Transition Home

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Painting a Moving Train Harold Kudler, M.
D. VISN 6 Deployment health mental illness
Research, Education and Clinical Center
(MIRECC) Department of Veterans Affairs
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Introduction
When I come to feeling overwhelmedI want a
one-on-one talk with a trained psychiatrist whos
either been to war or understands war.
--Staff Sgt. Gladys Santos, who attempted suicide
after three tours in Iraq. Newsweek February 11,
2008
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Introduction
The most complex and dangerous conflicts, the
most harrowing operations, and the most deadly
wars, occur in the head.
(Anthony Swafford, Jarhead from PBS video
Operation Homecoming)
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Introduction
For the first time in American history, 90 of
wounded (soldiers) survive their injuries
A greater percentage of men and women are coming
home with TBI and severe Posttraumatic Stress.
(Alive Day Memories Home from Iraq HBO
documentary
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Introduction

• How many of you are
• A Military Member or a Veteran?
• Spouse of a veteran ?
• Other family member of veteran?

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Introduction

• How many of you are
• Psychiatrists, physicians?
• Substance abuse counselors?
• Psychologists?
• Social workers, counselors (including schools)?
• Psychiatric nurses or other nurses?

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Introduction

1. Painting a Moving Train General Magnus Analogy
2. Scope of issue why this training?

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Scope of the Issue

• Length of current combat operations
• As of November 27, 2006, war in Iraq has been
  going on longer than WWII.
• An all volunteer force multiple deployments

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Scope of the Issue

• 1 ½ million service members have served in Iraq
  and Afghanistan.
• The war in Iraq remains very personal. Over 75
  of Soldiers and Marines surveyed reported being
  in situations where they could be seriously
  injured or killed 62-66 knew someone seriously
  injured or killed more than on third described
  an event that caused them intense fear,
  helplessness or horror.
• --From the Office of Surgeon General Mental
  Health Advisory Team (MHAT) IV, Final Report, Nov
  06

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Scope of the Issue

• The challenges are enormous and the consequences
  of non-performance are significant. Dataindicate
  that 38 of Soldiers and 31 of Marines report
  psychological symptoms. Among members of the
  National Guard, the figure rises to 49.
  Further, psychological concerns are significantly
  higher among those with repeated deployments, a
  rapidly growing cohort.
• --Report of the DoD Task Force on Mental Health,
  June 2007

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Scope of the Issue

• Psychological concerns among family members of
  deployed and returning OEF/OIF veterans, while
  yet to be fully quantified, are also an area of
  concern. Hundreds of thousands of children have
  experienced the deployment of a parent
• --Report of the DoD Task Force on Mental Health,
  June 2007

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Basic Training Military Culture
Understanding the nature of the military culture,
combat and the stresses of living and working in
a war zone are critical to establishing
credibility with your clients.
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Basic Training Military Culture

• Army
• Army National Guard
• Navy
• Marine Corps
• Air Force
• Air National Guard
• Coast Guard

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Basic Training Military Culture

• High standard of discipline that helps organize
  and structure the armed forces
• Professional ethos of loyalty and self-sacrifice
  that maintains order during battle
• Distinct set of ceremony and etiquette that
  create shared rituals and common identities
• Emphasis on group cohesion esprit de corps that
  connect service members to each other.

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Basic Training Military Culture

• A word about lingo

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Who VA Serves

• Of 23.4 million veterans currently alive, nearly
  three-quarters served during a war or an official
  period of conflict
• Women account for 8 of all veterans (roughly 1.8
  million women veterans)
• About a quarter of the nation's population is
  potentially eligible for VA benefits and services
  because they are veterans or family members
• VA currently provides health care to 5.5 million
  veterans (roughly 1 in 5 veterans)
• Roughly 10 of VA users are women veterans

http//www.va.gov/
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Care Access Points

• 153 medical centers
• at least one in each state, Puerto Rico and the
  District of Columbia
• 909 ambulatory care and community-based
  outpatient clinics
• 47 residential rehabilitation treatment programs
• 232 Veterans Centers

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Care Access Points

• 88 comprehensive home-care programs
• 4 DoD/VA Polytrauma Centers
• My HealtheVet http//www.myhealth.va.gov/
• 21 Veterans Integrated Service Networks (VISNs)

