understanding the returning veterans
TRANSCRIPT
6/7/2010
1
Understanding the Returning Veterans
Julia E. Hoffman, Psy.D.
National Center for PTSD
VA Palo Alto Health Care System
National Center for Telehealth & Technology
Defense Centers of Excellence
The views expressed in this presentation are
those of the presenter and
do not reflect the official policy of
the Department of Veterans Affairs,
the Department of Defense
or
the United States Government
Disclaimer
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Overview
Military 101
Overview of Operation Enduring Freedom
and Operation Iraqi Freedom
Demographics of student veterans
GI Bill Update
Resources for Student Veterans
Military 101
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America’s Wars
Total U.S. Service Members
American Revolution (1775-1783) 217,000
War of 1812 (1812-1815) 286,730
Indian Wars (approx. 1817-1898) 106,000
Mexican War (1846-1848) 78,718
Civil War (1861-1865) 2,213,363
Spanish-American War (1898-1865) 306,760
World War I (1917-1918) 4,734,991
World War II (1941-1945) 16,112,566
Korean War (1950-1953) 5,720,000
Vietnam War (1964-1975) 8,744,000
Desert Shield/Desert Storm (1990-1991) 2,322,000
Global War on Terror (October 2001 - ) Approximately 1.2 million*
(U.S. Dept. of Veterans Affairs, 2010)
Military Rank Structure
Enlisted Service
Members
84%
Warrant Oficers
2% Commissioned
Oficers
14%
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Four Branches
The armed forces are comprised of four
branches each with a different function and
purpose and each with a unique culture of
its own.
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Army Structure
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Navy Structure
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Active versus Reserve Components
Active Component
• Works “full time” for the military
• Full time hours, full time benefit
• On-call 24 hrs/day, 365 days a year
• Permanent force of the military in war and peace
• Benefits:
1. Competitive salary and bonuses
2. Free healthcare for SM and family (TriCARE, VA)
3. 30 days annual leave
4. Base Privileges
5. Retirement after 20 years
6. Camaraderie and pride
Active Component Stressors
Permanent Change of Station (PCS)
Temporary Duty (TDY)
Deployment
Risk of injury or death
Behavioral expectations
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Reserve Components
Part-time duties
One weekend a month, 2 weeks a year
Can be activated to augment Active Components
There are seven reserve components of the U.S. military:
• Army Reserve
• Army National Guard
• Air Force Reserve
• Air National Guard
• Navy Reserve
• Marine Corps Reserve
• Coast Guard Reserve
Reserve versus National Guard
National Guard is “owned” by its state, while
the Reserves are “owned” by the federal
government.
NG may also be activated into military
service as needed
NG has a dual mission to serve state as well
as federal government
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Benefits and Stressors for NGR
Benefits include:
• Flexibility to serve while working on educational or occupational goals
• Pay for Drill and Annual Training
• Bonuses
• Healthcare for SM and family for a fee (TriCARE, VA)
• Base Privileges
• Pro-rated retirement pay at age 60 after completing at least 20 years of
part-time service (39 days a year).
Stressors include:
• Being “citizen soldiers”
• Mobilization and deployment
• Separation from job, family, school, etc.
• Isolation from military structure and social support
• Some limited benefits
• Training issues
Military and Veteran Treatment 101
Most Service Members will initially be treated in military
treatment facilities (MTFs)
Many return to the Continental US (CONUS) with injuries
and are treated in MTFs, VA hospitals, Vet Centers, civilian
treatment centers, or other facilities
Chaplains are the only fully confidential counseling in the
Military
Medical Boards
Service Connection
Services can be found through VA or MilitaryOneSource
All stateside DoD and VA health records while stateside are
electronic
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Profile of U.S. Veterans
65 and
older
39%
40 - 64
48%
39 or
younger
13%
Age
•Among the post 9/11
population, 73% of
Veterans are aged 39 or
younger
•This population is
expected to grow from
1.2 million to nearly 2
million by 2013.
