Military and Trauma Counseling: Treating the Mind, Body, and Spirit of Active Duty and Veterans Mark...

Military and Trauma Counseling: Treating the Mind, Body, and Spirit of Active Duty and Veterans Mark A. Stebnicki, Ph.D., LPC, DCMHS, CRC, CCM Professor- Coordinator of Military and Trauma Counseling Certificate Dept. of Addictions & Rehabilitation East Carolina University [email protected]

Military and Trauma Counseling Network http://www.ecu.edu/cs-dhs/rehb/omtc.cfm http://www.ecu.edu/cs-dhs/rehb/omtc.cfm Military and Trauma Counseling on Facebook https://www.facebook.com/ECUMTCN

Military Statistics NC * North Carolina has deployed 50,886 troops to OIF/OEF since 9/11. * There are more than 750,000 veterans living in North Carolina. veterans living in North Carolina. * There are 150,000 Active Duty North Carolina residents Duty North Carolina residents * 35% of NC population comprise Military * Bases: Fort Bragg; Camp Lejeune; Camp Geyger, New River Air Station, Cherry Point, Seymour Johnson Dept. of Veterans Affairs, 2012 3

MTC Certificate Program: Military Culture Courage Commitment Loyalty Integrity DOD Military and Associated Terms https://blackboard.ecu.edu/bbcswebdav/pid-6462558-dt-content-rid- 17376600_1/courses/REHB6375601201380/Dictionary%20of%20Military%20terms.pdf DOD Military and Associated Terms https://blackboard.ecu.edu/bbcswebdav/pid-6462558-dt-content-rid- 17376600_1/courses/REHB6375601201380/Dictionary%20of%20Military%20terms.pdf https://blackboard.ecu.edu/bbcswebdav/pid-6462558-dt-content-rid- 17376600_1/courses/REHB6375601201380/Dictionary%20of%20Military%20terms.pdf https://blackboard.ecu.edu/bbcswebdav/pid-6462558-dt-content-rid- 17376600_1/courses/REHB6375601201380/Dictionary%20of%20Military%20terms.pdf Officer Rank Insignia http://www.defense.gov/about/insignias/officers.aspx Officer Rank Insignia http://www.defense.gov/about/insignias/officers.aspx http://www.defense.gov/about/insignias/officers.aspx Enlisted Rank Insignia http://www.defense.gov/about/insignias/enlisted.aspx Enlisted Rank Insignia http://www.defense.gov/about/insignias/enlisted.aspx http://www.defense.gov/about/insignias/enlisted.aspx Military Unit Size Military Unit Size https://blackboard.ecu.edu/bbcswebdav/pid-6462569-dt-content-rid-17376721_1/courses/REHB6375601201380/Military%20Unit%20Size.pdf Military Code of Conduct [punitive articles, NJP] http://www.dtic.mil/whs/directives/corres/pdf/130021p.pdf http://www.dtic.mil/whs/directives/corres/pdf/130021p.pdf http://www.dtic.mil/whs/directives/corres/pdf/130021p.pdf

The Psychological Cost of War: Personal Testimonials of Trauma and Resiliency I was only getting 2 hrs of sleep I was only getting 2 hrs of sleep Your head is always on a swivel Your head is always on a swivel We were stuck at an FOB for 3 months of intense fightingcommand would fly-in for a morale-boost theyd stay for an hour-then leave We were stuck at an FOB for 3 months of intense fightingcommand would fly-in for a morale-boost theyd stay for an hour-then leave My Master Gunny Sergeant told me to do (xyz)I said are you kidding me? My Master Gunny Sergeant told me to do (xyz)I said are you kidding me? Ive seen my best buddy get burned alive Ive seen my best buddy get burned alive %#@&*$# ragheads- you just dont know whos going to take you out... %#@&*$# ragheads- you just dont know whos going to take you out...