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OIF/OEF Veterans and VA

• As of the 4th Quarter, FY 2008
• 945,423 OEF/OIF veterans eligible for VA services
• 42 (400,304) have already sought VA care
• Their three most common health issues
• Musculoskeletal
• Mental Health
• Symptoms, Signs and Ill-Defined Conditions

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Beyond the DoD/VA Continuum

• Ideally such problems will be picked up somewhere
  within the DoD/VA continuum of care but
• If only 42 of All OEF/OIF Veterans eligible for
  VA care have come to VA where are the other 58?
• There is a silent majority of OEF/OIF veterans
  not coming to VA

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Comparison to the National Vietnam Veterans
Readjustment Study

• Only 20 of the Vietnam Veterans with PTSD at the
  time of the study had EVER gone to VA for Mental
  Health Care yet
• 62 of all Vietnam Veterans with PTSD had sought
  MH care at some point
• Kulka et al. 1990, Volume II, Table IX-2

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Boots on the GroundUnderstanding the Experience
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Boots on the GroundUnderstanding the Experience

• Theres nothing normal about war. Theres nothing
  normal about seeing people losing their limbs,
  seeing your best friend die. Theres nothing
  normal about that, and that will never become
  normal
• Lt. Col. Paul Pasquina, MD from the movie
  "Fighting For Life"

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Boots on the GroundUnderstanding the Experience

• In war, there are no unwounded soldiers.
• --Jose Narosky

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• I learned early that war forms its own culture.
  The rush of battle is a potent and often lethal
  addiction, for war is a drug, one I ingested for
  many years...
• War exposes the capacity for evil that lurks not
  far below the surface within all of us.
• And this is why, for many, war is so hard to
  discuss once it is over.
• Chris Hedges, Veteran War Correspondent, War
  is a Force that Gives Us Meaning

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Post Deployment Concerns among Active and
Reserve Component Soldiers

• Study followed 88,235 US soldiers returning from
  Iraq who completed both a Post Deployment Health
  Assessment (PDHA) and, 6 months later, a Post
  Deployment Health Reassessment (PDHRA)
• Screening includes standard measures for
• Posttraumatic Stress Disorder (PTSD)
• Major Depression
• Alcohol Abuse
• Traumatic Brain Injury
• Other Mental Health problems

Milliken, Auchterlonie Hoge (2007). JAMA
2982141-2148
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Changes among Active Duty (AD) and Reserve
Component (RC) Soldiers at PDHRA

• Roughly half of those with PTSD sx on PDHA
  improved by PDHRA yet
• There were twice as many new cases of PTSD at
  PDHRA
• Depression rate doubled in AD (10) and tripled
  in RC (13) at PDHRA
• Overall, 20.3 AD and 42.4 RC were identified as
  needing MH tx post deployment

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Changes among Active Duty (AD) and Reserve
Component (RC) Soldiers at PDHRA

• 4-fold Increase in concern about interpersonal
  conflict
• Alcohol abuse rate high (12AD/15RC) at PDHRA
  yet few (0.2) referred for tx
• If this is the progression among Service Members
  over the first 6 months, what about their family
  members?

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Why Might Reserve and Guard (RC) Members be at
Greater Risk than Active Duty (AD) Soldiers?

• AD have ready access to healthcare but RC DoD
  health benefits (TRICARE) expire in 6 months
• More than half of RC soldiers were beyond
  standard DoD benefit window by PDHRA
• Special VA benefits end 24 months after
  separation so, despite the stigma, the need to
  secure ongoing VA healthcare may push RC to
  report sx on PDHRA
• Other potential factors unique to RC may be the
  lack of day-to-day support from war comrades and
  added stress of transition back to civilian
  employment

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Mental Health Among OIF/OEF Veterans

• Possible mental health problems reported among
  44.6 (178,483) of the 400,304 eligible OEF/OIF
  veterans who have presented to VA
• Provisional MH diagnoses include
• PTSD 92,998
• (23 of all who presented to VA)
• Nondependent Abuse of Drugs 27,246
• Depressive Disorder 63,009
• Affective Psychoses 35,937
• Neurotic Disorders 50,569
• Alcohol Dependence 16,217
• Drug Dependence 7,412

