the expert and does most of the
  talking.
• Imposes a diagnostic label.
• Worker behaves in a punitive or coercive manner.
• (Description taken from Addiction Technology
  Transfer Center)

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HARM REDUCTION APPROACH

• The Harm Reduction approach was developed in
  the 1980s and 1990s.
• Harm Reduction has its origins in HIV / AIDS work
  (i.e. Needle Exchanges)

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DEFINITION OF HARM REDUCTION

• Harm reduction is a set of strategies that reduce
  negative consequences of the addiction. The
  strategies range from safer use to abstinence.
  Harm reduction meets people where theyre at.
  (Harm Reduction Coalition)

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HARM REDUCTION (Continued)

• Accepts that the addiction is part of our world
  chooses to minimize the harmful effects rather
  than ignore or condemn them.
• Acknowledges that some ways of using are clearly
  safer than others.
• The focus is on persons well-being not
  necessarily on stopping the use.

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HARM REDUCTION (Continued)

• Recognizes that realities such as poverty, past
  trauma, and other issues affect peoples ability
  to deal with the addiction.
• Does not attempt to minimize or ignore the real
  and tragic harm and danger associated with the
  addiction.

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MOTIVATIONAL INTERVIEWING

• Developed in 1990s as a response to frustrating
  attempts to change harmful behavior.
• Client-centered counseling style
• Motivation to change is not imposed on the
  client by the worker the worker tries to
  mobilize the clients strengths and values.
• Relationship between client and worker is more
  like a partnership than Expert Recipient
  roles.

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LEADERS ROLE (HOT TOPICS, p.7)

• Understand the effect of substance abuse on
  personal and mission readiness
• Know about local resources for referrals
• Intervene BEFORE a problem develops
• Emphasize off-duty alternatives to substance use.

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HELPING OTHERS IN RECOVERY (Recoverforever.com)

• Help others find their talent and help them
  emphasize it.
• Spirituality is a help.
• Avoid cleaning up their mess.
• Let them know it is OK to feel
• Get them out of their heads

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CAPELLA STUDY What Helps

• 77 of service members seeking mental health
  services said the assistance was helpful with
  community mental health providers receiving
  higher rankings than military providers.
• 87 felt that setting a goal (Degree, new career)
  was helpful.