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





Dueling Disorders- the battle inside…

30 08 2013

Dueling

No, the title is not a typo. I know that Dual Disorders   and Co-occurring Disorders  are the correct terms for the combination of substance abuse and mental health disorders. I think a better term to bring home the power of this comorbid brain and body chaos is “Dueling Disorders.”  That’s what killed my brother. The mental health issues and addictions battled within him, each fueling the fight until he finally surrendered. The treatment he was given did not help him stop the battle.

I do not believe he had any hope that the behavioral health and medical system could help him. Maybe it was the lack of hope for healing that really killed him and not the Dueling Disorders? Our family will never know for certain.

In our work, I ponder if we too easily  compartmentalize people’s needs and address only their parts we are most comfortable with?  If yes, does this impair our ability to see the whole person in front of us- their strengths, their joys, their dreams, their level of confidence, their history of trauma, their façade or “curtain” that they put forth to hide behind, as well as the parts of themselves with addictions and mental health challenges? Humans hide in plain sight so what does it take to create a good therapeutic relationship so you can have a chance to  see the whole person and engage them in treatment?

Why was I inspired to write this post?

Obviously, my brother is always on my mind. But also because the title of an article in the August 2013 publication of Counselor: The Magazine for Addictions Professionals stopped my breath: Dual Diagnosis: Expectation, Not Exception.   The point being that we should expect that our clients come to us with a Dual Diagnosis and not just expect a single diagnosis.  And working at a school of social work with a trauma-informed curriculum and trauma continuing education programs, I am acutely aware of the need to see the whole person. I don’t know if any care provider ever saw the whole of my brother. I think they only saw his successful facade and the little bits he would reveal that he needed help with. 

According to SAMHSA, approximately 8.9 million adults have co-occurring disorders.  And approximately 90% of those seen in public behavioral health settings have a trauma history. I find these numbers horrifying, a sad statement about the world we live in.

Thoughts on how to begin to help people more effectively

  • Is your agency or practice current with evidence-based treatment for co-occurring disorders? Does it adhere to the principles from SAMHSA for an integrated screening and assessment process?
  • Does it offer a trauma-informed environment that follows the guiding principles of safety, trustworthiness, choice, collaboration, and empowerment? Are services person-centered? Is there universal trauma screening? How do staff effectively build  therapeutic relationships?
  • If your organization has clinicians who are highly skilled in working with those who have a co-occurring disorders, is there anything more that can be done to share their skills with less experienced clinicians?
  • If your clinicians lack sufficient skills and knowledge to best meet the needs of this population, what is one step you could take to begin to address this need?
  • Is lethality assessed and if there is risk, is it part of the treatment plan?
  • If you or your agency are in state of “overwhelm” from workloads, complex client needs, and rapidly changing regulatory expectations, what is one step you can take to best serve this population? If you woke up tomorrow, and clients were better served, what would be different?
  • if your services are not where you want them to be and you do not know what to do first, start by asking the “5 Whys” to get to the root issue.
  • Have you reviewed your strategic plan  for needed updating to better serve people’s needs?
  • Do you collect program evaluation data so you know what service  outcomes are?

Some days, we just need to stop and take a breath to celebrate how much we already do to effectively help people heal, and identify the steps to get us to enhanced skills in evidence-based and best practice so that even more people can have that chance. And remember that hope is one of the most powerful things we can give our clients in a therapeutic relationship. Resource information is listed below.

Hope and belief in the ability to heal is a lifeline.

Author: Lesa Fichte, LMSW, Director of Continuing Education

Selected References & Resources

 SAMHSA

TIP 42 Substance Abuse Treatment for Persons with Co-Occurring Disorders http://store.samhsa.gov/product/TIP-42-Substance-Abuse-Treatment-for-Persons-With-Co-Occurring-Disorders/SMA12-3992

Based on TIP 42 Substance Abuse Treatment for Persons with Co-Occurring Disorders http://www.samhsa.gov/co-occurring/topics/healthcare-integration/CODQGAdmin.PDF

Effectively serving individuals with co-occurring mental and substance use disorders requires integrated screening and assessment processes.http://www.samhsa.gov/co-occurring/topics/screening-and-assessment/index.aspx

Evidence-based Practice for Dual Disorders  http://www.samhsa.gov/co-occurring/topics/training/OP5-Practices-8-13-07.pdf

Jacobs, D. & Brewer, M. (2004).  American Psychiatric Association Practice Guideline: Provides recommendations for Assessing and Treating Patients with Suicidal Behaviors. Psychiatric Annals 34:5 (373-380). Also on line at www.stopasuicide.org/downloads/Sites/Docs/APASuicideGuidelinesReviewArticle.pdf

Trauma-Informed Care

National Center on Trauma-Informed Care  http://www.samhsa.gov/nctic/

Trauma-Informed Assessment and Screening PowerPoint http://view.officeapps.live.com/op/view.aspx?src=http%3A%2F%2Fwww.theannainstitute.org%2FDTSA.ppt

Trauma Assessment for Adults – Self-Report Version (one tool from the above PowerPoint) http://www.istss.org/AM/Template.cfm?Section=TraumaAssessmentandDiagnosisSIG&Template=/CM/ContentDisplay.cfm&ContentID=3227

Greater Buffalo Trauma-Informed System of Care Community Plan http://www.hfwcny.org/Tools/BroadCaster/Upload/Project327/Docs/HFCWNY_Trauma_Report_Interactive___Final.pdf

Online Trauma-Informed Clinical Foundation Certificate Program, University at Buffalo School of Social Work Office of Continuing Education http://www.socialwork.buffalo.edu/conted/trauma-ticfc.asp

University at Buffalo School of Social Work Institute on Trauma and Trauma-Informed Care http://www.socialwork.buffalo.edu/research/ittic/

Treatment Outcome Evaluation

Scott D. Miller, PhD. Free Session Rating Scale and Outcome Rating Scale. http://scottdmiller.com/performance-metrics/

Therapeutic Relationship

Evidence-based Therapeutic Relationships http://www.nrepp.samhsa.gov/Norcross.aspx

Therapeutic Relationship vs. Treatment Model blog post by Ricky Greenwald, PsyD http://www.childtrauma.com/blog/therapeutic-relationship-vs-treatment-model/

Videos

Video from TedX: 11 minutes of a powerful story from a young man who tells a “stop in your tracks” story about what depression feels like. A must listen for every human service professional. http://www.upworthy.com/this-kid-thinks-we-could-save-so-many-lives-if-only-it-was-okay-to-say-4-words?c=ufb1

Video: 5 minutes from Claudia Black Ph.D. – Double Jeopardy: Addiction & Depression http://www.youtube.com/watch?v=Xean4EFGjC0

Photo Credit: Free Photos from www.morguefile.com

 








%d bloggers like this: