John Straznickas, MD Substance Use PTSD Team Leader San Francisco VA Medical Center

Working with Veterans in the Community

John Straznickas, MDSubstance Use PTSD Team LeaderSan Francisco VA Medical Center

Thanks to our Veterans for their service to our Country

Increased SUD tx engagement with veterans

Improve Identification of veteransCross-Cultural “Military” TrainingThe veteran re-integration process

Military Culture Take-home PointsTake a stance where your patient teaches you

about their veteran experience.It’s got similarities and differences for each

veteranKnow the basic language of the military

Assess weapons differentlyEngage differently depending on their view of

their military/veteran statusAssess whether a referral to the VA is useful

for them.

Examine your own biasesYour view of weaponsYour view of warYour view of the warrior

Separating the warrior from the warYour view of people who commit violence

Separating the person from the warrior

Basic Military HistoryWhich Branch did they serve in?

Army, Navy, Air Force, Marines, Coast GuardThey are NOT the same.Particular allegiance to their units

Active Duty, National Guard or Reserves?What was their job/MOS?

Basics of a Military HxWhat was their Rank – Enlisted or Officer

Enlisted – E-1 (Pvt) up to E-9 (Sergeant Major/Master Chief

Petty officer)

Officers W-0 (Warrant Officer) up to @W-5(Chief W. Officer

5) O-1 (2nd Lt./Ensign) to O-10 (General/Admiral)

How SUD affects RankRank does not increase while in the military

Demotion of rank

Disciplinary action?

Basic Military HistoryDid they serve in a combat-zone

? How many tours“Outside the Wire.”No safe zones with insurgent warfare

MOS doesn’t say much about exposure to combatCooks, Convoy drivers and Clerks see combat

Basic Military HistoryType of Discharge from the Military:

HonorableGeneral under honorable conditionsDishonorable

Military Sexual Trauma - MSTUnwanted sexual advances?Men and Women are both affected

At least 25% of Women veteran1/5 reportedly raped – under-reported

Culture of hiding/minimizing sexual injuryLoss of trust in a valued institution

This is not ‘only’ work-place harrassment. They ‘live with’ their abuser.Their abuser is protected by the chain of

command

A veteran’s relationship to weaponsAssume they have a weaponTheir weapon is an important part of their

identityFor protection - not harm.

Separate the gun from the bulletsUse trusted friends, colleaguesTrigger locks

If lethal ideation is active, get a safety plan

Not all veterans’ military service was the same

Individual differencesWar differences – VN vs. OEF/OIF

Cross-Cultural perspectivesYour patient has been trained within a strong

cultural environment.Viewing ‘veteran’ as a racial-identityYour patient will have a unique response to

military culture and to his identity as a veteran.

The ‘Military’ as a cultureCultural values

HonorRespectLeave no brother behindProtect yourself - weaponsChain of command

Follow orders

Ways veterans can present to community-based programsConformity – devalues the military and

emphasizes the civilian life

Dissonance – ambivalent about the two ‘cultures’

Immersion/Resistance – Idealization of the military and denigration of the civilian culture

Helms’ Racial Identity Model

Using this Model to work with veterans in the community.The ‘conforming’ veteran

Don’t challenge the devaluing Don’t actively join the devaluing

The ‘dissonant’ veteranUse Motivational Interviewing techniques to

explore the ‘yes-but’ communicationsThe ‘immersion/resistance’ veteran

Don’t challenge the devaluingFocus on the present problem and solution

Keep the VA as a potential resource for services.

Added resourcesSpecialized services

Special challenges for war veterans.Age old problem of coming home and re-integrating.

Homer & Sophocles

More difficult due to the fact that only 1% of the population has done active duty.

Typical Warrior ChallengesA hazardous path at multiple levels

Reluctant to talk about the warPast-Present-Future time distortionsSoldier-Civilian integration

Frustrating journey

Reluctant to talk about the warLegitimate fears of

Judgments – morally questionableMisunderstandings of what war is.

“It’s not like the movies”Facing painful combat experiences/death

High Co-occurrence of SUD/PTSDLook for PTSD in all your SUD patients.

Intrusions – NMsAvoidance – isolation, numbnessHyper-arousal – Insomnia, irritability

These symptoms get worse in early sobriety.Don’t confuse avoidance symptoms with

resistance

SUD/PTSD and AAAvoidance of AA is misunderstood as

resistance.Issue of ‘God’ or a benign higher power.

War is NOT benign.Issue of groups increase PTSD hyper-arousalIssue of listing amends and making amends –

Amends done for their violent soldier duties are a trigger for relapse.

Thanks for your service to our nations veterans

Very rewarding to help the 1% of our Nation’s Warriors

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