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Transcript
Veterans, Families, &
Communities Under Fire
Clinical and Ethical Guidelines
for Treating the Effects of War
R. Blaine Everson, Ph.D.
Marriage & Family Therapist
Samaritan Counseling Center
Learning Objectives



Learn a systems based
approach to common
problems seen with vets
and families
Better understand military
culture & language upon
practice & broader culture
Ethics of assessing,
evaluating, & treating vets
& their families from a
systemic perspective



Utilize knowledge of indepth ethics associated
with interventions where
needs of vets & families
may diverge.
Learn more about seeking
& providing supervision for
working with vets & their
families.
Identify ways of become a
more veteran friendly
therapist and attracting
clients.
2
Military Culture

Sociologists define culture as …
•
Language - nomenclature; acronyms, abbr.
Beliefs – defenders of Democracy
Value systems – leave no one behind
Norms & rules – formal & informal conduct
Material products – weapons systems
•
•
•
•
Associated with a social system & unique to a given
system.
3
Language Barriers for Civilians

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
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MOS
BNOC
NTC
PCS
DCU
AWOL
LTC
NCO
BAH
ETS
FOB

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Type of Uniform
Preparation Encampment
Desert Warfare Training
Moving
Sergeant
Staff Sergeant’s School
Rent Money
Leaving Without Permission
Leiutenant Colonel
Job in the Military
Separation from Service
4
Military Cultural Influences
on Society



Military systems and its participants
have influenced our society at-large in
various ways – politics, business, etc.
Language – “snafu”, “whole 9 yards”,
“son of a gun”, “dressed to the 9’s”, etc.
Behaviors – smoking cigarettes
becomes fashionable for males after
WWI b/c common in rations.
5
A Warrior Caste

Military is a caste system into which marines, soldiers,
sailors, & airmen are reborn as recruits via basic training
& re-socialized into specific roles within the military
system.

Total institutions where many aspects of life are dictated
and contrived via rules & regs.

Then they are ritualistically baptized by combat & set
apart from the rest of society for remainder of their lives
due to these extraordinary experiences.

A “warrior” from that point in time onward.
6
Creeds and Mottos of Military
USMC Rifleman’s Creed
This is my rifle. There are many like it, but
this one is mine. It is my life. I must master
it as I master my life. Without me, my rifle
is useless. Without my rifle, I am useless. I
must fire my rifle true…Before God I
swear this creed. My rifle and I are the
defenders of my country…and there is no
enemy.
7
Military Families As Embedded Systems
Service Member
Military Family
Service Unit/Support
Military Installation
Local Community
National Defense
System
Understanding How Military Families Influence (and Are Influenced by)
Multiple Systems Is A Must for Practitioners Working With this Clientele
8
Military Family Life Cycle
<May be 1st deployment for both partners>
-Courting
-Pregnant
Deploy
New family
begins in
absentia
<Missed 1st year of marriage>
Mid-tour
leave
-Marriage
Parental
adj &
young
children
Return &
Reunion
Resume
normal
routines
<Divorce & remarriages w/ kids for previous relationships are common – complex stepfamily>
ETS or
Retire
Families w/
teens &
possibly
steps
Relocation
Return &
Reunion
Family w/
school
agers
Redeploy
Transitions are often marked by crisis points in the family life cycle.
9
A Dynamic Family Systems Model for
Understanding Military Family Problems
Changing
External
Environment
“Withdrawal”
Amplifying
Info Out
(+)
feedback
e.g. “cut-offs”
Complex
Adaptive
Behaviors
Emerging
Features
(Symptoms)
Info In
Info In
(-)
feedback
“Re-deployment”
Dampening
e.g. “secrets”
Info Out
Changing
External
Environment
“Therapy”
Changing
External
Environment
Changing
External
Environment
Reactive Relational Dynamics
“Misbehavior”
10
Basic Emotional Triangulation between
Military Families and the Military System
military
service
member
children
spous
e
Returning Warriors: Your Practice


