Veterans, Families, & Communities Under Fire
Clinical and Ethical Guidelines for Treating the Effects of War
R. Blaine Everson, Ph.D.
Marriage & Family Therapist
Samaritan Counseling Center
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Learning Objectives
Learn a systems based approach to common problems seen with vets and families
Better understand military culture & language upon practice & broader culture
Ethics of assessing, evaluating, & treating vets & their families from a systemic perspective
Utilize knowledge of in-depth ethics associated with interventions where needs of vets & families may diverge.
Learn more about seeking & providing supervision for working with vets & their families.
Identify ways of become a more veteran friendly therapist and attracting clients.
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Military CultureMilitary Culture
Sociologists define culture as …Sociologists define culture as …
• LanguageLanguage - nomenclature; acronyms, abbr. - nomenclature; acronyms, abbr.• BeliefsBeliefs – defenders of Democracy – defenders of Democracy• Value systemsValue systems – leave no one behind – leave no one behind• Norms & rulesNorms & rules – formal & informal conduct – formal & informal conduct• Material productsMaterial products – weapons systems – weapons systems
Associated with a social system & unique to a given Associated with a social system & unique to a given system.system.
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Language Barriers for CiviliansLanguage Barriers for Civilians
MOSMOS BNOCBNOC NTCNTC PCSPCS DCUDCU AWOLAWOL LTCLTC NCONCO BAHBAH ETSETS FOBFOB
Type of UniformType of Uniform Preparation Encampment Preparation Encampment Desert Warfare TrainingDesert Warfare Training MovingMoving SergeantSergeant Staff Sergeant’s SchoolStaff Sergeant’s School Rent MoneyRent Money Leaving Without PermissionLeaving Without Permission Leiutenant ColonelLeiutenant Colonel Job in the MilitaryJob in the Military Separation from ServiceSeparation from Service
Military Cultural Influences on Society
Military systems and its participants have influenced our society at-large in various ways – politics, business, etc.
Language – “snafu”, “whole 9 yards”, “son of a gun”, “dressed to the 9’s”, etc.
Behaviors – smoking cigarettes becomes fashionable for males after WWI b/c common in rations.
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A Warrior CasteA Warrior Caste
Military is a Military is a castecaste system into which marines, soldiers, system into which marines, soldiers, sailors, & airmen are reborn as recruits via basic training sailors, & airmen are reborn as recruits via basic training & re-socialized into specific roles within the military & re-socialized into specific roles within the military system.system.
Total institutions where many aspects of life are dictated Total institutions where many aspects of life are dictated and contrived via rules & regs.and contrived via rules & regs.
Then they are ritualistically baptized by combat & set Then they are ritualistically baptized by combat & set apart from the rest of society for remainder of their lives apart from the rest of society for remainder of their lives due to these extraordinary experiences.due to these extraordinary experiences.
A “warrior” from that point in time onward.A “warrior” from that point in time onward.
Creeds and Mottos of Military
USMC Rifleman’s Creed
This is my rifle. There are many like it, but this one is mine. It is my life. I must master it as I master my life. Without me, my rifle is useless. Without my rifle, I am useless. I must fire my rifle true…Before God I swear this creed. My rifle and I are the defenders of my country…and there is no enemy.
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Military Families As Embedded SystemsMilitary Families As Embedded Systems
National DefenseSystem
Local Community
Military Installation
Service Unit/Support
Military Family
Service Member
Understanding How Military Families Influence (and Are Influenced by) Multiple Systems Is A Must for Practitioners Working With this Clientele
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Military Family Life Cycle
-Courting
-Pregnant
-Marriage
Deploy Mid-tour
leave
New family begins in absentia
Parental adj & young
children
Transitions are often marked by crisis points in the family life cycle.