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Traumatic Events in OEF/OIFA Sampler

• Multi-casualty incidents (Suicide Bombers,
  VB/IEDs, ambushes)
• Seeing the aftermath of battle
• Handling human remains
• Friendly fire
• Witnessed or committed atrocities

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Traumatic Events in OEF/OIFA Sampler

• Witnessing death/injury of close friend/favored
  leader
• Death/injury of women children
• Feeling/being helpless to defend or
  counter-attack
• Being unable to protect/save a colleague or
  leader

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Traumatic Events in OEF/OIFA Sampler

• Killing at close range
• Killing civilians/avoidable casualties or deaths

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Barriers To Treatment

• Treatment beliefs not addressed
• Fears of failure and fears of success
• Labels and stereotypes
• Avoidance
• Realistic concerns

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Identifying/Treating Post Deployment Mental
Health Problems Among New Combat Veterans and
their Families

• OEF/OIF veterans often seek care outside DoD/VA
• Family members are also dealing with
  deployment-related stress and look for help in
  the community
• Is your practice prepared to identify or treat
  post deployment problems?

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If You Dont Take the Temperature, You Cant Find
the Fever

• Know something about our nations military
  history and about our present military conflicts
• Know something about DoD and VA
• Ask each patient if he/she is a Service
  Member/veteran or a family member/ significant
  other of a service member or veteran?
• Know something about the different Service
  Branches and respect the difference!

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Our Focus
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Posttraumatic Stress Disorder (PTSD)

• Characterized by a constellation of symptoms that
  follow exposure to an extreme traumatic event
  which involves actual or threatened death or
  serious injury
• The response to the event must include intense
  fear, helplessness or horror and symptoms that
  persist more one month, including
• re-experiencing the traumatic event through
  intrusive recollections, dreams or nightmares
• avoidance of trauma-associated stimuli, such as
  people, situations, or noises and
• persistent symptoms of increased arousal, which
  may include sleep disturbance, hypervigilance,
  irritability or an exaggerated startle response

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Posttraumatic Stress Disorder (PTSD)

• PTSD diagnosis must also be accompanied by
  clinically significant distress or impairment in
  social, occupational or other important areas of
  function
• Problems must persist at least one month after
  the event

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Traumatic Brain Injury (TBI)

• Problems with memory, concentration, emotional
  lability or irritability may also suggest TBI
• Screen with the 3-Question Screening Tool
  developed by the Defense and Veterans Brain
  Injury Center (DVBIC)

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Traumatic Brain Injury (TBI)

• Proximity to explosions, thrown from a vehicle,
  lost consciousness (knocked out or down) and for
  how long, having symptoms of concussion
  (dizziness, headache, irritability, etc.)
  afterwards the blast
• Current symptoms headaches, dizziness, memory
  problems, balance problems, ringing in the ears,
  irritability, sleep problems, change in ability
  to smell or taste, sensitivity to sound or light,
  irritability, fatigue, trouble with
  concentration, attention, thinking.

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Combat/OperationalStress Reactions/Injuries
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A Combat Stress Injury

• Happens to a person (not chosen)
• Involves loss of normal integrity
• Causes loss of function at least temporarily
• Provokes predictable self-protective or healing
  symptoms
• Cannot be undone (though it usually heals)
• --Capt. Bill Nash in Combat Stress Injury

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Combat Stress Injury/Trauma

• Participant in/witness to event(s) involving
  horror, feelings that you or someone close to you
  will die, helpless, powerless

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Combat Stress Injury Discomfort/Fatigue

• Accumulation of stress over time, environmental
  hardships

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Combat Stress Injury Grief

• Loss of people who are cared about both in Iraq
  and at home

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Tricare
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Beyond Diagnosis

• Many problems faced by returning combat veterans
  and their families are not so much clinical and
  they are functional
• Work Stress/Unemployment
• Educational/Training Needs
• Housing Needs
• Is your patient homeless or perhaps functionally
  homeless?
• Financial and/or Legal Problems)
• Family Issues
• Lack of Social Support
• Estrangement
• Family Breakup
• Kids in trouble

