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Brittany Hall-Clark, Ph.D. University of Texas Health Science Center at San Antonio
Mobile Crisis Outreach Training
July 31, 2014
Acknowledgements STRONG STAR
Multi-disciplinary PTSD Research Consortium UTHSCSA Jeremy Joseph, PhD
LCDR Allah Sharrieff Carl R. Darnall Army Medical Center
Ms. Sonceri Hutch Military spouse
Importance Calls for increased collaboration between community, mental health providers,
VA, and clergy (Straits-Troster et al., 2011; Weaver, Koenig, & Ochberg, 1996) Vets more likely to present to primary care, faith-based, MHP in own
community than DoD or VA Increased interaction between first responders & SMs/veterans (Rahilly, Tuttle,
& Gitelson, 2011) San Antonio is Military City USA
Consistent military presence for nearly 300 years Home to several military installations
Fort Sam Houston DoD largest medical center at Joint Base San Antonio
Camp Bullis Camp Stanley Brooks City-Base Lackland Air Force Base Randolph Air Force Base
Top military friendly city in US out of 381 cities(2011)
Who’s in the audience? Social Workers (LMSW or LCSW) Case Managers/Care Coordinators Licensed Professional Counselors (LPCs) LVNs & RNs Licensed Professional of the Healing Arts (LPHAs) Qualified Mental Health Professionals (QMHPs) Physician Assistants Law Enforcement Service Members Military Family Members
When might you encounter Service Members/Veterans? Client/patient care Crisis management Accidents Traffic stops Intoxication
Military Personnel in the US Active duty constitute about 1% of overall US population (US Census, 2010) Over 2,000,000 military personnel have deployed since 2001
Significant risk for psychological health problems (Institute of Medicine, 2012) OEF/OIF/OND veterans at heightened risk for deployment-related emotional and
behavioral difficulties compared with civilian populations (Hoge et al, 2004) Posttraumatic stress disorder (PTSD) Depression Anxiety Substance use 2007 DoD Task Force on Mental Health report of psychological symptoms after
returning from deployment 38% of Soldiers 31% of Marines 49% of National Guard
20.3% of active duty Soldiers and 42.4% of the reserve component required further mental health assessment or treatment (Milliken, Auchterlonie, & Hoge , 2007)
Prevalence rates of PTSD and depression ranged between 23 and 31% (Thomas et al., 2010)
Demographics of US Military Today’s Armed Forces quite diverse (Cozza, Benedek,
Bradley, Grieger, Nam, & Waldrep, 2004) Racial/ethnic minorities
24% of Air Force 40% of Army
16% women Over 50% married Over 95% graduated from high school or completed
GED
Overview Introduction to Military Culture
Branches of Services Rank Structures Military Values Phases of Deployment Cycle
Adjustment issues for military families When Service Members, Veterans, and Military Families Need Help
Common mental health issues affecting Service Members, Veterans, and military families
Evidence-based treatments Resources for helping Service Members, Veterans, and military families
Culturally Sensitive Interactions with Military Populations Intersectional identities (Military, racial/ethnic, and spiritual) Cultural strengths and stressors
Questions and Answers
Awareness Exercise You are asked to speak with Mike, age 27, White,
male, after he has been in a car accident Looking around constantly Uncomfortable when you come near him
Questions What impressions do you have?
Guarded Anxious Stigma Concerned about being in trouble
What possible symptoms did you observe? Re-experiencing Hypervigilance Disturbed sleep/fatigue Anxiety Irritability
What could lead to miscommunication? Acronyms and jargon Not addressing SM’s concerns
What important questions were not asked? Military experience What “feeling funny” means? Substance use Risk assessment
Helpful terminology Family Advocacy Program (FAP) Military Occupational Specialty (MOS)
91B: Wheeled Vehicle Mechanic National Training Center (NTC) in Ft. Irwin Non-Commissioned Officer (NCO) Improved Explosive Device (IED) Physical Training (PT) http://militaryacronyms.net/
Cultural Differences Service branch
Missions Entrance
Air Force, Navy, & Marine tend to be highly educated Army more flexible: more GED holders & more waivers as OEF/OIF/OND
escalated Reserve status Enlisted vs Officer Deployment location Era
Draft or volunteer Peacetime or conflict
Values Rank Structures
Army Values Loyalty- Bear true faith and allegiance to the U.S. Constitution, the Army, your unit
and other Soldiers. Bearing true faith and allegiance is a matter of believing in and devoting yourself to something or someone. A loyal Soldier is one who supports the leadership and stands up for fellow Soldiers.
Duty- Fulfill your obligations. Doing your duty means more than carrying out your assigned tasks. Duty means being able to accomplish tasks as part of a team. The work of the U.S. Army is a complex combination of missions, tasks and responsibilities
Respect- Treat people as they should be treated. In the Soldier’s Code, we pledge to “treat others with dignity and respect while expecting others to do the same.
Selfless Service- Put the welfare of the nation, the Army and your subordinates before your own. Selfless service is larger than just one person. In serving your country, you are doing your duty loyally without thought of recognition or gain.
Honor- Live up to Army values. Integrity- Do what’s right, legally and morally. Integrity is a quality you develop by
adhering to moral principles. It requires that you do and say nothing that deceives others.
Personal Courage- Face fear, danger or adversity (physical or moral). Personal courage has long been associated with the Army. With physical courage, it is a matter of enduring physical duress and at times risking personal safety.
Phases of Deployment Cycle Pre-Deployment Phase (6-8 weeks prior to
deployment) Deployment Phase (during deployment) Reunion Phase (1-6 weeks prior to reunion) Post-Deployment Phase (1-6 weeks post
reunion) Military Deployment Guide, FEB 2011
PTSD DSM-5 Criteria
A: Traumatic event: actual/threatened death, serious injury, or sexual violence B: Re-experiencing
Upsetting intrusive thoughts/memories/nightmares/flashbacks C: Avoidance
Behavioral/Situational: triggers, people, family isolation Cognitive: Memories/thoughts Emotional: Feelings
D: Negative alterations in cognitions & mood Persistent & exaggerated beliefs about self, others, & world Distortions about cause or consequences of trauma Persistent negative emotional state Numbing Dissociative amnesia
E: Hyperarousal Easily startled, always on guard Hypervigilance Irritability/anger outbursts Sleep disturbance Reckless/self-destructive behavior Exaggerated startle Concentration problems
F: At least 1 month G: Significant distress or functional impairment
Prevalence in PTSD in Veterans Military
Vietnam 26% (Kulka et al., 1990)
OIF/OEF /OND Non-treatment seeking: 5-20% (Ramchand et al., 2010) 23% of tx-seeking (VA, 2008)
• Racial/ethnic minority • Higher rates for African American & Latino veterans (Kulka et al., 1990)
• Mediated (Frueh et al., 1998; Schwartz et al., 2005) • Trauma exposure • SES
• Gender inconsistently associated with PTSD (Ramchand et al., 2010) • NVVRS (Kulka et al., 1990)
• Male: 15% (current); 31% (lifetime) • Female: 8.5% (current); 27% (lifetime)
• Combat exposure is strongest predictor of PTSD
Getting Trained in Evidence-Based Treatments (EBTs) Mental health professionals at all levels can successfully administer
EBTs Importance of protocol adherence
VA roll-outs National workshops Websites Webinars Books
Manuals Importance of ongoing supervision & consultation
Other Common Mental Health Issues for Veterans Combat stress Depression
Loss of interest or enjoyment Loss of energy/restlessness Insomnia/hypersomnia Decreased/increased appetite Depression
Vietnam: 48% (Kessler et al., 1995) OIF/OEF: 6-24% (Grieger et al., 2006; LaPierre et al., 2007)
Suicidality/Homicidality Thoughts of harming oneself + intent + plan
Common Health Issues for Veterans Substance Abuse/Self-medication
Reckless behavior 30-50% of SUD have PTSD (Boden et al., 2012: Ouimette
et al, 2003) Kessler et al. (1995)
Men: 50% Women: 28%
Medical Insomnia TBI
When Professional Help is Needed Signs that additional help needed:
Significant distress Impairment of functioning
Professional Social Financial Self-care
Problems not improving or getting worse
Veteran Encounters with First Responders Often potentially traumatic situations Sirens, loud noises, lights, authority figures (Rahilly,
Tuttle, & Gitelson, 2011) May trigger re-experiencing symptoms
Barriers to Help-Seeking Stigma
General Koenen et al. (2003)
Beliefs 28.7% said can handle on own 18% afraid of what people think 13% afraid to take meds 9% don’t think have disorder 6% treatment won’t help
Resources(insurance, can’t afford, access)
40% of those with PTSD did not know where to get help Military
Downsizing Gender Racial/ethnic
Cultural mistrust (Terrell & Terrell, 1981) Racial socialization Distrust of therapists (Whaley, 1998)
Overcoming Barriers Strive for cultural competence Providing psychoeducation Biopsychosocial models
Medical analogy Partnering with community
Education about when to seek professional help Clergy
Cultural Considerations Identity
How does the SM view him/herself? Cultural identity ADDRESSING model (Hays, 2007) Intersection of identities
Acculturation Which cultures does the SM identify with? Bi/multicultural?
Consider important values and value conflicts Protect vs. Kill
Verbal and Nonverbal Communication May verbally agree to be polite
Worldview Locus of control Beliefs about health/illness
Consider role of privilege
Cultural Stressors Repeated, extensive trauma over a long period of time Multiple deployments Environment of constant danger Multiple types of trauma (e.g., life-threatening, horror, “moral
injury”, traumatic loss) Culture of denying personal difficulties Culture and training to have increased sense of personal
responsibility Hypervigilance trained in military
In civilian life can become safety behaviors Discrimination, racism, and prejudice
Intercultural & intracultural (skin color, hair type, body type) Acculturative stress Stereotypes
Cultural Strengths Unit cohesion
Vertical Horizontal
Community orientation Extended kinship
Flexibility in family roles Many SMs say families are biggest source of motivation
Religion/spirituality Church Scripture Emotional processing God’s will Forgiveness Spiritual figures as role models and examples Discussion with pastors/chaplains
Perspective Exposure of talking
Positive racial/ethnic identity Belonging Affirmation Pride
Cultural Competence: Assessment Ask preferred name Listen for culture and self-identification Ask about clients’ experience of culture
Culturally educated questions (Rodriguez & Walls, 2000) Consider environmental influences
Stressors Protective factors
Personal strengths from culture Environmental considerations
Seating Artwork
Measures
Cultural Competence: Diagnosis Be aware of cultural differences in symptom expression
Somatization Anger is more socially acceptable than other emotions in military
Be aware of value-laden diagnoses Psychosis
Overdiagnosed in African Americans (Whaley, 1997) Cultural Paranoia (Terrell & Terrell, 1981)
Personality Disorders Dependent Personality Disorder Schizotypal
Cultural Formulation in DSM-5 (Section III and Glossary of Cultural Concepts of Distress)
Cultural Competence Language fluency and educational level
Minimize jargon Look for cultural strengths as source of alternative/balanced
thoughts Not inferior, different
Consider incorporating family members into treatment Cultural factors and norms in relation to symptom expression
Depression Anger
Consult with respected healers/authority figures (e.g. pastors) Discuss culturally relevant values and beliefs
Cultural Competence Educate self about cultural groups that clients identify
with Accessible homework assignments
Behavioral activation SES Culturally congruent
Reading assignments Educational level, fluency
Validate experiences of oppression Challenge after more trust has developed
Do not challenge core cultural beliefs
Cultural Competence: Crisis Response Risk Assessment Crisis Response Plan
Identify triggers Self-soothing
Grounding Social support
Family Friends Church community Motorcycle clubs Military chaplains
Formal resources
Discussion Questions Do you feel more equipped to help active duty
personnel, veterans, and military families? What steps can you take to strive for cultural
competence in your clinical work? What are your take-aways from today’s presentation?
Resources Handouts
Local & national veteran organizations Websites Apps Military Culture resources
Veteran Crisis Line: 1-800-273-TALK
Please contact me at hallclark@uthscsa.edu for copies of presentation, questions, or feedback.
References APA Commission on Ethnic Minority Recruitment, Retention, and Training in Psychology Task Force
(CEMRRAT2) & Office of Ethnic Minority Affairs APA Public Interest Directorate. (2005) A Portrait of Success & Challenge: Progress Report: 1997-2005. American Psychological Association.
