REINTEGRATING AMERICA'S RETURNING WARRIORS

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REINTEGRATING AMERICA'S RETURNING WARRIORS TO
THE WORKPLACE
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PRESENTERS/CONTRIBUTORS
Jeffrey Yarvis, PhD, LTC U.S. Army Assistant
Professor of Family Medicine and Director of
Social Work, University Services University of
the Health Sciences Jose E. Coll, PhD Chair,
Military Social Work and Veterans Service
Program USC School of Social Work Catherine M.
Harrell, MSW (08) University of Southern
California R. Paul Maiden, PhD, LCSW Vice Dean
and Professor USC School of Social Work
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OBJECTIVES

• Understanding the military as a sub-culture.
• Who are our returning veterans?
• Identify the health and mental health needs of
  military veterans and citizen soldiers as they
  return to the workplace.
• Identify supportive measures that EA
  professionals need to take to assist in the
  successful reintegration of military veterans
  into the civilian workforce.
• Assess the co-morbidity of PTSD and mild and
  traumatic brain injury (TBI) and implications for
  disability accommodation in the workplace.
• The utilization of technology as a tool for
  transition.

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DEFINING THE MILITARY
Who are we? What constitutes the U.S. armed
forces? Who can serve in the military?
Why do most people join the military?
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WHO CAN SERVE IN THE MILITARY?
Between 18 and 35 High school diploma Without
a criminal record In relatively good health
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WHY DO MOST PEOPLE JOIN THE MILITARY?

• Opportunities for travel and adventure
• Means of saving money for college
• Career choice
• Family tradition
• Patriotism
• Adventure (adrenaline / civilian life)

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MILITARY WORKPLACE CULTURE
MILITARY CULTURE is a set of values, beliefs,
traditions, norms, perceptions and behaviors that
govern how members of the armed forces think,
communicate, and interact. The CULTURE
influences how veterans engage with each other
and with civilians as well as how they view their
function in life, their status, and the role of
the military in American Society.
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MILITARY VALUES (Desirable Characteristics)
Honor Integrity Courage Commitment Loyalty R
espect Devotion to Duty
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CULTURAL DIFFERENCES

• Military Culture
• Emphasis on unit cohesion
• Emphasis on the mission
• Devotion to duty
• Chain of command

• Civilian Culture
• Emphasis on individuality
• Individual achievement
• Personal freedom
• Fluid social relationships

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WHO ARE OUR WAR FIGHTERS?

• Currently there are approximately 200,000
  women which make up
• approximately 15 of service members
• Guardsmen and Reservists make up approximately
  35 of the
• deployed force in Iraq/Afghanistan (141,000)
• Currently there are approximately 26,400,000
  veterans.
• It is estimated that the ratio of PMF to
  Military personnel OIF/OEF is
• currently in 110 vs. 1100 during the Desert
  Shield

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REASONS FOR AVOIDING MENTAL HEALTH SERVICES

• Fear of a poor performance rating
• Fear of losing security clearance
• No guarantee of confidentiality
• Fear of appearing weak
• Fear of letting the team down

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ACTIVE DUTY COUNSELING ISSUES

• Faith issues
• Stress and anxiety
• Redeployment or reunion issues
• Moral and ethical values conflicts
• Requests for emergency leaves
• Requests for hardship discharges
• Full spectrum of clinical problems

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COMBAT TRAUMA

• Trauma is highly subjective
• It is not possible to determine who will
  experience a trauma
• It is not possible to know the specific
  characteristics of an event that will make it
  traumatic for a particular individual

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SIGNS OF POOR READJUSTMENT

• Living in isolation
• Socially isolated externally
• Socially isolated internally
• Inability to reintegrate

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SIGNS OF POOR READJUSTMENT

• Use of abusive and hurtful language
• May indicate PTSD
• May indicate substance abuse
• Does indicate poor interpersonal communication
• and family distress

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INTERACTION IN NON-CLINICAL SETTINGS

• Context is important
• Questions about service experience are OK
• What branch of the service were you in?
• Where were you stationed?
• What was your occupational specialty?
• What was your component? (active or reserve)
• Communicating to your civilian counterparts

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PTSD HISTORY

• PTSD History

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W W I
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W W II
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HOLOCAUST

• April, 1945 Jewish prisoners at Auschwitz,
  liberated by Russian soldiers (AP)

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PTSD AND TRANSMISSION
PTSD AND TRANSMISSION

• 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)

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VIETNAM
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TREATMENT OF OEF/OIF VETERANS WITH
POSTTRAUMATIC STRESS TODAY
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REASONS

• Psychological (mind) AND physical (brain and
  body) injury is a common
• result of war and deployment. The current
  wars in Iraq and Afghanistan
• are returning thousands of war-fighters with
  psychological, brain and
• bodily injuries, many with long-term
  symptomatic and functional
• consequences.
• War is a fertile breeding ground for PTSD and
  provides a renewed
• emphasis on clinical practice AND research.

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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?

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THE CHALLENGE

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

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PTSD DSM DIAGNOSTIC CRITERIA

• Typically develops following an exposure to
• an event that is perceived to be threatening
  to the well-
• being of oneself or another.
• Person must be exposed to event or actual
  perceived
• threat.
• Symptom clusters
• Re-experiencing (1 of 5)
• Avoidance and emotional numbing (3 of 7)
• Hyper-arousal (2 of 5)
• Significant distress or impaired functioning

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TAXONOMIC ISSUES

• Kraeplins classification system based on
• medical model affecting predictive validity.
• Appears to be diagnostic yardstick with a
• sliding scale.
• No one-size-fits-all category has persisted
• over time.
• Debate over what constitutes normal and
• pathological responses continues
• PTSD has been a labile polymorphic disorder-
• Solomon.
• DSM versus ICD.

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PTSD RATES

• 1990-1999 (OOTW at height)
• there were 1,380 hospitalizations and
  18,597 ambulatory visits for
• treatment of active duty U.S.
• soldiers for PTSD (Hoge, et al.,
• 2002).
• Sub-threshold PTSD accounts for
• another 20 to 40 of impaired
• soldiers (Yarvis, Bordnick et al.,
• 2005).
• MHAT 10-20

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CONSTRUCTS OF TRAUMA

• Types I, II, III trauma (Terr, 1999)
• Cultural and racial trauma (Allen, 1998
  Pinderhughes, 1988)
• Civilian trauma vs. combat trauma

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SAME OR DIFFERENT TODAY? EX. VIDEOS
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THE STIGMA

• Patton_Coward_Video2.wmv

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LEADERSHIP MITIGATES STIGMATIZING EFFECTS
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SAME AND DIFFERENT TODAY

• The multi-component and overlapping nature of
  injuries
• in returning war fighters are appropriately
  considered as
• war-related, trauma-induced spectrum disorders
  (wrTSD)
• and may be of a different character than
  civilian TSD.
• gt15 of soldiers returning from the wars in
  Iraq and
• Afghanistan suffer from diagnosable
  post-traumatic
• stress disorder (PTSD).
• Nearly 40 report stress-related symptoms and
• dysfunction that significantly prevent
  re-integration into
• a full, productive life.
• 96 survive wounds.

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STRESSORS 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 AND Leaving Again

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THE SOUNDS OF COMBAT STRESS
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THE SOUNDS OF COMBAT STRESS
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WEATHER
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BEARING WITNESS I.E., POVERTY AND DEPRIVATION
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PASSIVE POSTURE
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FIRST EXPOSURE AND WMD
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CULTURAL DIFFERENCES
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HOME-FRONT, THE MEDIA AND UNIT CASUALTIES
Next slide VERY GRAPHIC
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DEATH OF CHILDREN
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MILITARY-INDUCED FAMILY SEPARATION
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MILITARY CULTURAL COMPETENCE

• Unconscious incompetence
• Conscious incompetence
• Conscious competence
• Unconscious competence
• Facts for Non-Military Social Workers (Kadis
• Walls)
• Iraq War Clinician Guide 2nd ed. (National
  Center for PTSD, 2004)
• Human Behavior in Military Contexts
  (Blascovich Hartel,
• 2008)
• (www.nap.edu/catalog/12023/html).
• www.americasheroesatwork.gov/index.html

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ROLE OF EMPLOYEE ASSISTANCE PROGRAM IN
REINTEGRATION

• Facilitating between service member,
  co-workers and
• civilian employer (Continuum)
• Evaluate complexities of service status
• Active duty, regular forces
• Active reserve or national guard
• Inactive reserve
• Individual augmentee vs. unit deployed

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ROLE OF EMPLOYEE ASSISTANCE PROGRAM IN
REINTEGRATION

• Establishing contact prior to re-entry
• Contact spouse, email veteran, expectations of
  their
• return
• Triaging their needs
• Planning a welcome back to work event
• Sensitivity to the returning employee
• Sensitizing the organization to their return

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NORMALIZATION FOR THE RETURNING VETERAN

• Passive observation Expect the worst, Hope
  for the
• best! But, dont over-react
• Expect a honeymoon period
• What was the employee like before deployment?
• Demeanor, work ethic, social and emotional
  maturity

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WHAT TO EXPECT?

• Displaced anger
• Hyper arousal
• May sound aggressive at times without intent
• Dark sense of humor that may be perceived as
• harassment or prone to violence
• Adverse to ambiguity which creates
  vulnerability
• Most of all observe the subtleties

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PROBLEM ASSESSMENT

• Pre-occupation with themes of war
• Survivor guilt
• Perceived mission failure
• Suicidal ideation

• Precursors to adjustment
• disorder
• Early indicators
• Low productivity
• Presenteeism
• Agitation
• Insubordination

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HOW TO RESPOND

• Organizational Perspective
• The EAP Perspective
• Re-establishing normalcy What is their
• new normal?
• Re-connecting family, community, and work
• Maintain contact with local Vet Center
• Case management

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RESPONDING TO FAMILY NEEDS

• Common family reactions
• Unique features of military family dynamics
• Involving non-family caregivers and schools
• Multiple systems affected

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REINTEGRATION PITFALLS FROM A SPOUSES PERSPECTIVE

• Education
• Communication
• Combining two different chains of command
• Self-awareness

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PROGRAMS OFFERED TO MILITARY COUPLES

• The 5 Languages of Love
• Redeployment/Reintegration Briefings
• Post- Deployment Battlemind Training
• Counseling Services
• Marriage Retreats

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THE RETURN IS THE BEGINNING
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THIS IS JUST THE BEGINNING!

• IN HONOR OF ALL OUR MEN AND WOMEN IN UNIFORM
• OUR WAR FIGHTERS ANDWOUNDED WARRIORS
• THANK YOU!JOSE, CATHERINE, PAUL AND JEFF