COMING HOME FROM WAR: A COMMUNITY’S RESPONSE

TO OUR VETERANS

“To care for him who shall have borne the battle, and for his widow, and his orphan”

A. Lincoln

88th Regional Readiness Command Combat Operational Stress Control Team

MAJ. Cynthia Rasmussen

The Products88th RRC Deployment Cycle Support Program

Education

Resource Materials and Briefings - to help leaders, Service members and families manage deployment stress

Networking and Marketing Presentations - to increase public awareness and support of military families

1:1 Counseling, Brief Intervention, Referrals, Command Consultation, Grief education and support

Suicide education/Intervention, First Responder Training

Sexual Assault Prevention and Response Program

OEF/OIF Veterans’ Statistics(from VA National WEB site & Womens vet. Center)

48% are Active Duty, 52% are Reserve/National

Guard88% are men, 12% are women (14%

AC/RC)65% Army; 12% Air Force; 12% Navy;

12% Marine34% were deployed multiple times52%, largest age group, is 20-29 years old

total number of soldiers who have been deployed during OIF/OEF

1.6 million

total number of soldiers who have been deployed to a war zone twice or

more

700,000+

86% Know someone who was seriously injured or

killed.

77% Have shot at ordirected fire at the

enemy.

68% Have seen dead

or seriously injured

Americans.

WHY A BRIEFING ON REINTEGRATION?

History has taught REUNIONS are more stressful than separations:

People grow and changeExpectations are Different Experiences were different

Understanding & having the right words to dialogue about changes and expectations has made significant strides in improving the reintegration process…

“Never before have we asked so few citizen soldiers to do so much in war time, while knowing they and their families have great psychosocial needs.”

Dr. Charles R. Figley

Mission Stressors Then Lack of/too much communication Lack of freedom of movement Environmental / climate

changes Isolation & boredom Poor sleep patterns Home-front worries Repetitious & routine duties Separation from loved ones Unclear / misunderstood

mission Uncertain redeployment

date

Operations Tempo Cultural Differences Lack of personal time Threat of attack Observation of atrocities Taking of life, watching

others die Recovering the dead Breaking of personal

moral code Experiencing abuse or

harassment POOR LEADERSHIP

War Zone Skills are not the same skills we need at home.

“Normal” behavior for a service member is often

not understood by family, friends, co-workers, or our

communities.

Service members need 2 sets of skills:

WAR/Survival Coping SkillsHOME Skills

Mission OrientedWAR

Once a mission is assigned other, unrelated tasks are unimportant Decisions need to be quick,

clear, accurate No time for discussion

“one person talks-everyone listens”

HOME/JOB/SCHOOL

Multiple competing tasks cause confusion Get angry with those who get in

the way of mission Difficulty participating in cooperative decision making Frustration with others“lead, follow, or get out of the way”

“I must be on time for everything”

“CHAOS” “everyone talks- everyone listens”

Safety & TrustWAR

Vigilance pays off Never Relax/ Never let guard down Assume everyone is the enemy

“suspicious of others you have known & trusted”

HOME/JOB/SCHOOL

Avoid getting involved Suspicious of everyone Test people to earn trust Always on guard Isolative “being suspicious isolates you”“I have never been able to go to

the mall again”“Holiday Weekend, My

family took a nap and I cleaned my weapon”

(female OIF Vet)

Emotions/Anger“NOT talking about your emotions in war (strength)

only leads to CAN”T talk about emotions at home (weak)”

WAR

Control emotions Numbing Anger useful, protective, IS a survival skill

HOME/JOB/SCHOOL

Insensitivity to others “look hot headed, hard headed” Decreased ability to read others emotions “you look / act emotionless” Decreased emotional enjoyment Increased irritability and

defensiveness Increased aggression “fed by constant frustration” “They think I have PTSD cause I don’t cry”

Increased alcohol/drug use to avoid feeling emotions

AuthorityWAR

Little room for choice “do what you are told when you are told”

May have had much authority

May not have faith in authority “bad decisions by authority = deadly consequences”

HOME/JOB/SCHOOL

May Resent authority “who are you to tell me what to do”

May be Reluctant to let others have authority “may cause grades to fall at school” ”loss of jobs” “etc”

May take on too much authority/ or want none at all

May lead to Increasedconfrontations

ClosenessWAR

Intense relationships Strong bonds, depending on

each other for survival If losses, learn to avoid getting close

HOME/JOB/SCHOOL

Long term intimacy more complicated “lonely” “not open with emotions” May expect same level of intensity of intimacy at home “not on the same page” May push loved ones away

“looking for replacements”

Intelligence/ TalkingWAR Restrict any information

that may be used against you

Can change world view and of self (may be unable to articulate changes) “I didn’t feel safe anymore”

HOME/JOB/SCHOOLGive little information

“feel like I need to shred it all”Keep to self/More comfortable talking

with Battle BuddiesAvoid talking “phone

vigilance/verification”Social chatter a waste

“very direct communication (cold, not friendly)”

“changing routes when

commuting”

Response Tactics

WARAct first think laterMaximum application of

force and or resources “everytime”

HOME/JOB/SCHOOL

Unable to think first act later“too much going on”

“you look reckless & uncaring /inconsiderate /selfish”

He/She may insist things not be out of place “you appear to be extreme”

May find self training the family to survive in a war zone “appear to be aggressive”

“I am not one of your troops!”

Hypervigilence “Adrenaline RUSH”

WAR A year or more of daily

Hypervigilence

HOME/JOB/SCHOOLHOME/JOB/SCHOOLInability to relaxInability to relaxSleep changes Sleep changes “too little/ too “too little/ too

much”much”DreamsDreamsMonitoring environment/Monitoring environment/perimeterperimeter

Attempts to relive Attempts to relive “RUSH”“RUSH”

War may be hell… but home ain’t exactly heaven, either.

When a Service Member comes home from war, He/She finds it hard…

…to listen to his son whine about being bored.

…to keep a straight face when people complain about potholes

…to be tolerant of people who complain about the hassle of getting

ready for work

…to be understanding when a co-worker complains about a bad

night’s sleep

…to control his panic when his wife tells him he needs to drive

slower

…to be grateful that he fights for the freedom of speech.

…to be compassionate when a businessman

expresses a fear of flying.

…to be silent when people pray to God for a new car.

…to not ridicule someonewho complains about hot weather.

…to just walk away when someone says they only get two weeks of

vacation a year.

…to control his rage when a colleague gripes about his coffee

being cold.

…to remain calm when his daughter complains about

having to walk the dog.

…to be civil to people who complain about their jobs.

…to be happy for a friend’s new hot tub

…to be forgiving when someone says how hard it is to have a new

baby in the house.

…to not punch a wall when someone says we should pull out immediately.

The only thing harder than being a Service Member…

……………

IS LOVING ONE…….

A gentle reminder to keep your life in perspective.

And when you meet one of our

Returning SERVICE MEMBERS/VETS/FAMILIES,

please remember what they’ve been through

and show them

Compassion , Tolerance, Respect, and the Best

Care.

Thank you.CPT ( Ret.) Alison L. Crane, RN, MS

WAR ZONE/ MILITARY SKILLS DO NOT AUTOMATICALLY CHANGE WHEN YOU/THEY COME HOME.

What is Operational Stress??What is Operational Stress?? Combinations of physical and

mental challenges (stressors) that can produce symptoms which temporarily interfere with performance.

Can happen to even the bravest warriors as well as those who have not been in combat

Operational stress can also produce positive behaviors. Negative effects diminish or resolve given time and positive support.

Two Types of Stress

There are Two Kinds of Stress

ACUTE – “Fight or Flight”

CHRONIC -

Acute StressAcute Stress• Body readies for “fight or flight”

Electrical changes in heart and sympathetic nervous system Increased production of hormones & sugars Immune system changes; blood pressure increases

• Experience: Thrill Exhilaration

Adrenaline rush Results in:

Focused attention Heightened strength Feeling of competence If stress is unmanaged, can result in ‘burnout’

Effects last at least 90 minutes

Chronic Stress Injury – Adaptation vs Injury

The Stealth Bomber of Stress Long term results of daily living.

