Supporting Veterans’ Resilience: The Rules of
Engagement
Alexa Smith-Osborne, Ph.D., M.S.W., L.C.S.W., A.C.S.W.
Associate Professor and Director of the Center for Clinical Social Work
Acknowledgement: This principal investigator’s military research is currently funded by the Dallas Foundation, the Amon
Carter Foundation, and private donors to the Student Veteran Project
Purpose
 To build knowledge and skills in engaging veterans and their
families in accessing and utilizing services which have
empirical evidence of effectiveness in promoting their
resilience across the life course.
 The session will address the areas of mental health and
substance abuse prevention/intervention, integrated
behavioral health, neurocognitive and psychosocial
rehabilitation, and complementary and adjunct therapies.
1
The Social Ecology of the Veteran:
Nationally and Locally
Implications of Veteran Social Ecology for
Rules of Engagement with Veterans
Components of veteran social ecology include
biculturality in military and civilian culture and the
current context for veterans just described
Civilian providers will experience improved
treatment engagement and cultural competence in
treatment planning and delivery with military
populations when they gain knowledge and
perspective on both these components
2
Current Veteran Context in America1
 National policy abolished conscription and changed the U.S.
Armed Services to an all voluntary force in 1973
 Less than 1% of the American population is serving in uniform
in the All Volunteer Force (AVF), the smallest proportion in any
era of our wartime history
 The longest wars in U.S. history, in order, have been in
Vietnam, Afghanistan, and Iraq
 Close to 2 million service members were deployed to Iraq and
Afghanistan from 2002-2011, with 58.2 % serving in multiple
deployments, primarily in the Army and Marines.
 These current conflicts have had a rapid deployment tempo =
less time between and more unplanned, sudden deployments
Current Veteran
Context in America
The AVF is the
best trained,
most
technologically
equipped and
medically
supported in
history, with
higher rates of
survivability
from injuries
3
Current Veteran Context in America
33% of returning servicemembers report mental
health or cognitive symptoms1
 37.7% of eligible Iraq (OIF) and Afghanistan (OEF)
veterans presenting to VHA identify mental
health/substance abuse issues2
This segment of the veteran population is more
likely to be female, younger, Reserve or National
Guard members, and African-American or Hispanic3
Current Veteran Context in America
Active duty suicide rates increasing, now higher
than civilian rates4 and veterans have historically
been at higher risk than civilians5
“Signature” injuries appear to be overlapping: TBI,
PTSD, amputation/loss of function2,6
Servicemembers on psychotropic medications,
those with 40% service-connected disability ratings,
and some amputees are now eligible to return to
active duty
4
Current Veteran Context in America6
A health care utilization study of Persian Gulf veterans found:
 The majority of these AVF veterans used private sources of
health care, not VHA facilities, and primarily used private
health insurance to pay for that care while 33% used Tricare
 For those who had never used VHA services, 40.2% said they
were not aware of or were not eligible for VHA care
 About 40% who received behavioral health treatment in the
year prior to survey did so in VHA facilities, however, as did
33% of those who had received outpatient treatment and 30%
of those who needed prescription medicines
Current Veteran Context in America1
 AVF military members are older, more likely to be married,
and more likely to have children than in prior eras
 AVF military children are more likely to have their mothers and
both parents deployed than in prior eras
 Military children whose parents are deployed experience more
emotional-behavioral problems than national averages,
especially older teens, girls during reintegration, those with
lengthier deployments, and those whose resident parent
reported lower psychosocial status
5
Veteran Context in Texas
 There are currently 15 active military installations in Texas, down
from 18 installations in 2008 (www.texvet.com)
 As of FY 2007: 1.7 million veterans in Texas, the second highest
state in number of overall and female veterans, including 161,000
female veterans7,8
 24% (410,394 ) of these veterans are in North Texas7,8
 Census-based data suggest around 181,000 OIF/OEF veterans may
reside in North Texas
 Ft. Hood reported at least 500 soldiers there dx with PTSD/TBI in
2008; 60% deployed at least 3x
(http://www.myfoxaustin.com/dpp/news/031609)
 VHA est.:16,462 OIF/OEF veterans seen in Dallas-region facilities for
any condition FY 2002- FY 2007, so national rates suggest that over
6206 of them were experiencing MHSA symptoms
Military Language/Culture Quiz: Basic
1. What is OIF?
a. Operational Infantry Force.
b. Occupational Infantry Flare.
c. Operation Iraqi Freedom.
d. Operation Iranian Nuclear Freeze.
ANS: C
2. What is GWOT?
a. Global War on Terror.
b. Global Western Command Operation Tempo.
c. General WISC (intelligence) Occupational Test.
d. General Warrant Officer-Tactical.
ANS: A
3. What are invisible wounds?
a. Psychotic disorders (all).
b. Anxiety disorders, including PTSD.
c. Wounds resulting from third shock wave
exposure from improvised explosive devices.
d. Service-connected wounds which do not leave
visible physical injuries.
ANS: D
4. What is OEF?
a. Occupational Explosive Force.
b. Officer Efficiency Field Training.
c. Operation Enduring Freedom.
d. Officer Endurance Forces.
ANS: C
5. What is the difference between a reunion and a
reintegration?
a. None, they are the same thing.
b. Reintegration is part of deployment cycle
support.
c. Reunion occurs after a deployment, while
reintegration occurs upon leaving the military.
d. All of the above.
ANS: B
6
Military Language/Culture Quiz: Advanced
MTF
CPL
PCS
DFAS
Partial DITY
NCOIC
POG
FOBIT
Garrison
PMCS
Formation
Article 15
Military Language/Culture Quiz
MTF
MILITARY TREATMENT FACILITY
CPL
CORPORAL
PCS
PERMANENT CHANGE OF STATION
DFAS
DEFENSE FINANCE & ACCOUNTING SERVICE
Partial DITY
DO IT YOURSELF MOVE
NCOIC
NON-COMMISSIONED OFFICER IN CHARGE
POG
PERSON OTHER THAN GRUNT
FOBIT
SOMEONE WHO DOESN’T LEAVE THE BASE
Garrison
HOME BASE
PMCS
PREVENTIVE MAINTENANCE CHECKS & SERVICES
Formation
GATHERING OF SMs IN AN ORGANIZED MANNER
Article 15
NON-JUDICIAL PUNISHMENT
7
How’d You Do?
*Score
12
Status
You’re Ready for the Frontlines
10-11
Welcome Aboard, Matey!
8-9
Get in the Back of Formation
6-7
Maybe the Army Will Take You?
<6
Stay Out of My Foxhole!
Military Culture Basics
“The possible we do today; the impossible may take
a little longer.”
Servicemembers are trained to be
adaptable, results oriented, and aimed at peak performance to
accomplish the mission.
“Every day above ground is a good day.”
Servicemembers are trained to be resilient, stoical, and to
place priority on a communitarian and achievement ethos.
High unit cohesion has been found to be a significant predictor
of resilience (i.e., a protective factor) to combat stress,
especially post-deployment
 “L.D.R.S.H.I.P.” Each service branch has a code of values.
The Army’s is: Loyalty, Duty, Respect, Selfless Service,
Honor, Integrity, Personal Courage
8
Military Culture, cont.
Compared to American mainstream culture, military
culture is collective, hypermasculine, hierarchical,
and authoritarian
The military lifestyle during active duty is even more
mobile and in transition than for civilian occupations
Servicemembers and their families who are
involved in longer military service tend to be more
highly acculturated, as are families in which both
parents have been servicemembers
Marines and their families tend to be more highly
acculturated than other service branches
Reasons for enlistment affect level of acculturation
Military Culture, cont.
Rank is the class system within the military and is
fundamental to the day-to-day operations
Consists of Enlisted, NCOs, Warrant Officers, and
Officers (each have their own belief system about
the military)
An officer that has been in one week technically
outranks an NCO that has been in for 30 years
9
Military Culture, cont.