(U.S. Dept. of Veterans Affairs, 2007)
Race and Ethnicity
All U.S. Veterans Veterans Age 39 or Younger
Non-
Hispanic
White
68%
African
American
16%
Hispanic/
Latino
10%
Other
6%
White
85%
African
American
10%
Asian
American
1%Other
4%
(U.S. Dept. of Veterans Affairs, 2007)
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Gender Distribution
1980 2006
Male
93%
Female
7%
Male
96%
Female
4%
(U.S. Dept. of Veterans Affairs, 2007)
Male
93%
Female
7%
Operation Enduring Freedom and
Operation Iraqi Freedom
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KIA and WIA
OFFICIAL DoD COUNT OF:
Troops Killed in Iraq: 4,391
Troops Killed in Afghanistan: 1,199
Wounded in Action in Iraq: 3,1839
Wounded in Action in Afghanistan: 6,141
(DoD, May 2010)
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Operation Enduring Freedom (OEF) and Operation
Iraqi Freedom (OIF)
Previously referred to as the Global War on Terror
(GWOT)
Afghanistan: mountainous with distinct seasons
(9/11 Attacks)
Iraq: desert with incredible heat (WMD)
Urban guerilla warfare, no front lines (and no safe
Military Occupational Specialties), difficult to
identify enemy
Frequent encounters with explosives (IEDs, RPGs,
etc.), which can be triggered with common devices
(e.g. key fob or mobile phone)
Experience of OEF/OIF Veterans
Career military with 53% doing multiple tours
Contact can be made with families at home using email,
cell phone, Skype, or other services
Generally daily (and/or nightly) missions, leave Green Zone
and then return at night
Frequent boredom and downtime is most unexpected
unpleasant experience
Driving challenges specific to these conflicts
Friendly with some Iraqi and Afghani civilians
No specific sleep schedule; use of caffeine drinks
Infrequent substance abuse comparatively
Carrying heavy materials constantly
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Exposure to war-zone stressors in OIF
Combat stressors:
• 51% reported they had been in serious danger of being injured or killed on at least several occasions during the deployment
Non-combat stressors: “high/very high trouble or concern”
• 87% uncertain redeployment
• 71% long deployment length
• 55% lack of privacy or personal space
• 54% boring or repetitive work
78% reported seeing destroyed homes and villages
67% (95%) reported seeing dead bodies or human remains
65% reported having hostile reactions from civilians
63% (93%) reported receiving small arms fire
61% (89%) reported being attacked or ambushed
59% (86%) reported knowing someone who was seriously injured or killed
37% reported engaging in a firefight
19% (48%) reported being directly responsible for death of enemy combatant
(14%) reported being responsible for death of non-combatant
(22%) reported having buddy shot or hit who was near you
11% (22%) reported engaging in hand-to-hand combat
10% (14%) reported being wounded/injured
*Reported during deployment (reported after deployment)
War-Zone Stressors (OIF)
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Military Sexual Trauma (MST)
23% of female VA patients reported experiencing at
least one sexual assault while in military
• < 1% of male VA patients???
Rates are higher in wartime
• Persian Gulf War
Sexual assault (7%)
Physical sexual harassment (33%)
Verbal sexual harassment (66%)
What’s Keeping the New Veterans from Seeking Care?
Practical Concerns
22%: I don’t know where to get help
18%: I don’t have adequate transportation
45%: It’s difficult to schedule an appointment
55%: Difficulty getting time off work
25%: Costs too much money (Hoge et al. 2004,
NEJM)
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What Else?
Stigma! 50%: It would harm my career
59%: Members of my unit might have less confidence in me
63%: Unit leadership might treat me differently
51%: Leaders would blame me for the problem
65%: I would be seen as weak
41%: It would be too embarrassing
38%: I don’t trust mental health professionals
25%: Mental health care doesn’t work
How Can We Reach the Newest Veteran?
Most appear to acknowledge having a problem• Army Iraq War returnees: 78% of those who screened positive for MDD,
GAD, or PTSD
Interest in receiving help, however, is much lower• Only 43% of positive screens
GAO 2006 Report on DD 2796• 5% of returnees screened positive for PTSD
• Only 22% of positive screens were referred for mental health evaluations
35% of returnees accessed mental health services in the year after returning home (Hoge et al., 2006)
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Mental Health Diagnoses for New Veterans in VA Care
13%
12%
9%
8%
5%
2%1%
0%
5%
10%
15%
PTSD
Drug abuse
Depression
Neurotic disorders
Affective psychoses
Alcohol dependence
Drug dependence
Problematic Drinking After Deployment (Hoge, 2004)
17%
13%
25%
18%
24%21%
35%
29%
0
0.05
0.1
0.15
0.2
0.25
0.3
0.35
0.4
Have you used alcohol more
than you meant to?
Have you felt you wanted or
needed to cut down on your
drinking?
Pre-Deployment Army Afghanistan Army Iraq Marine Iraq
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New Veterans May Minimize Substance Use
Problems….
