Returning from Combat: Understanding the Mental Health Effects of Deployment on Education Mark C' Br

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Returning from CombatUnderstanding the Mental
Health Effects of Deployment on EducationMark C.
Brown, MD, MAJ, MCThanks to Roger Duda, MDMAJ,
MC4th Sustainment Brigade Psychiatrist
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Agenda

• Deployment Stress
• Emotional Cycle of Deployment
• Post Deployment Reactions
• Stressors and Combat Experiences
• Recovery
• PTSD and Depression
• Coping with Post-Deployment Stress
• Post-Deployment Growth
• Resources

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Introduction

• Military families have experienced the emotional
  trauma of deployment on an unprecedented scale
  since the end of the Gulf War
• Military downsizing increased likelihood each
  soldier will eventually participate on extended
  missions
• Long separations are increasing concern with
  two-thirds of soldiers now married
• Differing coping strategies are needed through
  five stages of deployment
• Education of health care providers, military
  leaders, soldiers and family members to
  anticipate these stages is crucial to ensure the
  soldier's safe return and to minimize stress
  impacts

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Deployment Stress

• Psychological responses to deployment
• Often no immediate symptoms
• Reasonable immediate functioning upon return home

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Emotional Cycle of Deployment

• Five distinct stages
• Pre-deployment, deployment, sustainment,
  re-deployment and post-deployment.
• Each stage is characterized by
• a time frame and specific emotional challenges,
  which must be dealt with and mastered by each of
  the family members
• Failure to negotiate challenges can lead to
  significant strife
• Early information about what to expect can go a
  long way towards "normalizing" and coping
  positively with the deployment experience
• Promoting understanding of the stages of
  deployment helps avert crises, minimize the need
  for command intervention or mental health
  counseling and can even reduce suicidal threats

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• Pre-Deployment
• Anticipation of loss vs denial
• Train-up/long hours away
• Getting affairs in order
• Mental/physical distance
• Arguments

• Deployment
• Mixed emotions/relief
• Disoriented/overwhelmed
• Numb, sad, alone
• Sleep difficulties
• Security issues

• Sustainment
• New routines established
• New sources of support
• Feel more in control
• Independence
• Confidence I can do this.

Emotional Cycle of Deployment

• Post-Deployment
• Honeymoon period
• Loss of independence
• Need for own space
• Renegotiating routines
• Reintegration into family

• Re-Deployment
• Anticipation of homecoming
• Excitement
• Apprehension
• Burst of energy/nesting
• Difficulty making decisions

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Stage 1. Pre-deployment

• Stage begins with the warning order for
  deployment
• Characteristics
• Anticipation of loss vs. denial
• "You don't really have to go, do you?"
• Train-up/long hours away
• Getting affairs in order
• Long "honey-do" lists
• Mental/physical distance
• Will my marriage survive?"
• Arguments
• "I wish you were gone already."
• It is easier to be angry than confront the pain
  and loss of saying goodbye

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Stage 2. Deployment

• Mixed emotions/relief
• Disoriented/overwhelmed
• Numb, sad, alone
• Sleep difficulty
• Security issues at home
• Positive side
• Ability to communicate home is a great morale
  boost

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Stage 3. Sustainment

• New routines established
• New sources of support
• Feel more in control
• Independence
• Confidence
• Discussing "hot topics"
• Unidirectional phone calls

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Stage 4. Re-deployment

• Re-deployment
• Essentially defined as the month before the
  soldier is scheduled to return home.
• Anticipation of homecoming
• Will he (she) agree with the changes that I have
  made?
• Will I have to give up my independence?
• Will we get along?"
• Excitement
• Apprehension
• Burst of energy
• Difficulty making decisions

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Stage 5. Post-deployment

• Honeymoon period
• Intimacy issues
• Social, sexual, recreational, spiritual,
  physical, affective, intellectual
• Myth of Infidelity
• Loss of independence
• Spouses may consider themselves to be the true
  heroes
• Need for "own" space
• "Who is this stranger in my bed?"
• Renegotiating routines
• Reintegrating into family
• Typical period where post traumatic issues appear
• Three to six months after deployment
• Communicate with patience focus on feelings,
  what not who

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Post Deployment Effects of Deployment and Combat
Experience

• Cognitive (thoughts)
• Emotional (feelings)
• Behavioral (actions)

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Top Deployment Stressors
Uncertain Re-Deployment Date
Long Deployment Length
Being Separated from Family
Lack of Privacy or Personal Space
Boring or Repetitive Work
Difficulties Communicating Back Home
Not Having Right Equipment or Repair Parts
Lack of time off for personal time
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Combat Experiences
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Combat Experiences
Receiving incoming artillery, rocket, mortar
Receiving small arms fire
Knew someone seriously injured or killed
Having a member of your own unit become a
casualty
Seeing dead or seriously injured Americans
Handling or uncovering human remains
Being directly responsible for the death of an
enemy combatant
IED/ booby trap exploded near you
IED question only asked during OIF-II
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Protective Factors

• Well-functioning/supportive unit
• Perceived control over events
• Strong commitment to tasks
• See adverse events as challenges
• No prior trauma exposure
• Good mental health pre-exposure
• Strong social/family support

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Risk Factors

• Severity of trauma
• History of previous trauma
• Preexisting psychiatric disorder
• Family history of psychiatric disorder
• Limited support systems
• Exposure to reactivating environmental events

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Changes in Thinking

• Unwanted reliving of combat experiences
• Distressing memories
• Disturbing dreams or nightmares
• Flashbacks
• Upset when reminded of war zone events

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Changes in Thinking (cont.)

