Preparing Our Communities To
Help Our Returning Soldiers
Lanny Endicott, LCSW, D.Min.
lendicott@oru.edu
http://drlannyendicott.com.tripod.com
Dexter Freeman, Ph.D.
Dexter.Freeman@amedd.army.mil
Some Information
Lanny Endicott
• 2,200,000 service members have experienced
deployment to Iraq (OIF) and Afghanistan (OEF)
• 800,000 have experienced multiple deployments
• 43% of today’s fighting force is comprised of
Reserve and Guard members
• 1% of the US population involved
• $4 trillion expended
• Approximately 35+% return afflicted with TBI
and PTSD
• Those who deploy more than once have 300
% increased probability for severe mental
health outcomes
• At least 130,000 and as many as 250,000 U.S.
veterans are homeless each night (over 7,000
are veterans of Iraq or Afghanistan)
• Suicide is now the top killer of military
veterans
Up to 31 percent of soldiers
returning from combat in Iraq
experience depression or posttraumatic stress disorder that
affects their jobs, relationships, or
home life, according to a new study
by Army researchers.
81 percent of Veterans
suffering from depression and
PTSD engaged in at least one
violent act against their partner
in the past year.
Active-duty female personnel make up
roughly 14.5 percent -- or 207,308
members -- of the more than 1.4 million
Armed Forces, according to the
Department of Defense.
One in three military women has been
sexually assaulted, compared to one
in six civilian women, according to
DoD
Military and Domestic Violence:
Risk Factors
• High percentage of military
personnel have prior histories of
family violence.
• Among Navy recruits, 54% of women
and 40% of men witnessed parental
violence prior to enlistment
Risk Factors
• Military population is concentrated in
the ages of highest risk for
interpersonal violence (ages 20-40)
• Constant mobility and geographic
separation isolates victims by cutting
them off from family and other support
systems
Military and Domestic Violence
Risk Factors
• Higher than average unemployment rates
for military spouses, leaving them
economically dependent on service
members
• Deployments and reunifications create
unique stresses on military families
“Our military does an exceptional job of preparing
soldiers, Marines, sailors and airmen for the fight –
boot camp makes warriors of recruits – but we do
little to ‘de-boot,’ to support that warrior and his or
her family as he or she comes out of the extraordinary
experience of having served in combat. A prosthetic
leg, some physical therapy and a bottle of meds do
not equal a homecoming plan.”
Nancy Berglass. America’s Duty: The Imperative of a New Approach to Warrior
and Veteran Care. November 2010. Center for a New American Security.
Workshop Objectives
• Articulate how military culture can both help or
hinder community re-integration
• Describe 2 evidence-based treatment modalities for
treating service members with PTSD
• Introduce “traumatic brain injury”
• Address the concept of “soul or moral injury”
affecting our service members and discuss ways
social workers of faith can address the issue
3,300 Members of the
Oklahoma National Guard have
returned home from
Afghanistan/Kuwait
A New Paradigm
• Despite their best intentions DOD and VA are
overwhelmed
• Less that 50% of veterans access services of
the VA - particularly “mental health’
• Private sector partners (non-profits and forprofits) can provide important services – but
need assistance with funding and training to
address the needs of veterans
• A key is that personalized care for our
veteran warriors includes the VA and
community partners working together
Community Partners
Engage coordinated and informed community planning efforts
VA + Community
• Community-based social service providers
• Educational institutions (universities, colleges,
tech schools)
• Faith communities (churches, synagogues, etc.)
• Court systems (Veterans Court)
• Employers
• Veterans Administration
• Military support organizations (Wounded
Warriors, Folds of Honor, Blueprint, Give an
Hour)
Veterans Initiative
Community Service Council (Tulsa)
• Bring agencies/organizations together to
discuss what they do
• Discover gaps/needs in services to veterans
– Preparation of therapists to accommodate
veteran clientele:
• military culture
• evidenced based treatment for PTSD
– Develop a “go-to-provider” in each agency: one
trained who functions as trainer for others
Wounded Warriors’ Grant
• Community Service Council (Veterans
Initiative)
• Three parts:
– Military Culture
– Cognitive Processing Therapy (Duke and TU)
– Create a “learning community” for application
and feedback of CPT
• Goal: train 60 therapists
ID Veterans and Families
• Identification of veterans and their families at
social services, doctors offices, employers,
educational institutions, etc.