PHYSIOLOGICAL EFFECTS

Mediates Hormones and Neurotransmitters Serotonin, Dopamine, Noradrenaline, GABA, CRF, Steroids

Exhaustion stage Available resources exhausted Performance becomes progressively worse Performance may stop

• The Goal of Military Training is to “HARDEN” (adapt) troops so they can operate under conditions where ACUTE STRESS is actually a CHRONIC condition.

The Thing is…

What’s the Difference Between a

Stress Adaptation and a Stress Injury?

Adaptation- The path of change can be traced over time- Individual feels like he/she is still

himself - A more gradual process- A focus of training and leadership

InjuryInjury– May be more abruptMay be more abrupt– A derailment, a change A derailment, a change

in selfin self– Individual feels like Individual feels like

he/she is not in controlhe/she is not in control

Two ways of looking at Battlefield stress:

Combat/ Operational Stress Reaction (COSR)

Physical Signs and Symptoms Common

• Fatigue• Jumpiness • Aches and pains• Upset stomach,

nausea• Diarrhea or

constipation• Changes in eating

()• Changing sleep

patterns ()

More Serious

Flinching Startle reaction Shaking/Trembling Limbs/Eyes/Ears don’t work

normally/ “right” Spaced out

Cognitive (Thinking)Signs and Symptoms

Common

Poor concentrationDifficulty making

decisionsForgetfulness (short

term)FlashbacksNightmaresDenial

More Serious

• Disregard for rules/regs• Thoughts of self-harm or • harming others (suicidal or• homicidal thoughts)• Long term memory loss• Loss of motivation Violent nightmares

involving actual violence upon waking

EmotionalSigns and Symptoms

Common

Frustrated/ angry Lowered Self-esteem Worried Keyed up Guilty, ashamed Depressed/ withdrawn Grief Numb Tearful Confused Sense of loss of control

More Serious

Panic attacksFeeling a sense of dread

“Flat” expression

Regression

Immobilizing depression

BehavioralSigns and Symptoms

CommonZoning out in meetings/classFailing deadlines/examsArguments/fights with others Tardiness /absenteeismDenial there are problemsAvoiding “triggers”“I don’t care” attitudeHides true feelingsIntimacy and relationship

difficultiesJob/Family difficultiesIncreased irritability/anger

BehavioralSigns and Symptoms

More Serious

Alcohol and drug useSuicidal/Homicidal gesturesDangerous/risk-taking behaviorsHyper-vigilanceDomestic abuse/family violenceChild abuseWithdrawal – stops performingImpulsive behavior

Operational Fatigue: What Is It?

• Gradual emotional changes after prolonged exposure to combat/operational stress How soon it sets in depends on how severe and continuous the operational stresses have been Eventually, everyone succumbs if exposure is continuous, even to low-intensity operational stresses

• Caused by an accumulation of small stresses Hardships Monotony Insufficient rest and recuperation

• More common in officers and SNCOs than in younger troops“Old Sergeant's Syndrome”

• Can develop without exposure to mortal danger

“I thought anyone with PTSD was a whimp, till I had to admit it hit me”

Combat Operational Stress Reactions are EXPECTED reactions

to UNUSUAL situations

…..whereas

Post Traumatic Stress Disorder is not a common problem.

Other concerns

DEPRESSIONTBI

ANXIETY

Post Traumatic Stress Disorder

Symptoms are stronger in intensity and durationThan COSR

symptoms worsen over time, esp. without professional symptoms worsen over time, esp. without professional interventionintervention

If left untreated, ability to tolerate additional trauma or stressful situations is compromised

DEPRESSION

Hopelessness

Helplessness

Worthlessness

SIGNS AND SYMPTOMS OF DEPRESSION

Sleep disturbancesIrritability (more than usual crankiness

or grumpiness)Loss of energy (not just “tired”)

Appetite disturbances (eat too much, eat too little)

Lack of pleasure in favorite activitiesAnxiety (butterflies or knots in belly)

