COMING HOME: REFUGE OR A COMING HOME: REFUGE OR A NEW COMBAT ZONE?NEW COMBAT ZONE?

Kathryn Karusaitis Basham, PhD, LICSWKathryn Karusaitis Basham, PhD, LICSW

June 26, 2008 June 26, 2008

INTRODUCTION: REUNION FOR FAMILIES INTRODUCTION: REUNION FOR FAMILIES FOLLOWING DEPLOYMENTFOLLOWING DEPLOYMENT

LESSONS LEARNEDLESSONS LEARNED

What are the challenges, stressors and rewards of What are the challenges, stressors and rewards of coming home for soldiers and their families?coming home for soldiers and their families?

How does research inform our understanding of How does research inform our understanding of the effects of combat on soldiers and their the effects of combat on soldiers and their families?families?

FocusFocus

Effects of deployment on attachments for soldiers, their Effects of deployment on attachments for soldiers, their partners and families?partners and families?

Protective and risk factors, including gender, race and Protective and risk factors, including gender, race and ethnicity?ethnicity?

Relationship patterns expressed by traumatized couples?Relationship patterns expressed by traumatized couples?

Practice methods that facilitate renewed attachments, Practice methods that facilitate renewed attachments, improved affect regulation and re-connection.improved affect regulation and re-connection.

After The ParadeAfter The Parade

RESPONSES OF FAMILIESRESPONSES OF FAMILIES

PositivesPositives

Enhanced self esteemEnhanced self esteem

Pride and masteryPride and mastery

Sense of duty and honorSense of duty and honor Return to civilian life: shifts in rolesReturn to civilian life: shifts in roles

work, reintegration to community work, reintegration to community CaregivingCaregiving

RESPONSES OF FAMILIESRESPONSES OF FAMILIES

Secondary trauma (Stamm, 1999) with PTSD-like symptoms of Secondary trauma (Stamm, 1999) with PTSD-like symptoms of hyperarousal, avoidance and numbing)hyperarousal, avoidance and numbing)

Marital conflict, attachment ruptures and divorce (Jensen et al. 1995; Marital conflict, attachment ruptures and divorce (Jensen et al. 1995; Jordan et al. 1992)Jordan et al. 1992)

Intimate partner violence (Clark & Messer, 2005; McCarroll et al. Intimate partner violence (Clark & Messer, 2005; McCarroll et al. 2000)2000)

Parenting issues and attachment adjustments (Samper et al. 2004)Parenting issues and attachment adjustments (Samper et al. 2004)

Effects on children (Rosenheck & Fontana, 1998; Marshall et al. Effects on children (Rosenheck & Fontana, 1998; Marshall et al. 2005)2005)

“What’s this they say, Billy, about a new, more virulent strain of teen-ager?”

Victim-Victimizer-Bystander ScenarioVictim-Victimizer-Bystander Scenario

Central relationship pattern with survivorsCentral relationship pattern with survivors of trauma (Staub, 1989, 2003;of trauma (Staub, 1989, 2003; Herman, 1992)Herman, 1992)

Victim (person who is victimized), the victimizer (offender) Victim (person who is victimized), the victimizer (offender) and a bystander (who often remains detached) relate in and a bystander (who often remains detached) relate in this scenario.this scenario.

Trauma survivor experiences victimization in the “here and Trauma survivor experiences victimization in the “here and now” AND internalizes the victim-victimizer-bystander now” AND internalizes the victim-victimizer-bystander relationship template that guides her world view.relationship template that guides her world view.

“I’ll abandon my medium- and shorter range missiles if you abandon yours.”

COUNTERTRANSFERENCE TRAPS COUNTERTRANSFERENCE TRAPS WITH TRAUMATIZED FAMILIESWITH TRAUMATIZED FAMILIES

PASSIVE INDIFFERENCEPASSIVE INDIFFERENCE HELPLESS VICTIMIZATIONHELPLESS VICTIMIZATION

RESCUER ENACTMENTRESCUER ENACTMENT

AGGRESSIONAGGRESSION REACTION FORMATIONREACTION FORMATION

RACE, ETHNICITY AND RACE, ETHNICITY AND DEPLOYMENTDEPLOYMENT

Lessons learned from Vietnam re. Lessons learned from Vietnam re. experiences for African American, experiences for African American, Hispanic and American Indian veterans Hispanic and American Indian veterans (Hoge et al. 2002)(Hoge et al. 2002)

Current demographics for Current demographics for

OEF/IEF OEF/IEF New immigrants and non-citizen New immigrants and non-citizen

residents residents

WOMEN AND COMBATWOMEN AND COMBAT

Wide range of duties with greater exposure Wide range of duties with greater exposure to combat (Vogt et al. 2005)to combat (Vogt et al. 2005)

Role adjustment as single mothers and Role adjustment as single mothers and caregivers (Kang, 1995)caregivers (Kang, 1995)

Military sexual assaultMilitary sexual assault (Goldzweig et al. 2006) (Goldzweig et al. 2006)

MENTAL HEALTH EFFECTSMENTAL HEALTH EFFECTS

Acute Stress ResponseAcute Stress Response Post Traumatic Stress Disorder (Seal et al.Post Traumatic Stress Disorder (Seal et al. 2007) 2007) Depression (Fiedler et al. 2002)Depression (Fiedler et al. 2002) Suicide (Toomey et al. 2007)Suicide (Toomey et al. 2007) Panic disorderPanic disorder Somatic complaintsSomatic complaints Substance use disorder (Jordan et al. 1991)Substance use disorder (Jordan et al. 1991) Disability (Physical, Cognitive and Mental Health)Disability (Physical, Cognitive and Mental Health) Traumatic brain injuryTraumatic brain injury

GUIDING PRINCIPLES :CLINICAL GUIDING PRINCIPLES :CLINICAL

SOCIAL WORK PRACTICESOCIAL WORK PRACTICE Relationship and connectionRelationship and connection

ResilienceResilience

EmpowermentEmpowerment

Cultural responsivenessCultural responsiveness

Role of Psychodynamic TheoryRole of Psychodynamic Theory

Strengths and Strengths and vulnerabilities established vulnerabilities established in childhood that influence in childhood that influence experiences of self and experiences of self and relationship with othersrelationship with others

Power of Power of unconscious/conscious unconscious/conscious phenomenaphenomena

Realm of symbolic Realm of symbolic meaningmeaning

Unique meaning of Unique meaning of narrative of individualnarrative of individual

Transference/CT Transference/CT

ATTACHMENT PATTERNSATTACHMENT PATTERNSSECURE ATTACHMENTSECURE ATTACHMENT (i.e. mutual, reciprocal and sustainable (i.e. mutual, reciprocal and sustainable

relationships)relationships)

INSECURE ATTACHMENTINSECURE ATTACHMENT

DismissingDismissing—fears of intimacy, intense —fears of intimacy, intense self –reliance and aloofnessself –reliance and aloofness

PreoccupiedPreoccupied-ambivalence, rage when disappointed -ambivalence, rage when disappointed and “keeping score”and “keeping score”

Disorganized/DisorientedDisorganized/Disoriented -extremes of rigidity and -extremes of rigidity and inflexibility, emotional chaos, potential violenceinflexibility, emotional chaos, potential violence

TRAUMATIC STRESS RESPONSE AND TRAUMATIC STRESS RESPONSE AND AFFECT DYSREGULATIONAFFECT DYSREGULATION

Attachment injuries and affect dysregulation (chronic repetition of Attachment injuries and affect dysregulation (chronic repetition of traumatic stress response)traumatic stress response)

““Rage storms”Rage storms”

Interference with mentalization (i.e. a capacity to regulate affect where Interference with mentalization (i.e. a capacity to regulate affect where there is a level of consciousness of the affect within oneself as well as there is a level of consciousness of the affect within oneself as well as within another person (Fonagy et al. 2002).within another person (Fonagy et al. 2002).

