Download Post Traumatic Stress Disorder and The Military Veteran

Post Traumatic Stress Disorder
and The Military Veteran Student
Autonomy
The organism possess a
certain degree of
freedom… It acts according
to its own inherent nature,
which is based on intrinsic
forces, and is not under the
compulsion of outside
influences
Autonomy
Characteristics:
 Self Governing
 Self Determination
 Self Understanding
 Intrinsic Forces
 “Self” is known
 “The World” is understood
 “Shattered Assumptions”
Autonomy
Assumptions about “Self” and the World
SELF
WORLD

Personal Empowerment

The World is a Safe Place

Sense of Personal Efficacy


Efficiently Manage Self and
Decisions
Some Personal Control over
the Environment

Sense of Personal Power
and Self Control
Efficiently interacts with the
Environment & Others

Empowered to Keep
Oneself & Loved Ones Safe
in the World


Capable of interacting
effectively with others
Autonomy: Once Assumptions are Shattered
Crisis with the SELF
 Failure to Maintain Sense
of Personal Power
 Question Ability to Self
Manage
 Question Efficiency and
Effectiveness of Choices
 Fear of Losing Control of
Self and Uncertainty about
the Future
World VIEW
 Questions Safety of World
 Questions Self and ability to
control any Aspect of Life.
 Questions Efficiency of Being
and Interacting in the World
 Questions Personal Ability to
keep Loved Ones and Self out
of Harms Way
Why Self and World View are Changed



The Crisis Event Rendered
the Person “HELPLESS”
Crisis events Cause a
Person to Question Their
SELF (Decision Making)
The Event is Incongruent
with Beliefs about Self
(Abilities and Strengths)


The Event is Incongruent
with Belief about Safety of
World.
An overpowering sense of
failure, inadequacy,
abandonment and/or
rejection will often set in due
to this incongruence.
DANGER As A Profession
• Military Veterans
• Police Officers
• Emergency Medical
Technicians
• Fire Fighters
• Emergency Room
Personnel
• FBI, ATF, other
dangerous professions
Danger
Powerful vs. Powerless
Mild danger vs. extreme
Danger
Impact of Traumatic Events
Self is Changed
 Beliefs
 Self Esteem
 Personality Shift
 Biological
 Fear
 Spiritual Crisis
Danger



Shatters one’s perception
about themselves and their
place in the world.
Shatters one’s sense of
safety & security
Most Devastating effect:
Autonomous ability to relax
Ego Defenses – (isolation,
anger, guilt, anxiety,
depression)
Danger
Other Ego Defenses develop:
 Inability to Trust
 Inability to Establish or Re-
Establish Intimacy
 Emotional Numbing
 Hyper-Sensitivity Toward
Injustice
 Pervasive Sense of Feeling
Damaged
Symptoms (P.C.E.B.S.)
Physical, Cognitive, Emotional, Behavioral, Spiritual
P.C.E.B.S.
Cognitive
Physical


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





Agitation
Fatigue
Headaches
Vision Problems
Hyper-arousal
Exhaustion
Chest Pain
Muscle Tremors
Grinding of Teeth









Intrusive Thoughts
Memory/Concentration
Confusion
Preoccupation
Uncertainty
Feeling Overwhelmed
Poor Problem Solving
Poor Abstract thinking
Intrusive Images
P.C.E.B.S. (Cont’d)
Emotional
Anxiety
 Depression
 Hopelessness
 Despair
 Rapid Mood Swings
 Unpredictable Mood
 Denial
 Agitation
 Intense Anger

Behavioral




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




Hyper-vigilance
Sleep Problems
Substance Abuse
Self Mutilation
Cry easily
Antisocial Acts
Defiance of Authority
Inability to Rest
Erratic Movements
Loss of Appetite
P.C.E.B.S. (Cont’d)

