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Working with Veterans in the Community
John Straznickas, MDSubstance Use PTSD Team LeaderSan Francisco VA Medical Center
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Thanks to our Veterans for their service to our Country
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Increased SUD tx engagement with veterans
Improve Identification of veteransCross-Cultural “Military” TrainingThe veteran re-integration process
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Military Culture Take-home PointsTake a stance where your patient teaches you
about their veteran experience.It’s got similarities and differences for each
veteranKnow the basic language of the military
Assess weapons differentlyEngage differently depending on their view of
their military/veteran statusAssess whether a referral to the VA is useful
for them.
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Examine your own biasesYour view of weaponsYour view of warYour view of the warrior
Separating the warrior from the warYour view of people who commit violence
Separating the person from the warrior
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Basic Military HistoryWhich Branch did they serve in?
Army, Navy, Air Force, Marines, Coast GuardThey are NOT the same.Particular allegiance to their units
Active Duty, National Guard or Reserves?What was their job/MOS?
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Basics of a Military HxWhat was their Rank – Enlisted or Officer
Enlisted – E-1 (Pvt) up to E-9 (Sergeant Major/Master Chief
Petty officer)
Officers W-0 (Warrant Officer) up to @W-5(Chief W. Officer
5) O-1 (2nd Lt./Ensign) to O-10 (General/Admiral)
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How SUD affects RankRank does not increase while in the military
Demotion of rank
Disciplinary action?
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Basic Military HistoryDid they serve in a combat-zone
? How many tours“Outside the Wire.”No safe zones with insurgent warfare
MOS doesn’t say much about exposure to combatCooks, Convoy drivers and Clerks see combat
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Basic Military HistoryType of Discharge from the Military:
HonorableGeneral under honorable conditionsDishonorable
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Military Sexual Trauma - MSTUnwanted sexual advances?Men and Women are both affected
At least 25% of Women veteran1/5 reportedly raped – under-reported
Culture of hiding/minimizing sexual injuryLoss of trust in a valued institution
This is not ‘only’ work-place harrassment. They ‘live with’ their abuser.Their abuser is protected by the chain of
command
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A veteran’s relationship to weaponsAssume they have a weaponTheir weapon is an important part of their
identityFor protection - not harm.
Separate the gun from the bulletsUse trusted friends, colleaguesTrigger locks
If lethal ideation is active, get a safety plan
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Not all veterans’ military service was the same
Individual differencesWar differences – VN vs. OEF/OIF
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Cross-Cultural perspectivesYour patient has been trained within a strong
cultural environment.Viewing ‘veteran’ as a racial-identityYour patient will have a unique response to
military culture and to his identity as a veteran.
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The ‘Military’ as a cultureCultural values
HonorRespectLeave no brother behindProtect yourself - weaponsChain of command
Follow orders
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Ways veterans can present to community-based programsConformity – devalues the military and
emphasizes the civilian life
Dissonance – ambivalent about the two ‘cultures’
Immersion/Resistance – Idealization of the military and denigration of the civilian culture
Helms’ Racial Identity Model
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Using this Model to work with veterans in the community.The ‘conforming’ veteran
Don’t challenge the devaluing Don’t actively join the devaluing
The ‘dissonant’ veteranUse Motivational Interviewing techniques to
explore the ‘yes-but’ communicationsThe ‘immersion/resistance’ veteran
Don’t challenge the devaluingFocus on the present problem and solution
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Keep the VA as a potential resource for services.
Added resourcesSpecialized services
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Special challenges for war veterans.Age old problem of coming home and re-integrating.
Homer & Sophocles
More difficult due to the fact that only 1% of the population has done active duty.
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Typical Warrior ChallengesA hazardous path at multiple levels
Reluctant to talk about the warPast-Present-Future time distortionsSoldier-Civilian integration
Frustrating journey
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Reluctant to talk about the warLegitimate fears of
Judgments – morally questionableMisunderstandings of what war is.
“It’s not like the movies”Facing painful combat experiences/death
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High Co-occurrence of SUD/PTSDLook for PTSD in all your SUD patients.
Intrusions – NMsAvoidance – isolation, numbnessHyper-arousal – Insomnia, irritability
These symptoms get worse in early sobriety.Don’t confuse avoidance symptoms with
resistance
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SUD/PTSD and AAAvoidance of AA is misunderstood as
resistance.Issue of ‘God’ or a benign higher power.
War is NOT benign.Issue of groups increase PTSD hyper-arousalIssue of listing amends and making amends –
Amends done for their violent soldier duties are a trigger for relapse.
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Thanks for your service to our nations veterans
Very rewarding to help the 1% of our Nation’s Warriors
Find a way back Home