• Heavy drinking is socially validated among young adults
• 37% of men under age 25 binge drink (drops to 20% in men age 45-64)
• Drinking to mask problems is less stigmatizing than admitting to PTSD or depression
• Admitting to drug use may have negative consequences
• Younger veterans often have not yet had enough time to encounter negative consequences of substance use (have not “hit bottom”)
Student Veterans
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Definitions
Military Students/
Student Veterans
Nonmilitary
Nontraditional
Students
Nonmilitary
Traditional
Students
Percentage Distribution of Undergraduates
Undergraduates by Military Status
Veterans (3.1%)
Military: Active Duty (0.6%)
Military: Reserves (0.4%)
Non Vet or Military Undergrads (95.8%)
Military Undergraduates by Current Service
Veterans,
75%
Active
Duty,
16%
Reserves
, 9%
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Demographics of Student Veterans: Age
0.5 0.9
18.115 13.6
81.9
31.4 37.2
0
28.226.5
0
24.9 21.9
0
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Military Nonmilitary
Nontraditional
Traditional
40 or older
30-39
24-29
19-23
18 or younger
Radford & Wun (2009)
Demographics of Student Veterans: Gender
26.9
64.852.9
73.1
35.247.1
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Military Nonmilitary
Nontraditional
Traditional
Male
Female
Radford & Wun (2009)
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Demographics of Student Veterans: Race/Ethnicity
60.1 5765.8
18.318.1
10.3
12.8 15.1 13.5
3.2 5.6 4.35.7 4.3 4.1
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Military Nonmilitary
Nontraditional
Traditional
Other
Asian American
Hispanic
African American
White
Radford & Wun (2009)
Demographics of Student Veterans: Dependency and
Marital Status
Dependent, 3%
Unmarried, no
dependents,
35%
Married, no
dependents,
15%
Married
parents, 33%
Single parent,
14%
Radford & Wun (2009)
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Military Experience (CSCMH data)
No
72%
Yes
28%
Did your military
experiences include any
traumatic or highly
stressful experiences
which continue to
bother you?
No
98%
Yes
2%
Have you ever been
enlisted in any branch of
the US military (active
duty, veteran, national
guard, or reserves?)
Difficulties of Student Vets with Trauma Exposure
0%
5%
10%
15%
20%
25%
30%
35%
40%
45%
I get angry
easily
I have difficulty
controlling my
temper
I have spells of
panic or terror
I have
unwanted
thoughts I
cannot control
I am afraid I
may lose
control and act
violently
I have no one
who
understands
me
The percentage of students who strongly endorsed
specific CCAPS items
Military with trauma Military without trauma Non-military
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Functional and Social Issues for Student Veterans
Liberal bias of professors
Feeling out of place due to differing
demographics and developmental mismatch
with peers
High marriage rate means student veterans
have more commitments
Military sexual trauma can lead to
relationship problems and medical refusal
Driving problems
Half of Us
4
8
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Factors of Graduation Success for Student
Veterans
GI Bill and
Financial Aid
Successul
Transition from
the Military
Support from
Academic
Institution
Physical and
Mental Health
Support
Employability
Following
Graduation
Sense of
Belonging on
Campus
(Student Veterans of America 2010 Legislative Agenda www.studentveterans.org )
GI Bill Update
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History of the G.I. Bill
19
40
19
50
19
60
19
70
19
80
19
90
20
00
20
10
Veterans’
Educational
Assistance Act
of 1984 (the
Montgomery
GI Bill)
Veterans’
Readjustment
Benefits Act of
1966
Veterans’
Readjustment
Assistance Act
of 1952 (the
Korean GI Bill)
1944
Servicemen’s
Readjustment
Act
Post-
Vietnam Era
Veterans’
Educational
Assistance
Act of 1977
Post-9/11
Veterans
Educational
Assistance
Act of 2008
Basic Eligibility Requirements or Benefits of the New GI Bill
Military service members and vets may be eligible for benefits under the new GI Bill if:
Served at least 90 aggregate days on active duty after September 10, 2001 and meet one of the 5 requirements:
1. Currently active duty
2. Honorably discharged from active duty
3. Honorably released from active duty and placed on the retired list or temporary disability retired list
4. Honorably released from active duty and transferred to the Fleet Reserve or Fleet Marine Corps Reserve
5. Honorably released from active duty for further service in a reserve component of the Armed Forces
OR served 30 continuous days after September 10, 2001 if honorably discharged from active duty for a service-connected disability)
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Type of Institution by Student Type
9 8 9
12 154
13 916
43 49
32
21 19
38
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Military Nontraditional
nonmilitary
Traditional
Public four-year
Public two-year
Private not-for-profit four-
year
Private for-profit
Others or attended more
than one institution
Attendance by Student Type
37 37
13
23 29
17
1614
14
23 20
56
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Military Nontraditional
nonmilitary
Traditional
Full time / full year
Full time / part year
Part time / full year
Part time / part year
Radford & Wun
(2009)
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Financial Aid (Including VEB) by Student and
Institution Type
66%
81%85%
98%
48%
67%
82%
97%
45%
73%
86%
95%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Public two-year Public four-year Private not-for-
profit our-year
Private for-profit
Military Nonmilitary nontraditional Traditional
Reasons for Choosing Institutions by Student
Type
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
Location Program/
Coursework
Cost Personal or
Family
Reputation Other
Military Nonmilitary Nontraditional Traditional
Radford & Wun (2009)
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Top 10 Schools Enrolling Students with GI Bill
Benefits
Institution Students using GI
Bill
1 U. Of Phoenix-Online Campus 17,714
2 American Inter-Continental U. 3,698
3 American Public U. System 3,668
4 U. Of Maryland U. College 3,359
5 Central Texas College 3,024
6 Colorado Technical U. 2,738
7 Saint Leo U. 2,688
8 Kaplan U. 2,460
9 Strayer U. 2,348
10 U. Of Maryland at College Park 2,260
U.S. Department of Veterans Affairs (2008)
Resources for Student Veterans and
Health Care Providers
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5
9
http://www.mentalhealth.va.gov/College/
Student Veterans of America www.studentveterans.org
Three primary missions:
•Develop student veteran groups on
college and university campuses and
coordinate by region between existing
groups.
•Connect student groups with
resources.
•Advocate on behalf of student veterans
at the state and national level.
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6
1
3-Tier Access Model:
• Visitors
• Registrants
• In-Person Authenticated (IPA)
Users
www.myhealth.va.gov
March 2010:
• Over 38.6 Million visits
• Over 976,000 registered users
(75% are VA patients)
• Over 186,000 users have an IPA
account
• Over 14.5 Million VA prescription
refills since August 2005
My HealtheVet Overview
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My HealtheVet Features Today
• Personal information (contacts, providers, etc.)
• Personal, family, and military health history
• Personal health summary
• HealtheLogs (blood pressure, weight etc.)
• Medications (over the counter drugs, herbals, etc.)
• Allergies and immunizations
• Medical events
• Food and activity journals
• Online VA prescription refills, VA prescription history
• My Complete Medications (printable summary)
• Wallet health information card
• Health calendar
• Trusted health education information
• Self-assessment tools, VA Wellness Reminders
• Mental health resources (including online courses)
• Secure Messaging (currently at 8 VA sites)
Considering Professional Help
Open-access,
30-minute
course with 5
topics
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Do I need help?
Take a quick self-check
For example: “I have been
feeling sad or depressed
almost all of the time for
more than one week.”
What is stopping me?
Includes known
barriers to help-
seeking
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What can I expect?
Actor videos of
transcripts of
Veterans who
have had to
overcome
concerns and
challenges
before
seeking helpDescription of types
of care that may be
available:
•Counseling
(Individual, group,
residential)
•Medication
Who can help me?
Provides
descriptions
of various
professionals
who can help
and what they
do
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Where can I find help?
Directories for
Veterans, including:
•Sites for returning
Veterans, facility
locator (VA and RCS),
etc. (and NCPTSD)
•Descriptions of
these links
Directories for
everyone,
including:
•APA,
physician
finder, ABCT,
ACA, AAPC,
etc.
•Descriptions
of these links
Afterdeployment.org
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Contents for Each Topic
Validated assessments
on related areas of
functioning (e.g. PCL;
PHQ-9)
Multi-session
interactive workshops
E-library
Links & books
Forums
Personal stories from
real veterans and
service members
http://store.pamphleteerpress.com/06.html
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Military Competence
Center for Deployment Psychology www.deploymentpsych.org
Operation S.A.V.E.
Operation S.A.V.E training will help you act with care and compassion if you encounter a person who is suicidal. The acronym summarizes the steps needed to take an active and valuable role in suicide prevention.•Signs of suicidal thinking •Ask questions •Validate the person’s experience •Encourage treatment and Expedite getting Help
7
4
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Questions?
National VA Hotline for Benefits and General Info:
1-800-827-1000
Julia E. Hoffman, Psy.D.