• Changes in Attitude and Outlook
• Preoccupation with news about the war
• Worry about friends still deployed overseas
• Miss excitement of combat, urges to return
• Confused about direction and meaning in life
• Blaming self for actions in war zone
• Loss of innocence and belief in former values

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Changes in Emotion

• Feeling unsafe, on guard
• Irritability and outbursts of anger
• Anxious, apprehensive, panicky, stressed out
• Guilt, shame
• Feeling alienated from others and society (I
  dont fit in any more!)
• Loss of interest and enjoyment in life
• Down, depressed, hopeless
• Shutting down and emotional numbness

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Changes in Behavior

• Trouble falling asleep and/or staying asleep
• Easily startled, jumpy
• Physical symptoms and health problems
• Problems with concentration and attention
• Avoiding people, places, or things that are
  reminiscent of military duty
• Increased use of alcohol or drugs
• Isolated, withdrawn, sullen, uncommunicative
• Overly controlling and worried about safety

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Recovery

• Understanding and the support of others helps
  stress reactions pass more quickly
• Structure your time with normal activities keep
  busy with a normal schedule
• Dont label this is a normal reaction to an
  abnormal event
• Talk to people it is the most healing medicine

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Recovery

• Get plenty of rest
• Eat healthy even if you dont feel like it
• Daily exercise
• Spend time with others
• Share your feelings
• Do things that feel good
• Dont make any big life changes

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Mental Health Awareness

• Returning Soldiers are at Risk for
• Domestic Violence
• Substance Abuse
• Depression
• Anxiety disorders
• Post-Traumatic Stress Disorder (PTSD)

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Current Statistics

• Depression
• 8-10 in post-deployment
• PTSD
• OIF 15-20 of returning soldiers
• OEF 10-15 of returning soldiers
• Substance Misuse
• Up to 30 of returning soldiers

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Effects of Witnessing Traumatic Events

• It is quite normal for people to experience
  emotional or physical reactions after a traumatic
  event
• They can occur immediately after the event, or
  may take hours, days, weeks or months to appear
• They are normal and for most will resolve or not
  have significant impact on life

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Risk Factors for PTSD

• Nature of the trauma prolonged, severe
• History of prior trauma
• Family history of anxiety disorders
• Personal history of mood disorder, anxiety
  disorder

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Suggested Coping Skills for Dealing with
Post-Deployment Stress

• Unwanted distressing memories, images or thoughts
• Remind yourself that they are just thatmemories
• Talk to someone you trust about them
• Sudden feelings of anxiety or panic.
• Slowing down your breathing may help.
• Learn to ride the wave
• Depression
• Talk about losses, changes and gaps between what
  you dream and what you have
• Monitor and disrupt negative self-talk
• See the doctor if it last longer than a month

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Suggested Coping Skills for Dealing with
Post-Deployment Stress (cont.)

• Feeling like the trauma is happening again
  (Flashbacks)
• Keep your eyes open. Look around you and notice
  where you are. Tell yourself, I am at ___
• Call someone you trust and tell them whats been
  happening.
• Trauma-related dreams and nightmares
• If you awaken from a nightmare in a panic,
  remind yourself that you are reacting to a dream
• Talk to someone or your doctor about your
  nightmares certain medications can be helpful.

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Suggested Coping Skills for Dealing with
Post-Deployment Stress (cont.)

• Difficulty concentrating
• Write things down. Making to do lists may be
  helpful
• Break task down into small do-able chunks
• Having difficulty feeling or expressing positive
  emotions
• Ensure regular participation in activities you
  enjoy or used to enjoy.
• Take steps to communicate caring to loved-ones in
  little ways pleasers, write a card, leave a
  small gift, phone and say hello

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Suggested Coping Skills for Dealing with
Post-Deployment Stress (cont.)

• Difficulty falling or staying asleep
• Avoid using your sleeping area for anything other
  than sleeping or sexual intimacies.
• Do not lie in bed thinking or worrying. Get up
  and enjoy something soothing or pleasant
• Irritability, anger, and rage
• Take a time out to cool off or to think things
  over
• Talk to someone about the triggers to the anger
  and irritability

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Helping A Person Affected By Combat Experiences

• Listen carefully
• Spend time with them
• Reassure them they are safe
• Help with everyday tasks
• Allow some private time
• Dont take their anger or other feelings
  personally
• Ask how you can assist them

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Post-Deployment Growth

• Improved sense of own vulnerability
• Sense of increased competence and self-reliance
• Increased gratitude for relationships with
  significant others
• More compassion and empathy for others
• Greater efforts directed at improving
  relationships
• Greater appreciation for life
• Positive changes in one's priorities
• Stronger religious/spiritual beliefs

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Resources

• WBAMC OPS 569-2801
• El Paso Child Guidance Center Grant
• TRICARE
• Military One Source
• Army Behavioral Health web site
• www.behavioralhealth.army.mil