Interruption of :Interruption of : attachment (careseeking or proximity seeking)attachment (careseeking or proximity seeking) caregiving (offering a safe haven) andcaregiving (offering a safe haven) and exploration (curiosity and initiative)exploration (curiosity and initiative)

PRACTICE APPROACHESPRACTICE APPROACHES

Individual treatment for veteran Individual treatment for veteran -Relationship-based psychodynamic-Relationship-based psychodynamic

- Cognitive-Behavioral (CBT) - Cognitive-Behavioral (CBT) Exposure therapyExposure therapy

Cognitive-Behavioral (CBT)Cognitive-Behavioral (CBT) Cognitive Processing Treatment (CPT) Cognitive Processing Treatment (CPT)

- EMDR, Somatic Experiencing, neural relaxation- EMDR, Somatic Experiencing, neural relaxation Couple and family therapyCouple and family therapy

-Phase oriented with relationship-base and -Phase oriented with relationship-base and psychoeducational focuspsychoeducational focus

Group therapy and re-building through communityGroup therapy and re-building through community

What helps soldiers, families and What helps soldiers, families and clinicians?clinicians?

BATTLEMIND SKILLSBATTLEMIND SKILLS BBuddies (Social Support)uddies (Social Support)

AAdding/subtracting family rolesdding/subtracting family roles TTaking controlaking control

TTalking it outalking it out

LLoyalty and commitmentoyalty and commitment

EEmotional balancemotional balance

MMental health and readinessental health and readiness

IIndependencendependence

NNavigating the Army Systemavigating the Army System

DDenial of self (self-sacrifice)enial of self (self-sacrifice)

RATIONALE FOR COUPLE/FAMILY THERAPYRATIONALE FOR COUPLE/FAMILY THERAPY

PROMOTE SECURE ATTACHMENTSPROMOTE SECURE ATTACHMENTS

REDUCE MENTAL HEALTH SYMPTOMATOLOGYREDUCE MENTAL HEALTH SYMPTOMATOLOGY

MINIMIZE SECONDARY TRAUMATIZATIONMINIMIZE SECONDARY TRAUMATIZATION

INCREASE KNOWLEDGE RELATED TO INCREASE KNOWLEDGE RELATED TO

TRAUMA-RELATED EFFECTSTRAUMA-RELATED EFFECTS

RESTORE A SENSE OF RE-CONNECTION AND RESTORE A SENSE OF RE-CONNECTION AND SOCIALVINDICATIONSOCIALVINDICATION

PHASE ORIENTED COUPLE/FAMILY PHASE ORIENTED COUPLE/FAMILY THERAPY PRACTICETHERAPY PRACTICE

Biopsychosocial AssessmentBiopsychosocial Assessment

Phase I: Safety, stabilization and establishing a Phase I: Safety, stabilization and establishing a context for changecontext for change

Phase II: Reflection of trauma narrativesPhase II: Reflection of trauma narratives

Phase III: Consolidation of new perspectives, Phase III: Consolidation of new perspectives, attitudes and behaviorsattitudes and behaviors

PHASE ONEPHASE ONESAFETY, SELF-CARE AND STABILIZATIONSAFETY, SELF-CARE AND STABILIZATION

Establishing safetyEstablishing safety

Self-careSelf-care– physical healthphysical health– mental healthmental health– sleep, nutrition and exercisesleep, nutrition and exercise– substance use, abuse and/or addictionsubstance use, abuse and/or addiction– bio-behavioral behavioral strategies for bio-behavioral behavioral strategies for stress reduction, self-soothing and affect regulation.stress reduction, self-soothing and affect regulation.

Support systems (e.g. spirituality/religion, family, work and community).Support systems (e.g. spirituality/religion, family, work and community).

Assessment of stability of familyAssessment of stability of family