24 October 2013 Bobby Walden, LCSW HUD-VASH Social Worker Dept. Veterans Affairs Capt. USAFR, BSC Understanding the Warfighter.

24 October 2013 Bobby Walden, LCSW HUD-VASH Social Worker Dept. Veterans Affairs Capt. USAFR, BSC Understanding the Warfighter

Disclaimer This presentation does not reflect the opinions or views of the United States Air Force nor the Department of Veterans Affairs.

Overview PRESENTATION 1. Eligibility for VA Healthcare. a. Overview of services available b. Service Connected condition c. Eligible Reserve/National Guard 2. The Culture of the Military a. Differences among the branches and their specific cultures. b. Core Values

Overview 3. Deployment. a. Emotional reactions b. Management strategies 4. Combat Stress Facility a. Treatment concepts 5. Discharge a. Returning Home b. Identity Issues. c. Common struggles.

Veterans Benefits We will not be discussing claims benefits. For purposes of this presentation we will only be discussing medical benefits

Basic Eligibility Active Duty Reserves/National Guard Most Veterans who enlisted after September 7, 1980, or entered active duty after October 16, 1981, must have served 24 continuous months or the full period for which they were called to active duty in order to be eligible.

Means Tested Examination of somebody's income: an examination of somebody's income and savings, carried out in order to determine whether the criteria for a type of assistance or financial aid are met.

Service Connected Disability Veterans who are disabled by an injury or illness that was incurred or aggravated during active military service. These disabilities are considered to be service-connected.

Priority Groups Priority Group 1 Priority Group 2 Priority Group 3 Priority Group 4 Priority Group 5 Priority Group 6 Priority Group 7 Priority Group 8

Priority Group 1 Veterans with VA Service-connected disabilities rated 50% or more. Veterans assigned a total disability rating for compensation based on unemployability.

Priority Group 2 Veterans with VA Service-connected disabilities rated 30% or 40%.

Priority Group 3 Veterans who are former POWs. Veterans awarded the Purple Heart Medal. Veterans awarded the Medal of Honor. Veterans whose discharge was for a disability incurred or aggravated in the line of duty. Veterans with VA Service-connected disabilities rated 10% or 20%. Veterans awarded special eligibility classification under Title 38, U.S.C., 1151, benefits for individuals disabled by treatment or vocational rehabilitation.

Priority Group 4 Veterans receiving increased compensation or pension based on their need for regular Aid and Attendance or by reason of being permanently Housebound. Veterans determined by VA to be catastrophically disabled.

Priority Group 5 Nonservice-connected Veterans and noncompensable Service-connected Veterans rated 0%, whose annual income and/or net worth are not greater than the VA financial thresholds. Veterans receiving VA Pension benefits. Veterans eligible for Medicaid benefits.

Priority Group 6 Compensable 0% Service-connected Veterans. Veterans exposed to ionizing radiation during atmospheric testing or during the occupation of Hiroshima and Nagasaki. Project 112/SHAD participants. Veterans who served in the Republic of Vietnam between January 9, 1962 and May 7, 1975. Veterans who served in the Southwest Asia theater of operations from August 2, 1990, through November 11, 1998. Veterans who served in a theater of combat operations after November 11, 1998, as follows: Veterans discharged from active duty on or after January 28, 2003, for five years post discharge

Priority Group 7 Veterans with incomes below the geographic means test (GMT) income thresholds and who agree to pay the applicable copayment.

Priority Group 8 Veterans with gross household incomes above the VA national income threshold and the geographically-adjusted income threshold for their resident location and who agrees to pay copays.

The Culture of the Military What counts is not necessarily the size of the dog in the fight - it's the size of the fight in the dog. - Dwight D. Eisenhower

Icebreaker

SlangMeaning Gedunk Candy A '96 4 days off POG Person other than Grunt Boot A term for Marines who are new to the Marine Corps. Derived from the term "boot camp", to insinuate that the Marine is fresh out of boot camp. Generally used as a pejorative term (even if in an affectionate manner) in the Fleet and elsewhere, sometimes as a way to explain that new Marines should know their place. It can also be used as a term for a Marine who is new to a rank or billet. e.g. - "He's a boot Corporal".

SlangMeaning Blood Stripe Red band on dress uniform trousers; symbolizes blood shed by Marines in war; worn by officers and NCOs. Also a form of hazing where NCOs inflict skin- damage on new Corporals. NCOs Knife Hand A way of getting your point across with the use of your hand High and Tight Very short haircut with just a little on the top Hit the Head Bathroom break Zero Dark Thirty Really early in the morning Scuttlebutt Started out the water fountain, became gossip Hit the Sack Go to bed, get some sleep Police the area Clean up Pogie bait Cookies, anything that can be used to distract or bribe non infantry personnel. In general; a bribe or an object used to distract someone

SlangMeaning PCS Permanent change of station TDY Temporary Duty Assignment CONUS Continental United States/State Side Down Range Deployed Gun Decking Falsifying reports

Why is it important to be Culturally Competent? What is Military Culture? Understanding military culture can: Result in improved abilities to understand, communicate, and effectively interact with service members/veterans and their families. Having basic knowledge regarding the values, structure, policies, can promote a stronger client-provider alliance and help develop skills to provide more effective clinical care.

A 20 year old male self refers to you for feeling "on edge", "pissed off," and having difficulty sleeping. He tells you that he is a SPC in the Army National Guard who returned about 4 months ago from a 15 month deployment to Afganastan. In your first meeting he tells you he is a gunner attached to Bravo Company, 2nd Battalion, 7th Infantry Regiment, First Brigade Combat Team 3ID. He's coming to see you because his First Sergeant expressed concern over his irritability during their last drill. He reports that he is still angry with everyone from his Company Commander down to his Platoon Leader for many decisions made down range. He is married with 2 children under the age of 4, one of whom was born during his deployment. He reports a strained relationship with is spouse who he says "doesn't get" what he went through during his deployment. He also indicates that he plans to volunteer to deploy again as soon as possible.

Questions What does it mean that he is in the Army National Guard? What is a SPC? A gunner? What does it mean that he is from the First Brigade Combat team 3ID? What does "down range" mean?

Military Rank Structure Enlisted Warrant Officer Commissioned Officer

Military Rank Structure See Handout Note the Navy and Coast Guard has a different Officer Rank titles

Enlisted Majority of military personnel approx 84% As members progress in rank, leadership responsibilities increase significantly specifically at the NCO level. Typically have specific job functions similar to employees at a company NCO Noncommissioned officer Enlisted members may also refer to their pay grade E-1 through E-6

Role of NCOs NCO = Noncommissioned officer. Traditionally the 1 st formal role in leadership. It is said among Marines No plan survives contact with the enemy so the Marine Corps places heavy value on small unit leadership to its lowest level. Marine NCO at an E-4 Other Branches typically E-5

Warrant Officers Experts at in their field. Primary task Technical expert - Trainers - Advisors - Coaches - Although above all enlisted ranks they are still below Commissioned officer grades - Make up approximately 2% of the military There are no Warrant Officers in the Air force.

Commissioned Officers Commissioned ranks are the highest in the military Similar to managers and leaders in a company Commissions are by order of the President of the United States Typically seen as generalist in nature, with the ultimate goal to take command over more and more personnel. Minimum of a four year Bachelors Degree. Make up approximately 14 % of the military

Uniformed Services United States Army United States Navy United States Marine Corps United States Air Force United States Coast Guard. United States Public Health Service

United States Army Motto: This Well Defend. Army's Mission: To fight and win our Nations wars by providing prompt, sustained land dominance across the full range of military operations and spectrum of conflict in support of combatant commanders.

United States Army The Army is the oldest and largest of the military services and represents the main ground force for the United States. The Continental Army was formed on June 14th 1775 to meet the demands of the Revolutionary War and was subsequently replaced by the United States Army which was created by Congress on June 14, 1784. The Army is comprised of an Active component and two Reserve components, the Army National Guard and the Army Reserves.

Army Core Values These core values are intended to guide service members throughout their careers and day to day life. 1. Loyalty 2. Duty 3. Respect 4. Selfless Service 5. Honor 6. Integrity 7. Personal Courage

United States Navy (USN) Motto: "Non sibi sed patriae" (unofficial) "Not for self but for country The Navy has not Motto because they dont need one! Navy Mission: To maintain, train and equip combat-ready Naval forces capable of winning wars, deterring aggression and maintaining freedom of the seas.

United States Navy The Navy is the second largest branch of service. The U.S. Navy was founded on 13 October 1775, and the Department of the Navy was established on 30 April 1798. The Navy is comprised of an Active and Reserve component but does not have a National Guard. In addition, the Navy also plays an essential role in augmenting air power and transporting Marines to areas of conflict.

Navy Core Values 1. Honor 2. Courage 3. Commitment

United States Marine Corps Motto: Semper Fidelis, Always Faithful Marine Corps Mission: The seizure or defense of advanced naval bases and other land operations to support naval campaigns. The development of tactics, techniques, and equipment used by amphibious landing forces. Such other duties as the President may direct. (National Security Act of 1947)

United States Marine Corps Smallest of the armed forces. Is a Department of the Navy but operationally is a separate branch. The USMC was originally organized as the Continental Marines on Nov 10, 1775 and served as naval infantry. The Continental Marines were disbanded by the end of the revolutionary war and then reestablished as the United States Marine Corps by Congress in 1798. Similar to the Navy, the Marine Corps is comprised of an Active and Reserve component but does not have a National Guard

Marine Corps Values 1. Honor 2. Courage 3. Commitment

United States Air Force Motto: Fly- Fight- Win Air Force Mission: To deliver sovereign options for the defense of the United States of America and its global interests to fly and fight in air, space and cyberspace.

United States Air Force The Air Force is the youngest of all the military services and represents the aerial warfare branch of the armed forces. The USAF was formed as a separate branch of the military on 18 Sept 1947 and was known prior to that as the Army Air Corps. The USAF is comprised of an active component and two reserve components, the Air Force Reserve and the Air National Guard. While the Army, Navy and Marines all have and utilize aircraft, it remains the mission of the Air Force to deliver sovereign options for the defense of the United States of America and its global interests, to fly and fight in air, space and cyberspace.

Air Force Core Values 1. Integrity First 2. Service Before Self 3. Excellence In All We Do

United States Coast Guard Motto: Semper Paratus, "Always Ready" Coast Guard Mission: To protect the public, the environment, and the United States economic and security interests in any maritime region in which those interests may be at risk, including international waters and America's coasts, ports, and inland waterways.

United States Coast Guard The United States Coast Guard is an armed force but differs from the rest as it is not a part of the Department of Defense but instead falls within the Department of Homeland Security. Its fundamental roles include maritime safety, maritime security, maritime mobility, national defense, and protection of natural resources. The USCGs mission is to protect the public, the environment, and the United States economic and security interests in any maritime region in which those interests may be at risk, including international waters and America's coasts, ports, and inland waterways. The Coast Guard can operate under the DoD as a service in the Dept of the Navy if Congress declares war or at the request of the President.

Coast Guard Core Values 1. Honor 2. Respect 3. Devotion to Duty

Inter Branch Rivalry A misunderstanding of the mission Navy & Air Force - Traditionally process driven highly repetitive, exercise and mission remains the same differ little. - Process failures Cause loss of life or millions or dollars in equipment due to loss of aircraft shipboard disasters. Marine Corps & Army Operate in environments by their very nature are unpredictable and are not controllable - Again see the importance of small unit leadership

Inter Branch Rivalry The flexible side views the process driven side as irrelevant the disparity of values is created which leads to cynicism It is important for you to see this distinction so that you understand your bravado veterans are not judgmental rather a product of the environment they served in.

Case Study Review What does it mean that he is in the Army National Guard? What is a SPC? A gunner? What does it mean that he is from the First Brigade Combat team 3ID? What does "down range" mean?

Summary Culture Understanding military language Rank Structure a. Leadership levels Reviewed the individual branches a. Core values b. Mission

Questions We will next be covering the differences between active duty and the reserve component.

Active Component/Active Duty Works full-time for the military Full time hours, full time benefits On-call 24 hrs/day, 365 days a year Permanent force of the military

AC Benefits include: 1. Competitive salary and bonuses 2. Healthcare 3. Annual leave 4. Base privileges 5. Retirement

Challenges/Stressors Permanent Change of Station (PCS) every 2-4 years Temporary Duty (TDY) Deployment

Reserve Component/Reserves Part-time duties One weekend a month (39 days/yr), 2 weeks a year Can be activated to augment AC 7 components (1.Army Reserve 2. Army National Guard 3. Air Force Reserve 4. Air National Guard 5. Navy Reserve 6. Marine Corps Reserve 7. Coast Guard Reserve)

National Guard vs. Reserves The National Guard continues its historic dual mission, providing to the states units trained and equipped to protect life and property, while providing to the nation units trained, equipped and ready to defend the United States and its interests, all over the globe. The National Guard may also be activated into Federal military service during times of need like the present wars in Iraq and Afghanistan. In this sense, the National guard essentially has a dual mission to serve its state as well as the federal government.

RC Benefits include: 1. Pay for drill and annual training 2. Bonuses 3. Healthcare 4. Base Privileges 5. Retirement

*Challenges/Stressors RC Deployment/Mobilization Lack of military installations close to home Interruptions in civilian life (jobs, school running business) Returning home access to military facility, healthcare other services Isolation from a strong military community.

Challenges/Stressors RC Traditionally active duty plan and train to deploy. That is the MISSION. Work ups for deployment begin approximately 1 year out from the actual deployment. They are in the field families have time to prepare to be alone. AC,members and their family are psychologically more prepared as this is talked about frequently and on a weekly basis. RC personnel are at the installations assigned at a minimal basis and often live most of their lives in a civilian capacity.

Questions Next topic Deployment

Deployment Eat & Drink Today Fore, We May Die Tomorrow

Objectives: Discuss typical emotional reactions during the stages of deployment and management strategies. Discuss management strategies for each of the stages of deployment.

8 Stages Deployment Model 1. Anticipation -Pre Deployment 2. Detachment & Loss Pre Deployment 3. During Deployment 4. Still Deployed Recovery and Stabilization 5. Anticipation of Homecoming 6. Post Deployment 7. Post Deployment Acceptance of new roles 8. Redeployment

Stage #1 Pre-Deployment: Anticipation of Loss (1-6 weeks prior to deployment) Assessment for Pre-Deployment: Anticipation of Loss (1-6 weeks prior to deployment) Excitement, Denial, & Fear Tension: Attempting to accomplish too many projects Unexpressed anger: bickering usually increases; This could be a useful tool to expose unspoken feelings and fears: Restlessness, Depression Irritability and/or Resentment

Management Strategies for Stage 1: Expression of a full range of emotional responses Encourage all family members to share their feelings Help the member to reassure partner of love and commitment Involve the whole family in preparing for the separation Create opportunities for warm loving memories Try to see the deployment as a challenging opportunity for growth Go through the Family Readiness Checklist together as a family (as least spouses) Identify key contact telephone numbers, include military contact numbers

Preparing children for separation: Talk to children before they are deployed; be open and honest. Build an emotional bond. Do not be afraid to hug your child. Displays of affection are powerful. Visit your childrens teachers Allow children to see the parents workplace Plan time for communication Help children to plan for the departure (timeline) Outline childrens responsibilities Tune into your childs specific worries

Stage #2: Pre-Deployment: Detachment & Withdrawal (1 week prior to deployment) Despair and hopelessness Decision making becomes more difficult Projects are never ending Fatigue increases Sexual relations may become ambivalent May stop sharing thoughts and feelings Departure delays increase tension

Management Strategies for Stage 2 Remember that the deployment is not forever Go through checklists with your partner Set realistic goals for yourself for the deployment period Communicate as openly and honestly as possible Be patient with yourself, your partner, & your children Recognize stress

Stage #3: During Deployment Emotional Disorganization (First 6 weeks of deployment) Operational stress accounts for up to 1/3 of deployment casualties Stress contributes to the loss of effectiveness and negatively impacts military readiness Exposure to devastation & death can cause physical, cognitive, emotional, behavioral, and spiritual reactions that greatly diminish fighting effectiveness Stressors: Climate extremes; sensory overload; loud/persistent noises; sleep deprivation

Still in shock - Initial sense of relief overcome by guilt Depression, withdrawal from peers, emotional withdraw from spouse Sense of abandonment, poor concentration On the Home Front- Young children may regress (toilet training & thumb sucking Complaints of stomach aches or headaches Older children may become clingy and demanding

Problem Prone Areas: Anyone with significant problems prior to deployment Substances abuse or who are in early recovery (Detox) Most common Stressors: Financial, Relationships, Children, No Power of Attorney, Unpaid Bills

Warning Signs: Feeling hopeless or helpless Acting out or seeking relief inappropriately Extreme mood swings Sleeplessness or too much sleeping Major appetite changes +/- 10% Loss of interests Inability to concentrate or poor memory Thoughts of hurting yourself or someone else

Management Strategies for Stage 3 for the Military member Hook-up with the Old hands - experience is more helpful than rank Military members who use high active coping report better health The shorter the deployment, the less likely bonding will occur Utilize MWR & recreation resource (non-alcoholic events) Use Mental Health assets Maintain healthy self-care practices established before departure Participate in support groups (formal and informal) Try to end phone calls on a positive note

Stage #4: Still Deployed. Recovery and Stabilization (Variable duration) Both military member and spouse may become mildly depressed, anxious, or vulnerable (risk for extra marital relationships?) On the Home Front Living without member contributes to sense of self- confidence New family patterns, eating habits and meal times change Social support may change Increased sense of freedom and responsibility More sickness due to stress

Management Strategies for Stage 4 Confide in trusted peers, family, and professionals Celebrate signs of positive growth in self, partner, children (new skills, freedom, and independence) Reassure your partner that you still long for the separation to end Be aware of emotions that lead to vulnerability and may result in impulsive behaviors READS (Relaxation, Exercise, Assertiveness, Diet, Sleep)

Stage #5: Anticipation of Homecoming (6 weeks prior to redeployment) Sense of being not ready, mission not complete Anticipation and apprehension of reunion, unrealistic expectations Decisions become harder to make; decisions are postponed until after the homecoming Heightening sense of loss Freedom, independence Restlessness and confusion Family roles may have to be re-evaluated or adjusted

Management Strategies for Stage 5 Reassure your partner of your love and commitment Plan to have some family time with the children before the honeymoon Include children in the homecoming celebration Acknowledge only officially confirmed return information (date, time, location) Ignore rumors; dont raise false expectations, frustrations)

Stage #6: Post-Deployment Honeymoon for about a day, or until first argument Together physically but maybe not emotionally Primary task is to stop being single Disorganized feelings; things are not in your control Assumptions and expectations governing the marriage must usually be adjusted Increased friction?

Management strategies for Stage 6 Renegotiation of relationships (First 6 weeks after returning) Accept feelings as normal and not a threat to the relationship Be patient with yourself and your partner Renegotiate roles and responsibilities- the workload can again be shared, but perhaps in a new way Celebrate personal growth together; each person has grown during the separation

Stage #7: Post-Deployment Acceptance of New Roles (6-12 weeks after returning) Try to use our instead of mine Establishing a new routine (new roles) Increasing sense of security and improved communication How to Cope: Continue to participate in support group/networks Seek professional counseling (chaplain, social worker, doctor, psychologist) for continuing signs of deployment stress, and other concerns

8th Phase: Redeployment Here we go again! See previous Effects and Stages of Deployment

Questions Next Services in a deployed setting/down range.

Combat Stress Facility Whats a normal reaction when in a combat zone? TREAT WHEN YOU MUST

Combat Stress Facility Mission Promote combat readiness Enhance adaptive stress responses Prevent maladaptive stress reactions Normalize reactions to stressful environment Opportunity for rest and recuperation Expectation of RTD Potential 24-hour operations

CSF Goals Maintain military identity with expectation of return to duty Normalize combat and operational stress reactions Not medical or psychiatric illnesses Provide rest and recuperation Skill acquisition Consultation with unit leadership

CSF Personnel Makeup CSF building blocks may include Clinical Psychologist and 7 Level Tech Clinical Social Worker and 7 Level Tech Psychiatrist and 5 level Tech 2 Mental Health Nurses 2 5 level Techs Expand and contract as the mission dictates (by patient census)

Overall Duties 24 Hour Operations 24 hours a day, 7 days a week At least one staff member must be present at all times CSF will have 20 bed capacity Normal patient stay appears to be 3-6 days

Referral Anyone can refer to the CSF Only BH staff assigned to the CSF can accept personnel for entrance to the CSF

Criteria for Acceptance Any cognitive, behavioral, emotional, or occupational impairment related to combat or operational stressors of such a nature to be responsive to 72 hours or less of rest and milieu therapy. Possible examples include: Significant sleep deprivation functional impairment Sudden reduction in performance or marked change in demeanor/behavior Recent combat exposure assessed with etiology related to a disturbance in mood, cognition, and/or behavior causing significant impairment in functioning Having endured strenuous duty assessed that interrupted an individuals personal hygiene and dietary needs. Such neglect is considered likely to cause significant impairment in functioning in most individuals

Disqualifying Criteria for Acceptance or Continued CSF Care Imminent risk to themselves or others Intentional self-injury or harm to others Serious medical problems preventing a person from functioning at a more independent level BH issue more appropriately handled at a different level of care or through administrative action SMs more appropriately handled by legal or administrative authorities Chronically behaviorally disordered persons

Criteria for Release Improvement to such an extent they can return to light/full duties Individuals who do not improve to the extent they can return to light/full duties Should be re-evaluated Considered for a different level of care or administrative disposition

Triage Categories HELP IN PLACE/UNIT (Unit) Active outreach, go to the unit REST (Unit) Close observation not required HOLD (Restoration Center) Medical/BH observation required CSF REFER (Reconditioning Center or other) Too disruptive for current level of care

Interventions Conduct assessments to identify Intervene consistent with protocols Triage as appropriate Treat consistent with BICEPS Provide R&R to RTD (3 hots & a cot) Implement/maintain CSF functions Consultation function Admissions function Therapeutic activities Command consultation

Restoration Principles BICEPS Brevity Immediacy Contact Expectancy Proximity Simplicity

Brevity Brief treatment, no longer than three days Usually at second echelon facility

Immediacy Identify the need for care early don't wait Provide care as soon as possible

Centrality Treat in separate location (not in hospital) Not physically sick, they just need rest

Expectancy Member must understand verbally and non- verbally they are returning to duty Patient is not ill Symptoms are passing reactions Recovery is rapid Wear of uniform while performing details allows member to maintain self-image/military bearing

Proximity Treat as close to home unit as possible Allow unit and friends to visit and offer support

Simplicity Keep treatment directed to patients return to duty No medications unless necessary and only under doctors supervision

5 Rs Reassurance Rest Restore Replenishment Return to duty

Phase I Reconstruction Basic needs/rest Hygiene Food

Phase II Reorientation Stress management Anger control Assertiveness training Relaxation techniques Goal setting

Phase III Reintegration Preparation for return to duty Work assignments in applicable areas Individuals role 1 Don't be a loner 2 Help others 3 Know your limits 4 Get at least four hour uninterrupted sleep. Nap when you can 5 Eat enough food 6 Drink water/stay hydrated 7 Good personal hygiene 8 Stay active

What Are We Restoring? Replenish physiological status - Rest Support military identity Structured military environment Military formations Unit update Restore confidence Normality of response Stress management Coping skills

Medication No meds on CSF equipment list Prescription medications should be used as sparingly as possible Emphasis should be placed on the fact that personnel admitted to the CSF are not considered patients

Outreach Formal outreach examples Commanders call First Sergeants Counsel Anger management Stress management Sleep hygiene Relaxation techniques Informal outreach Walk abouts Stealth Mental Health

Going to the FOBs (Forward Operating Bases) Usually the Tech will be the person who conducts outreach to these remote locations. Typically it may be a 1x per week - How are they perceived? - Will members talk to them?

Cultural Differences Differences among the branches - How they treat mental health - Respect between members and rank

Questions Next section Discharge

Discharge 1 st Civ Div, 1 st Force Recline. John Rambo reporting for civilian Duty.

Discharge/PCS/Going Home By choice? Forced? What have they lost? What have they gained? What went untreated or not talked about? Did they simply drop their pack? Do they feel like an outsider? Are they thinking about suicide?

Conclusion 1. Eligibility for VA Healthcare. 2. The Culture of the Military 3. Deployment. 4. Mental Health Services Down Range 5. Discharge

24 October 2013 Bobby Walden, LCSW HUD-VASH Social Worker Dept. Veterans Affairs Capt. USAFR, BSC Understanding the Warfighter.

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