Breslau, J., Aguilar-Gaxiola, S., Kendler, K. S., Su, M., Williams, D., & Kessler, R. C. (2006). Specifying race-ethnic differences in risk for psychiatric disorder in a US national sample. Psychological Medicine. 36 57-68.
Dana, R. H. (1993). Multicultural Assessment Perspectives for professional psychology. Longwood Professional Books.
Foa, Keane, & Friedman (2000). Effective Treatments for PTSD. New York: Guilford. Maxfield, B. D. (2010). Blacks in the Army: Then and now. Office of Army Demographics. Retrieved from:
http://www.armyg1.army.mil/hr/docs/demographics/MRA_booklet_10-ARMY.pdf Military City USA San Antonio website. http://www.militarycityusa.com/index.htm Hays, P. (2007). Addressing Cultural Complexities in Practice: Assessment, Diagnosis, and Therapy, Second
Edition. American Psychological Association. Hays, P. (2009). Integrating Evidence-Based Practice, cognitive-behavior therapy, and multicultural therapy:
Ten Steps for culturally competent practice. Professional Psychology: Research and Practice, 40 (4), 354-360. Institute of Medicine. (2007). Treatment of Post-Traumatic Stress Disorder: An Assessment of the Evidence.
Washington, DC: The National Academies Press. Irish, D. P., Lundquist, K.F., & Nelsen, V. J. (1993). Ethnic Variations In Dying, Death, and Grief: Diversity and
Universality. Koenen, K. C., Goodwin, R., Struening, E., Hellman, F., & Guardino, M. (2003). Posttraumatic stress disorder &
Treatment-Seeking in a National Screening Sample. Journal of Traumatic Stress, 16 (1), 5-16.
References (continued) Kulka, R.A., Schlenger, W.A., Fairbank, J.A., Hough, R.L., Jordan, B.K., Marmar, C.R.,... Cranston, A.S. (1990). Trauma
and the Vietnam War generation: Report of findings from the National Vietnam Veterans Readjustment Study. New York: Brunner/Mazel. 503-520.
Military Deployment Guide (2011). http://www.militaryonesource.mil/12038/Project%20Documents/MilitaryHOMEFRONT/Service%20Providers/Deployment/DeploymentGuide.pdf
Powers, R. (2013). Minimum Required ASVAB Scores and Education Level. http://usmilitary.about.com/cs/genjoin/a/asvabminimum.htm
Rodriguez, R. R., & Walls, N. E. (2000). Culturally educated questioning: Toward a skills-based approach in multicultural counselor training. Applied & Preventive Psychology, 9, 89-99.
Straits-Troster, K. A., Brancu, M., Goodale, B., Pacelli, S., Wilmer, C., Simmons, E. M. & Kudle, H. (2011). Developing community capacity to treat post-deployment mental health problems: A public health initiative. Psychological Trauma: Theory, Research, Practice, and Policy, 3 (3), 283-291.
“San Antonio tops 'Military Friendly Cities' list; Texas lands 7 in Top 50.” http://www.kens5.com/story/news/local/2014/06/26/10458290/
Snowden, L. R., & Cheung, F. K. (1990). Use of inpatient mental health services by members of ethnic minority groups. American Psychologist, 45, 347-355.
Visit San Antonio website. http://visitsanantonio.com/english/Explore-San-Antonio/Attractions/Military Weaver, A., J., Koenig, H. G., & Ochberg, F. M. (1996). Posttraumatic stress, mental health professionals, and the
clergy: A need for collaboration, training, and research. Journal of Traumatic Stress, 9, (4), 847-856. Whaley, A. L. (1997). Ethnicity/race, paranoia, and psychiatric diagnoses: Clinician bias versus sociocultural
differences. Journal of Psychopathology and Behavioral Assessment, 19, 1-20.
Additional Discussion Questions What is the culture of your profession? How did your professional training add to or shape
your cultural identity? What are the unspoken rules about health or illness
you share with your co-workers? How does your job title change the way people think of
you? How would YOU react if someone came up to you and
said, “Hey, you don’t seem like your normal self, is everything ok?”
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