When Veterans and Their Families Come for Help: What Service Providers Need to Know

10 04 2015

Guest author: Erica Zulawski, MS, MSW candidate

Military welcome home Jack

Through my personal and professional experience with veterans, I have come to understand the unique needs and challenges some male and female veterans experience when readjusting to civilian life. Many veterans say that the military has forever changed them, especially if deployed to areas of combat or conflict.

Soldier with flag FREE morguefile0001980652808

When PTSD is not diagnosed and treated…

My father was a Vietnam veteran. I would like to share some parts of our family’s story.

  • My father would wake up in the middle of the night screaming from awful nightmares and night terrors. I had never heard a man or anyone scream like that before. I was afraid. My siblings and I did not know what was happening to him, and there was no one to explain anything.
  • My dad drank a lot while I was growing up, and he would isolate himself from friends and family. He was there physically, but rarely emotionally available.
  • I resented him for missing a great part of my childhood because of his alcoholism. I also resented the military in many ways because it had taken away my father’s ability to be a good dad and live a meaningful and satisfying life.
  • He was always angry and irritable with overwhelming emotion, always on edge. Family members were also always on edge hoping not to upset him. My father’s illness controlled and dictated the temperament of each of us.

Vet Blog Post Man a with drink photo from FreeDigitalPhotos.net

  • Though severely “rocked” by his traumatic Vietnam experiences, my father would still proudly hang the American flag each morning. I would say that he struggled with a “love/hate relationship”, a love for his country and the military, but hatred for what he lost of himself in the war.
  • He was a very broken person, consumed with emotional and physical pain, suffering every day and drank heavily to self-treat his symptoms. He desperately needed help, but had no idea that he needed it and was deteriorating with each passing day. My mother had no idea how to get him help, so he suffered in silence until he wasn’t able to do it anymore. There was the lack of support and services available for my father and for us as a family to cope with his PTSD, depression and alcoholism. We felt helpless, scared and overwhelmed.

The only time I ever heard him talk about Vietnam was when his “war buddies” would come over to our house to talk and drink. I still don’t know what he endured in the military. When I began working with veterans, I gradually started to understand that what my father was struggling with wasn’t uncommon among that era of veterans: Post-Traumatic Stress Disorder (PTSD) and depression from his military service.

Why is it important to understand and identify the unique challenges and needs of veterans and their families?

Soldier hands behind back FREE morguefile0001566431353

I believe there is a great need for social workers  and other human service professionals within the community (both veteran and non-veteran affiliated agencies and organizations) to become educated on serving veterans and their families so that they can best meet their needs. Policies and program are needed to help veterans and families develop coping skills and find supports. Some of the reasons are listed below.

