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# The Role of Family in Addiction & Recovery

Creative Ways to Help Families Heal Through Recovery

Estimated watch time: 49 mins

Available credits: none

Objectives and Summary:

Jasmyne Kettwick has been working in psychiatric treatment with children, adults and families for more than 11 years. In her presentation on family therapy strategies, she shares some helpful approaches to treating the family unit as a whole, including how to determine which roles family members take on and how to help them communicate effectively.

After watching her presentation, the viewer will be able to:

Understand the roles that family members typically take on during active addiction and recovery.
Learn strategies for fostering effective communication, overcoming roadblocks within families, and helping individuals feel heard.
Find ways to frame talking points in less judgmental ways using Enneagrams and similar approaches.

Presentation Materials:

PowerPoint Presentation:

Transcript:

Welcome to the Community Education Series hosted by The Recovery Village and Advanced Recovery Systems. Hi, I’m Jasmyne Kettwick from Relate Family Therapy in Centennial, Colorado, and today I’m going to be presenting on creative ways to help a family heal through recovery. I have been working with kids, families, and adults for about 11 years now in different outpatient and inpatient pieces. I helped run a residential facility. I worked in outpatient psychiatry. I worked in in-home case management, and I’ve been running a private practice for several years now where we have an entire team that can help all members of the family.rnrnDuring today’s presentation, we’re going to go over a little bit about who Relate is and what’s different about our private practice as opposed to other ones, and kind of talking through the different roles in a family and ways to engage the family system. Because when we know there’s an identified patient (IP), a lot of times, people want to just work on the IP. I want to help transition and work on the entire family system to help the IP as we move through.rnrnRelate is a very client-centered practice. We have several offices designed for the client instead of for the therapist. So if you come in to Relate, you don’t come into a therapist office — you come into your space. So we have a young child playroom. We have an older teen/tween space. We have several offices that are just for individual and couples therapy, and we hope to keep those offices very comfortable and inviting because we want people who are experiencing high trauma to feel safe and less stressed.rnrnThere’s also already so many reasons that they have to be overwhelmed that being able to come into a clean space that’s really dedicated to them, I thought, was just a nice way for them to feel more centered and grounded. Relate has three waiting spaces for families that maybe are experiencing divorce, or the parents are in some sort of high conflict. So when the kids come in, they don’t feel like their parents have to sit together, or one of them can’t be present and has to go to the car or can’t come to the therapy sessions at all.rnrnAll of our therapists specialize in different areas. So we have some people that will work in DBT, CBT, parent-child interaction training, play therapy specific for young children or older children, family dynamics work. We have a lot of different specialties in order to help an entire family come together, and we want to be a one-stop-shop for therapies. So if you have experienced a family trauma or addiction piece, you would come to Relate and we hopefully could see the kids and you at the same time, or we could have staggered sessions so you wouldn’t have to be in therapy all week long. You can have a certain time when you’re there and hopefully get the work that you need, and hopefully we can help find the best people for what you’re looking for.rnrnWe’re going to get started talking about family systems work. Family systems work is something that started in the ‘50s because, at that point, there was a lot of pathology towards an individual person. They had decided that working with an individual was the way to make change and kind of motivated that person to go ahead and work, but what they found was as they moved that individual person back into their home or back into the relationships that they were in before, that person regressed. They recognize that family systems and relationships and connections really was the piece that created the long-term change for a lot of cases.rnrnThere are different paths, like schizophrenia and that sort of thing, that that’s not necessarily true, but when we’re really working with that family systems piece, we’re working on changing the relationship and the connections in order to create a new sense of homeostasis. Because homeostasis is that piece where you’re going back to that original point. You’re where you’re most comfortable where that family lies, and oftentimes, that carries a lot of trauma. And so they might recognize, “Where we’re at is not necessarily good, but it’s what we know. It’s where we’ve always been, and this is the way we function.”rnrnSo there becomes this piece where they’ve identified one certain patient in that family or one person that holds the trauma and carries it likely the most. They’re the ones that exhibit the symptoms, and so as they do that, the rest of the family pushes off the problem onto them and then identify them as the problem. There are a lot of times when that person does have a lot of great concerns, like addiction, and some of these pieces that all of you can work with outside of the family system individually. But as they start to heal, what we want to do is we want to take a look at the whole system and work on how to help them change as well so that the person who’s individually changing isn’t just changing to go back into the same system and then work back into their old patterns of behavior.rnrnA lot of times, the identified patient is the one who makes the waves in the family. They are often the black sheep. They’re emotionally unregulated. Everyone might be to some degree, but you feel this person’s emotions — their ups and downs make the entire family’s ups and downs, and they can sense that when that person isn’t around, there’s more comfort in the family because they’re used to staying in that homeostasis position. You often see that the dysfunction manifests itself through that individual, and the family doesn’t like it.rnrnSo, the rest of the family. Many times when people have identified the problem and then that person, for whatever reason, leaves the family system for a while, they calm down. They feel like, “Hey, even though this isn’t necessarily great — the way we’re behaving — it’s way better than it was when that IP was involved and was there.” So sometimes, it’s difficult to get the rest of the family on board. They might not want to work together and come together to change because, for them, they believe wholeheartedly that that IP is the problem, and if you could solve their problems, then they would be better. And they can cite the fact that when that person’s gone, things do often seem a little bit better.rnrnSo we have to find a way to engage them and help them feel like they’re part of your work by saying, “How can we learn about you? How can we just learn about your family? It will help that identified patient if we learn about you.” The first way to do that is to talk about some of the roles in the family. So, there are often a lot of roles within a family system, and some people might play more than one role. We’re wanting to look at that from just that outsider perspective. Who’s the caregiver? Who’s the clown? Who becomes the savior when you’re in different situations?rnrnWho’s that intellectual mind, the one that can create a space between their emotions and what they’re thinking? They can give you, “These are the things that are going on, this is what I’m seeing,” and they really don’t necessarily relate them back to emotions the way that maybe the clown or the black sheep would. Being able to talk to the family about the roles is kind of the first step in just addressing what’s going on within the family system and understanding roles for yourself. So you can see as they’re coming up that, “Oh yeah. This person is playing the role of the caregiver — they’re the most parentified,” or, “This person has been the black sheep, and that’s how they become the identified patient.” Being able to work with that is a really nice start in family systems because you can get a sense of where they are, and then you can start to formulate your plan around that.rnrnSpecifically within families that have addiction, there are roles that have been identified that are really good to go over. Many people that have studied addiction have already kind of talked through the roles, like the family hero and the rescuer and the mascot, but I wanted to go through some of these roles that maybe are just a little more specific that you hadn’t heard of or maybe thought about for a while. One of them is the adjuster; this is the person who never seems like they’re bothered by what’s happening. They know things are wrong and they find ways to cope, but they just go from one chaotic piece to the next and they find a way to just fulfill what’s needed in the moment. They don’t really have that strong sense of identity. They’re just somebody who will help in the moment and then say, “Well, that’s over. We’re moving on to the next thing,” and they just learn to adjust. They don’t become too attached to things because they know things are chaotic and they’re going to keep changing.rnrnThe next one is the doormat, and this is a pretty obvious one. It’s typically someone who’s been abused or has experienced some high stress and trauma, and they’ve just learned to survive by just letting people do what they want. They sense that if they end up confronting them, it could become very dangerous. So they’ve decided they would just go through the pain and let others walk on all over them in order to avoid the potential of having something dangerous happening to them. They recognize that someone has injured them, but they don’t really relate to the feelings of it. They don’t say that it’s painful or shameful or they’ve hurt them or there’s a lot of guilt there — there isn’t really that connection to the feelings. They just recognize that there’s been a negative behavior and that they don’t want to confront it.rnrnThe rebel: This person is someone who has that up-and-down sense. If there’s an action, they have a reaction, and it’s often shifting the pendulum, right? They go from calm and fine and something happens within the system and they have a very strong reaction to it. This is the person who is very visible to the outside and can be part of the IP, depending on the family system, because they’re the one who makes a lot of noise. Sometimes other people, like in schools or like family members like grandparents and that sorta thing, might recognize the child who’s the rebel because the school might sense they’re doing really well and then all of a sudden they’re doing so poorly in class. They might then try to talk to the parents, or things might come out about this family because the rebel has been acting out and they’ve had these mood swings or had some big actions that have happened that other people have taken notice of.rnrnThe scapegoat: This child takes the blame and shame of the other members. This is kind of an obvious one too. The members of the family recognize that something’s wrong, but they often decide that it’s because of that specific person. That person is dysfunctional, and as long as their dysfunction is highlighted, that means the rest of us are okay. So, we’re okay as long as that person can get help and get out of there. It’s very similar to the black sheep in a lot of ways because everyone else is okay if that person is okay. But when they’re not okay, everyone else feels like, “Gosh, that person is not okay again, so it’s making us have to wonder, worry, think about things again. But if they were okay, we’d be fine.”rnrnThe bully: This is often someone who’s been the victim of the most abuse, the most trauma. In terms of the parents, maybe they’ve decided that they focus the physical, sexual or emotional abuse on this person, and then they find ways to create an outlet for themselves by becoming a bully for others. They often really regret that because they know the shame and the pain of being the bully, but they continue to abuse others because it’s easier than facing the trauma that’s come to them. So this could be someone over their lifetime who ends up being the bully because they haven’t received that acknowledgment and been able to be vulnerable to their own pain.rnrnThe lost child: This is often the youngest child or someone that maybe has the personality where they just want to stay out of the way. They expect nothing, they want nothing, they sneak quietly out of the picture. They often end up at friend’s house all the time, they don’t want to come in and do family work, they just would rather ignore things, they don’t want to talk. Oftentimes when you’re doing family work, they will not talk. They will pretty much refuse to talk, and you sit there and wait and wait for them to talk and they just do it. So the lost child will just be the least threatening and stand back.rnrnThe last hope is the caretaker for the family, and they want to make sure that things are right; they want to make sure that family feels right. Whatever’s happening in there, they will feel like it’s going right. “I want to do best for my family, I know they’re all struggling, I know this is hard for them, but I want to do what’s right.” So they often are good students. They often find jobs. They often take on a lot of burdens in the household because they want to make sure that they are doing their part, but they can create that imbalance where they really do too much, and they do so much to help the family because they feel like that is their role. That’s the way that they were going to have success within that system.rnrnSo now that we’ve kind of gone over some of these roles within addicted families, I want to talk about ways to engage the family, because this really is at the heart of the work, right?rnrnWe so often can recognize the roles and kind of see what’s going on in the system. We’ve talked to maybe the IP, and maybe we’ve gotten a sense through assessments of what we see that’s going on, but we have to find a way to motivate that family for change. And one of the big pieces is that there’s often so much resistance to that.rnrnI wanted to use this platform as a way to talk about some more creative ways to get that work started, so people feel like they’re connecting to something new and something different. An Enneagram is a great way to get started in that. This is something that’s coming up more and more. You’ve heard of many personality tests, but the Enneagram is nice because it really works around a framework to talk about personality in segments. There’s nine segments, and each one of those segments has a different type. There’s the helper, the achiever, the individualist, the investigator, the loyalist, challenger. So there are nine of them, and everyone, when they take this test, will be assigned numbers. They’ll have like their strongest personality type and then they’ll have a couple of sub-personality types.rnrnWithin that, there’s kind of some similarities between these other pieces that we were talking about — specifically, around the rules within the family. So you’re able to address the challenger in a way that’s around the Enneagram and not so much about being in an alcoholic or addicted household. You can say, “Based on the test that you took and that Enneagram, your personality is going to say that these are some of the things fears that you have. So you’re a number three; you tend to fear failure.” Being able to say that is a nice, indirect way to say to that achiever number three style, “You really do feel fear of failure. Since you fear failure, this is hard for you. Doing the work in this system probably feels like you could fail. This person has relapsed before. There have been feelings before where you failed, and working on your family now feels like something you don’t want to do because you really do fear that failure, once again, coming up.”rnrnThat’s a great way to align the current concerns that you’re seeing in the therapeutic setting with this personality test — by externalizing the problem and putting it in the Enneagram and saying, “This is what this test is about your personality.” You’re not pinning yourself into a place where you say, “I can tell you’re the striver,” or, “You’re a high achiever in this family and you’ve recognized this failure before.” Somebody might create a defensive stance from that, but if you talk about it in terms of their Enneagram, they might be more open to sharing some of that.rnrnIn addition to the fears that come up, you can also sense people’s values. The fears and the values are two big parts of this Enneagram test, and being able to recognize what somebody values is also a nice way to segue in family therapy. So if somebody is a type six, they really value predictability. So that loyalist comes up as someone who is committed and then they want security, so they want things to remain predictable. Just as number three, fears failure and doesn’t want things to not succeed and is very shy and standoffish about doing the therapeutic work. Number six might feel that too because they sense so much up and down in the work, and that there’s a lot of regressive behaviors when you address them head on, and that makes their feelings more unpredictable. So being able to say, “As a six, you really value predictability. Maybe we can set up some things to make this more predictable to you, and I can help you and kind of talk through what we’re going to go through in a session and that sort of thing.” That might help them sense that, “Yeah, she’s working on what my personality says as opposed to judging me or coming from a negative place.”rnrnAnother great tool to use creatively is the brain dump. There are lots of different brain dumps that can come up. Brain dump is an exercise where someone just writes out all sorts of different things on the paper that just come to their heads. So there, they can often be set up in like four sections on a paper, or maybe it’s like past, present, future, would, should, what you need, what you want, what you’re hoping for. They can even be as simple as, “What are your worries for today? What are you going to address or work on today?” Basically, finding a way to organize the thoughts within the mind through a piece of paper and just some simple scribbling of thoughts.rnrnThis is nice because that current worry can come up for you, and maybe if you have the entire family do a brain dump exercise, you’ll see some parallels that are coming up. And it’s something that they’re just quickly writing out and not really putting a lot of thought into, and they’re just getting themselves out on that paper. So you don’t really have to have them talking and processing; it’s just a chance to just write what they feel. Come at it from that perspective of, “Let’s just go through what you’re thinking right now,” and you can then see what matches up and what’s different on these different brain dumps and process from there. And that’s a nice black-and-white way to organize, “These are the thoughts of dad, these are the thoughts of child or spouse,” and comparing and contrasting them as a way to just creatively say, “These are the thoughts that are coming up for you in some of the first things that you’re thinking of.”rnrnThe biggest things that you want to work on with creative interventions is you want to present some problem-solving exercises. A lot of times when we have addicted families, problem-solving is not necessarily a strength. Looking at how the family works together without intervening can be a challenge as a therapist, but you can learn a lot. Give them an exercise, give them a game, give them something where you just sit and watch them. I’ve had families that I’ve done this with, with a variety of tools I’ve used — taking playing cards and having them build a house of cards. I’ve just given them the cards, and I’ve said, “I really want you guys to work together to build a house of cards,” and I’ll make it just that non-directive to start with. Like, just build one. And then, as they work, some families will set up expectations like, “It needs to be three cards high to be a house,” or some families will just work to make a box and then they’ll just quit and say they’re done. Using that intervention, you can kind of go from there.rnrnYou can make it more challenging or you can just continue to watch if they really are struggling to kind of talk through, “What’s going on here, why isn’t this working? How can we create a better structure, some parameters around this?” But sometimes within it, I might just switch it up and say, “Okay, now I want only the child to touch the cards,” because maybe the parent is doing too much of the work themselves, and that I want to see how the parent will give directions to the child doing the exercise. Or I might say, “Okay, so now you’ve built one that’s really nice and there’s maybe four cards stacked. Now, I want you to make one where you only have the faces facing out.” So only if you have like the spades or the diamonds, so every side has to face out. So just some kind of silly directive really, but seeing how they follow it and how they piece it together is a nice way to see how they problem-solve in the system, and it’s a very indirect way to see how they work together.rnrnThe other piece that can be important is just sitting in the room and