The New Military: Not Your Fathers Military Combat Training & Combat as an occupation: Combat Training & Combat as an occupation: - Demands of killing - Avoidance of being killed - Caring for the wounded - Witnessing death and injury - Frequent geographic relocation - Separation from family and other support systems - Being available 24/7/365

Challenges of OIF and OEF No clearly defined front line or Rear or FOB Highly ambiguous environment Complex and changing missions Long deployments Repeated deployments Environment is very harsh

Operation Enduring Freedom (2001), Operation Iraqi Freedom (2003), Operation New Dawn (2010) 50,000-100K + wounded 50,000-100K + wounded 6,825 + fatalities 6,825 + fatalities -Blast wounds / TBI (13-24%) - Soft tissue/orthopedic injuries - Amputations - Burns - Hearing loss - SCI

Exposure: OEF (AFG, 2001) OIF (2003) OND (2010) Mortar Mortar Rocket Rocket Artillery Fire Artillery Fire Small Arms Fire Small Arms Fire Multiple High-Intensity blast Multiple High-Intensity blast Roadside bombs Roadside bombs IEDs IEDs Sniper Attack Sniper Attack

MIL MH vs Community MH The Occupational MH Model of PTSD (Adler & Castro, 2013) Community MH models based on Community MH models based on - the unexpected - freezing, shutting down - person as the victim Military acquired PTSD Military acquired PTSD -adaptive and survive -adaptive (not maladaptive) response -aggressive (not stress)!!

Occupational MH Model of PTSD Community MH model: Community MH model: - Person experiences full range of symptoms - Many times critical event is experienced by self Military acquired PTSD: Military acquired PTSD: -Person most always experiences critical event in small and large groups of others in their unit -full range of symptoms may occur to a lesser degree of intensity during combat training exercises -symptoms (i.e., hypervigilence) is adaptive-esp. in combat

Suicide Ideation & Threats Number of suicide completions in MIL- 2012 (N=349) have surpassed those who died in combat the previsous year (N=295) Number of suicide completions in MIL- 2012 (N=349) have surpassed those who died in combat the previsous year (N=295) Suicide on increase from 10.3%-16.1% (Marines); 19.3% (Army) per 100k (2001-2008) Suicide on increase from 10.3%-16.1% (Marines); 19.3% (Army) per 100k (2001-2008) Suicide Methods: 49% Firearms (non-Mil issue); 21% Hanging; 19% Other; 11% Firearms (Mil issue) Suicide Methods: 49% Firearms (non-Mil issue); 21% Hanging; 19% Other; 11% Firearms (Mil issue) Suicide is the 8 th leading cause of death among adults in U.S.; the 2 nd leading cause of death in adolescents#1 cause of death (2012) with military and vet population. Suicide is the 8 th leading cause of death among adults in U.S.; the 2 nd leading cause of death in adolescents#1 cause of death (2012) with military and vet population. Suicide (inward directed anger & depression) often coexists with homicide (outwardly directed) Suicide (inward directed anger & depression) often coexists with homicide (outwardly directed) Suicide behavior include assessing risk factors of age, medical/physical conditions, psychiatric conditions, intellectual and emotional conflicts Suicide behavior include assessing risk factors of age, medical/physical conditions, psychiatric conditions, intellectual and emotional conflicts

Traditional Suicide Assessment: Community MH vs Military Culture If the person answers yes to any of the following they are considered high risk: Does the person communicate an intent? [MIL- emotional detachment] Does the person communicate an intent? [MIL- emotional detachment] Have they devised a specific detailed plan ? [MIL- access to weapons] Have they devised a specific detailed plan ? [MIL- access to weapons] Person has no friends, family, or support system? [MIL- departure leads to isolation, disconnect from battle-buddies little structure in life, decreased meaning and purpose, typically unemployment] Person has no friends, family, or support system? [MIL- departure leads to isolation, disconnect from battle-buddies little structure in life, decreased meaning and purpose, typically unemployment] Is there a concrete life stressor (death of spouse, girl/boy friend, family, friends, pet, facing legal issues such as incarceration, has a medical physical condition, or life-threatening illness, mental health condition) [MIL IS family death surrounds our Family] Is there a concrete life stressor (death of spouse, girl/boy friend, family, friends, pet, facing legal issues such as incarceration, has a medical physical condition, or life-threatening illness, mental health condition) [MIL IS family death surrounds our Family] Has person had past attempts? Has person had past attempts? Is the person a male? Is the person a male? Is the individual on an anti-anxiety or anti-depressant? Is the individual on an anti-anxiety or anti-depressant?