Rank can provide insight into types of problems
veteran is dealing with
Veteran may feel disrespected if not addressed by
rank or if status is minimized during therapy/intake
(generally higher rank)
On the other hand: Lower enlisted or those shorttimer military may not connect with the therapist if
he/she is too rigid regarding rank
Therapist may be viewed and treated as an officer
equal by former officers
Military Culture, cont.
Language
1. Learn the military acronyms; nonverbals like
uniform/appearance and body posture are also
important military shorthand
2. Ask if you don’t know or understand something
3. Acknowledge lack of military experience upfront
4. Learn what the tabs/patches mean on uniforms
•Rank
1. Learn the rank structure
2. Ask how the SM would like to be addressed
3. Accept the courtesy of being called “Sir” or
“Ma’am”
10
Military Culture, cont.
Beliefs and Views
1. Be aware of your personal beliefs and how they
may conflict with the veteran’s beliefs
2. Be careful when tempted to focus on individual
goals vs. group goals
3. Don’t be afraid to be directive during treatment
4. Be aware of the stigma associated with seeking
treatment in the military; talk with the veteran
about it; reinforce his/her courage to seek
treatment
5. For those who may feel forced to be in treatment,
revisit issues of confidentiality as needed; don’t
spend a lot of time talking about the referral
source
Engaging Military Families
http://vimeo.com/38925724
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Engaging Military Families
http://vimeo.com/38925724
Resilience Tied to Performance Enhancement
 OIF/OEF/OND servicemembers in most service branches are
being exposed to prevention and behavioral health promotion
initiatives that are tied to mission readiness, preparedness,
fitness for duty, and performance enhancement
 These initiatives are commonly referred to as resilience
building initiatives NOT treatment
 However, they all build in treatment engagement mechanisms,
integrated behavioral health, and embedded mental health
treatment providers in theater
 Programs include Battlemind, Total Force Fitness, and
Comprehensive Soldier Fitness
12
What is resilience?
The concept of resilience was developed to
“describe relative resistance to psychosocial
risk experiences” (Rutter, 1999, p. 119)
The development of the concept emerged from longitudinal studies of
child development under adverse conditions, to explain the
exceptions who were not observed with developmental
psychopathology outcomes. It is one of the few theories to be
developed from large longitudinal empirical studies instead of from
individual provider clinical observations
Rutter, M. (1999b). Resilience concepts and findings: Implications for family
therapy. Journal of Family Therapy, 21, 119-144.
Resilience Theory Consistent with Public
Health Perspective
 Resilience theory examines the impact of cumulative risk and
protection
 Resilience theory focuses on long-term developmental
trajectories and their outcomes, not symptoms
 Resilience theory-based research and treatment aims to
identify what pre-existing strengths combined with relevant
protective factors and mechanisms interact with pre-existing
vulnerabilities combined with the operative risk factors in a
given context of adversity
 Resilience theory emphasizes not only innate traits and
capacities but also social ecological resources that are in
place or can be added/reactivated
13
Resilience and Veteran Social Ecology
Discussion Exercise
Turn to the person next to you and discuss:
How are these elements of resilience theory
consistent with or show goodness of fit with
military culture?
How are these elements of resilience theory
consistent with or show goodness of fit with
the current context, including characteristics
of OIF/OEF veterans?
Evidence-based MH/SA for Veterans
 Assessment will be more accurate if it takes military lifestyle and culture into
account; for example, there are differences in alcohol use patterns and levels
of stress symptoms, including PTSD presentation, in military versus civilian
populations
 Harm reduction and psychosocial rehabilitation approaches have been found
to be effective with veterans, compared to standard treatment approaches not
embedded in these approaches
 Telehealth approaches are being used with active duty servicemember, with
promising results, so may be useful for veterans in supporting behavior
change within a harm reduction approach for both mental health and
substance abuse treatment
 Combination therapies, including adherence-focused group and behavioral
interventions (e.g., twelve step facilitation therapy and acceptance and
commitment therapy), may be more effective with military populations than
biological treatments only
14
Evidence-based MH/SA for Veterans, cont.
 Integrated behavioral health has shown promising effects in
civilian studies and is now being utilized by military treatment
facilities in theater and by pilot projects within VHA primary
health care clinics and CBOCS
 Integrated behavioral health provides enhanced screening
using standardized instruments by the regular medical
provider for prevalent mental health conditions as part of
routine health care visits in primary care settings
 Integrated behavioral health then provides diagnosis and
treatment for identified issues by embedded mental health
professionals or paraprofessionals under their supervision
using brief task-oriented and stepped care interventions with
follow-up enhanced monitoring by regular medical provider
Evidence-based MH/SA for Veterans, cont.
 Non-diagnostically driven adaptations of psychosocial
rehabilitation, cognitive remediation, and harm reduction
interventions are being tested with veterans reintegrating with
the civilian community who are not in need of admission
 Complementary and adjunctive interventions are being tested
with active duty and veterans as an alternative to admission as
well as on an outpatient basis
 Complementary and adjunctive interventions being studies
include therapeutic horseback riding and carriage driving,
unmounted equine-assisted activities, acupuncture and
acupressure, yoga/mindfulness CBT/other relaxation
exercises, adapted martial arts, adapted sports, exercise
15
References
1.
2.
3.
4.
5.
6.
Hosek, J. (2011). How Is Deployment to Iraq and Afghanistan Affecting US Service
Members and Their Families? An Overview of Early RAND Research on the Topic.
Santa Monica, CA: Rand National Defense Research Institute.
Dole, R., Shalala, D., Eckenhoff, E.A., Edwards, T., Fisher, K., Giammatteo, M. et al.
(2007 July). Serve, support, simplify: Report of the President’s Commission on Care
for America’s Returning Wounded Warriors. Retrieved March 4, 2008, from
http://www.pccww.gov/docs/Kit/Main_Book_CC%5BJULY26%5D.pdf
Peterson, A.L., Baker, M.T., & McCarthy, K.R. (2008). Combat stress casualties in
Iraq. Part 2: Psychiatric screening prior to aeromedical evacuation. Perspectives in
Psychiatric Care, 44, 159-168.
Elliot, D. Schoomaker interview, retrieved 9/11/08 from the AT&T News Associated
Press website at:
http://admin.stage.att.net/bellsouth/s/editorial.dll?pnum=3&bfromind=8386&eeid=6088
689&_sitecat=1522&dcatid=0&eetype=article&render=y&ac=0&ck=&ch=ne
Kaplan, M.S., Huguet, N., McFarland, B.H., Newsom, J.T. (2007). Suicide among
male veterans: A prospective population-based study. Journal of Epidemiology and
Community Health, 61, 619-624.
Smith-Osborne, A. (2013). Do VA health care policies support resuming expected life
trajectories after military service? Social Work in Public Health, 28, 81- 96.
doi:10.1080/19371918.2011.552038
References, cont.
7.
8.
Texas Veterans Commission (n.d.). Geographic distribution
of VA expenditures for FY 07: Texas. Retrieved from the
Commission website at: www.tvc.state.tx.us-PPTFY07_GDX-TX.xls
Texas Veterans Commission (n.d.). Strategic plan: Fiscal
years 2013-2017. Retrieved from the Commission website at
http://www.tvc.state.tx.us/documents/TVC_Strategic_Plan_2
012_electronic.pdf
16
Examples of Military Culture Materials that
can be found via the Internet
FM 22-51 Leader’s Manual for Combat Stress Control
AR 40-206 Neuropsychiatry and Mental Health
Army Officer’s Guide (Bonn, 2002)
Enlisted Soldier’s Guide (Rush, 2006)
AR 600-18 The Army Family Advocacy Program
Army Pamphlet 611-21 Military Occupational Classification
and Structure
17