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Beyond PTSD and TBI

• Psychological trauma may
• Surface indirectly as an exacerbation of chronic
  physical ailments (shortness of breath in an
  asthmatic, increased pain in a person with war
  wounds) or
• Be expressed in new somatic symptoms (headaches,
  abdominal pain) or
• Present as new or exacerbated substance abuse or
• Lie veiled behind vague complaints of poor
  energy, poor sleep or malaise

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Common themes Presenting Problems

• Marriage, relationshipproblems
• Medical issues
• Financial hardships
• Endless questions fromfamily and friends
• Guilt, shame, anger
• Lack of structure

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Common themes Presenting Problems

• Feelings of isolation
• Nightmares, sleeplessness
• Lack of motivation
• Forgetfulness
• Anger
• Feeling irritable, anxious, on edge

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Impact of Deployments and Combat Stress On the
Family
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Emotional Stages of Deployment

• Pre-deployment
• Deployment
• Sustainment
• Re-deployment
• Post-deployment

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How does combat/operational stress affect family
members?

• Avoidance
• Guilt Shame
• Anger
• Drug and Alcohol Abuse
• Health Problems

• Sympathy
• Depression
• Grief
• Fear Worry
• Loss of Sleep

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What to expect of children when service member
comes home

• o Preschoolers Feel guilty for making parent go
  away, need time to warm-up to returning parent,
  intense anger, act out to get attention, be
  demanding.
• o School Age Excitement, joy, talk constantly to
  bring the returning parent up to date, boast
  about the returning parent, guilt about not doing
  enough or being good enough.

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What to expect of children when service member
comes home

• o Teenagers Excitement, guilt about not living
  up to standards, concern about rules and
  responsibilities, feel too old or unwilling to
  change plans to meet or spend extended time with
  the returning parent.

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Positive Aspects of Deployments

• Foster maturity
• Encourage independence
• Strengthen family bonds

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Assessment Questions

• Why did you join the Marine Corps, Army, Navy,
  etc.? What did you hope to accomplish?
• Combat tours when, location, MOS, job in
  Iraq
• Satisfaction with training preparation
• Satisfaction with leadership and equipment
• How do family members feel about the military?
  About the separations?

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Assessment Frames

• Deployment Cycle
• Nature of Deployment
• Stages of Change

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Assessment -Deployment Cycle

• Pre-Deployment
• Deployment
• Post-Deployment

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Assessment -Deployment Cycle

• Pre-deployment
• Deployment orders can change/be revised
• Worry about safety of loved ones/themselves
• Activities of Daily Living finances, health
  care, child care, pets
• Single Parents
• Reservists - jobs, houses, family members
• Preparing not to come home

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Assessment -Deployment Cycle

• Deployment - stresses from in theater and
  home, e-mails/news coverage/internet

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Assessment -Deployment Cycle

• Post Deployment-Garrison life adjustment to lack
  of control, family life, pressures of daily
  living, broader focus, turning in weapons,
  personal protective gear

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Assessment Nature of Deployment

• Low intensity fear of death or injury is less
  imminent but chronically present.

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Assessment Nature of Deployment

• High intensity firing rounds at enemy, combat
  patrols, long duty hours, lack of sleep, whos
  the enemy, altered rules of engagement

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Assessment Nature of Deployment

• Highest Intensity - Terrorist activities,
  guerilla warfare tactics VBIEDs, IEDs, mortar
  attacks, chronic strain anxiety
• Friends, comrades killed/injured
• Split second decisions may be second guessed.
• Friendly fire

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Assessment stages of change

• Pre-contemplation Problem? What problem?
• Contemplation Do I need to change?
• Preparation Can I change?
• Action How do I change?
• Maintenance How do I keep on doing what Ive
  been doing thats working?