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Uninjured or unimpaired, but with familial
problems.
Physically injured seen with familial
problems.
Psychologically injured with familial
problems.
Physical & psychological injuries
impacting families.
12
Veterans And Families Under
Fire
Part II
Ethical Understanding of Treatment
Options & Interventions
13
A Systemic Orientation
Family Structure
 Boundaries
 Family Roles & Rules
 Triangles
 Birth Order
 Ecosystems
Family Development
 Lifespan Development
 Resilience & Vulnerability

Crisis in Families
 Belief Systems
Family Process
 Emotional Regression
 Differentiation &
Separation
 Multigenerational
Influences
 Paradoxical Situations
 Family Secrets
 Family Rituals
 Sibling Relationships
Assessing Problems &
Systems Treatment – Part I

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History taking

Clinical interview
Life span stage
Scales & indices
Genograms

Mindset during
assessment: willing to
include military service
in history taking.
Multiple life cycle phases
experienced
simultaneously & may
conflict w/ phase
progression.
Disruptions frequently
erupt in a crisis state &
must be managed by
therapist.
15
Assessing Problems &
Systems Treatment – Part II
Genogramming
Complexity!!!
Unit members may be
2nd order family.
Time consuming b/c of
complexity
Helpful for teasing out
systemic issues
related to step-family,
FOO, etc.
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


m. 04
m. 99 – d. 03
16
Assessing Problems &
Systems Treatment – Part III
Church



Ecomapping is a graphical
representation showing all of
the systems at play in an
individual's life
Sometimes more helpful to
focus on extra-family
connections
Helps understand stressors
stemming from embedded
nature of families
Son (5)
Dad
Unit
Mom
Step-son
(8)
Scouts
17
Systems Oriented Therapy



Should not view the family problems as
simply vet’s readjustment issues (context)
Family problems may have existed prior to
ETS or last deployment (history)
Presenting px should be viewed within
larger focus of recent service (events)
18
Systems-Based Diagnosis of
Common Operational Maladies

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Traumatic Brain Injury
Combat Stress Injury
Post Traumatic Stress Disorder
Generalized Anxiety Disorder
Panic Disorder
Depressive Disorders
TBI & CSI in a Systemic Context
Traumatic Brain Injury
 Ranges from mild to
severe – concussions to
major intracranial trauma
 Concussive episodes –
IED, RPG, etc.
 Sx include: of memory
loss, poor concentration,
sleep px, body aches,
pain, high BP, fatigue
 R/O b/w mTBI & PTSD
Combat Stress Injury
 Exposure to deployment
related stressors &
operations
 Physical, emotional &
cognitive impact
 Sx may morph into major
clinical syndrome
 Combat Exposure Scale
is valid & reliable for
assessment of CSI
20
PTSD & CSI

PTSD: three symptom sets




Hyperarousal – startles easily & hyper-vigilance
Intrusions – flashbacks & nightmares (terrors)
Constriction of affect – numbing or dissociation
Combat Stress Injury:





Physical hardships >noise, blasts, dirty, malnourished
Cognitive > +/- information, mission ambiguity, lack of
contextualizing
Emotional > fear of injury or death of comrades,
shame/guilt, helplessness, killing
Social > social support vs. privacy issues; public opinion
Spiritual > forgiving; self-forgiveness; loss of faith
21
Systemic Considerations in Stress
Disorders



Allostasis vs. homeostasis – equilibrium restored by
shifting set point - w/ allostasis the fulcrum is moved in
a particular direction disallowing the return to previous
functioning
Neurotransmitter-receptor hypothesis – changes due to
stress & predispositions may be irreversible due to
depletion of NE & 5-H serotonin in the CNS
New modalities for treating stress disorders are
emerging or improvement in existing methods in
response to more severe & tx resistant disorders
22
Family Empowerment Therapy:
Five Phase Model