  • Many veterans fail to get the help they need because of social stigma and barriers to health care and other services. Some non-veteran affiliated organizations and agencies may provide services and treatment to veterans because they may not qualify for some or any VA benefits or health care because of their type of discharge; were never activated from a Reserve or National Guard unit; and/or have some apprehension about using the VA system. There are others who are unaware of the benefits and services available to them. Please refer to the link in the Resource section to learn more about the U.S. Department of Veterans Affairs: Health benefits and eligibility.
  • Being culturally competent and sensitive may decrease the challenges in providing effective services to veterans and their family members. Some veterans will present with chronic and acute mental, social, and physical conditions, as well as being at risk for: unemployment, poverty, homelessness, substance abuse, depression, and PTSD that may be attributed to military related trauma and experiences.
  • To alleviate the backlog of specialty appointments, particularly mental and behavioral health appointments, the VA and Congress implemented the Veterans Choice Card program in August 2014. Veterans who meet the criteria for the program will be allowed to seek health care services outside of the VA system. Please refer to the link in the Resource section to learn more about Veterans Access, Choice, and Accountability Act of 2014.
  • Veterans who live in rural areas may not have easy access to VA health care and services and are more likely be treated in non-VA affiliated agencies and organizations. Providers in these demographic areas need to be familiar with their unique needs and challenges. Please refer to the link in the Resource section for more information about Rural Assistance Center: Veterans and Returning Soldiers.
  • Both VA and non-VA affiliated providers need to understand the complexity of deployment and how multiple deployments can impact the mental, emotional and psychological well-being of a person and their ability to reintegrate and adapt back into civilian life, their community and their family. Please refer to the link in the Resource section to learn more about How Deployment Stress Affects Families.
  • Providers need to be aware of signs and symptoms to recognize if the person they are working with has been in the military. In addition, providers need to be aware of referring agencies and organizations and the services available to veterans and their families if the provider is unable to offer needed services. It’s important that the provider not be afraid to ask appropriate and sensitive questions about the person’s military experiences to gain a better understanding in an effort to treat the “whole” person.
  • VA and non-VA agencies and organizations can network to use the best assessment tools, interventions and treatments for veterans and their families.  Please refer to the link in the Resource section to learn more about the Joining Forces initiative.
  • Agencies and organizations can create an environment where veterans and their families feel safe to reach out and find the support and guidance they need. Make it as simple and convenient as possible, and remove barriers to rigid, structured and complex systems that may feel overwhelming and burdensome. Many who try to access services and treatment will either give up or not bother if it’s too confusing and/or has the potential to trigger or retraumatize.
  • Consider the veteran’s life before the military. Think about adverse childhood experiences (ACEs) that may contribute to the issues and problems that the veteran is struggling with- consider pre-military trauma. Think about how the veteran’s complex trauma, pre-military, peri-military and post-military experiences have impacted and affected their overall life within their roles and responsibilities to the family structure, the community, their jobs and school. Please refer to the Adverse Childhood Experiences Study link in the Resource section.
  • It is beneficial to ensure that services and treatment for veterans and their families are implemented in a way that provides the five principles of trauma-informed care: safety, empowerment, trustworthiness, collaboration and choice. Please refer to the link in the Resource section for more information about Trauma-Informed Care (TIC).
  • Children of service members and veterans also have unique needs and challenges, and can be at risk for emotional and mental health issues like secondary PTSD from being affected by their parents’ military related trauma. Please refer to the link in the Resource section for more information about Overall Effects on Children.

Resources

Online self-study course: Trauma-Informed Care: Working with Veterans, Service Providers and the Military Culture with Patrick Welch, PhD, Sgt. USMC (Ret)

U.S. Department of Veterans Affairs: Health benefits and eligibility

Veterans Access, Choice, and Accountability Act of 2014

Rural Assistance Center: Veterans and Returning Soldiers

How Deployment Stress Affects Families

Joining Forces initiative

The Adverse Childhood Experiences Study

Overall Effects on Children

Treatment Approaches

NASW Standards for Social Work Practice with Service Members, Veterans, & Their Families

Free online course: The National Child Traumatic Stress Network: Trauma-Focused Cognitive Behavioral Therapy (TF-CBT)

Cognitive Processing Therapy (CPT) Fact Sheet for Clinicians

Free online course: Cognitive Processing Therapy

Trauma-Informed Care (TIC)

U.S. Department of Veterans Affairs: PTSD: National Center for PTSD

Other Helpful Resources

‘Why Is Dad So Mad?’ Veteran writes book to explain his PTSD to his daughter.  Also available at www.amazon.com

Military Times: Rand: Civilian mental health providers don’t ‘get’ the military

The Impact of Deployment on U.S. Military Families

Understanding the Impact of Deployment on Children and Families

Using Trauma-Informed Care with Veterans – Dr. Patrick Welch

Use Veteran recovery stories to build connections

Photo Credits

Welcome Home Jack- Our Hero

Hands behind his back

Soldier with flag

Man with a drink





Improving the System for Our Loved Ones: A Mother’s View of Addiction and Services

16 07 2014

Depressed teen free Morgue file

Guest author: name withheld for confidentiality

The day before Christmas, I received a phone call from my oldest son asking me to pick him up on a downtown corner in a risky neighborhood. He gets in the car wearing sunglasses even though the day is dark and cloudy.  My inner alarm sounds and my heart starts to tear… he is high again.  Back home I watch him slowly begin to detox. How many times does this need to happen?  My rule is that he can stay at home as long as he is willing to get help. Of course he agrees as he has nowhere to go. We plan to go to a local hospital inpatient unit but you have to be in a certain physical state to get admitted, and this depends on who is doing the intake and bed availability. Sometimes he can be admitted, sometimes not- yet he is the same person each time, out of control and in need of addiction treatment. We have to wait until Christmas morning to go there.  Not exactly my plan for a family Christmas but I am prepared to do whatever it takes to save his life. 