Exposure to Combat 56% of all active duty reported combat exposure (High= 23%; Mod= 21%; Low= 12%) 56% of all active duty reported combat exposure (High= 23%; Mod= 21%; Low= 12%) Personnel exposed to high level combat were identified as heavy drinkers (10%) and use of prescription drugs (34%) Personnel exposed to high level combat were identified as heavy drinkers (10%) and use of prescription drugs (34%) Personnel exposed to high level combat with TBI reported binge drinking (39%); 45% prescription overuse Personnel exposed to high level combat with TBI reported binge drinking (39%); 45% prescription overuse Personnel exposed to high level combat with TBI reported depression (23%); anxiety (43%); suicide ideation (10%); self- inflicted injury (13%); high risk taking (18%); high levels of anger (18%); low affect (16%); and suicide attempts (2%) Personnel exposed to high level combat with TBI reported depression (23%); anxiety (43%); suicide ideation (10%); self- inflicted injury (13%); high risk taking (18%); high levels of anger (18%); low affect (16%); and suicide attempts (2%) http://www.murray.senate.gov/public/_cache/files/889efd07-2475-40ee-b3b0-508947957a0f/final-2011-hrb-active-duty- survey-report.pdf http://www.murray.senate.gov/public/_cache/files/889efd07-2475-40ee-b3b0-508947957a0f/final-2011-hrb-active-duty- survey-report.pdf http://www.murray.senate.gov/public/_cache/files/889efd07-2475-40ee-b3b0-508947957a0f/final-2011-hrb-active-duty- survey-report.pdf http://www.murray.senate.gov/public/_cache/files/889efd07-2475-40ee-b3b0-508947957a0f/final-2011-hrb-active-duty- survey-report.pdf

Characteristics of OEF, OIF, OND At least 19% (30-60%?) of active duty men/women returning from Iraq - Afghanistan will be dx:PTSD. At least 19% (30-60%?) of active duty men/women returning from Iraq - Afghanistan will be dx:PTSD. 26-39% of all military met positive screen for PTSS (gen. pop= 12%). 26-39% of all military met positive screen for PTSS (gen. pop= 12%). Strong r between being shot at, handling dead bodies, knowing someone who was killed, or killing the enemy and developing PTSD. Strong r between being shot at, handling dead bodies, knowing someone who was killed, or killing the enemy and developing PTSD.

Characteristics of OEF, OIF, OND 32% + screen for depression; 25% + alcohol abuse; 33% met criteria for addiction. 32% + screen for depression; 25% + alcohol abuse; 33% met criteria for addiction. Only 38%-45% report receiving help for mental Only 38%-45% report receiving help for mental health services within a year. health services within a year. 25% come home with a medical health problem & co-morbid physical injuries (TBI, SCI, blast wounds, soft tissue orthopedic injuries, burns, hearing loss, amputations) doubles the risk for mental health problems. 25% come home with a medical health problem & co-morbid physical injuries (TBI, SCI, blast wounds, soft tissue orthopedic injuries, burns, hearing loss, amputations) doubles the risk for mental health problems. Women comprise 14% of deployed forces, more than ever before- creating multiple traumas. Women comprise 14% of deployed forces, more than ever before- creating multiple traumas. Multiple deployment (Marines avg. 7 mos; Army 12 mos; 15) Multiple deployment (Marines avg. 7 mos; Army 12 mos; 15)

Research: PTSD (PSS) is a Significant Predictor of Current and Future Medical & Psychosocial Adjustment Men & Women (post deployment), have more frequent number of visits to their healthcare provider than those w/o PSS. Increased onset of cardiovascular, gastrointestinal, dermatological, and musculoskeletal conditions. Increased onset of cardiovascular, gastrointestinal, dermatological, and musculoskeletal conditions. Increased onset of cardiovascular, gastrointestinal, endocrine, vision, hearing, dermatological, and musculoskeletal, and chronic pain conditions. Increased onset of cardiovascular, gastrointestinal, endocrine, vision, hearing, dermatological, and musculoskeletal, and chronic pain conditions. Mortality has declined due to advances in body armor and battlefield medicine BUT 28% sustained TBI primarily closed head and blast wound TBI. Mortality has declined due to advances in body armor and battlefield medicine BUT 28% sustained TBI primarily closed head and blast wound TBI. Four variables were positively associated with re-entry: being an officer; having a consistently clear understanding of the missions while in the service; being a college graduate; and, for post-9/11 veterans but not for those of other eras, attending religious services frequently. Four variables were positively associated with re-entry: being an officer; having a consistently clear understanding of the missions while in the service; being a college graduate; and, for post-9/11 veterans but not for those of other eras, attending religious services frequently.

Overall Problems in Medical/Psychosocial Adjustment Multiple reconstructive surgeries require not just one adjustment to disability- rather there are multiple re-adjustments. Reliance on medical equipment/tech RFC leads to permanent disabling conditions TBI, PTSD, SUDs, Chronic pain Significant vocational/career impairments.

Veterans Vocational & Career Obstacles #1 Disability (Pew- 44% acquired MH/Phy) #1 Disability (Pew- 44% acquired MH/Phy) #2 Lack of Civilian job experience and transferable skills to other occupations. #2 Lack of Civilian job experience and transferable skills to other occupations. #3 Policies that hinder licensing, certifications, and other skills that transfer to civ jobs. #3 Policies that hinder licensing, certifications, and other skills that transfer to civ jobs. Jobless rate all Vets about 7% (Nov 2013) Jobless rate all Vets about 7% (Nov 2013) Unemployment NC Guard = 19% (Nov. 13) Unemployment NC Guard = 19% (Nov. 13) Gulf War II vets have 28% unemployment Gulf War II vets have 28% unemployment

The Stigma of Counseling: Reducing Barriers to MH Tx (Mental Health Advisory Team, 2011) Service men/women report: difficulty in getting time off for an appt. and dont know where to go for help Service men/women report: difficulty in getting time off for an appt. and dont know where to go for help 29% reported embarrassment 29% reported embarrassment 38% reported mental health counseling would harm their career 38% reported mental health counseling would harm their career 42% reported their units would lose confidence in them 42% reported their units would lose confidence in them 50% report they would be seen as weak 50% report they would be seen as weak Others could loose security clearance Others could loose security clearance http://www.murray.senate.gov/public/_cache/files/889efd07-2475-40ee-b3b0- 508947957a0f/final-2011-hrb-active-duty-survey-report.pdf DoD Health-related Behavioral Survey.2011 http://www.murray.senate.gov/public/_cache/files/889efd07-2475-40ee-b3b0- 508947957a0f/final-2011-hrb-active-duty-survey-report.pdf http://www.murray.senate.gov/public/_cache/files/889efd07-2475-40ee-b3b0- 508947957a0f/final-2011-hrb-active-duty-survey-report.pdf http://www.murray.senate.gov/public/_cache/files/889efd07-2475-40ee-b3b0- 508947957a0f/final-2011-hrb-active-duty-survey-report.pdf

Intake Assessment - What is your MOS? What is your RATE (for Navy) -Where did you do your basic training? -What advanced training do you have? -Any experiences that you remember that caused negative or disturbing memories? -Have you talked to anyone about these experiences? -Are you (were you married) during your service or when deployed? -Do you (have you ever used) the VA? -Were you in a combat zone/combat space? FOB? -Ever surrounded by the enemy? Blown up? Under fire? -See death of any member of your unit or others you know?

PTSD & Other Measures Personal Interview & Observations CAPS Life Events Checklist (LEC) Primary Care PTSD Screen (PC-PTSD) Combat Exposure Scale (CES) BDI-II ASI- 5 th ed.

Spiritual and Religious Values We are all spiritual beings traveling through time having a human experience The most important question to humankind is where we came from before we were born and where we will be going to after we pass-on Making sense of combat, death, catastrophic injury is a spiritual question- not CBT Q

Deployment Cycle Treatment Options Pre-deployment Deployment Post Deployment Re-deployment Reintegration Sustainment

Family Issues (or if the Army wanted men to have a wife -they would issue one) Primary caregiver may neglect own mental-physical- spiritual wellness Family/spouse misinterprets absence of spouse as (they dont love me-putting work before family) and resents role of single mother-father Family/spouse experiences loss & grief of deployed service member- communication may not occur for weeks or months- deployed location cannot be disclosed Family structure and roles are significantly altered and routines disrupted during deployment https://blackboard.ecu.edu/bbcswebdav/pid-6462562-dt-content-rid- 17376703_1/courses/REHB6375601201380/Facts%20for%20Families%20in%20the%20Military.pdf

Sexual Assault in the Military https://www.youtube.com/watch?v=Scsb5 uB1Z7Yhttps://www.youtube.com/watch?v=Scsb5 uB1Z7Y [NBC Today Show- Rape in the Military] https://www.youtube.com/watch?v=Scsb5 uB1Z7Y https://www.youtube.com/watch?v=Wl2BN eLi5c0https://www.youtube.com/watch?v=Wl2BN eLi5c0 [Deborah Slagboam- MST] https://www.youtube.com/watch?v=Wl2BN eLi5c0

Modern Military Family 2 million + have served 2 million + have served 47,000-70,000 LGBTs (RAND Corp.; UCLA School of Law) 47,000-70,000 LGBTs (RAND Corp.; UCLA School of Law) DADT Fact Sheet https://blackboard.ecu.edu/bbcswebdav/pid-7621821-dt-content-rid- 32857248_1/courses/REHB6375601201530/Quick_Reference_Guide_Repeal_of_DADT_APPROVED.pdf DADT Fact Sheet https://blackboard.ecu.edu/bbcswebdav/pid-7621821-dt-content-rid- 32857248_1/courses/REHB6375601201530/Quick_Reference_Guide_Repeal_of_DADT_APPROVED.pdf https://blackboard.ecu.edu/bbcswebdav/pid-7621821-dt-content-rid- 32857248_1/courses/REHB6375601201530/Quick_Reference_Guide_Repeal_of_DADT_APPROVED.pdf https://blackboard.ecu.edu/bbcswebdav/pid-7621821-dt-content-rid- 32857248_1/courses/REHB6375601201530/Quick_Reference_Guide_Repeal_of_DADT_APPROVED.pdf 1.2 million children have at least one active duty parent 1.2 million children have at least one active duty parent 75% of these children experienced at least one parent deployed 75% of these children experienced at least one parent deployed 55% of troops are married 55% of troops are married 50% report negative affects on the psychological health of partners and children 50% report negative affects on the psychological health of partners and children Intimate partner (intense arguments, emotional/behavioral dysregulation, physical/sexual violence) violence widespread- much attributed to PTSD, TBI, SIDs Intimate partner (intense arguments, emotional/behavioral dysregulation, physical/sexual violence) violence widespread- much attributed to PTSD, TBI, SIDs

LGB Military, Partners & Family As a group LGB military experiences health disparities and poor health outcomes. As a group LGB military experiences health disparities and poor health outcomes. GLMA, 2006; MPFC, 2011 report only 45% LGB come-out to physician; self-disclosure may create negative reaction, fears of retribution, rank, promotions, career. GLMA, 2006; MPFC, 2011 report only 45% LGB come-out to physician; self-disclosure may create negative reaction, fears of retribution, rank, promotions, career. There is an invisibility and isolation that exists for LGB serve members, partners, & familymoreso for transgender service personnel There is an invisibility and isolation that exists for LGB serve members, partners, & familymoreso for transgender service personnel

DADT 2010 Dont Ask, Dont Tell Repeal Act, 2010 which took effect Sept. 2011 allows LGB to serve- NOT transgender individuals. Dont Ask, Dont Tell Repeal Act, 2010 which took effect Sept. 2011 allows LGB to serve- NOT transgender individuals. Former Defense Secretary Chuck Hagel every qualified American should be allowed to serve; AMPA, 2015 U.S. Army reviewing policies on transgender; Defense Secretary Ash Carter (Feb. 24, 2015) transgender individuals should be allowed to serve [supported by Pres. Obama] Former Defense Secretary Chuck Hagel every qualified American should be allowed to serve; AMPA, 2015 U.S. Army reviewing policies on transgender; Defense Secretary Ash Carter (Feb. 24, 2015) transgender individuals should be allowed to serve [supported by Pres. Obama] Military IS hypermasculine, heterosexual environment where women and minority groups have a much different experience. Military IS hypermasculine, heterosexual environment where women and minority groups have a much different experience.

The New TBI: The Signature Injury of OEF-OIF-OND

Mild Traumatic BI Mild TBI- 85% of all TBIs BUT 52% of mTBI dx: PTSD!!! Mild TBI- 85% of all TBIs BUT 52% of mTBI dx: PTSD!!! Altered state of consciousness-brief loss up to 30 minutes loss of consciousness. Altered state of consciousness-brief loss up to 30 minutes loss of consciousness. Glasgow rating of 13-15 or higher. Glasgow rating of 13-15 or higher. Person feels stunned & disoriented, has reduced concentration, focus, loss of memory immediately before-after, learning new tasks. Person feels stunned & disoriented, has reduced concentration, focus, loss of memory immediately before-after, learning new tasks. Many go untreated until Postconsussion Syndrome appears- headache, vertigo, tinnitus, sleep disturbance, depression, irritability, reduced attention span/memory. Many go untreated until Postconsussion Syndrome appears- headache, vertigo, tinnitus, sleep disturbance, depression, irritability, reduced attention span/memory. After 3 mos post-injury 78% have persistent headaches; 59% have memory problems; 34% unable to R-T-W. After 3 mos post-injury 78% have persistent headaches; 59% have memory problems; 34% unable to R-T-W.

Closed/Open vs Blast Injuries and Battlefield Medicine Initial shock wave from a high-intensity-explosive detonation or blast, resulting from supersonic blast-wind or blast-wave of inhalations of dust, smoke, carbon monoxide, other chemicals, burns from hot gasses or secondary fires, and crushing injuries from structural collapse. Initial shock wave from a high-intensity-explosive detonation or blast, resulting from supersonic blast-wind or blast-wave of inhalations of dust, smoke, carbon monoxide, other chemicals, burns from hot gasses or secondary fires, and crushing injuries from structural collapse. Consequence: penetrating and thermal trauma, soft tissue, orthopedic injuries due to person thrown against fixed objects, falling, vehicle crash, penetrating injury from blast projectiles. Consequence: penetrating and thermal trauma, soft tissue, orthopedic injuries due to person thrown against fixed objects, falling, vehicle crash, penetrating injury from blast projectiles. Classification of Blast Injuries: Primary: rapid changes in atmospheric pressure caused by blast wave. Primary: rapid changes in atmospheric pressure caused by blast wave. Secondary: objects accelerate by energy of explosion causing blunt or penetrating ballistic trauma. Secondary: objects accelerate by energy of explosion causing blunt or penetrating ballistic trauma. Tertiary: injuries resulting from persons body being thrown by expanding gasses, high winds, penetrating injuries from blast projectiles and soft tissue, orthopedic wounds. Tertiary: injuries resulting from persons body being thrown by expanding gasses, high winds, penetrating injuries from blast projectiles and soft tissue, orthopedic wounds.

Cognitive Consequences of BI Memory Attention & Concentration Self-awareness Problem-solving & Decision-making Information Processing Concept Formation Judgment, Reasoning and Insight

Personality Affect Personality Changes Anger Irritability Nonconformance to Social Norms Loss of Self- esteem Apathy Depression

Impact that Stress & Traumatic Stress Have on Emotions and Illness

Peripheral/ANS: Sympathetic-Parasympathetic Nervous System

Pathways to Traumatic Memories Object Recognition (Neural pathways-what- when-where-how-why?) Consciousness (Cognitions, thoughts, symbols, feelings, emotions, purpose, meaning) Activating Event Seeing, Hearing, Smelling, Tasting, Touching, Physical-sensory, Balance Working Memory (Here & Now or Past )

Stress and Post Traumatic Stress Excessive, recurrent, and intense emotional arousal of an unhealthy nature results in stress and disease; Excessive, recurrent, and intense emotional arousal of an unhealthy nature results in stress and disease; Repeated reactivation of our perceptual-cognitive- affective response that is unhealthy in nature; Repeated reactivation of our perceptual-cognitive- affective response that is unhealthy in nature; Stored unhealthy thoughts, perceptions, and emotions, become a worn neural pathway which leaves an imprint on our cognitive unconscious and causes a mind-body interaction. Stored unhealthy thoughts, perceptions, and emotions, become a worn neural pathway which leaves an imprint on our cognitive unconscious and causes a mind-body interaction.

So Why Dont All Those Exposed-Die from Stress? We all differ as to the: We all differ as to the:-pattern - frequency -exposure-magnitude/intensity -immune competence & resistance ..of how we turn-on our own stress response

Complex Grief Reaction Preoccupation with the deceased. Disbelief about the death. Pain in the same area as the deceased. Envious of others. Memories are upsetting. Lonely most of the time. Avoid reminders of the death. Bitter about the death. Death is unacceptable. Difficulty trusting others. Feeling life is empty. Difficulty caring about others. Longing for the person. Feeling stunned or dazed. Hear the voice of the person who died. Feel it is unfair to live when this person died. Drawn to places and things associated with the deceased. See the person who died. Anger about the death.

The New PTSD-Typically Complex PTSD TBIDepression Suicide Ideation SUD Chronic Illness & Physical Disability Sleep Disorders

The New PTSD: DSM V Classification- Trauma and Stressor-Related Disorder (Not under Anxiety Disorders in DSM-IV) 313.89 (F94.1): Reactive Attachment Disorder 313.89 (F94.2): Disinhibited Social Engagement Disorder 309.81 (F43.10): PTSD 308.3 (F43.0): Acute Stress Disorder

309.81 PTSD: A Review of DSM-V A. Exposure to actual or threatened death, serious injury, or sexual violence in one or more of the following ways: (experiencing, witnessing, learning about, experiencing repeated or extreme exposure to aversive details of event(s)- NOT electronic media) B. Presence of one or more of the following intrusion symptoms associated with traumatic event(s)-beginning after the trauma (recurrent, involuntary, intrusive distressing memoires, distressing dreams, dissociative reaction which individual feels or acts as if the trauma were occurring (e.g., flashback), intense prolonged psychological distress of internal or external cues that symbolize or resemble trauma event) C. Persistent avoidance of stimuli associate with the traumatic event(s) beginning after the traumatic event as evidenced by one or both: (avoidance of distressing memories, thoughts, feelings closely associated with trauma; avoidance of external [people, places, conversations, activities, objects, situations)

309.81 PTSD: A Review of DSM-V D. Negative alterations in cognitions and mood associated with trauma, beginning or worsening after trauma has occurred as evidenced by two or more (inability to remember important aspects of trauma due to dissociative amnesia [not due to TBI, alcohol/drugs] persistent and exaggerated negative beliefs of self and others; distorted cognitions; negative emotional state; diminished interest or participation; feelings of detachment or estrangement from other; persistent inability to experience positive emotions- happiness, satisfaction, or loving feelings) E. Marked alterations in arousal and reactivity associated with traumatic event beginning or worsening after trauma as evidenced by two or more (irritable behavior, recklessness or self-destructive behavior, hypervigilance, exaggerated startle response, problems w/concentration, sleep disturbance)

309.81 PTSD: A Review of DSM-V F. Duration of disturbance (Criteria B, C, D, E) more than 1 month. G. Disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning. H. Disturbance is not attributable to the physiological effects of a substance or another medical condition. Specify whether: 1. Depersonalization (detached) or 2. Derealization (unreality)

Psychosocial Aspects of Suicide in Military Life: DoD Suicide Outreach http://www.suicideoutreach.org/Docs/Reports/DSPO_2012_Annual_Report_MARCH_2013_FINAL.pdf http://www.suicideoutreach.org/Docs/Reports/DSPO_2012_Annual_Report_MARCH_2013_FINAL.pdf Major depression is the #1 cause of suicide followed by PTSD and substance abuse disorders. Major depression is the #1 cause of suicide followed by PTSD and substance abuse disorders. The grieving process is different for those in the Military: - Death surrounds us - Prolonged intrusive images - Survivor guilt, constant reminders of self-blame

Holistic Approach to Transition Services From Active Duty to Civilian Life Dx: and treatment of mental health disorders. Dx: and treatment of mental health disorders. Psychosocial counseling. Psychosocial counseling. Family and/or relationship counseling. Family and/or relationship counseling. Vocational evaluation, career, Ed. assessment. Vocational evaluation, career, Ed. assessment. Medical and healthcare services. Medical and healthcare services. Medical supply and assistive technology. Medical supply and assistive technology. Allied health services. Allied health services.

The tragedy of life is not death; itself but what dies inside of us as we live -Norman Cousins

Post-Traumatic Growth: A Journey into Healing (Calhoun & Tedeschi) 1. Strength: a sense of self-efficacy, coping, resiliency, thriving. 2. New Possibilities: new meaning, purpose, positive future-oriented attitude, with crisis comes opportunity. 3. Relationships: deeper appreciation of relationships with family, friends, intimates 4. Appreciation of Life: sense that one has been given a second chance at life which should not be wasted, less time at work more with family members, dont sweat the small stuff, overall- a significant shift in priorities. 5. Spirituality: a renewed sense of religious-spiritual strength, knowing God through adversity, trauma-experiences may have been a gift to bring them closer to God.

The Resiliency Advantage Dr. Al Siebert 1. Making conscious choices in life. 2. Power of Positive Thinking. 3. Take responsibility. 4. Internal locus of control. 5. Self motivate yourself. 6. Dont fear trying-out new things. 7. Take control of your life. 8. Practice positive approaches to life.

Green Zone Training: Transitioning from Base to Campus Location recognized by veterans - service members as a Safe Place.

Transition Difficulties May have difficulty relating to classmates (Campus Life, College Student Culture, Age-related differences, Marriage, Dep.) May find loud noises to be disturbing May be anxious with structure, assignments, changes in the classroom May have excessive absences May have symptoms of trauma from military experiences Post-911 G.I. Bill/Montgomery Bill

Transition Strengths Veterans/ Servicemembers transitioning out of the military onto college campuses bring a unique perspective Veterans/ Servicemembers transitioning out of the military onto college campuses bring a unique perspective Military training Life experience Established Identity A more worldly view Skills taught in the military help Skills taught in the military help students to be successful students to be successful Leadership Motivation Time Management Work Ethic Stress Management 53

Treatment Programs-Provider Resources Defense Centers for Excellence for Psychological Health & BI http://www.dcoe.mil/blog/13- 10-30/Benefits_of_Mindfulness_Push-ups_for_the_Brain.aspx http://www.dcoe.mil/blog/13- 10-30/Benefits_of_Mindfulness_Push-ups_for_the_Brain.aspxhttp://www.dcoe.mil/blog/13- 10-30/Benefits_of_Mindfulness_Push-ups_for_the_Brain.aspx Tricare Provider Handbook https://blackboard.ecu.edu/bbcswebdav/pid-7503897-dt-content-rid- 31972644_1/courses/REHB6375601201530/REHB6375601201530_ImportedContent_201501 05024914/TriCare%20Provider%20Handbook.pdf https://blackboard.ecu.edu/bbcswebdav/pid-7503897-dt-content-rid- 31972644_1/courses/REHB6375601201530/REHB6375601201530_ImportedContent_201501 05024914/TriCare%20Provider%20Handbook.pdf Military Deployment Guide https://blackboard.ecu.edu/bbcswebdav/pid-7522387-dt-content-rid- 32000897_1/courses/REHB6375601201530/DeploymentGuide.pdf https://blackboard.ecu.edu/bbcswebdav/pid-7522387-dt-content-rid- 32000897_1/courses/REHB6375601201530/DeploymentGuide.pdf Soldiers Resiliency Guide https://blackboard.ecu.edu/bbcswebdav/pid-7503838-dt-content-rid- 31972449_1/courses/REHB6375601201530/REHB6375601201530_ImportedContent_201501 05024914/ARNG.Leaders%20Guide%20to%20Resilience.pdf https://blackboard.ecu.edu/bbcswebdav/pid-7503838-dt-content-rid- 31972449_1/courses/REHB6375601201530/REHB6375601201530_ImportedContent_201501 05024914/ARNG.Leaders%20Guide%20to%20Resilience.pdf Real Warriors-Real Battles- Real Strength http://www.realwarriors.net/taxonomy/term/13 Veterans Employment Toolkit http://www.va.gov/vetsinworkplace/

Military and Trauma Counseling: Treating the Mind, Body, and Spirit of Active Duty and Veterans Mark...

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