Interpersonal Violence in Military Families

Interpersonal Violence in Military Families

Brian L. Meyer, Ph.D.

PART 2

What We Need to Do

for Children of Veterans

What We Need to Do:

Identify the Children

• Most state and local agencies that serve

veterans in the general population (such as

child support and child welfare) do not collect information about veterans’ status

• We need to create a “box on the form” to determine how many veterans are in these agencies’ caseloads or how many children of veterans may need or receive services related to their parent’s deployment

What We Need to Do:

Conduct the Research

• There is very little research on children of

veterans who have completed military service

• We need to conduct research on child outcomes:

• Child maltreatment

• Mental health

• Behavioral problems

• Education

What We Need to Do:

Pre- and Post-Natal Family Visitation

• Children of multiply-deployed veterans may be a high-risk population

• Nurse-Family Partnerships involving pre-natal and post-natal visitation for up to years show:

• Fewer behavioral problems

• Less child maltreatment

• Fewer juvenile arrests

• Less alcohol use

• Fewer runaways

• Lower rate of teen pregnancy

Olds et al., 1994; Olds et al., 1997

What We Need to Do:

Screening and Assessment

• Community needs

assessments for children of veterans should be

conducted

• Local agencies need to

screen and assess the needs of children of veterans so they can respond

What We Need to Do:

Treat Secondary Traumatization

• Use Trauma-Focused Cognitive Behavioral Therapy (Cohen, Mannarino & Deblinger, 2006)

• Teach self-care skills:

• Deep breathing

• Progressive muscle relaxation

• Engage in a hobby

• Smile

• Do yoga

• Sing out loud

• Drop 3

• Exercise

• Listen to soothing music

• Listen to happy music

• Play with friends

• Create art

• Dance

What We Need to Do:

Develop School Supports

• Schools with more than 10% of students from military and Veterans’ families should:

• Provide training for teachers

• Have specially trained counselors

• Run groups for those children

• Meet with parents to identify particular needs

• Maintain relationships with community agencies

• This is being done in a community outside Ft.

Hood, TX

What We Need to Do:

Create Service Networks

• Link the VA and DOD systems of care to Wounded Warriors and networks of state and local agencies to provide services to children of veterans

• This may require start-up funding

What We Need to Do for Veterans

Treatment of Co-Occurring PTSD and Substance Abuse

in Veterans

Why Should We Treat Co-Occurring Disorders Integratively?

• Mental health problems do not go away with abstinence

• Improved mental health does not bring about abstinence from substance use

• Separate treatment is at best uncoordinated and at worst countertherapeutic

• Integrated treatment leads to better

outcomes

The Importance of Integrated Treatment for PTSD and SUDs

• Treating one disorder without treating the other is ineffective

• Sequential treatment (usually SUD first) is ineffective

• Fully integrated treatment is optimal

• Simultaneous treatment is next best

The Importance of Integrated Treatment for PTSD and SUDs

• Recent evidence on integrated and simultaneous treatment

suggests:

- If PTSD symptoms decline, so do SUDs - If SUDs decline, PTSD symptoms do not

• Therefore, treating substance abuse without treating PTSD will fail

• This includes ASAP programs

Some Barriers to Integrated Treatment

• Most insurance does not pay for substance abuse treatment

• Separate payment streams

• Separate treatment systems

• Professional training biases

• Lack of dually trained clinicians

These may be overcome by referring

veterans to VHA treatment

PTSD and Substance Abuse Treatment

• PTSD symptoms may worsen in the early stages of abstinence

• PTSD exposure therapies may trigger substance abuse relapses

• Some aspects of 12-Step groups are difficult for some trauma patients

• Powerlessness

• Higher Power

• Issues of forgiveness

Phases of Integrated Treatment

After Herman, 1992

Phase I:

Safety and Stabilization

Phase II:

Remembrance and Mourning

Phase III:

Reconnection

Treatment of

Substance Use Disorders

Medications:

• Alcohol:

• Antabuse (Disulfiram)

• Naltrexone

• Acamprosate

• Opiates:

• Methadone

• Buprenorphine

Treatment of

Substance Use Disorders

Evidence-Based Treatments:

• Motivational Interviewing

• Motivational Enhancement Therapy

• Cognitive-Behavioral Therapy (CBT)

• Contingency Management

• Twelve-step Facilitation Therapy

• Behavioral Couples Therapy

Treatment of PTSD: Medication

Medication for trauma symptom management and co-morbid disorders

• Antidepressants

• Mood stabilizers

• Atypical antipsychotics

• Anticonvulsants

• Anxiolytics not benzodiazepines

• Sleep aids

There is no medication that specifically treats PTSD; only Prozac, Paxil, and Prazosin have been approved

Treatment of PTSD and SUDs

Evidence-Based Psychotherapies for Integrated Phase I Treatment:

• Seeking Safety

• Dialectical Behavior Therapy (DBT)

• Therapies for specific problems

• Imagery Rehearsal Therapy

• Cognitive-Behavioral Therapy

• EMDR resource building, safe place, etc.