Feeling helpless or hopelessInability to concentrate or remember

simple thingsSadness for little or no reason

Many Disorders Mimic Each Other

DepressionOperational

StressPost

Traumatic Stress

Disorder

Traumatic Brain Injury

Hopelessness X X X X

Helplessness X X X X

Worthlessness X X X X

Anxiety X X X

Physical Symptoms

X X X X

Anger/Irritability /X X/X X/X X/X

Sleep Disorders X X X X

Re-experiencing X

Avoidance/Numbing

X/X X X/X

Arousal/Agitation X/ X/X /X

Memory Problems X X X X

Alcohol/*Drug Abuse

X X/ X/X X

Personality Changes

X X X X

Grief/Guilt X X X X

Spiritual Turmoil X X X X

Traumatic Brain Injury – another war to fight

What is Traumatic Brain Injury (TBI)?

A blow or jolt to the head or a penetrating head injury that disrupts the function of the

brain.

Mild Mild –– 80% 80% •a brief change in mental status or a brief change in mental status or

consciousnessconsciousness•Like Like ““shaken baby syndromeshaken baby syndrome””

MODERATE– 10%

SEVERE– 10% extended period of unconsciousness or amnesia after the

injury.

Primary Causes of TBI(From the CDC National Center for Injury Prevention and Control)

Transportation (vehicle crashes) – 44%Falls – 26%

Other/Unknown – 13%Non-Firearm Assaults – 9%

Firearms – 8%

are the leading cause of TBI for military personnel within a war zone.

Impairments Associated with TBI

PHYSICAL• Impaired hearing,

vision, speech• Balance problems• Fatigue• Muscle spasticity• Seizures

COGNITIVE• Memory loss• Concentration or

processing difficulty• Organizational

problems• Spatial disorientation• Impaired judgment

and inability to multi-task

Impairments associated with TBI

Psychosocial, Behavioral, Emotional

• Failure to recognize deficits• Increased anxiety• Depression and mood swings• Sexual dysfunction• Impulsive behavior• Lowered self-esteem• Reminders needed to initiate or complete

tasks

• Low-grade headaches that won’t go away 

• Having more trouble than usual: 

– Remembering things 

– Paying attention or concentrating 

– Organizing daily tasks 

– Making decisions and solving problems

• Slowness in thinking, acting, speaking, or reading 

– Getting lost or easily confused 

– Neck pain

– Feeling tired all the time, lack of energy 

Concussion (mild head injury)

• Change in sleeping pattern: 

– Sleeping for much longer periods of time than before 

– Trouble sleeping or insomnia  

• Loss of balance, feel light-headed or dizzy 

• Increased sensitivity to: 

– Sounds 

– Lights 

– Distractions 

Concussion (mild head injury)

• Blurred vision or eyes that tire easily 

• Loss of sense of taste or smell 

• Ringing in the ears 

• Change in sexual drive 

• Mood changes: 

– Feeling sad, anxious, or listless 

– Becoming easily irritated or angry for little or no reason 

– Lack of motivation

Concussion (mild head injury)

The Impact of TBI at Home, Work, School

• Significant stress in relationships with family & peers

• May experience loss of

- function - relationships

- self-esteem - financial self-sufficiency

- job/career

• Managing multiple changes: challenges of brain injury are in addition to challenges of re-integrating back home following deployment separation.

The Impact of TBI on Educational Pursuits

• Many returning Veterans plan to use military educational benefits – however they often don’t feel like they fit in.

• TBI may negatively impact school performance due to Cognitive and Behavioral impairments

The Impact of TBI on Re-entering the Workforce

• May require accommodations

– Modified work schedule

– Re-introduction to the work, orientation to job, training & feedback

– Job checklists & cues

– Breaking work into manageable steps to improve sequencing

– Changes in office location to minimize distractions

Has the Veteran experienced a TBI?

1. History of head trauma?

2. Experienced OVERPRESSURE from blast.

3. Ringing in ears after blast or head trauma.

4. Loss of consciousness? How long?

5. Any lingering problems (headache, concentration, difficulty with new learning)?

6. Are there still problems?

Symptoms may be related to:

• Structural damage – ex. Impulsiveness or agitation

• A psychological reaction to the situation – ex. Anxiety or depression

• A character trait – ex. Dependency or mistrustfulness

Post-TBI Depression

• Estimated 50% become depressed within the first year after injury

• Symptoms include altered sleep pattern & loss of appetite or libido, (which can also reflect underlying medical problems)

• Differential diagnosis includes sense of apathy, emotional lability, adjustment disorder, or PTSD

The Brain in TBI-Related Depression

• Biological basis = altered patterns of release of peptide transmitters.