sitting in silence, letting them kind of lead, see who speaks and see who talks for whom, being able to be within that system and sort of sitting there and letting them own this space. You’re kind of outside of it a little bit more — that can help you watch and see how they problem-solve within something that’s kind of uncomfortable just naturally. Another piece that’s kind of fun to do is family representations. How do they see each other? I really like to use the styles of communication presented by Satir for this. They are placating, blaming, computing, distracting and congruent communication. So, looking at the way that this family sees each other communicating.rnrnYou would ask them, “What are some things you really value about your dad,” or, “What are some things that you would like me to know about your relationship with your mom? What are some of their strengths? What are some of the stories that you share from your past that are stories that you felt afraid, stories where you felt happy or proud?” Having these family members represent their experience of each other to you can help you get a really good backbone on how they communicate, how they connect, how they repair their relationship and where they go for help within the system. That’s a nice way to say, “I’m watching you and I’m learning about you and I’m gaining the tools that I need in order to help you as we move forward.” There are things that they value about each other. There are things that they might like about each other, and if they can’t name those, there might be some sort of piece that is working towards self-sabotage.rnrnSelf-sabotage is just a huge piece of working with highly traumatized families, particularly ones that have had addiction in their household. Self-sabotage is something that we as therapists often run into, and when we do, we aren’t always sure what to do with it. We don’t know if it’s time then to stop therapy or if it’s a way that we need to seek outside consultation on it, or maybe I feel like we’re not the best fit for that family, and I really want to challenge you to look at self-sabotage and figure out where this family’s at and what their block is to achieving that success. Once the family has some tools and there’s not really any logical or rational explanation for why they’re not reaching their goals, there is some sort of sabotage in play. So being able to address that means looking at all the members of the family and why they’re not meeting the expectations that have been set, and it may or may not have even been by you. It may have been set by them in the recovery process, or even within their own home. Maybe they’ve already had times where they’ve set up strong boundaries and they didn’t follow through with them.rnrnSome of the ways that self-sabotage comes up, or self-defeating behaviors, are that they look for immediate results. And when I say immediate, I mean they’re coming into the first session naming, “You know what? We’re not going to be here for long. We’re not going to be able to stay in therapy for long,” or, “I’m not going to be able to pay for this,” or, “I can’t take off work, so I’m thinking I’m only going to be able to come here for two or three times.” When they’re already coming in with that sense that we need to get this over with, they’re setting themselves up for failure. Another way is the classic way, and the reason that we’re doing this presentation in the first place is because they’ll often name that identified person and they will just sit there and tell you reason after reason after reason why that person is the problem and how I’m not getting it — I don’t understand, I’m not seeing that person for who they are, they’re manipulating me — and they won’t consider their own role in the system.rnrnThe second you go towards talking to them about their place or that they have something to do with it, they immediately shut you down and talk about that IP. Really, they feel like that person has pulled the wool over your eyes and that you are being manipulated by them like so many before have. Because, especially in addiction, they often are manipulating the system, right? They are wanting to make sure they can feed their addiction, and so they have manipulated the system. So that person is coming in with something that is a genuine fear of theirs — that you also, as the therapist, are being manipulated by somebody who has done so much in their lives to manipulate others. But to some degree, we have to work in that idea of trust and that, “I understand, and we’re going to have ways to hold that IP accountable,” or, “They’re working their program where they’re doing these things. I’m looking at this other piece as well.” So you have to name for them that yes, there is an accountability here for that person and we want to get there, but you are also part of this, and I want to make sure that your life feels better or that things that are coming up for you are addressed.rnrnAnother way that self-sabotage comes up is that they avoid those underlying issues just to push that first order change. So they might come in and say things like, “My child’s now going to bed on time, so this is better. I really don’t think we need to be here anymore. My kid’s doing well in school now, so the issue is gone.” They find something in a behavior that’s shifted as you’ve done some work, and they immediately then want to cut off the therapy because to them, it’s like, “Well, it’s easier. Now the kids go into bed, they’re doing better in school. We don’t really need to address any of these really hurt feelings or get really vulnerable because things are good enough, like maybe they’ll never be perfect, why do you keep pushing that things need to change?” That’s a way for them to avoid that underlying issue they pushed the therapist to triangulate in others. And this doesn’t just have to be the IP. We often are very savvy about recognizing when they’re pushing in the IP’s agenda, but sometimes we miss that piece where they’re pulling in other members like step-parents or grandparents, or even other children.rnrnWhen you sense that they’re talking more about someone else outside of the system, or potentially even in the system that you’re not naming, they’re triangulating them in. You need to redirect them and get them into a place where they’re addressing the relationship, whatever that is, as you, them and the person that you’re talking about. Not somebody who says that, “Oh, my mom always tells me how Johnny, blah, blah, blah,” or, “You really should talk to my mom about this because she watches him and she tells me the same thing. And these are some of the things that are coming up for her, and she wants me to do this and that.” Well, that’s great, and I’m willing to address some of those things maybe with your mom, if that’s necessary, but right now I’m talking with you and how you feel about it or what do you do with him.rnrnThey guard family secrets in the name of lack of rapport and supports. Okay, this is a really tough one. They’ll come in and they’ll say, “You don’t know the half of it,” or, “There are things you don’t understand,” or, “There are things that I can’t tell you yet,” or, “I don’t really want to tell you because I don’t know you well enough.” And this is something where if that comes up for them and it’s consistent, you have to put into play some sort of boundary around you. Either need to share this with an individual therapist, and there has to be some sort of form of communication where, “I can talk with them if it’s too difficult for you,” or we need to figure out a way to work around this piece and work on the other traumas that are coming up. Because stopping in the name of a family secret is part of the reason we’re here in the first place, right?rnrnThere are things that are being guarded. There are ways that this family has been keeping up this homeostasis, and family secrets is often one of them. There is a person within the system sometimes that can get highly emotional. They will get so emotional in a session, they will be angry and screaming, they will be crying the whole time, they really can’t regulate themselves emotionally in your family sessions and you often have to kind of spend that time really focused on them. That person may need their own individual therapy and their own work. The other way that you can kind of work through it is maybe you can kind of start with them and say, “I recognize how emotional this is, and I know that this is difficult for you.” Maybe they can have a notepad and they can just write things down and do some of their part that way, because we don’t want to avoid people because they become stoic and they don’t engage and they disengage when you’re talking or because they’re so highly emotional that the rest of the system kind of becomes standoffish and doesn’t know what to do.rnrnLike a child who might say, “I don’t want to talk about this because it’s going to make my mom cry.” We have to hold that space for the child and say, “If your mom cries, I’m going to help take care of her in this session. I’m going to work with her and we’re going to figure that out, but you have to be able to talk about your feelings too.” And that child needs to be able to self-advocate their needs while this parent is having that emotional reaction and reactivity. So we’re holding space for both people and we’re showing them that we’re emotionally ready to be neutral to whichever way it’s going and allowing for everybody to have the floor and have the room and space to feel like they can connect and talk, as opposed to self-sabotaging the situation and saying, “Every time we come in here, mom cries and cries. Maybe this isn’t good for her anymore.”rnrnOne of the largest ways I’ve recognized self-sabotage within a family is confusion. People will start to express confusion when they’ve been in therapy with you and they start to sense things are going okay. They will do it through things like, “I don’t get it. I don’t get their point of view. We’re never going to understand them. I’m never going to understand what they’re saying. I’m just so confused about what we’re doing here. I don’t even know why we come here. I have to come here because my son wants me to, I don’t understand. We’re not getting anywhere. We are not on the same page. I want something, he wants something, you don’t understand as the therapist — either one of us or our point of views. You weren’t there. You weren’t part of this until a couple months ago. How do you think you can understand us? We are not on the same page. I am completely lost to what we’re doing here.”rnrnI’ve heard this many times when someone is getting to that place where they have to do some work. Where they’re not holding down their end of the boundaries or we’ve set up rules — we’ve set up ways that they can hold to them. “You cannot give the addict money.” Both parents: “Great. We’re not going to give him any more money.” The mom comes back and she says, “Oh, I gave him a hundred bucks. He really needed to cover his rent.” The dad gets upset about that, and mom comes back and says, “Well, I’m confused. I didn’t know we couldn’t pay for his rent. I thought I couldn’t give him just money to pay for alcohol or that sort of thing.” And then everyone’s like, “Well, no, we really agreed that we were not going to give him any money,” and so this parent then is suddenly very confused about what the rule was. “I can’t change unless you can tell me why.” So that comes up for people because they sense they can’t trust you. So there’s this communication of like, “Unless you can tell me why it’s important to do this,” or, “What are your qualifications to give me these rules or to tell me to do this? Do you have kids?”rnrnThey come up with a lot of excuses as to why you can’t help them change because you can’t tell them exactly why or what to do with it in a way that they trust, or that they believe that, yes, this is the right thing to do. And that can become very frustrating from a therapist’s point of view, because you might be working with the whole family and you’ve really built rapport with all of them, and there might be this one person who just keeps questioning it and who just keeps feeling like maybe they’re the one who’s the holdup. Maybe they’re the one sabotaging the system and you can’t get them to move, and the rest of the family just feels defeated because that person will not hold up their end of the bargain. Those connections and having the expectations just are explained away with their confusion.rnrnWe can work on this by using connection. It can be so tough to stay present and to have that family sit in that pain. Oftentimes, people within the system just don’t want to do that. They’d rather disengage. They’d rather not be able to share their whole experience of it because it is really painful, and being vulnerable can be scary. They have these injuries that have been built up over years and years of behavior, and so not being able to name them is just part of the defense that has come up. The way that they cope is that, “I’m not going to be part of this, I’m not going to work on this,” but finding ways for those clients and that family to stay present in that pain is going to be a huge part of your work in reconnecting this family system. And one of the most basic ways is to allow the space for the shared events that have gone on and for everyone’s perspective of those events and getting to that place where there’s the communication around what we’re going to change in the future so those hurt feelings and that pain doesn’t come up. What are you willing to do? That’s a tough question. That’s one of those questions that you’ve had to build strong rapport, you have to have a deep connection with that family system, and you’ve had to sit with them and slow down a little bit.rnrnSome of the big blocks to this connection are the fears of the unknown. We often fear the unknown in everyday situations, and people recognize that there is relapse. We could be setting ourselves up for failure and being played the fool again. People don’t want to feel like they’ve done all this hard work and their family member hasn’t, and we need to acknowledge that for people — “You’ve put in so much effort, you’ve put in so much money, you’ve put in so much time and you don’t want to feel like this fails again.” Being able to do that and acknowledge that for somebody can be a really big floodgate opener, because seeing them for what they’ve put into this whole situation, it might just feel like a relief. Someone’s validating their position. Someone’s validating the fact that they’ve worked so hard to help somebody who really has to help themselves. That’s built up in resentment of the past. That past is just such a big piece and it’s a huge block. Your identified patient has got to work through acknowledging they’re hard and making amends is a big piece, whether or not you use a 12-step program.rnrnMaking amends within the system comes in three different ways. The first way is direct: They need to understand and repair. They need to put themselves in a position where they take responsibility for their previous actions. That is a huge way to heal and move forward. The next way is indirect amends. It’s that you recognize that you’ve done some irreversible damage here. You’re not going to get back those years of your child’s childhood. You’re not going to be able to replace the car that you wrecked of your parents. You might not be able to do some of these things that your family had done before, and saying, “I know you can’t get that back and I’m really sorry about that,” is a great way for them to acknowledge the past. And the third way to make amends is just by living, and living their best life now and choosing the positive pieces. That will help this system heal, saying, “I know I didn’t do that well before, but I’m doing better now,” and actually showing the family how they are doing better now is a good way to help erase some of the wounds that can come up in that period piece, where they’re building pain and pain and pain on top of each other.rnrnThe last piece is recognizing that they’ve always had problems and this is just making them feel worse. “Fixing this doesn’t make our family better.” They have assimilated to their problems, and we’ve talked about it before. Their sense of homeostasis is there. When someone’s assimilated and said, “You know what? We don’t need to really work on this. You are bringing up our pain. You’re making us come in here and talk about stuff we don’t want to, you’re not fixing us. You’re making us worse. We go home and we feel bad. We don’t like being here.” There is so much of that that can come up with that, and part of that is trusting that therapeutic relationship and building on it and saying, “I know that this is really hard work. This hour that you’re in here is like exercise for your head and your heart. We are exercising these emotions and these muscles, and you’re lifting a lot of weight. It is one hour. And I believe that if we do this consistently, this is going to get easier, but I know right now it is really hard for you and I can see that.”rnrnSo that’s a big piece: empowering them. All members of the system have a part, and saying, “Your part’s important. You have strengths in the system. You also have some weaknesses, but your strengths really outweigh those as we work forward and move into a place where you have some things that you’re giving this IP and that you’re giving each other that are so important.” And being able to look at a family and hear them laugh together when they haven’t done it for a long time — that is just one of my favorite parts of family therapy. When we’ve gotten to a place where some of that hurt has moved out just enough where they can connect again, and they can sense their family system for what it is. There are things that come up that are kind of funny, and they have their inside jokes and the way that they look at things. And when they’re willing to laugh together, you can feel some of the strength of that system coming through, and that’s a very powerful moment for all of us.rnrnWhen you start the work with the family, we have to look at what their first goal is and what our first goal is. Being able to meet some of their needs while you’re meeting some of the system’s needs from the therapeutic standpoint can really work with best results, and for that partnering piece. If you go back and do some of that work that we talked about earlier — where you’re using those creative interventions, you’re seeing what all the family members really want, what they’re hoping for, what they’re working towards, what they’re wanting to get out of therapy — if you can make sure that you’re tandemly addressing it with some of the pieces that you think are most important to start with, your partnership will be stronger because they’ll sense that they’re getting what they came to therapy for. They might really want to be able to use some things that are coping skills for them and that sort of thing, and you might really be wanting to focus on something that maybe they aren’t seeing as important, but partnering by making both things part of your initial treatment plan will help keep them on board and help those family members sensing that their input is really important. Of course, we have to address unsafe behaviors first, and I think that most people recognize and understand that, but from there, working on that partnership is really important.rnrnThe way we do that is finding that balance between you as an expert and you as a partner. Having clear goals that have a real check-in date that are often strengths-based. We don’t have to have every goal of these strengths-based, but making sure that we have some that are. We know that evidence-based treatment relies on strengths-based goals, and that can help people sense that they are moving in a more positive direction. So really, having clear goals with a measurable piece and an end date can help those clients recognize that we’re working towards something. Have knowledge that helping the goals might be part of the plan, but they might not always understand the entire way to get there. They have to build trust with you, and that takes time, especially in highly wounded relationships and systems.rnrnSlowing down and recognizing that there’s a healing process to growing that relationship can be very important through the therapeutic work. You might not reach the same goals as quickly as you want to. You might have to spend more time in that rebuilding and repair piece for you because you’re mirroring this system. You’re helping them progress into a place where they can trust, and that might be on their time — not yours. The last part is just being consistent with checking in on those goals, staying black and white and using those goals as the pillar and helping them see we are working on the things that you find important and that I think are going to help heal you to get you to where you need to be. Staying on track with that, not allowing them to sabotage, for them getting off and talking about and triangulating someone else, not putting in additional plans and additional work before we’d solve some of these pieces that we’ve come up with initially. These are all ways that they might get out of the hard work that you guys have set in place through these goals. Goals are a key piece to this, and recognizing what they are is a nice way to hold people accountable and to show your accountability to your work.rnrnSo finally, if you have any additional questions or things that come up around this presentation, feel free to reach out to me to chat a little bit more. This is my email address, the phone number and the website for Relate. Thanks for coming to this presentation. I really appreciate your time, and I hope you learned something.rnrnThank you for watching this video. We hope you enjoyed the presentation.

PowerPoint Presentation:

Link to Timothy’s presentation

Articles:

Substance Abuse Resources for Veterans

Veterans and PTSD

3 Ways to Promote Veteran Mental Health

Transcript:

Welcome to The Community Education Series, hosted by The Recovery Village and Advanced Recovery Systems. Hey everybody, thanks for showing up to this. It’s nice to get together with folks for an hour that isn’t trying to pick apart clinical details through a video. This is really relieving; I’m sure all of us clinicians are feeling that a little bit. So what I’m going to do is — you all can keep doing the chat — I’m going to go ahead and do a screen share and dive in a little bit. Since we only have the hour, I might move a little fast through this, just to make sure that we really get through enough material. What you’re going to get today is a really brief, basic view of veteran culture. This is by no means going to make you entirely competent if you’re not familiar — it’s going to give you what you need to get competent. It’s going to give you some questions to ask yourself about your practice, about the community. It’s going to give you some resources on how to find more and hopefully open you up to some of the common mistakes that clinicians make, who aren’t trained.

The reason why I’m the one to do this training specifically is I spent five years in the Air Force and served as an intelligence analyst, which was really not as exciting as it sounds. I was a victim advocate for military sexual trauma survivors, which is how I got my foot in the door for mental health support, and I was the primary trainer for the bystander intervention program. This was back in the days when they finally figured out that talking to the people around the people who were likely to be victimized was the best way to stop violence. It was a lot of fun; it was my favorite job in the world. I got to “talk Airmen into punching rapists,” was the joke. It was a great, great gig.

Then when I got out, I went to the Auraria campus. I took a peer support program with two members, mentoring about 30 people a semester, to a group that mentored every single veteran that signed up for benefits on the entire campus, netting a staff of about 20. The best part of that time was I got to facilitate an exploratory group that studied factors for survivability of suicide, and I got to facilitate the meetings of 20-year clinicians, which was pivotal in my growth as a clinician. It really opened my eyes up to a lot of what’s in this training. I took that out to a local trauma center and developed their Safe Harbor program, which was training all the trauma clinicians on how to serve the veteran population on reduced costs. Since then, I’ve been in private practice for four years, doing these trainings and having a third of my practice being first responders and veterans. So that’s where this experience is coming from.

We’re going to start with some of your — well, let me keep going with this a little bit. Why this training is important: Back in 2013, the VA was instructed to open up their doors to clinicians that weren’t part of their system. The only barrier they had was a bureaucratic one, and if you could apply for an insurance panel, you could become a Tri-Care provider. Then, they did a follow-up study to figure out what was going on with the providers they let in, and they figured out that 84% of the mental health professionals that were serving weren’t competent to serve the population. The main reason for that was they weren’t using evidence-based techniques, they weren’t trauma-informed and only 8% of non-affiliated clinicians were deemed culturally competent for the population. I think by now, “trauma-informed” is becoming a byword in the community. I think more and more clinicians are getting that, which is really comforting to me. Today, we’re going to cover the cultural components.

If you can go into your chat, I’m going to stop screen share so I can see what y’all are chatting. What is something — what is one thing that people assume about you when you tell them you work in mental health? The first thing that comes to mind. “Crazy.” That you “work in a medical model.” I get both of those. Now we’re going to go over to the next question. What do you assume about someone when they say they’re a veteran, or you see a license plate or a hat? Or, if we have other veterans in the room, what are things that you notice people assume about you when you disclose that you’re a veteran? “Shutdown, resistant to treatment, that they’ve seen things that you can’t imagine, they’ve unresolved or unintegrated emotional aftermath of a traumatic experience, that you’re angry and that you’re gonna snap without notice.” Good assumption that they may not necessarily want to be identified as a veteran — for some of us, it was a time of our life; it’s not an identity we wear every day. This might go into the “they’ve seen things that are there that I can’t imagine,” right? They’ve seen it, they’ve been in it, they’ve seen too much. So every veteran has got a lot of “too much,” a lot of overwhelmed, a lot of assumptions for trauma. “High likelihood of vicarious trauma,” yeah. “You’ve seen that they compartmentalize, they hold back parts of themselves.” Okay, that’s pretty good. I get that one a lot too.

One of the things that I love about this exercise is it’s actually incredibly comparable. The military is an incredibly broad experience. Between the branches, the different jobs, the different roles and the different activities that they’re involved in, it’s even more varied than our field. And we’re going to get back into the slides a little bit to cover some of that. For me, since I hold both of these identities, I haven’t been exposed to violence. I consider myself a nonviolent and competent person, but none of that was in the military. I was an intelligence analyst. I sat in front of computers my entire five years. I’m not Republican, I don’t own any weapons, I’m not Christian, I don’t tend to snap without notice unless I’m really hungry. I did ironically have unintegrated emotional aftermath of traumatic experiences until I started having to get ready for this job and have to actually do the work, right? I’m pretty sure most of you can imagine the things I’ve seen — if nothing else as clinicians, we’re really good at imagining because we’ve gotten a lot of stories from people. I’m gonna go back to the slides now, and we’re gonna talk about this a little bit.

So, the big cultural differences that you’re going to see is that in American culture, we are an incredibly individualistic culture. And I think this is one of the bigger things that the military struggles with, like people that identify with that veteran experience or don’t have been shaped by this. Civilian culture is about your grade, your job, your paycheck, your family, your house. In the military, it’s about the mission. It’s about us; it’s about the unit. It goes back into an individual achievement. Did you get that promotion? Did you earn that accolade in the military? We actually get uncomfortable more often than not when we get accolades. It’s about what the unit accomplishes, not about us.

Individual culture is all about personal freedom. You know, live your truth, be who you want to be, chase down the American dream. And in the military, it’s absolutely not about the personal freedom. It’s about the devotion to duty. It’s about the flexibility to complete the mission. In civilian culture, we are really about socially fluid relationships, the lines at different companies, different schools between professors, power dynamics — they’re all really muddy, and every group seems to have a different way to come at it. That’s all individually driven; in the military, it’s a very rigid social structure. You do not spend time socially with people that are higher ranking than you. You do not have the ability to call them by their first name, to talk about their families. You are locked in with your peer group, and those peer groups are incredibly regimented.

None of these things are bad, and this is really important. The idea of a collective is culture versus an individual’s culture. People like to romanticize either, depending on what they’re talking about, and the reality is there’s pros and cons to each. There are going to be different ways to come at it. Most veterans, if they’ve been out for a little bit, do fairly well in living in both worlds. They’ve done one, they’ve got some skill out of it, and it’s going to be important to recognize that. If they’re newly out, there is going to be a large culture shock. “I don’t know why I didn’t meet that promotion. I’ve done the best work, but he goes out to coffee with this other guy all the time. I don’t understand what happened there. I feel like I got passed over. I don’t know why people get really angry when I’m very direct. It doesn’t make sense to me. If there’s a problem, I’m going to say something and do something.”

So, the branches are comparable to social workers, LPC’s, career counselors and school counselors. An experienced career counselor at a high school has seen a lot of trauma, has been involved in a lot of things, but their role is to help people find their future. They’ll know referrals to make, they’ll know how to support that work, but it’s not theirs. A social worker, they’re going to be really good at systems work; they’re going to be about finding the resources. Clinical social workers, five years in, are going to be just as good as any LPC, but their training is going to be more broad and knowing those resources, and we appreciate the differences. We all picked our credential for a reason. We all value the distinctions, and the public doesn’t understand it, right? If you say you work in mental health, they assume that you are all of these things, and they don’t really know which is which. Same thing with the military. You choose the Army for a reason — you identify with that culture. There are differences between the Army, Navy Marines, Coast Guard and the Air Force. There’s a value in an earned title that’s important to recognize. So when someone says they’re a veteran, a really good follow-up is, “Which branch did you serve? What title did you make?”

The differences are pretty stark by on what their operational footprint is. The Army is the largest branch, and they have the most varied duty. So when someone says they were a soldier, you really can’t assume anything about their experience. The Army literally has almost every job that the other branches have because they’re just so huge. Cooks, lawyers, combat specialists — they have more boats than the Navy, believe it or not, which I think is hilarious. The sailor tradition is the oldest. It’s kind of like the elder branch because they’re taking tradition from the 1400s from England. They also have the most time away from home outside of combat because of the ship life, and a surprisingly large amount of sailors never get on a boat or a ship, so that’s going to be important to take in. The thing that’s funny there is they have more planes than the Air Force, which ours are better though, so don’t worry about that. We have the best planes.

The Air Force is really going to be the technical branch; 70% of the Air Force is in technical fields. It’s almost all aimed at keeping really expensive, very powerful hardware and supply to the people that are on the ground. It’s more of a corporate culture. Some Airmen get uncomfortable talking about it like that, but that’s the best way to look at it from the outside. My Marines, I love my Marines. They’re actually the main population that I end up working with now, and their focus is on being a warrior, being a fighter or being a rifleman. Every Marine, on some level, was ready and willing to be in violence when they join, while that is not always true for the rest of the branches. They’re also the most culturally rigid. They are — there’s no, like, Marine that “gets out.” You’re a former Marine, you’re always a Marine. It’s a lifetime identity piece that they try to really put into you. The Coast Guard is probably the most discounted branch. If you’re talking about times of service, before the war on terror, they actually had more combat experience than most of the other branches during the war on drugs. After 9/11, they got upgraded to a military branch, and I actually run into them a lot more in Colorado than you would think.

Military families: This is going to be the one that comes up a lot for people. The transition out of the military is essentially like losing the family member that was in control. The way to look at a military family is there is an extra person in that family, and they take preeminence. Military families have to give over everything to the mission. The spouse’s life is around the mission before it’s around the family. To give you an idea on how stringent that is in the military, if you have children, it’s required that you have a family care plan. And what that means is that you have someone on file within your command that, in 24 hours, will take your children. That you will be able to leave and go do whatever the mission requires in 24 hours’ notice, and that your children will have somebody to be handed to. The military structure is really designed to have a partner in service and a partner managing the family. Dual military spouses are becoming more and more common, and what that means is they have to have somebody on deck for this. To give you an idea on how serious that is, if you’re called up and your unit decides they need you to go somewhere and you say that you can’t get your children cared for, you can lose rank. It has serious financial and social consequences to not have that happen.

They’re also much more likely to marry young. They’re constantly disrupted spouses. It’s incredibly hard to have a career in a military family because of all the relocation. They’re expected to move about every two to three years, about 10 times more often than civilian families. They’re also pretty heteronormative. The spouses tend to be under 35 and largely female; only 5% of military spouses are men. They get married and have children a lot younger because the structure encourages deep commitment early. So when I was in training, I was actually in training for a very long, long time. My training was a year long in two six-month stints, and you’d meet somebody on the training base, out in the public or within your unit, and you had six months to determine whether the relationship was worth continuing or not. And if it was, that person had to move with you.

On top of that, if you do get married, you get to live off of base or get a house away from the dormitory’s barracks where all the other guys and gals are sleeping, and you basically double your paycheck because they give you a stipend to support your family. So it’s financially incentivized, it’s romantically incentivized, and its relationship and connection incentivized. All of this means that they’re doing this a lot younger than their peers and that when they rejoined civilian life, there’s a huge power vacuum. The mission is no longer there. The preeminence of the partner’s career that was serving is no longer there. You may have a spouse that’s been waiting their turn, you may have a very rigid sense of order that is no longer being provided from the outside. Really, treat it like an estrangement from the powerful member of the family if you work with those families when they get out.

Mental health struggles: I’m not going to train you how to diagnose. I’m assuming that you’re going to get that training other places. What this is about is what diagnosis generally means to the people you’re talking to and what happens for them. So, depression and anxiety — just like everywhere else in the country, everybody’s anxious and depressed right now as far as I can tell. I don’t think there’s a clinician that can use the diagnosis code for generalized anxiety and not in some way be correct. For the military members and their transition on the way out — and this is going to be my focus here because it’s where my focus has been in my career — it makes a lot of sense that people are struggling with sadness and stress. They miss the camaraderie. In the military, you don’t choose who you’re with, so you’re forced to value them. I was an intel analyst. I worked shifts, which meant that I was doing 12- to 15-hour days, and we would swap days and nights. We would do three days at times, so your schedule is chaotic. You never know what day of the week it is.

So you’re spending your time, both at work and off, with the people that you serve with. For me, it was around 10 people that were always together because who else were we going to hang out with at two in the morning on a Tuesday, getting ready for your next set. So even though I would never spend time with these people outside — we didn’t share politics, we didn’t share hobbies, we didn’t share cultural background, we didn’t share age, I was much older than most of the people I served with — we were forced into very close camaraderie that we maintain to this day. You lose that. You lose the easy friendships that come from just consistent exposure and forced time. You also make no decisions when you’re in the military. You don’t choose who you spend your time with, you don’t choose where you live, you don’t choose the career you get, you don’t choose the posting you did. You can have influence and get lucky, but at the end of the day, it’s all needs of the service.

So you haven’t made a life direction choice other than who you marry for the entire length of your service, and now you’re flooded with choice once you get out. You’re also feeling different. A lot of people — just like when people come home from college or they come home from living somewhere else, where they expect the world to have stayed the same and it hasn’t — they also expect to engage that world in the same way, but they’re different from their experiences. The military members are also classically bad at financial management because finances are so secure. You’re paid like clockwork, your food and board is taken care of for you. You’ve never had to really figure out how to manage those, so it’s not uncommon not to know what to do with money or what to do without money.

So this is an important statistic when we talk about that repressed trauma. When we talk about combat experience, only 6% to 10% of Iraqi and Afghanistani veterans are affected by PTSD or TBI. And this is really important to understand — only one in 10 military members will be exposed to combat. For every person that’s in the field that’s in harm’s way, there are literally nine people standing behind them, making sure they have everything they need to be as safe and as effective as possible in that environment, which means that most of us weren’t exposed to that. In addition, combat does not have to be a negative experience. I’m going to say that again: Combat does not have to be a negative experience. There’s poetry written about it. It’s a classic test through the time of humanity that people have sought to test themselves.

One of the struggles I see a lot in the field is that many of us are pacifist in nature — we’re abhorred by violence. We’re really invested in the idea that you use your words; it’s what we work with. It’s our skillset. So coming across somebody who values being violently competent can be jarring. Be ready for that. The other thing is that that story that the public has, veterans have too — most veterans are terrified of that post-traumatic stress diagnosis. It’s what they assume they have when they’re struggling. When really, it might just be transition struggles, it might be depression. It might be, “I can’t find a job. I don’t know what to do with me and my wife now that we’re out of the situation and we don’t seem to like each other.” It’s a much broader perspective on the health and that.

The way that the military’s ad campaigns framed it is a normal reaction to an abnormal situation. It’s a really common theme because they really beat it into the media in the military for about 15 years, that was the awareness campaign. There’s the common social stigma that no one likes — I don’t know, a veteran that relates to the TV ads that shows like the screaming veteran with a gun to his head flashing back to combat experiences, trying to make public awareness. That’s a really offensive ad campaign that impacts us. Almost no veteran I know is comfortable with the idea of the diagnosis until they’ve been educated by someone like you. The other thing is that TBIs can mirror post-traumatic stress. There’s also different things that have come up.

There’s a malaria drug that was utilized for veterans — for about 15 years — going down in South America or going into any jungle environment. They figured out much later about 6% of the folks that got it would get chemical brain damage, which mirrored PTSD and TBI. What you’ll see a lot of times is it’s really hard to assess TBI without really specific training. So it’s not expected for clinicians to have that, right? It’s okay if you misdiagnosed for post-traumatic stress. What you want to watch for is we know that post-traumatic stress is curable. We know that the skills using DBT, using MDR, using all of the different skill sets we have — most of the time, our clients are going to get better. If you’re not seeing improvement and you see dedication and commitment to the treatment and your client, get those follow-up tests for that TBI. See what else has happened to them. Don’t just sit there for two months of the treatment, not seeing any improvement. That’s what you want to watch for.

Okay, TBI. This is the funny one that I didn’t know — athletes are actually the most common occurrence for TBI. We’re also consistently learning more and more about the brain. I know all of you have had some kind of training in neurology and what’s happening in the brain. It seems like every year, they’re figuring out something new that’s been consistent with TBI as well. It doesn’t really matter whether somebody had a concussion or not. If they were inconsistent little explosions, if they were injured in other ways where they got shaken around — it’s pretty common for those light jarrings, those lighter hits that we didn’t used to associate to cumulative effects, to have problems. And again, since it’s with the brain and it’s literally your brain getting damaged from trauma, the symptoms are incredibly broad. So be aware of that. Unless you have specific training in TBI, refer out to get it tested. That’s okay; don’t expect that to be in your skill set if you’re not trained for it. I don’t have it. I refer out for it.

Military sexual trauma. This is a really big passion of mine. I’ve spent fully 15 years of my life working against this in multiple communities. Roughly one in four females and 1% of males are reporting experience with sexual assault and trauma in the military, which is almost perfectly mirrored with college experience. Sexual assault is a societal problem and is not a military problem, and to frame it as such is really unfortunate. The difference is the military, culturally, is framed as a large family. So what you will tend to see are themes closer to incest due to the cultural values of the military. If the mission comes first and someone in my unit did this to me, and I know that it’s going to split the unit if I report and come forward, I won’t. I will put the mission first ahead of my trauma. The military justice system struggles very similar to the civilian courts.

It’s not that the punishments aren’t there. It’s not that the stringent consequences aren’t there — it’s that proving sexual assault is incredibly difficult due to the nature of sexual assault. The other thing that tends to happen is it’s incredibly difficult for many survivors post-service to prove a service connection, because they often don’t report during their service. And the way that benefits go for the military is you have to prove the service connection, so it’s incredibly difficult for those folks. The other thing that’s different is military members are denied friend peer support through this process because every uniformed person is a mandated reporter. If I’m a uniformed person — I don’t have special training and a special role — and someone comes to me and says they were assaulted by another member, I can be disciplined if it’s found out that I know and didn’t report it. And that sounds horrible; it sounds antithetical to getting people to support. It’s a reach by commanders and by the command structure to show that they are intolerant of this behavior, that it’s against the military values and they want to punish and get the people out of the military that do this. So while it’s misaligned, it’s coming from a very strong, very caring place from the command structure. It’s important to recognize that.

The other thing that I’m seeing a lot of is one of the female providers that I work with: Military men will not report. So my last year in, I was now kind of a subject matter expert. I trained the bystander program to most of the bases in England. I was kind of a sought-after resource in Colorado, and I was tagged to come help train the next set of folks before I got out. And I was really heartened because everybody that showed up for the last training that I was part of volunteered, which is actually really rare. More often than not, people are assigned duties. Everybody that was there volunteered to be there, and they were passionate about taking on this problem.

The training was a week long, we were four days in, and then again, it had been a great group — really vulnerable, really honest, angry where I wanted them to be angry, committed, and passionate where I wanted to be passionate. More empathetic than I experienced before with people in uniform. We then watched a video where a former police officer discloses a sexual assault that he experienced while on duty. The officer was alone in his cruiser. He saw a trash can in an alley. He decided to walk and remove the hazard. Someone put a gun to his head and assaulted him — two men assaulted him. The entire room erupted in anger that this police officer would let that happen to him. This incredibly kind, dedicated, passionate group of people were appalled that a man in uniform that was armed would let that happen and wouldn’t choose to die trying to stop it. So if you get the gift of a man coming forward and acknowledging this, be incredibly delicate with that.

Addiction. Veterans drink heavy in service; 70% of us struggle with alcohol at some point in their lifetime. This comes with common additives, right? Drinking like a sailor. A common tradition across all branches is something called dining, in where it is not uncommon to see a unit commander doing a kegstand. I was stationed in Korea. The common tradition there — Korea is probably one of the harder drinking cultures because its culture’s frozen a little bit in time — was, we call it, “green bereting” a new member. The local liquor in Korea is called soju, and soju’s kind of mythical power is you can’t really taste it with any kind of mixer. It’s an incredibly insidious alcohol and it’s not regulated over there, so it doesn’t always come out as the same alcohol property. It’s incredibly difficult to gauge how much you’ve had.

What they would do is they would take the new member — and the drinking age over there was 18, so it’s every new member — they would sit them on a barstool and they would continue to pour liquor to them until they fell out of the barstool. That’s still happening today. That’s the culture around drinking. The other thing is the mission comes first. So if I’m in pain, if I’m struggling, if I’m dealing with things that need to numb, alcohol is the one thing I can go to that I’m allowed to. I’m not allowed to smoke pot. I’m not allowed to take time off. I’m not encouraged to go through medical — and to be honest, medical’s response tends to be much more problem-oriented than health-oriented, so they’re not going to give me anything different. This is also a really common theme with veterans that are out of the service with bad paper, meaning that they were left under other-than-honorable terms, they got a DUI, they got in fights, they showed up to work drunk, they had a domestic violence incident at home that kind of tossed out. You’ll find alcohol is really tied to this because essentially, what that means is they failed to cope along the way, and the one tool that was handed at some point was the alcohol. So watch the screening for them.

Suicide. This is pretty common now, right? Everybody’s aware that veterans struggle with suicide. The number 22 is a pretty accepted number across a number of platforms. That’ll move a little bit, depending on where you look. The important part of this is, just like police and other people that are exposed to violence, we have a plan. If I was to kill myself, I know how I do it. I came up with it on set, talking with my peers at two in the morning, really bored one night, trying to figure out the best way to do it, to hurt the fewest people, to make sure I left my family with my life insurance. That’s something that we did because we have a plan for everything. There’s a plan for every violent outcome — that’s part of our training. We’re also exposed to more lethality than our civilians. We know what death is, we’re around it, we’re trained around it. So we’re more likely to be successful, and that also lowers the barrier between us and the violence that causes us to be successful in a suicide attempt.

Female veterans follow the same statistics that their civilian counterparts do. They’re just more successful because they’re not using pills, they’re not using the softer methods, they’re much more likely to use lethality — firing a weapon at themselves. This is the one place where the VA has really turned things around and become a very active resource. Getting somebody in for general mental health at the VA in most places is still an incredible struggle. It is still really hard to get in, and there’s a month wait and then they’re likely to come to somebody like me outside the system. If you, as a clinician, call the crisis line — and I’d highly recommend it if you’re gonna work with veterans — call the crisis line as a provider and just tell them, “Hey, I’m a provider. I’m looking to learn more about your resource and to figure out how to integrate my care with it successfully.” It’s very supportive. I can’t speak well enough to those. Combat veterans are not the most at risk. Combat does not incline you to suicide. In fact, what we found is during service, combat veterans are the most resilient against suicide. Our non-deployed members were the ones we were losing during service.

Once they’re out of service, that might change, but people that have gone through combat have some resiliency, even if it traumatized them and they have struggled since. The most at risk in younger populations are non-combat-deployed Marines. Every Marine is a rifleman. Their purpose is combat. If they never got to see combat, they did not meet their purpose. They’re ridiculed within that service, they are less than in that service, and they own that. They’ve been indoctrinated into that. Aging veterans is actually who we lose the most — veterans over 60, veterans with health problems, which is more common with our population. The things they give us, the things we do, the things we’re exposed to in our life means we’re far more likely for complex health issues later in life. This has been highlighted over and over with Vietnam veterans, and it’s coming up more with Iraq veterans. We don’t age well, we have complex medical issues and we value functionality and not being a burden on our families. So that’s the population that you really want to watch out for.

The other thing that happened is was the Army, back in I think it was 2011, their suicide rate in one year doubled. Which terrified them, as it should, and they did a postmortem study and tried to look through and figure out what was happening, why they lost all these people. And they expected it to be because our operations tempo; the Army at the time was doing longer deployments and they were doing back-to-back deployments. They were really being awful, due to the operational tempo, to the people that were doing it. What they found was it wasn’t their combat veterans; more often than not, it was people with less than a year of service. And the further they were away from the cultural norm of the military — which is white, male, 19, heterosexual, Christian, American — the further away they were from those points, the more likely they were to have committed suicide. Their risk factors skyrocketed. The other thing to notice is that, a lot of veterans, their trauma doesn’t come from their service — their service was their escape from their trauma. It was my way out; it was how I got out of the inner city, it was how I got away from the home that hurt me, it’s how I got out of financial destitution. It was my opportunity to get out. So these were people that came in with trauma were looking for a solution and didn’t find it. That data continues to be true once they’re outside of the military, because their relationship to the military was probably strained.

Common barriers to care: Non-trauma-informed clinicians is a big one. Sadly, our programs — our master’s degree and our PhD programs — don’t put an emphasis on trauma. However, most centers do, so that’s changing, which is nice to see. Many veterans don’t have a sense that they merit care. For an example for this — just from a personal story — part of my job when I was doing the transition program on campus was to help people get guided to resources and an incredibly in-depth network. I knew what was available. I knew how the resources wanted to be used. And I have a disability rating; I have injuries from my service. I didn’t get them for the first year until one of my students that I was working with called me out on it. I was talking him through his process, and I would do a little shame sometimes to get them to take the help, and then the guy just looked at me. He’s like, “So what do you got going on? You were telling me your shoulder’s bummed, you know. Did you get help?” Oh no, man. I don’t want to walk down this.

So he’s just like, “That’s convenient, so you come at us about it.” It took one of my guys coming at me to get me to do it. There’s always someone worse off than you. If you show up to the VA for care, inevitably, you’re going to see somebody without a limb. You’re going to see an elderly veteran that you know, by his hat, served in some serious things. Just looking like he’s in pain — like he doesn’t have anything — but you’re going to go in ‘cause you got tinnitus. You’re going to go in ‘cause you got nightmares and, you know, the system is bogged down. So we don’t feel like we merit care. Now, the other thing is many veterans feel judged by clinicians. We know that caregivers are often nonviolent people. The same assumptions that you were talking about, where they assume that you’re liberal, and if you’re liberal, then you don’t support people that have been to war. All of those polarizing kind of tribal things that are happening in our country right now land just as hard on them.

The other thing is the military’s approach to health care is focused on function and not wellbeing; it’s all mission first. It’s the difference between me taking a pill that’s going to make it so I’m not in pain versus fixing the issue, but the pill will get me back to work tomorrow versus six months of recovery. I’m going to take the pill and the doctor’s going to tell me to take the pill. Mental health care in the military is also very similar. It’s about getting them back to work. It’s not about getting them better, and that’s not because they’re bad clinicians — it’s because it’s what the clients want. It’s what the system wants. It’s what’s important to them. So be very ready to unpack slower moving tools with people that already sought help. You see that on a lot of folks that have been on multiple deployments. Care between deployments has been normalized, so they’ll come in with some skills, they’ll come in with having some therapy, but you really need to frame it out that we’re going to do deeper work. We’re to resolve these things as opposed to band-aid them to get you better. And there’s an actively earned distrust with the resources that are available — that the VA has a very sordid history, the government has not handled veteran care well.

Other cultural factors to pay attention to is generational struggles. Iraq veterans are going to have different struggles than I have Afghanistan veterans. Korea veterans are going to be very different from Vietnam veterans. “Peacetime” veterans, and the reason I’m doing air quotes for peacetime is because we have been an armed conflict since World War I. We may not have declared war, but we’ve been in combat the entire time. They’re going to have different feelings around it. Politics of service members. So, when you all were talking, somebody put down that they took on the politics of the service. That’s not quite true. What happens is when I’m in uniform, my only political voice is my vote. I’m not allowed to caucus. I’m not allowed to run for office. I’m not allowed to publicly express political opinion, and I’m certainly not allowed to critique the policies of the administration. I’m allowed to vote.

The military structure is just like the American structure. The people at the top are white, older, educated males with money who tend to skew Republican. So that’s where the voice for the military comes from. Some of them will really identify with that, some of them will really wear that identity, just like other people in the country. They’re going to be varied in their opinion.
They’re going to be committed to it in various ways, and they’re getting more and more polarized as time goes by, just like everybody else. So be ready for that. The military rank structure is going to make for very different experiences in the military. Someone who served as a junior enlisted and got out as a junior enlisted is going to have very different experiences from someone who was an NCO, versus someone who was an officer, versus someone who was a senior officer.

The biggest way I can highlight this is to talk about the officer’s structure. So, you have to have a bachelor’s degree to become an officer in the first place. There are nine ranks all the way up in the officer corps. To get past a third rank in every branch, you have to have acquired a master’s degree on your own time. From then on, every time you progress in rank, you get another degree. They send you back to school every time. So by the time someone’s a Colonel or a Navy captain, they have at least four master’s degrees, if not a PhD. Their struggles are going to be very different as far as what their responsibilities were. Pay attention to that and learn the differences. I’ve talked a lot about the struggles when leaving service.

Common clinical mistakes: We know that trauma and trauma response is pretty universal. We know that the body is going to react in a certain way. However, what I hear a lot of is clinicians overreaching for connection by disclosing or trying to normalize a traumatic response. The most common one I hear from both my responders and my veterans is they’ll come in, they’ll be talking about their trauma response and they’re coming to a specialist. The military respects specialists, and that’s what they expect you to be. They expect you to be a specialist. They expect you to know your lane. However, when you say something like, “Oh, you know, it’s really normal that you’re having nightmares. My daughter was in a really traumatic car accident when she was 16 and she still has nightmares five years later, occasionally, about that accident.” We know that the traumatic response nightmares is going to be common; however, you just compared a car accident to military sexual trauma to combat trauma. That’s not the same frame, and it’s gonna make them feel unheard and like you don’t understand. It’s okay to be curious. It’s okay to not fully understand and speak the language — just don’t make those overreaches.

The other one that I hear is, oddly, a lot of us are married to pilots. I don’t know what that’s about. I hear this all the time where someone will say, “You know, it was really hard. I missed three of the five years of my child’s life and my wife has really struggled with that.” And they’ll say, “Oh, you know, I can really relate. My partner travels for work all the time; it does make it really hard at home.” While that’s kind of true, you weren’t worried about your partner not coming home, you weren’t worried about this happening. A very dear friend of mine went from their most intense combat experience of their career, in which they were awarded a bronze star, and two days later, they were holding their son for the first time. It’s more complex than that. Don’t overreach for those clinical connections.

I know I blitzed through this. It was really, really fast; we barely scratched the surface on what’s available. What you can do now is two things. The first one I want to mention is remember that you are a dedicated, well-trained, caring professional. If a veteran walks in right now and all you’ve had is this, you know how to connect with people. You know how to be kind, you know how to do your job well, and that’s going to go farther than anything else. So, own your expertise. You can also do a little bit more to learn about your clients so they’re not having to educate you as much, right? They need you, they need access to you, they need this normalized. You’ve got the open door to that. Make sure that in your practice, you say that you’re open to working with veterans. Write something up about why and how you want to work with them and what you appreciate about them. Get some more education. I’m going to talk a little bit about that. Find local allies and advocates and specialists to consult with. If any of you ever need 15 minutes for a client consult, please reach out to me. As a community, we should all be willing to give somebody 15 minutes in our specialty to make sure that the people that we care about — the people that brought us to this field — are getting the best service possible from a broadest range of folks. Find those people and trust yourself.

For resources, I cannot recommend PsychArmor.org more. It’s a nonprofit, it’s free, it’s very polished. They’ve got hundreds of hours of different courses on a very broad range of topics. Most of the information I use for my longer training comes from them. If you’re looking for a little bit more in-depth and more modern and, like, the cutting edge of trainings, you’re getting the deployment psychology. The Center for Deployment Psychology is amazing, but they’re all kind of nerds. They’re big data geeks. So they’re really boring, like endless. So unless you’re really into the information, that’s kind of hard to connect to. But it’s astounding, and they’re always putting out what they’re finding. It’s really, really good — in-depth.

Readings and social media: On Killing by David Grossman was the highly recommended book for me when I was starting out. I haven’t talked to a clinician that works with combat freshmen where that isn’t the first recommendation. I also just recommend this for anybody working with anybody in the community, particularly men. Tribe: On Homecoming and Belonging by Sebastian Junger is an absolutely wonderful book. It’s a short read. He does the reading. You can get it on Amazon. He’s got a TED talk if you wanna check that out; it’s a great bit of information. The Invisible War is free and available on Amazon Prime. It follows what happens to, I think, about a dozen veterans that were struggling with military sexual trauma. My caveat to that is make sure that you are watching the full version. I have real issues with how they cut it down and what they did as far as what their information was and the stew that it gives it, if you don’t watch the full version of that. Okay, so we blitzed through; I’m trying to respect your time. I know we’re at the hour mark. I can hang out a little bit for folks, like for questions. If you need to run, please email me and I’ll get back to you.

Thank you for watching this video. We hope you enjoyed the presentation.

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The Recovery Village aims to improve the quality of life for people struggling with substance use or mental health disorder with fact-based content about the nature of behavioral health conditions, treatment options and their related outcomes. We publish material that is researched, cited, edited and reviewed by licensed medical professionals. The information we provide is not intended to be a substitute for professional medical advice, diagnosis or treatment. It should not be used in place of the advice of your physician or other qualified healthcare providers.

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