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Assessment Measures

• Primary Care PTSD Screen (PC-PTSD)
• Combat Exposure Scale (CES)
• PTSD Checklist Civilian Version (PCL-C)
• Trauma Symptom Checklist - 40 (TSC-40)
• 3 Question DVBIC TBI Screening Tool
• Other measures as appropriate

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Clinical Practice Guidelines and Treatment
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Post Deployment MH Problems Now that You Found
Them

• The key is to develop a supportive and
  collaborative therapeutic alliance with the
  patient and with his/her significant others
• Other steps/options include
• Early recognition of PTSD and other post
  deployment MH problems
• PTSD-related education
• Pharmacotherapy
• Psychotherapy/Supportive counseling
• Identifying resources
• Regular follow-up and monitoring of symptoms

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Treatment

• VA/DoD Clinical Practice Guidelines

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Clinical Practice Guidelines

• Assist clinicians in learning about available
  treatments, reviewing their evidence base and
  making practical, patient-specific choices among
  them
• Provide clinical algorithms that walk clinicians
  through the necessary steps from screening and
  initial assessment through treatment and
  re-assessment
• Most relevant among these is the VA/DoD Clinical
  Practice Guideline for the Management of
  Posttraumatic Stress

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VA/DoD Clinical Practice Guideline for the
Management of Posttraumatic Stress

• Created by a working group of VA and DoD
  clinicians and researchers
• Separate algorithms defined for primary care
  providers and mental health professionals
• Evidence tables provided for each recommendation
  and a substantial literature review included
• Available at www.oqp.med.va.gov/cpg/PTSD/PTSD_Base
  .htm
• In the public domain

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Clinical Practice Guidelines

• The American Psychiatric Association has
  published a Practice Guideline for Patients with
  Acute Stress Disorder and Posttraumatic Stress
  Disorder
• The International Society for Traumatic Stress
  Studies, the worlds largest international
  multidisciplinary professional organization
  working in the field of psychological trauma,
  provided a comprehensive set of treatment
  guidelines in 2000 with a new edition expected in
  2008
• Both guidelines provide a thoughtful introduction
  to available therapies, significant background
  information and evidence-based treatment
  recommendations.

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Triaging TBI

• Consider consultation
• Rehabilitative Medical Specialist
• Neurologist
• Speech Pathologist
• Audiologist
• Vision Assessment

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A Point of Caution

• Little evidence to support the use of Critical
  Incident Debriefing in the prevention of PTSD
• Debriefing in heterogeneous groups may actually
  increase the risk of PTSD by re-traumatizing
  survivors who are not prepared to be re-exposed
  to horrific memories

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Treatment OptionsCognitive Therapy (CT)

• Identify and clarify patterns of thinking
• Identify distressing trauma-related thoughts
• Convert these thought patterns into more accurate
  thoughts
• Address core beliefs about self, others, larger
  world

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Treatment OptionsExposure Therapy (ET)

• Reduce the fear associated with traumatic
  experience through repetitive, therapist-guided
  confrontation of feared places, situations,
  memories, thoughts, and feelings
• Exposure can be imaginal or in vivo
• Reduced intensity of emotional and physiological
  response is achieved through habituation.

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Treatment OptionsStress Inoculation Training
(SIT)

• Anxiety management is among the most useful
  psychotherapeutic treatments for PTSD clients
  (Expert Consensus Guideline Series)
• SIT can be thought of as a set of skills for
  managing stress and anxiety
• Breathing control, Deep Muscle Relaxation,
  Assertiveness Training, Role Playing, Covert
  Modeling, Thought Stopping, Positive Thinking,
  Self Talk

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Treatment OptionsEye Movement Desensitization
and Reprocessing (EMDR)

• Accessing and processing traumatic memories to
  bring these to resolution.
• The client focuses on emotionally disturbing
  material while at the same time focusing on an
  external stimulus (usually therapist directed
  bilateral eye movements, hand tapping, sounds)

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Pharmacotherapy

• Specific serotonin reuptake inhibitors (SSRIs)
  and venlafaxine have the strongest evidence
• While many drugs from a wide range of classes
  have been studied in PTSD, there is little
  evidence for their use except as adjunctive tx
• Antipsychotics often prescribed in military
  settings
• Available research suggests that prazosin
  reduces the frequency and intensity of
  posttraumatic nightmares and may be effective in
  managing other symptoms of PTSD but it cannot yet
  be recommended as stand-alone tx
• Benzodiazepines are not effective as first line
  agents in the treatment of PTSD
• Because of potential for dependence and abuse,
  their use as single agents is strongly
  discouraged

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Battlemind

• Developed by Walter Reed Army Institute of
  Research
• A motivational intervention that makes ignoring
  readjustment issues feel like a mistake
• Training, NOT Treatment
• Emphasis on adaptive change and the capacity for
  continued change

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Battlemind Defined

• Key Message Combat skills and Battle mindset
  sustained your survival in the war-zone
• Battlemind is the Soldiers inner strength to
  face fear and adversity in combat with courage
• But Battlemind may be hazardous to your social
  and behavioral health on the home front if it
  isnt transitioned
• In other words Battlemind represents a Soldiers
  successful adaptation to combat but Dont try
  this at home!