Return & Reunion
Resume normal
routines
<Missed 1st year of marriage>
Re-deploy
<May be 1st deployment for both partners>
Family w/ school agers
Return & ReunionRelocation
Families w/ teens & possibly
steps
ETS or Retire
<Divorce & remarriages w/ kids for previous relationships are common – complex stepfamily>
A Dynamic Family Systems Model for
Understanding Military Family Problems
Emerging Features
(Symptoms)
Changing External
Environment
“Therapy”
Changing External
Environment
“Withdrawal”
Changing External
Environment
“Misbehavior”
Changing External
Environment
“Re-deployment”Complex Adaptive Behaviors
Info In
Info In
Info Out
Info Out
(+) feedback
(-) feedback
Reactive Relational Dynamics
Amplifying Dampening
e.g. “secrets”e.g. “cut-offs”
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Basic Emotional Triangulation between Military Families and the Military System
military
service member
spouse
children
Uninjured or unimpaired, but with familial problems.
Physically injured seen with familial problems.
Psychologically injured with familial problems.
Physical & psychological injuries impacting families.
Returning Warriors: Your Practice
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Part II
Ethical Understanding of Treatment Options & Interventions
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Veterans And Families Under Fire
A Systemic Orientation
Family Structure Boundaries Family Roles & Rules Triangles Birth Order Ecosystems
Family Development Lifespan Development Resilience & Vulnerability Crisis in Families Belief Systems
Family Process Emotional Regression Differentiation &
Separation Multigenerational
Influences Paradoxical Situations Family Secrets Family Rituals Sibling Relationships
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Assessing Problems & Systems Treatment – Part I
History taking Clinical interview Life span stage Scales & indices Genograms Mindset during
assessment: willing to include military service in history taking.
Multiple life cycle phases experienced simultaneously & may conflict w/ phase progression.
Disruptions frequently erupt in a crisis state & must be managed by therapist.
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Assessing Problems & Systems Treatment – Part II
Genogramming Complexity!!! Unit members may be
2nd order family. Time consuming b/c of
complexity Helpful for teasing out
systemic issues related to step-family, FOO, etc.
m. 99 – d. 03m. 04
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Assessing Problems & Systems Treatment – Part III
Ecomapping is a graphical representation showing all of the systems at play in an individual's life
Sometimes more helpful to focus on extra-family connections
Helps understand stressors stemming from embedded nature of families
Son (5)Mom
Dad Step-son (8)
ScoutsUnit
Church
Systems Oriented Therapy
Should not view the family problems as simply vet’s readjustment issues (context)
Family problems may have existed prior to ETS or last deployment (history)
Presenting px should be viewed within larger focus of recent service (events)
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Systems-Based Diagnosis of Common Operational Maladies
Traumatic Brain Injury Combat Stress Injury Post Traumatic Stress Disorder Generalized Anxiety Disorder Panic Disorder Depressive Disorders
TBI & CSI in a Systemic Context
Traumatic Brain Injury Ranges from mild to
severe – concussions to major intracranial trauma
Concussive episodes – IED, RPG, etc.
Sx include: of memory loss, poor concentration, sleep px, body aches, pain, high BP, fatigue
R/O b/w mTBI & PTSD
Combat Stress Injury Exposure to deployment
related stressors & operations
Physical, emotional & cognitive impact
Sx may morph into major clinical syndrome
Combat Exposure Scale is valid & reliable for assessment of CSI
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PTSD & CSI PTSD: three symptom sets
Hyperarousal – startles easily & hyper-vigilance Intrusions – flashbacks & nightmares (terrors) Constriction of affect – numbing or dissociation
Combat Stress Injury: Physical hardships >noise, blasts, dirty, malnourished Cognitive > +/- information, mission ambiguity, lack of
contextualizing Emotional > fear of injury or death of comrades, shame/guilt,
helplessness, killing Social > social support vs. privacy issues; public opinion Spiritual > forgiving; self-forgiveness; loss of faith
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Systemic Considerations in Stress Disorders
Allostasis vs. homeostasis – equilibrium restored by shifting set point - w/ allostasis the fulcrum is moved in a particular direction disallowing the return to previous functioning
Neurotransmitter-receptor hypothesis – changes due to stress & predispositions may be irreversible due to depletion of NE & 5-H serotonin in the CNS
New modalities for treating stress disorders are emerging or improvement in existing methods in response to more severe & tx resistant disorders
Family Empowerment Therapy:Five Phase Model
Beginning & Exploration of Problems Framing Problems & Balancing Ind
Needs: Optimizing Therapy Environs Retelling of Events: PTSD & STS
related Reframing, Altering Structure, & Healing
Narrative Closure & Follow-up (p. 198-203 FUF)
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Injury-Extent of Injury-Limitations
Φ – physicalaspects
Ψ – emotional impact
Soldier
Spouse
Children
CoupleRelational Dynamic
Parent-ChildRelational Dynamic
Parent-ChildRelational Dynamic
Parent-Child Disability Dynamic-reduced interaction-estrangement-negative reactions (stage dependent)-# of children
Spousal Disability Dynamic-reduced intimacy-disengagement-poor communication
Secondary Disability Dynamic
-Δ in communication-w/h negative info?-parentified child?