Beginning & Exploration of Problems
Framing Problems & Balancing Ind
Needs: Optimizing Therapy Environs
Retelling of Events: PTSD & STS
related
Reframing, Altering Structure, &
Healing Narrative
Closure & Follow-up (p. 198-203 FUF)
23
A Paradigm for Understanding Post-War Healing
Within Veteran Families
Key:
Solid – represent overt interactional pattern
Dashed - represent covert interactional pattern
The Healing Journey
Secondary
Disability Dynamic
Spouse
-Δ in communication
-w/h negative info?
-parentified child?
- accounts for changes &
transitions in family
dynamics across time,
situations, & stages of life
(ETS, PCS, etc.)
Parent-Child
Relational
Dynamic
Spousal Disability
Dynamic
Couple
Relational
Dynamic
-reduced intimacy
-disengagement
-poor communication
Parent-Child
Relational
Dynamic
Children
Soldier
Injury
Φ – physical
aspects
-Extent of Injury
-Limitations
Ψ – emotional
Parent-Child Disability Dynamic
-reduced interaction
-estrangement
-negative reactions (stage dependent)
-# of children
The entire family dynamic changes from this
point forward in time as the family attempts to
accommodate the injury and adapts to new
situations as they arise.
Physical rehab & psychotherapy must balance
emotional and physical aspects of injury with
family support, while maintaining focus on the
value of the family as a healing environment
and attending to family member’s emotional
needs to that end – all must heal together.
impact
24
PTSD & Secondary Trauma:
Case Illustration – Sgt. Love
-PTSD
-Depression
-Affair
-Secondary stress
-ETOH Abuse
-Withdrawal
37
42
46
m. 96 – d. 2002
m. 2006
-Presenting problem?
10
22
7
- Diagnosis?
- Treatment plan?
- Strengths?
-Referrals?
Genogram circa 2011
1) Lived parallel lives since Afghan Deployment. 2) Lost Battle Buddy in IED blast – injured himself. 3) Working as a
foreman at a metal fabricator. 4) Difficulty talking to one another.
25
Ethical Issues Associated with
Treating Veterans & Families
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Must balance needs of family and
veteran needs simultaneously
Consultation with other healthcare
professionals may be needed
Ethics associated with labeling vets &
stigma attached to labels
Working with VA resources & systems
can be frustrating for private providers
26
Veterans And Families
Under Fire
Part III
Systems Based Supervision &
Being a Veteran Friendly
Therapist
27
Supervision Issues



Sometimes difficult to
see multiple layers of
systems
Orient to family
lifespan development perspective
Differentiate
relational diagnoses
from individual axes

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Help supervisee
understand triangle b/w
themselves & family
Help integrate systems
based knowledge into
ongoing treatment
Videotape & audiotape
in place of live
supervision
28
Levels of Systemic Supervision
1.
2.
3.
Learning basics of systems theory &
concepts within military scope
Integrating systemic theory in light of
interactions with military families &
organizing of formal assessment
Integrating assessment into an
informed selection of effective clinical
intervention
29
Goals for Systemic Supervision With
Vet Friendly Therapists



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Deepen understanding of family process & theory
as applied to vet families
Increase sensitivity to dynamic processes &
recognize in systems of vet families
Help with systemic assessments, formulations of
treatment goals, & selection of interventions
Help to step back and learn from successes &
failures, while instilling confidence to try new &
creative approaches
30
Veteran Family Friendly Therapist

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Tricare/Value Options paneled; others are
BCBS, UBHS, Magellan
Partner with VA to provide ongoing
services that they don’t provide, specialty
groups, family therapy, spousal support,
etc.
MFT & LPC are eligible for jobs in the Dept
of Defense and the VA
31
References in Brief
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Beder, J. (Ed.) (2012) Advances in Social Work Practice
with Military Families. Routledge.
Everson, R. & C. Figley (Eds.) (2011) Families Under Fire.
Routledge.
Figley, C. & W. Nash (Eds.) (2007) Combat Stress Injury.
Routledge.
Hall, L. (2008) Counseling Military Families. Routledge.
Hoge, C. W. (2010) Once A Warrior… Guilford.
Lee, R. & C. Everett. (2004). The Integrative Family
Therapy Supervisor. Routledge.
32