Questioning Good and Evil

Attempting to Make Sense of
Senselessness

Searching for the Meaning of
the Experience

Struggling with
Understanding Why

Questioning God/Faith
Spiritual
Human Toll: Depth of Change
 First Responders and Horrific Scenes
 Violent Law Enforcement Action
 Katrina & Natural Disasters
 Virginia Tech Carnage
 Oklahoma City Bombing
 Columbine
 9/11
 Military Combat
Readjustment After Combat:
What the Soldier Brings Home
“No one comes
back unchanged”
COL (Dr.) Tom Burke,
Department of Defense,
Director of Mental Health Policy
Life on the Front
To understand what the soldier brings home, one needs to look at how the
environment of war gets inside the mind.
What the Soldier Brings Home

86% received artillery fire.
 93% were shot at with small arms.
 77% fired at the enemy.
 95% saw dead bodies or remains.
 89% were attacked or ambushed.
 86% know a troop injured or killed.
 65% saw dead or injured American.
 69% saw injured women/children
and were unable to help.
-- These numbers correspond in part to a study in the New England Journal of Medicine and pertain to service members in Iraq.
VA HEALTHCARE UTILIZATION
Total who served in Iraq (OIF) and Afghanistan (OEF)
2.3+ million*
OIF and OEF war veterans separated from military
and eligible for civilian care
1.4 million*
 766,081 (~55%) Former Active Duty troops
 630,396 (~45%) Reserve and National Guard
* FY 2002 to Dec 2011. Office of Public Health, Veterans Health Administration, Department of
Veterans Affairs
Total Deployed by State- Active Duty +Guard/ Reserve
since June 2010
10,725 8,761
65,497
11,554
5,531
25,568
25,557
11,562
12,071
9,866
31,935
24,218
76,846
63,550 81,898 39,94013,764
32,969
18,453
37,748
19,396
20,893
63,192
25,744
33,360
12,678
23,914
36,303
5,325
28,482
17,243
7,108
13,044
21,249
56,444 83,027
12,022
184,721 18,245
4,622
15,772
55,274
26,413
48,690
29,410
52,440
267,720
29,209
CTS
deployment
File Jan 2010
SERV
Proprietary and Confidential
206,699
VA HEALTHCARE UTILIZATION
OIF/OEF veterans seen by VA Health Care:
• Over 742,000 OIF/OEF era veterans have sought VA
Healthcare since 2002 (mostly outpatients).
- Reflects ~ 8% of ALL patients treated at VAMC’s (6 million).
- No. of newest veterans seeking help has doubled in 2 yrs.
• Ages: ~ 45% = 19-29; 28%=30-39; 28% = 40+.
• Gender: ~ 12% females.
VA HEALTHCARE UTILIZATION
Over 52% (385,700+) of all OIF/OEF veterans seeking VA
care have presented with a mental health problem.
• Approx 35% have utilized MH services at least once.
• Approx 18% diagnosed with psychiatric problem.
• Over 3.2% (~24,000) OIF/OEF veterans are being
seen at Ohio VA’s (VISN10).
Frequency of Possible Mental Disorders
OIF/OEF Veterans since 20021
Disease Category (ICD 290-319 code)
Total Number of
OEF/OIF Veterans2
PTSD (ICD-9CM 309.81)
207,161
Depressive Disorders (311)
156,189
Neurotic Disorders (300)
134,754
Affective Psychoses (296)
94,486
Alcohol Dependence Syndrome (303)
44,169
Nondependent Abuse of Drugs (ICD 305)
30,870
Special Symptoms, Not Elsewhere Classified (307)
26,577
Mental Disorder due to Organic Brain Damage (310)
26,039
Drug Dependence
22,974
Sexual Deviations and Disorders (302)
22,310
1 The total will be higher than all unique patients who received a diagnosis of a possible mental health disorder. A Veteran may have
more than one mental health disorder diagnosis and each diagnosis is entered separately in this table.
What the Soldier Brings Home
The PTSD Syndrome (12-16% of soldiers)
• Intrusive thoughts/memories
• Nightmares
• Avoidance/isolation
• Anger/angry outbursts
• Hyper-startle response
• Flashbacks
• Hyper vigilance
• Feelings of grief, guilt, & loss
What the Soldier Brings Home
It’s not just about PTSD
Disillusionment with “civilian life”
& activities.
– Irritability & anger toward
non-military.
– Profound feeling of alienation.
– Social isolation.
• Self-blame or guilt for acts of war.
•
• Physical health problems
What the Soldier Brings Home
Alcohol and Drug Abuse
• Work as way to cope with post-trauma internal distress.
• Quick way to alleviate anxiety symptoms.
• Allows social interaction without emotion inhibitions.
• Dulls memories; creates fast moving, transient
emotional states
• Helps maintain status quo.
• Helps develop and reinforce “safe” social alienation.
What the Soldier Brings Home
Most veterans with traumatic stress symptoms get better
over time even without professional help or with
minimal (2-3 session) interventions.
What the Soldier Brings Home
The soldier does not have
energy or time to process
events until after leaving the
battlefield. It is only on
return that many incidents
begin to impinge on his or
her daily life.
What the Soldier Brings Home
Prolonged exposure to combat stress
•
Most soldiers exposed to multiple terrorism or life
threatening events.
•
Some may have
participated in atrocities.
•
Witness to or participant
in atrocities creates sense
of alienation from “civilians”.
What the Soldier Brings Home
In Iraq & Afghanistan, there is a sense of danger all the time.
• Constant fear & stress over long period of time creates distrust of
any new environment.
• Adaptation to combat violence
as “norm” generates tendency
to get overly aroused
physically in arguments.
• Often develop a mindset of
“act immediately, debate later”
In the class room they may have
difficulty with debates.
What the Soldier Brings Home
They often have experienced death
of close friends or comrades
that still bothers them greatly.
For many, a comrade’s
death is an overwhelming
experience, often leading
to prolonged unresolved
mourning and anger.
What the Soldier Brings Home
What They Say Are Problems (from Focus Groups)
●
Wanting to be left alone - Social avoidance/isolation
●
Sensitivity to loud noises and jumpiness – hyper-arousal
●
Anger, lack of patience - irritability
●
Chronic joint pain, generally ankle, knee and back pain
●
Memory problems or "lapses“ - trouble concentrating
●
Drinking or smoking too much
●
Personality changes, emotionally distressed
●
Body image issues: scars, weight changes, etc.
Coming Home: Life, Work, Learning
Difficulties with Public Interactions
• Soldier may be tense about the “politics” of war.
• Public may not always know what to do or say.
• Veteran unsure who he/she can talk to.
Questions can arise about:
What will they want me to talk about?
What can I talk about?
How will they react to a story or event?
Coming Home: Life, Work, Learning
Difficulties Reconnecting
• Some found violence scary and
exhilarating. Many say combat
was the most exciting and
important thing they have
ever done. They are often bored
with classroom experience.
• Difficult for soldier to discuss this
with “civilians” who do not
understand military or combat
(will gravitate toward veterans).
Coming Home: Life, Work, Learning
Learning Environment Problems
• Internal chaos (intrusive images and memories) may intrude on
ability to concentrate, pay attention.
• Hyper-arousal (on guard), in crowds, among new persons,
changing environments (new classroom each course), may
create tension, irritability, anxiety.
• Veteran may feel students behave differently toward him/her.
• Tendency toward social isolation leads to difficulty seeking help
for studies, working with other students.
Coming Home: Life, Work, Learning
Learning Environment Problems
• Veteran and classroom expectations may conflict.
• Homework assignments (group assignments may be difficult)
• Subject matter or presentation may arouse anger, irritation,
isolating response (politics, history, social sciences are
especially red flags).
• Has difficulty with “vague” subject matter or mixed
conclusions. Need for concrete outcomes, “usable” learning.
Coming Home: Life, Work, Learning
Learning Environment Problems
Aftereffects of mild Traumatic Brain Injuries (mTBI) or multiple
extreme concussions may create short term cognitive deficits.
 Physical Issues: Headaches, ears ringing, dizziness, visual blurring
 Assignment Overload: May not be
able to focus on single subject for
long periods of time.
 difficulty with remembering details,
memorization, etc.
 Not write as well, move as
quickly as others.
Welcome To College
Developing a Welcoming Environment
Information, Information, Information
• How to park, where to park, who to see about what.
• E-mail a map if possible (Website Information helps)
• Work with other veterans who are willing to be “buddies”
Orientation
• Provide a personal walk through
• Show major important areas (with a fellow vet if possible)
Welcome To College
First Engagements: Veterans Orientation Event
• Try to have a group orientation for veterans only
• Find Instructors who are veterans willing to be mentors
• Invite local Vet Reps who will provide free services:
– Dept of Veteran Affairso Veterans Benefits (BVA) Reps
o Veterans Healthcare Reps if possible
- Local Vet Center
- Community Based Outpatient Clinics
– State or County Veterans Reps (Veteran Service Commission)
– Community Veteran Organizations
○ AMVETS, VFW, Local Service Officers
Welcome To College
Setting A Path of Matriculation
• Assign a Veterans Benefits Administrator job at University.
– Able to guide them on paperwork, timelines,
– Give them a list of what is needed from them for benefits.
– Discuss unexpected costs, especially books
• Discuss cost of living allowance delays
Won’t get first check until 6-8 weeks after 1st day
Welcome To College
Mentoring and Counseling
• Encourage tutors on first day of school