Add a question on veteran status in intake forms
Veterans Courts
 Promote establishment of Veterans Courts
 Tulsa has Veterans Courts on both County and
City level
 Modeled after the “drug court”
 2-year program: treatment, case management,
mentors
Preparing Educational Institutions
• Educational institutions should have:
Go-to person to work with veterans
Veteran organization
Veterans Lounge (private meeting place)
Training of faculty and staff for working with veterans
Referral network for assisting veterans and their
families
See SVA Toolkit: www.vetfriendlytoolkit.org
University of Denver Study
• Of 800,000 veterans who attended college
• 88% dropped out after the first year
• 3% graduated from college
Coffee Bunker
• Tulsa is a large community without a military
instillation nearby
• Coffee Bunker is an evening drop-in center for
veterans of all services
• Volunteers are trained in QPR
• Recent grants from Wounded Warriors and
United Way (Venture Grant) will help expand
program to its own site
Summary
In general, prepare and educate the community
for veteran reintegration
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Remember the 1%
$4 trillion of borrowed money
Lack of sacrifice from the community in general
Old news becomes less newsworthy
A Matter of National Defense
“The willingness with which our young
people are likely to serve in any war, no
matter how justified, shall be directly
proportional to how they perceive the
Veterans of earlier wars were treated and
appreciated by their nation.”
President George Washington
WHEN YOU THINK OF THE MILITARY
(UNIQUE FACETS)
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Frequent separations
Regular household relocations
Mission comes first
Early retirements
Loss
Detachment
System security
Rank focused
THE DEPLOYMENT CYCLE
(EMOTIONAL FACTORS)
• Predeployment – “Gearing up”
• Anticipation, detachment, sadness, restless
• Deployment – “Boots on the ground”
• Emotional disorganization, sleep disturbance
• New patterns, psychological presence
• Postdeployment (Redeployment)
• Relief, boundary ambiguity
• New normal, prepping to gear up
COPING WITH DEPLOYMENT
(AWAITING SPOUSE’S CONCERNS)
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Safety of Deployer (49%)
Loneliness (47%)
Anxiety or depression (36%)
Difficulty sleeping (36%)
Sole parent concerns (32%)
Inaccurate information (31%)
Household duties/repairs (28%
Job/education demands (26%)
DATA FROM 2008 SURVEY OF ACTIVE DUTY SPOUSES,
DEFENSE MANPOWER DATA CENTER (2009)
For training in military culture
Military Culture: “Paint a Moving Train” (Kudlar)
http://www.mirecc.va.gov/visn6/paint-moving-train.asp
For introduction to treatment of PTSD (Cognitive Processing
Therapy):
http://www.ptsd.va.gov/professional/ptsd101/ptsd-101.asp
http://cpt.musc.edu
“Psychological First Aid”
http://www.ptsd.va.gov/professional/manuals/psych-first-aid.asp
What we know about Army Families: 2007 update
http://www.army.mil/cfsc/research.htm
PTSD
• Think of PTSD as inability to recover from a
traumatic event
• In normal recovery, intrusions and emotions
decrease over time and no longer trigger
each other
• In those not recovering, strong negative
emotion leads to escape and avoidance
Symptoms of PTSD
Three Categories:
1. “Reliving” the event:
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Flashbacks
repeated upsetting memories of the event
repeated nightmares
strong uncomfortable reactions to situations
that remind one of the event
2. “Avoidance” or emotional numbing or feeling one
doesn’t care about anything
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Feeling detached
Being unable to remember important aspects of
event
Having lack of interest in normal activities
Avoiding reminders of event: places, people,
thoughts
Showing less of one’s moods
Feeling like one has no future
3. Arousal
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Difficulty concentrating
Startling easily
Exaggerated response to things that startle
Feeling more aware (hypervigilance)
Feeling irritable or having outbursts of anger
Having trouble falling or staying asleep
Feeling guilt about the events (“survivor guilt)
Symptoms typical of anxiety, stress, tension:
o Agitation or excitability, dizziness, fainting,
feeling heart beat in one’s chest, headache
PTSD Treatment
VA recognizes two therapies with best
evidence:
– Cognitive Processing Therapy (CPT)
– Prolong Exposure Therapy (PET)
VA website for Cognitive Processing Therapy
http://www.ptsd.va.gov/public/pages/cognitive_process
ing_therapy.asp
VA website promoting Mobile App: PTSD Coach
http://www.ptsd.va.gov/public/pages/PTSDCoach.asp
Mobile App: PE Coach
Traumatic Brain Injury (TBI)
Symptoms of Mild TBI
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Brief loss of consciousness (seconds to minutes)
Headache
Vomiting
Nausea
Lack of motor coordination
Dizziness
Difficulty balancing
Lightheadedness
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Blurred vision or tired eyes
Ringing in the ears
Bad taste in the mouth
Fatigue or lethargy
Changes in sleep patterns
Behavioral or mood changes
Confusion
Trouble with memory, concentration, attention, or
thinking
Moral Injury
• Is a suspected contributor to soldier suicide
• Is not PTSD: an injury of trauma leading to
suppression of fear and lack of integration of
feelings with coherent memory – leading to
symptoms including flashbacks, nightmares,
dissociative episodes and hyper-vigilance
• Moral injury is a negative self-judgment
based on having violated core moral beliefs
and values or feeling betrayed by one in
authority
• It includes loss or destruction of moral
identity and loss of meaning
• Its symptoms include shame, survivor guilt,
depression, despair, addiction, distrust,
anger, a need to make amends and the loss of
desire to live
A Consequence of Training
• “Mission first” training – can contribute to
resiliency in soldier’s mission (including
survival) while ignoring empathy for others
and deep moral values
• Soldiers taught to see events in a neutral
light, not labeling them as good or bad, and
to focus on those things that are positive
• A soldier could experience the
incomprehensible while on mission: killing a
family, including women and children, after
kicking down the door of suspected
insurgent; losing a close friend; or torturing
detainees?
• Will the soldier see as neutral or positive?
Person of faith
• Many soldiers seek the help of clergy:
– To avoid a negative psychological record
– To seek help with religious meaning, moral
issues, and matters of conscience
• Social workers of faith can also provide caring
and empathetic help through careful listening
and understanding as soldiers may seek
community professionals to avoid mental
health labeling
Treatment
• Moral injury is not a clinical condition that
can be medicated or cured by psychology
• Requires the reconstruction of a moral
identity and meaning in life with the support
of a caring, nonjudgmental community
(chaplain, pastor, therapist, social worker)
that can provide a way for the veteran to
learn to forgive
PTSD Treatment
Cognitive Processing Therapy
• Address event(s) – thinking – feelings
connection
• Writing about detailed trauma event(s) &
reading them to the therapist
• Utilizing worksheet assignments
Prolonged Exposure
• Teach relaxation
• Expose person to discussing/experiencing
traumatic event (invivo – imaginal)
Moral Injury
• Two types of violations: co-mission or
omission
• Violation of moral, cultural, religious and/or
other deeply held beliefs
• Military training emphasizes mission with
suppression of individual beliefs
• Moral Injury does not come from a specific
traumatic event
Treatment of Moral Injury
• Shame: the consequence
• Forgiveness, repentance: the treatment via help
from community therapists, clergy, chaplains, or
trusted moral authority
• Honor: community events, ceremonies
celebrating and honoring returning soldiers
“Honor is the antidote of shame”
Grief
• The soldier may be experiencing “grief” from
loss (i.e., death of colleague, separation from
unit & mission, leaving of spouse)
• The treatment is an application of “grief
therapy”: talk through the loss while
recognizing that people process grief
differently
Resources for Moral Injury
http://www.ptsd.va.gov/professional/pages/moral_injury_at_
war.asp
http://www.commondreams.org/view/2012/06/29-8
Questions/Comments