We arrive at the inpatient unit only to have him turned away. They say he is not sick enough. Really? He is an out of control addict using heroin, asking for help and I am terrified he will die. So now what?  He can’t come back home and refuses to go to a different hospital inpatient unit to see if he can be admitted there. So he decides to stay with a ‘friend’ as he cannot stay with me if he is not in treatment- it is too risky for my family because of past incidents. I drop him off, not knowing what he will do next and the heartache I feel is overwhelming.  What kind of mother turns her son out Christmas day? I feel like I am living in a perpetual grief state as I wait for the worst to happen.  Will this be the last time I see him?

It wasn’t always like this. His childhood was blessed- large and loving family, many friends, fun activities, and strong church involvement.  He graduated near the top of his high school class and attended a private university. But drugs don’t care if you have a college degree.

 Drug use. addictionImage courtesy of Victor Habbick-FreeDigitalPhotos.net ID-10073274I was told people can have the potential to be an addict long before they touch a drug.  This is true of my son.  He is very creative with an eccentric personality that is so fun yet always intensely, sometimes obsessively, focused on the current interest. When he latched onto a new interest that was not so healthy, the consequences became deadly.  After having suffered several major psychological traumas in his late teens, his addictive personality took over to stop his thoughts and feelings.  First it was alcohol, then marijuana, then pain killers finally escalating to heroin. The lies, the deceptions, the thefts from family and friends could no longer be ignored but I was determined not to lose my child. The service system is far from perfect and whether or not your child is receptive to help makes a difference.

older woman head in hands free morgue fileI have had people telling me to cut him off, let him hit rock bottom, and move on in with my life. And a few who said never give up on your child. How can I move on in my life when my son is a big part of it and needs help?  I also walked a fine line trying to avoid being the enabler. I struggled with every decision and often doubted if my choices were right.  Rock bottom can mean death. Will this push him to suicide or will he survive the next overdose? Will he start cutting his arms again? I have cried my eyes out over this, made myself physically and emotionally sick with worry and stress, mourned his death over and over, and planned his funeral.

Twice he was kicked out of inpatient residential programs for not following the rules leaving him with no place to go. How did that help him? He also quit seeing several outpatient therapists because he was smart enough to recognize their insufficient skills or they lacked the rapport needed to keep him in treatment. I have had him arrested, requested a three-day hold in psychiatric unit, cut him off financially, visited him in jail, begged for the best treatment placements through the drug court, taken him to therapy, attended NA meetings with him- often to no avail. I watched him make gains in his recovery only to relapse and have to start over. I remember when I first admitted to friends that he was an addict, I was told that expect him to relapse.  I was stunned by this statement- not my kid, he can do this. I was so wrong as the addiction was more powerful than my amazing, talented son.

 If I could offer any advice to families walking in my path and the service system, it would be:

 

  • For families, please persevere.  Ask many questions, seek help, get therapy, cry if you need to, get mad, and be prepared to fight the battle of your life. Give them hope when they are unable to do it for themselves.
  • Always believe in the person battling an addiction and never give up on them. Be compassionate and persistent even in the face of lies and relapses.
  • The addiction service system needs to find improved ways to meet the needs of people who are up sick and desperate for treatment.
  • Please stop turning them away from treatment saying they don’t meet criteria, or there is no room and giving them no place to go when they are sick and desperate.  
  • Find better places for residential treatment homes so they are not close to ‘crack’ houses that create great temptation.
  • When they keep their cell phones in residential treatment their dealers are still calling them- another temptation that could be avoided.
  • When they are in drug court, break the rules for participation and get throw out of treatment,  why are they immediately discharged from treatment on their own  and not turned immediately back over the custody of the courts?  They do eventually get re-arrested but the time in between can be deadly.  This is a big gap in the program that needs to be fixed.
  • Trauma and addiction go together as I saw this with my son. Psychological trauma is often part of why the person is addicted and both parts of who they are need to be treated as the drugs never go away as long as the emotional pain is still there. So intertwined, yet many of the counselors I interacted with did not have the skills or knowledge to provide effective treatment. I am told this is called a dual-disorder. Agencies need to support staff in gaining advanced treatment skills.
  • Remember that the family is suffering, too. My son’s addiction traumatized all of us. Family members need support. Whether you are a friend, family member or service provider, please understand and empathize with the feelings of shame, sadness, anger, guilt, embarrassment and helplessness we feel. The effect of addiction is devastating and the impact on families and friends is horrific, widespread and so long lasting as trust is often irreparably broken.

Epilogue: As of this moment, my son is in recovery and making progress with the support of a very skilled trauma and addiction therapist. I hope and pray each day that healing and recovery continue. Yet part of me still is still scared, still holding my breath each time the phone rings…

Resources:

New York State Combat Heroin & Prescription Drug Abuse http://combatheroin.ny.gov/

National Institute on Drug Abuse www.drugabuse.gov

Narcotics Anonymous www.na.org

Alcoholics Anonymous www.aa.org

Nar-Anon Family Groups www.nar-anon.org

National Council on Alcoholism and Drug Dependence www.ncadd.org

SAMHSA evidence-based treatments for addiction http://www.nrepp.samhsa.gov/SearchResultsNew.aspx?s=b&q=addiction

SAMHSA Co-Occurring Disorders http://media.samhsa.gov/co-occurring/

National Center on Trauma and Trauma-Informed Care http://beta.samhsa.gov/nctic/trauma-interventions

Photo credits:

Woman and teen photos from www.morguefile.com

Drug photo credit- Drug and addiction use courtesy of Victor Habbick at www.freedigitalphotos.net





Hoarding: the complex slide into clutter blindness

13 04 2014

room that is hoarded

Hoarding is a personal and/or professional issue for many of us. Some have a gift for viewing it compassionately. For others, especially when confronted by family members who are hoarding, it can create revulsion, horror, anger and great sadness for their lack of quality of life. Children may grow up experiencing shame and trauma from living with a caretaker who cannot stop hoarding. I have been on the verge of vomiting after trying to tackle the hoarding of a family member, and I could not go in to the house without someone with me for support.

Locally, we sometimes hear about animal hoarding in the press where someone whose love for animals and other mental health issues causes them to adopt more animals than they can manage. In areas populated by apartment and condominium complexes, there is the added risk to neighbors’ safety due to the potential for fire, mold growth and rodent/insect infestations. Some people are able to keep the hoarding inside their homes and family members, neighbors and co-workers are unaware of the situation. Others have lost control and the hoarding spreads out onto the lawn and other property. One woman even bought the house next door so she could expand her storage as she had filled her own home to capacity with hoarding. The thought of giving away a small item that most of us would consider as trash can cause significant anxiety for some individuals. My heart aches for them. It is important to remember that hoarding is not about laziness, yet this is often the judgment made.

What is hoarding?

Hoarding is a complex disorder that includes: collecting too many items (valuable as well as trash); difficulty letting items go (selling, giving away, throwing away, recycling); and disorganization (growing piles mixed with valuable items and trash with difficulty de-cluttering). There is also commonly a lack of recognition of the seriousness of the problem. Hoarding may be referred to as “compulsive hoarding”.  Clutter blindness refers to the inability to “see” and recognize the accumulation of hoarding and its impact. Animal hoarding focuses more specifically on the acquisition of animals and often includes the inability to adequately care for the animals resulting in unsafe situations for the animals and humans caring for them. DSM-5 hoarding disorders summary.

Why do people develop hoarding behavior?

This is a hard question to answer. Hoarding may co-occur with other diagnoses including Obsessive Compulsive Disorder, depression, General Anxiety Disorder, eating disorders, as well as Posttraumatic Stress Disorder. Hoarding can be a reaction to psychological trauma. When there is hoarding involved, it adds an additional level of complexity to the assessment, diagnosis and treatment plan. Sometimes hoarding is seen in several family members such as the adult child raised by a hoarder grows up and displays similar hoarding behavior.

Other aspects of hoarding development are defined by Paul Salkovskis, PhDobsessive compulsive hoarders; deprivation hoarders (have been through a period of massive deprivation) and those that Salkovskis defines as the hardest to treat – sentimental hoarders (damaged by unpredictability and possibly even neglect during childhood, possessions have become more reliable than people).

How to assess and diagnose hoarding behavior

There are tools at the International OCD Foundation website and the tools below are an excerpt from their website:

 Saving Inventory-Revised (SIR)

The Saving Inventory-Revised is a 23-item questionnaire designed to measure three features of hoarding: excessive acquisition, difficulty discarding, and clutter.

Hoarding Rating Scale (HRS)

The Hoarding Rating Scale is a 5-item semi-structured interview that can also be used as a questionnaire. The five questions include questions about clutter, difficulty discarding, excessive acquisition, distress caused by hoarding and impairment resulting from it. Initial studies suggest that a score of 14 or higher indicates a probable hoarding problem.

Clutter Image Rating (CIR)

In our work on hoarding, we’ve found that people have very different ideas about what it means to have a cluttered home. For some, a small pile of things in the corner of an otherwise well-ordered room constitutes serious clutter. For others, only when the narrow pathways make it hard to get through a room does the clutter register. To make sure we get an accurate sense of a clutter problem, we created a series of pictures of rooms in various stages of clutter – from completely clutter-free to very severely cluttered. People can just pick out the picture in each sequence comes closest to the clutter in their own living room, kitchen, and bedroom. This requires some degree of judgment because no two homes look exactly alike, and clutter can be higher in some parts of the room than others. Still, this rating works pretty well as a measure of clutter. In general, clutter that reaches the level of picture # 4 or higher impinges enough on people’s lives that we would encourage them to get help for their hoarding problem. These pictures are published in our treatment manual (Compulsive Hoarding and Acquiring: Therapist Guide, Oxford University Press) and in our self-help book (Buried in Treasures: Help for Compulsive Acquiring, Saving, and Hoarding, Oxford University Press).

How to treat hoarding

Hoarding is often very challenging to treat. In many areas, there are not any experts in hoarding behavior. Treatment approaches may include elements of Motivational Interviewing; Cognitive Behavioral Therapy (CBT); individual and group therapy; medication for depression, anxiety or OCD;  and trauma specific treatment for those who have a trauma history. When the person feels ready and choose to de-clutter their home, a plan for volunteers and services to assist them.

Author: Lesa Fichte, LMSW, Director of Continuing Education
Photo Credit: Compulsive Hoarding Wikipedia

Select Resources

Understanding a Hoarding Disorder

Compulsive Hoarding

Hoarding as a reaction to trauma. Psychology Today

International OCD Foundation, Annual Hoarding Meeting

Anxiety and Depression Association of America Hoarding Basics

Help for Hoarders (UK)

Hoarding Inventories and Scales, International OCD Foundation

Treatment for Hoarding Disorder: Therapist Guide (Treatments That Work) by Gail Steketee, Randy O. Frost

Buried in Treasures: Help for Compulsive Acquiring, Saving, and Hoarding (Treatments That Work) by David Tolin, Randy O. Frost and Gail Steketee

Stuff: Compulsive Hoarding and the Meaning of Things Hardcover by Randy O. Frost  (Author), Gail Steketee

Animal hoarding FAQs, ASPCA

Animal hoarding and laws, Animal Legal and Historical Center, Michigan State University College of Law

Animal Hoarding from Wikipedia

Diogenes Syndrome, Hoarding – or Merely an Avid Collector? (thanks to Dorlee at Social Work Career Development blog)

From Dante to DSM-5: A Short History of Hoarding

Hoarding disorder as defined in the DSM-5

 








%d bloggers like this: