Since September 11th, 2001, about 2.5 million members of the Army, Navy, Marines, Air Force, Coast Guard and related Reserve and National Guard units have been deployed in the Afghanistan and Iraq wars. Of those, more than a third were deployed more than once; nearly 37,000 Americans had been deployed more than five times, among them 10,000 members of guard or Reserve units. Records also show that 400,000 service members have done three or more deployments (Adams, 2013). Multiple factors related to the conflicts in Iraq and Afghanistan and the Global War on Terror (e.g., multiple deployments, length of deployments, intensity and nature of combat operations) have led to an increase in psychological disturbance among service members following their deployments (Rand Study, 2008). Behavioral health issues such as posttraumatic stress disorder (PTSD), depression, traumatic brain injury (TBI), and substance misuse have been seen at increasing higher rates not only in active-duty service members, but in our veteran population as well. Obviously, these problems do not end when an individual separates from the military, but the onus of responsibility for who is responsible for their care does. This shift in responsibility does not fall solely on the Veterans Administration (VA), it also falls on civilian providers of healthcare in the community. President Obama’s signing of an Executive Order to improve access to mental health services for veterans, service members, and military families on August 31, 2012 highlights how these issues have been recognized at the highest levels of government, and that a change in national strategy is needed to meet the needs of our military that have been identified and continue to be unmet. Part of President Obama’s multi-pronged approach asks for partnerships between the VA and community providers to enhance access to mental health care (White House Press Release, August 31, 2012). There is recognition that both within and outside of the VA it can be difficult to identify treatments that work as well as individuals who are competent to provide such treatments.
Examining these challenges for our service members, veterans, and military families on a more local level, the RAND Corporation conducted A Needs Assessment of New York State Veterans in 2011. Sponsored by the New York State Health Foundation, this study found that, among New York State veterans, a significant proportion of those surveyed (56%) were identified as having a need for mental health services. Despite this need, only about half of those individuals actually sought care in the prior year. Most concerning, for the half who sought services, only half received or completed a “minimally adequate” course of treatment. Regarding preference for where veterans want to go for care, 46% indicated they would prefer to receive mental health services from a civilian provider (as opposed to the VA).
Focusing on the area of substance misuse, it has been well documented that the incidence of alcohol misuse and misuse of prescription pain medications (specifically opiate-based pain medications) has increased dramatically for active-duty service members over the past 10 years, and these difficulties often extend to our veterans as they reintegrate (National Institute on Drug Abuse, 2013). There is a strong relationship between posttraumatic stress symptoms and alcohol misuse (binge drinking and dependence), and there is a real need for us to develop effective and accessible outpatient programs to assist our veterans (National Center for PTSD, 2013). When considering integrated treatment for substance use disorders for veterans and military family members in an outpatient setting, a program grounded on the following pillars (such as the one we have developed with the ARCH Program at Bridge Back to Life Center, Inc.) is best suited to address the complex needs of the population under consideration.
Pillar One: Integration of trauma theory into the conceptualization of substance use disorders: Prevalence data and clinical experience working with veterans speaks to the high co-morbidity of traumatic exposure (both developmentally and adult-onset) and addiction. Whether an individual’s capacity to self-regulate inner experience is derailed during key developmental years by interpersonal neglect or abuse (Cook, et al, 2005; van der Kolk, 2005), or is derailed by exposure to trauma related to military life (e.g., combat trauma) (Shay, 1994), addiction is often the result when the individual turns outside themselves to modulate their emotional swings, recurring thoughts, and physiological arousal/pain. Substance use becomes what in the trauma lexicon is called a “survival strategy” aimed not at pleasure-seeking, but rather at diminishing pain and emotional discomfort (Fisher, 2000). For many who have survived trauma and now struggle with addiction, they vacillate between states of physical/emotional numbness while using and physical/emotional pain when not. Physical/emotional arousal and pain become a trigger for substance misuse, and is part of the individual’s addiction and relapse cycles. Adapting treatment models that educate veterans on this relationship and incorporate these concepts into effective treatments is key.
Pillar Two: Incorporating a working understanding of military life and military culture (and how this may inform treatment) into the therapeutic model and organizational culture: Educating clinical and support staff on military cultural considerations is vital in order to both build trust with veterans (a core issue for many given their experiences in the military and their socialization into a military mindset) and to deliver treatments that take into consideration how military culture may play into the development of certain struggles (including substance misuse) and inform the meaning that these struggles have for veterans. Outside of the obvious, concrete aspects of military culture that need to be thoughtfully woven into the language and treatment environment (e.g., use and understanding of branches of service and differences between each, use of acronyms, visible displays of military culture and patriotism, structure and timeliness of services), one must also consider the context of each veterans military experience and how this may inform their current difficulties with sobriety and possibly readjustment. For example, there is a clear directive from the Department of Defense and each branch of service that alcohol misuse is unbecoming of one who serves and puts them in violation of both the core values of their branch of service as well as regulations. At the same time, many served in an environment of tacit acceptance of alcohol use or even one where the use of alcohol was part of the social culture and expectation of their unit. Was the discovery of alcohol/substance misuse used punitively to force and individual into treatment or separate them from the military? Has one’s socialization to approaching “problems” with quick, definitive action (i.e, a warrior mentality) cultivated substance-seeking as a “quick fix” to manage physical/emotion pain despite short and long-term consequences. Being able to have an informed consideration of these and other salient points related to military culture for each veteran served allows us to direct treatment and support accordingly.
Pillar Three: Offering a clinically-informed amalgam of evidence-based substance recovery programming and specialized wellness and resilience services that address substance misuse and comorbid struggles on multiple functioning levels: Recovery from addiction not only needs to incorporate trauma theory and the possible role of traumatic exposure in the etiology and maintenance of addiction (see Pillar One), it must also provide a core curriculum of knowledge, structure, and support to assist the veteran to achieve abstinence and initiate a long-term program of recovery. As an example, Bridge Back to Life Center, Inc. has all clinicians trained in the Matrix Model for intensive drug and alcohol treatment (Rawsen, Obert, McCann, & Ling, 2005). This model, with a 20-plus year evidence base, allows for the education and teaching of recovery-specific knowledge and skills that are the foundation for abstinence. Staff are also trained in the Duluth Power and Control intervention to assist those perpetrating aggression as part of their clinical picture. Similar evidence-based models are available for those who we are driving under the influence, and Seeking Safety (Najavits, 2002) is available for those with identified trauma are part of their presentation. Despite their sound base and application, these models are only part of the clinical program that needs to be offered. Wellness and resilience interventions that are proven in literature and experience to assist veterans manage the psychical, cognitive, and emotional dysregulations related to both substance misuse and traumatic exposure also need to be brought to bear to empower individual to manage their inner experience in a more effective, safer way. Mindfulness practice, yoga, acupuncture, and body-based somatic interventions provided in unison with the recovery approaches above enhance recovery and allow veterans to undue the lasting effects of what they have seen and what they have done. Having the capacity to address existential angst and moral injury related to both addiction and combat/military experiences, as well as identity and role issues related to service and reintegration, allow a program to address the wide range of pressures and challenges that may inform one’s substance use disorder. Formal and informal access to Chaplains, both Military and civilian, can also be another avenue for exploration of these higher-level concerns.
Pillar Four: Incorporation of veteran-specific peer support and community reintegration: For many service members and veterans struggling with the crisis of addiction and posttraumatic stress, or reintegrating home from deployment, a sense of separation, alienation, and isolation can set it. Family, friends, peers- even society as a whole- can be experienced as not understanding and not supportive. Creating spaces where veterans can begin to relate to and connect with one another is a crucial aspect of recovery. Assisting those in recovery develop “sober social supports” is a goal of most programs; programs that work with veterans must try and take this one step further a provide peer-to-peer opportunities for sharing, for understanding, and for support.
Of particular benefit are programs that allow for intergenerational veteran peer support; a Vietnam combat veteran who has found the road to recovery from posttraumatic stress and addiction has a unique perspective and frame of understanding to pass on to our younger generation of OEF/OIF veterans. The universalities of brotherhood and esprit de corps crosses all generations of veterans, and allowing this to unfold in both clinical groups and less-formal shared spaces can facilitate recovery and growth for all.
Pillar Five: Family Focused Interventions: When an individual joins the military, their entire family joins as well. The service and sacrifices of our Nation’s military is carried squarely on the backs of our military families, and when a service member is suffering from acute behavioral health issues, the family suffers as well. Many family members of wounded warriors are tired from being in a caretaking role, are confused and do not have a clear understand of what their family members is truly suffering from or dealing with, and are in need to support themselves as they try to keep their families intact. Finding ways to have family’s members take an active part in the treatment of their service member, and ways to provide education and support to family members so that they and the entire family is more resilient, is truly necessary to maximize inpatient and outpatient treatment gains. Outside of military service and sacrifice, addiction is also best understood in the context of family, and it is best treated in a program that can educate the family about the disease of addiction and the parts each can play in lasting recovery for our veterans.
Pillar Six: Integration of Experiential Modalities into the treatment model for veterans: There are many pathways to recovery for veterans, and not all are based in verbal and skills-building interventions. Allowing for the use of creative, experiential, and non-verbal modes of therapy and expression benefit our veterans by offering them unique opportunities to engage with each other, to make meaning out of their experiences, and to integrate split-off traumatic memory traces (e.g., affect states, body sensations, image fragments, etc) back into declarative, narrative memory networks so that they are more in the volitional control of the service member and carry less intensity over time. Expressive art therapy is a perfect example of a modality that “taps” into stored experience that may not be conscious (i.e., verbally-mediated) yet drives unrest, pain, and addiction. The use of metaphor can allow a veteran to capture in image what he/she can’t capture in word and thought, using this as a springboard for healing and recovery. Symbolic work around the nature of addiction itself has been proven effective in promoting increased motivation for treatment, shifts in perceptions of self and the use of substances, and positive outcomes (Collie, Backos, Malchiodi, & Spiegal, 2006; Johnson, 2008). Trauma-informed drama therapy, collaborative song writing, writing workshops, and focused dialogues between groups of veterans and civilians each, in their own unique way, allow a veteran to learn about themselves in relation to others and apply this experience in their journey of recovery and return.
In conclusion, we are all responsible for the care of our veterans and our military families. For those working with veterans dealing with addiction, finding an informed way to layer traditional recovery-oriented programming with trauma-informed care practices, trauma-informed treatments, complimentary/alternative models of care, and a true understanding of military culture and its impact is what is required to truly support recovery and abstinence for those who have served. Our civic duty is to stand ready to provide care and support where we can, and to do so in a way that honors the service and sacrifice our military gives on behalf of us all.
Michael DeFalco, Psy.D is Director of Military and Integrative Services at Bridge Back to Life Center, Inc. Aynisa Leonardo, BC-LCAT is Clinical Coordinator or Military Services at Bridge Back to Life Center, Inc. Any inquiries or correspondence regarding this article should be directed to Dr. Michael DeFalco at mdefalco@bridgebacktolife.com
References
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