• Related to disruption of neural circuits involving the prefrontal cortex, amygdala, hippocampus, basal ganglia, and thalamus (Jorge & Robinson, 2002)

• More common with injuries to right hemisphere, left basal ganglia, and dorso-lateral frontal cortex (Borod et. al., 2002)

• Lesions in above areas trigger neurochemical responses that produce depression.

ANXIETYANXIETY• 28% experience anxiety symptoms

within one year of injury

• Expressions of– Fear, panic, flashbacks– Worry– Irritability– Restlessness

Apathy

• Increased level of apathy in individuals with right hemisphere lesions.

• Apathy may reflect an initiation problem from frontal lobe damage

• Individuals with TBI make less use of social support and may experience substance use / abuse (especially prescription drugs)

Anger

• Agitation – constant uninhibited movement

• Irritability – easily annoyed or upset, may be frustrated with limitations of injury, impatient with other people

• Anger - limbic system lesions (frontal, prefrontal & anterior temporal cortex, amygdala, hypothalamus & septum)

• Episodic dyscontrol – violent, unprovoked attacks

TBI Management Strategies

Accommodations• Speed – extra time• Attention – repetition• Memory – multiple

modes

Compensatory Strategies• Day planners• Written instructions• Alarm watches• Tape recorders

TBI Management StrategiesCreate Structure

• Scheduling– Maintain consistent daily routine

– Use external cues (notes, calendars, etc)

• Communication– Eliminate background noise when speaking

– Consider fatigue factor & time of day

– Use written step-by-step instructions

– Repeat key points in conversation

• Environment– Create message boards, information centers

– Use reminder notes on mirrors, doors

– Buy appliances that shut off automatically when not in use

TBI Management StrategiesCreate Support Systems

• Soldier/veteran

• Medical & Social Support Systems

• Family

• Employer, school

• Peers/co-workers

• Community Organizations

Reasons Service Members Don’t Seek Help

Didn’t know where to get help 22%Didn’t have adequate transportation 18%Too embarrassing 41%Would harm my career 50%Other unit members/fellow workers would have less confidence in me 59% Unit leader/boss would treat me differently 63%Leaders would blame me for the problem 51%I would be seen as weak 65%Doesn’t trust mental health professionals 38%Mental health care doesn’t work 25%

Specific Emerging Issues Motor vehicle accidents Reintegration difficulties

(Workplace/School/Home, etc ) Violence, Spouse abuse, Child abuse Divorce/Relationship Changes Drug addiction/Alcoholism Job Loss Feeling of not belonging Medical Changes, Mental Health Issues,TBI

(Traumatic Brain Injury)--POLYTRAUMA Suicide/Homicide

MEANWHILE……….

“Mission” Stressors Now• Culture shock• “Celebrity” status• Family and Friends • Work or School• Health• Finances• Changed perspectives• Finding the year lost• Ungrateful people• Lack of understanding• You name it…

How have family members changed?

More independent Used to making their own decisions New friends/relationships Children may be significantly different New routines New perspectives Changes in the environment“I was angry for months, my wife

and kids had grown without me”

READJUSTMENT

No definite time period

Can take weeks or months depending on length of separation, experiences, resources.

Requires NEW WAYS OF NEW WAYS OF THINKING THINKING

88th Regional Readiness Command

Coping and Problem-SolvingCoping and problem-solving are dependent on a

combination of many factors:

Extent, duration, & intensity of the problem

Nature of the problem

Number & type of co-occurring problems

Resources available

Presence/absence of a social support network

Existential beliefs Developmental history Experience/maturity Cognitive capabilities Physical health

REESTABLISHING ROLES CAN BE CHALLENGING

88TH Regional Readiness Command

Communication is the bedrock of intimacy

CLOSENESS TRUST COMMUNICATION

KIDS’ REACTIONS TO CHANGES IN FAMILY DYNAMIC

Remember Children HAVE gone through this too……

Predictable overall

Vary by age of child

Will pass if you don’t make a big deal over it

Shouldn’t be taken personally88th Regional Readiness Command

What Did They Gain?

• Lifetime membership in a culture of <1% of all Americans…

• Experience• Confidence • Camaraderie• Personal growth• Veteran status• A great shot record

HELPING VETERAN’S, SERVICE MEMBERS AND FAMILIES REINTEGRATE

What can you do????????????What can you do????????????

OUT IN THE TRENCHESHow do we reach them?

Family Readiness Picnics (KEVIN)Phone calls from the VA (GERALD)Phone calls from family (68%) (TIM)Grocery store, Hospital Employees,

Parking lotsMilitary One Source Briefings, PDHRA’s, Veteran OrganizationsContact from Commands/Battle

Buddies/Employers/Friends…..YOU………

What gets in the way?Despite comprehensive outreach initiative many

Service members and veterans are still hesitant to seek treatment.

!! STIGMA !! “It will damage my military career”, “It’s a sign of

weakness”, “I’m not crazy”, “I’ll be fine” “I’m normal”

Would you wait in your doctor’s office for 2-5 hours? Would you continue to get care from someone who

did not respect your complicated needs? Would you continue to go for care somewhere if you

were treated rudely, had to fill out the same paperwork 3 times, or were made to prove that you deserved care, etc, etc?

Would you continue to get care somewhere when it interfered with your ability to work, make your own decisions, relate to your family, and to reintegrate?

“Culture shock”Workplace has changed; or may have no

workplaceMay not be interested in things they were

interested in before they leftVeteran may feel discounted or

disrespected“JUST DOING MY JOB”

Recognize What May HaveRecognize What May Have

Changed…Changed…

Family members may have new

power and responsibilitiesMay feel they have been displacedMay have new priorities for their lives,

NEW NORMALMay have achieved a new level of maturityChildren and friends have grown and changed Veterans who have seen

combat - old work/job

may seem dull by comparison

Recognize What May Have Recognize What May Have Changed…..Changed…..

Identify how they may feel…………Identify how they may feel…………

They may have little patience for “nonsense”Their sense of humor may have changedThey may feel uncomfortable being a

“Civilian”May feel uncomfortable in a crowdThey often want to take on more job

responsibilitiesThey may feel unneeded at work or that they

do not belongTheir thoughts may still be overseas with

Buddies/Others who are still serving

Identify how they may feel…………Identify how they may feel…………

Lose the sense they had of being “heroes” or are embarrassed to be thought of as Heroes, especially women

Often do not think of themselves as VeteransFeel that no civilian could ever understand

their experiences“Head space” still in the war zone: a sense of

disconnectedness in present environment: forget names, directions, old tasks, etc.

May be fearful of future deployment/may not want to plan for the future (ex. School, job advancement, family planning, etc.)

May feel that the stress of civilian life is trivial and have a hard time fitting in.

WHAT NOW?............DOD increasing support and use of Military, VA ,

Veteran and Civilian Resources.Continue the fight against the stigma.Collaboration and ingenuity to provide care to the

new generation of Service Members/Veterans Ongoing ETOH/DRUG evaluation with concern of

possible underlying Mental Health Issues (Polytrauma care)

Education and more educationTreating the whole system (Family & Community)User friendly customer oriented servicesBe Culturally Competent

POINTS TO POINTS TO PONDERPONDER

“No One Comes Back Unchanged”

(COL (DR.) Tom Burke, DOD, Director of Mental Health Policy)

War changes persons for the better !!!!

Operational Stress Responses will resolve with time, patience, support……

Help is available Service members/VETS are Us,

our family, friends, neighbors, & coworkers.

Resources

• Military Agencies (Guard, Reserve)• V A Hospital System• DVA, Order of the Purple Heart, VFW, Am.

Legion, etc.• State and National Brain Injury Resources• Employers Support of the Guard and

Reserve (ESGR)• Local community, Brain Injury

Associations

THANK YOU FOR CARING

Questions ?Questions ?