The entire family dynamic changes from this point forward in time as the family attempts to accommodate the injury and adapts to new situations as they arise.Physical rehab & psychotherapy must balance emotional and physical aspects of injury with family support, while maintaining focus on the value of the family as a healing environment and attending to family member’s emotional needs to that end – all must heal together.
Key:Solid – represent overt interactional patternDashed - represent covert interactional pattern
The Healing Journey- accounts for changes & transitions in family dynamics across time, situations, & stages of life (ETS, PCS, etc.)
A Paradigm for Understanding Post-War Healing Within Veteran Families
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PTSD & Secondary Trauma: Case Illustration – Sgt. Love
37 42 46
10 22 7
m. 96 – d. 2002m. 2006
-PTSD
-Affair
-ETOH Abuse
1) Lived parallel lives since Afghan Deployment. 2) Lost Battle Buddy in IED blast – injured himself. 3) Working as a foreman at a metal fabricator. 4) Difficulty talking to one another.
-Depression
-Secondary stress
-Withdrawal
-Presenting problem?
- Diagnosis?
- Treatment plan?
- Strengths?
-Referrals?
Genogram circa 2011
Ethical Issues Associated with Treating Veterans & Families
Must balance needs of family and veteran needs simultaneously
Consultation with other healthcare professionals may be needed
Ethics associated with labeling vets & stigma attached to labels
Working with VA resources & systems can be frustrating for private providers
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Systems Based Supervision & Being a Veteran Friendly Therapist
Veterans And Families Under Fire
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Part III
Supervision Issues
Sometimes difficult to see multiple layers of systems
Orient to family lifespan develop-ment perspective
Differentiate relational diagnoses from individual axes
Help supervisee understand triangle b/w themselves & family
Help integrate systems based knowledge into ongoing treatment
Videotape & audiotape in place of live supervision
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Levels of Systemic Supervision
1. Learning basics of systems theory & concepts within military scope
2. Integrating systemic theory in light of interactions with military families & organizing of formal assessment
3. Integrating assessment into an informed selection of effective clinical intervention
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Goals for Systemic Supervision With Vet Friendly Therapists
Deepen understanding of family process & theory as applied to vet families
Increase sensitivity to dynamic processes & recognize in systems of vet families
Help with systemic assessments, formulations of treatment goals, & selection of interventions
Help to step back and learn from successes & failures, while instilling confidence to try new & creative approaches
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Veteran Family Friendly Therapist
Tricare/Value Options paneled; others are BCBS, UBHS, Magellan
Partner with VA to provide ongoing services that they don’t provide, specialty groups, family therapy, spousal support, etc.
MFT & LPC are eligible for jobs in the Dept of Defense and the VA
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References in Brief Beder, J. (Ed.) (2012) Advances in Social Work Practice
with Military Families. Routledge. Everson, R. & C. Figley (Eds.) (2011) Families Under Fire.
Routledge. Figley, C. & W. Nash (Eds.) (2007) Combat Stress Injury.
Routledge. Hall, L. (2008) Counseling Military Families. Routledge. Hoge, C. W. (2010) Once A Warrior… Guilford. Lee, R. & C. Everett. (2004). The Integrative Family
Therapy Supervisor. Routledge.
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