They won’t want to at first : Sign of weakness
Try to find student veteran tutors
• Develop Veteran Lounge/Center
on campus (Support)
Provides a gathering place
for the veterans (support)
• Train a counselor on military
culture and veteran MH issues.
Welcome To College
Classroom Strategies
Orient Professors on how to be veteran friendly
• Do not point veterans out as “victims” of War or feel sorry for them.
• Do not belittle, demean lapses in completing assignments or
•
•
•
•
•
failures to grasp material.
Allow them to leave classroom if necessary.
Allow them to sit in back of class.
Professors who do not agree with decision to serve should be
discreet.
Be aware of subject matter drifting to volatile topics.
Be open to requests to change classes.
Tailoring the Learning
Environment for Success
Fifteen Environmental Cues That May
Trigger Increased Symptoms
Cues that May Cause Agitation, Anxiety, Panic,
Intense Anger, Apprehension, Sadness:
 Inefficient Support Services
 Non-Compassionate Attitude of Staff Members
 Waiting in Long Lines for Services
 Getting the “run-around” about Administrative Paperwork
 Immoral or Unethical Practices by Staff, Faculty or Students
 Lack of Clear “Chain of Command” to resolve problems or
concerns
Environmental Cues (Cont’d)
 Lack of Respect for &
Acknowledgment of Veteran
and Their Service
 Lack of Respect by Faculty
or Staff for Sacrifice of
Veteran’s Friends Killed and
Injured in War
 Childish Behavior by
“Traditional Teenage
Students” (Loud Music after lights
out – Dorm life)
 Roll Call
 Overall Lack of effective and
efficient leadership at the college
 Timeliness of GI Bill Processing
and Other Financial Supports
 Large, Loud and Crowded
Classrooms
 Classrooms Where Veteran
Cannot Sit With Back to the Wall
 Chaotic Classroom – Instructor
Not in Charge
Sensory Triggers to Consider
Visual
 Use of Laser Pointer
 Emergency Light
Flashing
 Middle Eastern
Student/Clothing
 Human Suffering
 Dry/Arid Environment
Sensory Triggers to Consider
Other Senses
 Loud Noises
 Helicopter Blades
 Smells (Raw Sewage)
 Smells (Sweat)
 Oppressive Heat
 Taste/Smell of Middle
Eastern Foods
 Sitting in uncomfortable
chairs with back pain, knee
injuries other chronic
medical concerns
Twelve Administrative Action Items
1.
Ask the Vets
2.
Special Supports During
Registration for Rapid
Enrollment
3.
Veteran Task Force
4.
Encourage and Develop
Peer Support
Organization (Student
Veterans of America)
www.studentveterans.org
5.
Host Veteran Recognition
and Welcoming Activities
6.
Specific College Policy and
Procedures addressing
action if student deployed.
7.
Institution Admin
consistency: GI Bill, course
credit for military schooling,
Financial Aid, etc.
Administrative Action
8.
Present “Veteran
Awareness and
Sensitivity” training for
all Staff & Faculty
9.
Create a Veteran
Resource Center &
Devote Office Space
10.
Register as Service
Member Opportunity
College (SOC)
(Cont’d)
11.
Develop a Veteran
Foundation Account to
Assist Student Veterans
with Tuition, Books,
Fees and Household
Emergencies
12.
Presidential and Senior
Leadership Support
Fifteen Faculty and Staff Actions
To Consider
1. Recognize you “Will”
Have Higher Numbers
of Both Male and
Female Veterans With
Traumatic Stress History
2. Recognize the Cultural
Diversity That Exists
Between Traditional
Students and Military
Veterans
3. Military Veterans are
Permanently Changed
Due to Experiences and
are Often in a Period of
Intense Adjustment and
Transition
4. Military Veterans with
Combat Experience will
Have Normal and
Predictable PCEBS
Faculty and Staff Action
5.Recognize there are
Potential Cues in the
College Environment
That Will Trigger PCEBS
Symptoms.
7.Understand there are
Major Financial Stresses
Due to GI Bill Delays,
Federal Red Tape, VA
Appointments, etc.
6.Recognize Some
Veterans will meet ADA
Criteria for Support
Due to Injury (TBI).
8.Readjustment after
Extreme Experiences
Cause Family Strain As
Well as College Stressors.
Faculty and Staff Action
9. Recognize the Veteran is
Reintegrating Into More
Than One Environment.
10. Some Veterans will Admit
Their Veteran Status
While Others May Keep it
Quiet (Women Veterans)
11. Honor and Respect Differing
Viewpoints and Strong
Emotional Commitment to a
Position or Belief
12. Be Flexible with Attendance
and Classroom Assignments
Faculty and Staff Action
13. Recognize and Support
Military Dependents
14. Learn the Various Trauma
Symptoms That Occur
with all Trauma Victims
15. Know all Veteran Support
Services on Your Campus
and in the Community
Institutional Services to Provide
Create Local College Military Veteran Task Force
Determines Specific Services - To Include the
Following as a Minimum:
 Orientation Program specific to veterans
 One stop Center of Excellence
 Veterans Advisory Council
 Prevention Program
 Veteran Volunteer Program
 Develop “on-line” and Print Educational Information
Resources Listing
National Center for Post Traumatic Stress Disorder (NCPTSD)
(www.ncptsd.va.gov)
National Child Traumatic Stress Network (NCTSN)
(www.nctsn.org)
National Center for Trauma Informed Care (NCTIC)
(ww.mentalhealth.samhsa.gov/nctic/)
VA National Centers for Veterans Benefits
http://www.oefoif.va.gov/
http://www.va.gov/vetdata/
Student Veterans of America
http://www.studentveterans.org/?page=Mission_and_History
Contact Information
Roger P. Buck, Ph.D.
Director, Counseling Services
Hocking College, 3301 Hocking Parkway
Nelsonville, Ohio 45764
Phone: (740)-753-6133
e-mail: [email protected]
Edgardo Padin-Rivera, Ph.D.
LS Cleveland DVA Medical Center
Cleveland, Ohio 44106
Phone: (216)- 791-3800, ext. 6814
Email: [email protected]
If you see a returning service member this month,
just say thank you.