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Key Signs of Battlemind

• Buddies vs. Withdrawal
• Accountability vs. Control
• Targeted vs. Inappropriate Aggression
• Tactical Awareness vs. Hypervigilance
• Lethally Armed vs. Unarmed
• Emotional control vs. Anger or Detachment

• Mission OPSEC vs. Secretiveness
• Individual Responsibility vs. Guilt
• Non-Defensive (Combat) Driving vs. Aggressive
  Driving
• Discipline Ordering vs. Conflict

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A Sample of Battlemind Training
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The Face of the New Veteran

• Developed as an all employee training for VA and
  other healthcare personnel
• Keyed to a set of Resource Guides
• Guide for providers
• Guide for Veterans and their Significant Others

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Call to Action
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Public Health Model

• Most war fighters/veterans will not develop a
  mental illness but all war fighters/veterans and
  their families face important readjustment issues
• This population-based approach is less about
  making diagnoses than about helping individuals
  and families retain a healthy balance despite the
  stress of deployment

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Public Health Model

• Incorporates the Recovery Model and other
  principles of the Presidents New Freedom
  Commission on Mental Health
• There is a difference between having a problem
  and being disabled
• The public health approach requires a
  progressively engaging, phase-appropriate
  integration of services

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Public Health Model

• This program must
• Be driven by the needs of the Service Member/
  veteran and his/her family rather than by DoD and
  VA traditions
• Meet prospective users where they live rather
  than wait for them to find their way to the right
  mix of our services
• Increase access and reduce stigma

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Beyond the DoD/VA Continuum Partnering with
States and Communities
DoD/VA/State and Community Partnerships Are
Already Under Way or in planning in

• Upstate New York
• Washington State
• Ohio
• Alabama
• Vermont
• Rhode Island
• New Mexico

• Oregon
• Minnesota
• Texas
• Missouri
• Virginia
• Maryland
• Other states?

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Advantages of Working at State and Community
Levels

• May enhance access for Service Members, veterans
  and family members concerned about seeking help
  within the DoD/VA continuum
• May enhance the quality of services veterans and
  family members receive in the community

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Advantages of Working at State and Community
Levels

• National Guard programs are organized by state
• Each state has its own veterans outreach program
• Builds a system of interagency communication and
  coordination that may serve well at times of
  disaster

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The North Carolina Governors Summit on Returning
Veterans and their Families

• On September 27, 2006, key leaders of North
  Carolina State Government, VA, and DoD met with
  representatives of state and community provider
  and consumer groups 
• Governor Michael Easley charged Summit
  participants to develop new ideas that would help
  veterans succeed in getting back to their
  families, their jobs and their communities
• The Summit was only the start of a process, not
  its end!

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Summit Goals

• Exchange information about respective agencies
  assets and goals
• Identify strategic partnerships
• Articulate an integrated continuum of care that
  emphasizes access, quality, effectiveness,
  efficiency, and compassion

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Summit Goals

• Emphasize principles of resilience, prevention,
  and recovery
• Optimize access to information, support, and,
  when necessary, clinical services across systems
  as part of a balanced public health approach

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Next Steps

• Governors Letter to Veterans and Families
• A strong and clear Thank you
• A toll free number from the State Department of
  Health and Human Services (1-800-662-7030)
• Access to health, educational, and vocational
  services for Service Members/veterans and their
  family members
• A new mission for veterans and their families
• Build stronger careers, families and communities
  for the good of all the people of North Carolina
  

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Goals

• Enhance outreach
• Increase appropriate referrals
• Reduce stigma
• Promote healthy outcomes/Resilience/Recovery
• Strengthen families
• Decrease military attrition
• Decrease disability
• Increase consumer and provider satisfaction
• Transform the post deployment health system

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The Bottom Line

• There should be No Wrong Door to which OIF/OEF
  veterans or their families can come for help

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QUESTIONS?