Treatment of PTSD

Evidence-Based Psychotherapies for Phase II Trauma Treatment:

• Cognitive Processing Therapy (CPT)

• Prolonged Exposure (PE)

• Eye Movement Desensitization and Reprocessing (EMDR)

• STAIR Narrative Therapy holds promise; it

sequences Phase I and Phase II treatment

Treatment of PTSD and SUDs

• There are no Evidence-Based Psychotherapies for Phase III trauma treatment

• but couples and/or family therapy may be helpful

• Cognitive-Behavioral Conjoint Therapy for

PTSD shows promise

Integrated Treatment for PTSD and Substance Abuse

Seeking Safety is the only empirically-

supported integrated treatment for both PTSD and Substance Abuse

But it is only a Phase I treatment for Safety

and Stabilization

DOD and VA Responses to

Problems in Military Families

Responses to Family Violence in the Armed Services

• In 1974, CAPTA required each armed service to develop programs to respond to child

maltreatment

• Soon after they also began responding to spouse abuse

• In 1982, Congress provided funds for Family Advocacy Programs (FAPs) in all four

branches of the military

Responses to Family Violence:

Family Advocacy Programs

• FAPS are on all 300 military bases with families

• FAPS have case review committees that make determinations about substantiation of child maltreatment and spouse abuse

• FAPS work with military command, military law enforcement, medical staff, family center staff, chaplains, and civilian organizations to coordinate responses to family maltreatment

Recent Responses to Family Problems

• The 2010 National Defense Authorization Act

(NDAA) created the Office of Community Support for Military Families with Special Needs (OSN),

requiring military branches to expand community support for families with special-needs members, including referrals and assistance in obtaining

services

• The 2013 NDAA creates “Special Victims Units” to improve investigation, prosecution and victim

support for child abuse and domestic violence

cases in military families, as well as sexual assault cases

Recent Changes at the VHA

• The Support and Family Education (SAFE) program

(Sherman, 2003)

• 18 session program developed for caregivers of veterans with PTSD or other mental illnesses

• Available for free download at w3.ouhsc.edu/safeprogram

• The Family-to-Family Education Program,

developed with the National Alliance on Mental Illness, trains family members to lead groups

• There is at least one program in a VA Medical Center in every state (Makin-Byrd et al., 2011)

Recent Changes at the VHA

• August, 2010, VHA directive allows provision of mental health services to family members if the mental health of the family member directly impacts the mental health of the veteran

• January, 2012, Caregivers and Veterans Omnibus Health Services Act requires VA to provide mental health

treatment for O/O/O Veterans and their families for 3 years after return from deployment

• Staff training has begun or is planned for:

• Integrative Behavioral Couples Therapy

• Behavioral Couples Therapy for Substance Use

• Cognitive-Behavioral Couples Therapy for PTSD

• Behavioral Family Therapy for Serious Psychiatric Disorders

Recent Changes at the VHA

• Beginning in 2013, every VA Medical Center was required to hold a Community Mental Health Summit

• Starting in 2014, summits must be held annually

• Many summits, including the one in Richmond, initiated collaborative regional workgroups to address child and family issues

• This can be done in your region; ask for an invitation

Why Use VAMCs and Vet Centers?

• Evidence-based treatments are trained and mandated

PTSD

Prolonged Exposure

Cognitive Processing Therapy Substance abuse

Motivational Interviewing

Motivational Enhancement Therapy Behavioral Couples Therapy

Why Use VAMCs and Vet Centers?

Costs are usually minimal:

• Billed to insurance if they have it

• Many veterans don’t have insurance

• Means test: reduces or eliminates costs

• Service-connection for PTSD results in free treatment for PTSD plus travel costs

A Proposal: Military/Veterans Family Dependency Courts

• We have Veterans Treatment Courts and Family Dependency Treatment Courts

• We need to develop hybrid Military/

Veterans Family Dependency Treatment

Courts

Military/Veterans

Family Dependency Courts

• For areas with a high density of current military and veteran families

• It would integrate dependency hearings with treatment using a special focus on military families

• Send Veterans to treatment services to rehabilitate underlying problems

• Regular court appearances

• Required attendance at treatment

• Random drug testing

Military/Veterans

Family Dependency Courts

• Involve child welfare, mental health and

substance abuse

counseling, VAMCs, Veterans support

organizations,

Veterans Centers, and volunteer

Veteran mentors

Military/Veterans Family

Dependency Courts: Participants

• Judge

• Attorneys for parent(s) & state

• GAL & CASA

• Child Welfare worker

• Therapists, including military or VA

• For VA, it might be the Veterans Justice Outreach Specialist instead

• Military or Veteran Peer Recovery Advocate

• Someone who has been through a similar experience

Military/Veterans Family

Dependency Courts: Training

• In Child Welfare

• In Substance Abuse

• In Mental Health

• Including Combat Stress and PTSD, TBI, Chronic Pain, Insomnia, and Depression

• In Military Culture

• In effects of deployment on children

• Including secondary traumatization

Resources

Resources

• What It Is Like to Go to War by Karl Marlantes

• Once a Warrior--Always a Warrior: Navigating the Transition from Combat to Home--Including

Combat Stress, PTSD, and mTBI by Charles Hoge

• After the War Zone: A Practical Guide for

Returning Troops and Their Families by Matthew Friedman and Laurie Slone

Resources

• When Someone You Love Suffers from

Posttraumatic Stress: What to Expect and What You Can Do by Claudia Zayfert and Jason Deviva

• The PTSD Workbook: Simple, Effective

Techniques for Overcoming Traumatic Stress Symptoms by Mary Beth Williams and Soili Poijula

• Finding My Way: A Teen’s Guide to Living with a Parent Who Has Experienced Trauma by

Michelle Sherman and DeAnne Sherman

Internet Resources

• Military culture:

• http://www.ptsd.va.gov/professional/ptsd101/ course- modules/military_culture.asp

• http://www.deploymentpsych.org/military-culture

• PTSD:

• www.ptsd.va.gov

• www.texvet.org

• PTSD 101 courses:

• http://www.ptsd.va.gov/professional/ptsd101/ course- modules/course-modules.asp

• http://mghcme.org/courses/course-detail/from_the_war_zone_

to_the_home_front_supporting_the_mental_health_of_veteran

Internet Resources

• PTSD 101 course about treating PTSD and

SUDs: http://www.ptsd.va.gov/professional/

ptsd101/course-modules/SUD.asp

• Practice recommendations for treating co-

occurring PTSD and SUDs: http://www.ptsd.

va.gov/professional/pages/handouts-

pdf/SUD_PTSD_Practice_Recommend.pdf

Internet Resources

• Parenting in military families:

• www.militarychild.org

• Age-based parenting tool kits for OEF/OIF veterans and their partners:

• www.ouhsc.edu/VetParenting

• http://stayingstrong.org

• Operation Enduring Families http://www.ouhsc.edu/OEF/

A 5-session family education and support program for

veterans who have recently returned from a combat theater and their family members.

Internet Resources

• Helping family members get veterans into treatment: Coaching Into Care

• http://www.mirecc.va.gov/coaching/index.asp

• Adjustment after deployment

• http://www.afterdeployment.org/

• http://maketheconnection.net/

• PTSD treatment can help

• http://www.ptsd.va.gov/apps/AboutFace/

Internet Resources

• More resources for parenting in military families:

• Free online parenting course for veterans:

www.veteranparenting.org

• http://www.startmovingforward.org

• Teaches problem-solving skills for families

Internet Resources

• Children in military families:

• www.va.gov/kids

• https://www.militarykidsconnect.org/

• http://www.facebook.com/SesameStreetFor MilitaryFamilies ^and

http://archive.sesameworkshop.org/tlc/

• http://www.militarychild.org/ Military Child Education Coalition

• http://www.operationmilitarykids.org/public /home.aspx

Online and Telephone Resources

Mobile Applications

http://www.t2health.org/mobile-apps

• PTSD Coach

• T2 MoodTracker

• Breathe 2 Relax

• Tactical Breather

• LifeArmor (includes family section)

Mobile Applications

http://www.t2health.org/mobile-apps

• PE Coach

• CBT-I Coach

• mTBI Pocket Guide

• Provider Resilience

• More to come!

Sesame Street Media

http://www.sesamestreet.org/parents/topics andactivities/toolkits/tlc

Mobile App:

Contact:

Brian L. Meyer, Ph.D.

Brian.Meyer@va.gov