- [Voiceover] Good evening, everyone.
I am delighted that we're here for this lecture
and for Kathryn Basham
giving us a sense of the richness of the scholarship
and commitment she has made.
This lecture is a result of a sabbatical year
but a long trajectory of work in the area
of dealing with the needs of service members
and their families.
As professor co-director of the Ph.D program
and editor of the Smith College Studies in Social Work,
Doctor Kathryn Basham engages in
research, writing, clinical social work practice,
and education related to the effects of deployment
and combat stress on the reintegration of service members,
veterans, and their families.
Doctor Basham earned both her
MSW and Ph.D degrees in clinical social work.
She has been appointed to
three congressionally mandated committees
with the Institute of Medicine
at the National Academies of Science,
charged to explore issues related to enhancing the
mental health treatment of military and veteran families.
The current four-year committee
that is producing two published texts
focuses on the evaluation of efficacy of treatment
of PTSD with service members, veterans, and their families.
In this setting, Doctor Basham co-authored four texts
published by the Institute of Medicine,
National Academies of Science.
Titles include: "PTSD Diagnosis in Treatment,"
"Physiologic, Psychological, and Psychosocial Effects
"of Deployment Related Stress with Gulf War Veterans"
in 2008, "Provision of Mental Health Counseling
"Under TriCare" in 2010,
and this past year, "The Assessment of On-going Efforts
"and the Treatment of Post Traumatic Stress Disorder."
I think what's important to note
is that in the work that she has been doing,
she has often been the only clinical social worker
among an interdisciplinary team.
She has held the voice of the field
and the expertise of the field extraordinarily well
and is represented by the fact
that she keeps getting invited back to serve on
these committees.
In earlier years, she published with Doctor Dennis Wheels
a text entitled, "Transforming the Legacy:
"Couples Therapy with Survivors of Childhood Trauma."
She's also focused her scholarship on
intercultural practice and pedagogy in diversity.
She has authored and co-authored numerous papers
on these topics and has presented in both
national and international forums
including Walter Reed National Medical Center,
several Veterans Administration medical centers,
the Canadian Forces social work core,
Austen Riggs Institute,
and various professional organizations.
Doctor Basham served on a major task force
of the Council for Social Work Education
to design military social work competencies
and participated on the expert panel of NASW
to design credentials in military social work
at the BSW, MSW, and advanced clinical MSW levels.
She is an active participant in the
National Interdisciplinary Organization,
the Alliance for Military and Veterans Family,
behavioral health providers.
Doctor Basham has been awarded an
"A Distinguished Clinical Practitioner"
with the National Academies of Practice
and maintains a clinical practice
in Northampton, Massachusetts
specializing in clinical social work practice
with individuals and couples and families,
supervision, and consultation.
What I would say about Kathryn is
as I really worked on re-instituting,
re-engaging the school much more actively
in our commitment to service members and their families,
she has been just very much there as a strong advocate
and as someone who has really put the school
on the national scene in regards to
the excellence in clinical social work education
that we provide here.
She has represented us well
and has done just an extraordinary job for the profession.
So I ask that you join me in welcoming Doctor Basham
to speak on women and the military rewards and challenges.
(applause)
- Good evening to everyone.
Thank you very much Carolyn for your kind remarks.
Can you hear me in the back?
Okay? Good.
Well, women in the military.
You have that I have this here
just to set the stage for some calm
as we move ahead throughout this presentation.
I'd first like to thank a number of people
as I was thinking about this particular topic and
think of the idea that it takes a village
to present a lecture, well, yeah.
I would like to thank a number of women in the military
who've been a particular support team in consultation.
Doctor Camille Hall who's teaching the Beyond Combat class.
This term teaching two sections of it.
I'm also very happy to be thanking Major Deborah Stone.
She is one of our MSW alumni who actually served
both in Iraq and Afghanistan as a clinical social worker
embedded with her particular unit.
Then I'm also interested in thanking a retired
Colonel Cameron Ritchie, who's an army psychiatrist
at Walter Reed Army Medical Center for a good two decades.
The Chief of the Department of Psychiatry,
this is no small feat for a woman
to be a Colonel in that setting.
So I share this talk with you tonight
and thank you for your wisdom.
People often wonder why am I in this field
and I only figured that out oh, some time ago.
But it wasn't fully evolved until, I'd say, 10 years ago.
Because I was reared in a family in New York City
and my father had served in World War II
in the burning south China front.
He was a newly minted physician at the time sent off to war.
He had had very little practice experience, if at all.
He was in a field hospital which consisted of a tent,
no running water.
He was there for two years.
No, very little contact, if you remember,
with the World War II vets back home.
He basically tended to the wounded combat veterans
as well as the veterans, and the local community members
who were suffering from tropical diseases.
So upon return to life in New York,
I was the post-appointed baby so
and we think about what are the effects,
so some of the inter-generational effects
both positive and negative.
So vulnerabilities and strengths,
rewards and challenges.
That's the talk that I'm offering today as well,
women in the military.
And my early years were certainly formed
by these experiences
and my father never talked about it
until I harassed him at about age 18
and insisted upon hearing about stories
and then he finally relented and started telling some
of various experiences that he had had.
But his basic message to me was,
"Don't push.
"If people do not wanna talk about these issues,
"do not insist,"
and that was a clear message.
Be respectful of the pacing for people
in talking about difficult experience.
He said he saw too much death, too much death
and upon return, his hope was to distill
some of the most positive experiences
during the war.
So growing up in New York, my friends always asked me,
"Why do you always, why everyone in your family
"whenever we come to visit you,
"all the meals are curry?
"Indian curry, Burmese curry,
"and meals that, from the far east?"
I said, "Well, I have no idea."
Frankly, this is when I was little.
Then I realized that even though he was
Lithuanian and Hungarian background
that we had adopted some different cultural backgrounds.
So this was a way of trying to distill some of the
really important features of the legacies of war.
So I just thought that I would let you know that.
I lived in D.C. for 20 years where I worked and practiced
and also saw many military and civilian families.
This is a depiction of some of the differences between
women in the military between 1943 and 2013.
Can you see what she is holding?
I don't know if you could see it,
but it's an MRE, meals ready to eat,
as compared with Rosie the Riveter.
She is currently in combat gear.
So I'm gonna be talking about what are the challenges,
stressors, and rewards for women
who served in the military
and then how does research inform our understanding
of the effects of deployment and combat
on women who have served in the military?
The role of gender in the military is absolutely crucial.
Just thinking of,
I'll amplify that as we go throughout this talk.
Want to look at what are the balance of risk
and protective factors in coping with deployment
and traumatic stressors?
Then we're looking at what are the psychosocial adjustments
for women in the military as they return home
and reintegrate?
What are the issues with physical health and well-being?
What are the mental health issues,
specifically military sexual trauma?
And then some of you, yes, bear with me,
but you know the mantra.
I find that it's important to think about
what do we need to do in clinical social work practice?
Some of the major features that I've considered
in this model is to think about relationally-based,
culturally responsive, theoretically grounded,
research-informed clinical social work practice.
So let's talk a little bit about history.
Women have served in the military
for a very long period of time.
With the War on Independence in 1775 to 1783.
Mothers, wives, daughters basically joined the forces
and cooked and washed clothes and tended to the wounded.
Then here, this picture is depicted in the Civil War.
Disguised as a man on the right, Frances Clayton
served many months in Missouri in
Missouri Artillery and Cavalry units in the Civil War.
This was not uncommon.
When detected, actually, and usually
they would be banished and often punished.
But it was very common for women to be serving
in combat positions during that time.
Then in 1901, Congress established the Army Nursing Corps
and several years later, the Navy Nursing Corps.
So women have been acknowledged in different service roles
throughout decades.
At the end of World War I, 49,000 women have had served
as nurses, clerks, typists, and telephone operators.
However, when they returned from the war,
they lost their jobs, mostly they had lost their jobs
that they had previously held.
They had no benefits.
There was no equity in terms of their rights
as service members.
That was during the time in World War I, you know,
we often hear the origin of the school in 1918
where our social work students were actually sent
to their internships were in Eastern Europe and Germany
at the time.
So it's quite incredible.
You think, those of you who are students,
if you think of traveling just to California,
this was a very different experience.
It was a combination of clinical social work
and helping the actual service members
who were dealing with shell shock as well as nursing.
So let's fast forward to Vietnam.
You're all very familiar, again, women were serving
in many medical roles and nursing roles.
But you also see a major presence
in terms of support positions.
In the 1990's, that's when women
were actually flying airplanes
and serving on ships, driving convoys,
you hear the increasing degree of combat exposure
as we have gotten through the decades
and clearly within the last decade
you see equity in terms of their experiences.
So if you can see the comments here.
Okay ladies, you've been equipped
with helmets and body armor as we await orders
to break through the glass ceiling.
Some of you have probably heard of this news.
Certainly, was just this year, which is pretty astonishing,
but in January of this year, women were basically
acknowledged as serving in combat.
The combat related ban was lifted when the Pentagon
released news that this seemed to be,
basically what they had to determine
was that by actually allowing so called,
allowing women to be in combat roles,
that it would not undermine the readiness of the forces.
So the claim was this took a while.
But if you hear the history of the women in combat,
this does seem it certainly did not make a lot of sense.
Okay, this is a slightly different scenario because
most women who I've talked with in the military
they don't want to be viewed as vulnerable
and different from their male counterparts
in terms of their jobs.
They don't want to be seen as victimized or pitiful
or somehow less than.
They want to be equal in terms of rights and pay
and opportunities for advancement.
I just want to talk about the notion of gender as well
because when you think about,
do you wanna be completely equal,
then is there room for difference?
In the military, one of the most important notions
is that there's a universality of values.
Then people would often say,
"Well, why am I in just military social work?"
Well, if you look at the values in the military,
they're directly compatible
with a social work code of ethics.
If you hear the sense of loyalty, pride, dedication,
self-sacrifice, duty, honor,
support of each other, self determination,
these are parallels with social work values.
So if there's a world of universality during combat,
it is important for the service members to pull together.
Because they're united, they're defending,
they're protecting each other.
This is not the time for diversity of differences.
That's when people talk about inter-spree decor.
But in the women in the military, on the one hand,
is there a way to assert
the need for advancements in Civil Rights
while also recognizing that there are differences?
Women experience combat and deployment stressors
in a different way.
So it's at both end that I'm hoping to convey today.
Here, change, yes.
As of January of this year, this is very important
that women are acknowledged in combat.
Because now they can have opportunities for equal pay,
advancement, and benefits.
That's all been denied even up until this past year.
But I love this cartoon here.
We'll change when the deciding about how much.
You see the pool table?
It has all the munitions and different activities.
So, I'll try not to go into too much detail
because it could be mind-numbing
and at quarter to eight, that's not a good thing.
I think it's important, I'm always reminded,
I want to look at the demographics and some of the data
on this population because it's so compelling
when you hear the number and also the situation
and again, think of the both end.
There's some similarities
between male and female service members.
There are differences.
So total number of all service members.
Over 2.2 million service members
have been deployed since 2001,
820,000 National Guard, 96,000 Reservists.
That's a daunting number.
With women, 50% of the current
OIF stands for Operation Iraqi Freedom,
OEF stands for Operation Enduring Freedom
which occurred in Afghanistan.
Of the population of active duty armed forces,
they're 15% of the total forces.
That has been an increase in recent years.
Children, 1.3 million, dependent military children
have been affected by deployments
throughout these last 10 years.
Again, I acknowledge the importance of thinking about
previous era veterans.
Which is incredibly significant
in terms of the work that we're doing,
particularly in the VA systems.
But I am deliberately focused on the OIF, OEF active duty.
Then there's the group of the OND.
This is the group that was in Iraq since 2010
when troops were withdrawn and the nature of combat changed.
Okay, what do you think of this statistic?
60,000,000 family members have been affected
by deployments and combat exposure
and 57% of active duty service members,
think of this one again, 57% of all
active duty service members
have primary family responsibility
of a spouse, children, and or a dependent.
That's daunting, isn't it?
That you can think of, just, it's worth noting.
In terms of just the trends in the field,
there's an increase in Hispanic and new immigrants
and a decrease in African-American troops.
I want to, again, listen to some of these data
and just think of the implications of a voluntary
armed forces.
In terms of race, in terms of the color of troops,
70% self define as White, 17% is African-American,
but that's including Hispanics, 4% Asian,
and when people are asked to report their ethnicity,
they actually say it's 18% of Hispanic origin.
That's a significant sort of number
and also growing number in terms of concentration.
You think of the forces and that
exists both in enlisted as well as officer corps.
In terms of marriages with active duty,
men, 59% are married in a heterosexual marriage
and 46% of women are married.
If you switch to the National Guard, 50% of men are married,
37% of women, you hear the drop?
So again just in terms of the data,
there are more women who are single in the military.
They're caregivers of children, parents,
and other family members.
Then we move on to the rates of divorce.
The rates of divorce between service members
and general community are pretty much the same.
However, the rates for women in the military
are two times the risk of having a divorce
as compared to civilians.
In terms of unemployment,
this is a daunting set of data as well.
12% of veterans at this point are unemployed
compared to the 7.4% rate.
But if you look at just the age range between 18-24,
the percentage of veterans who are unemployed
kicks up to 30%.
This is really significant.
If you start actually reviewing the seriousness
of these data.
These are unemployment, these are service members
returning home, separated from the military
looking for work.
Whether maybe they're reservists or the guard
who had their jobs and had lost their jobs.
Homelessness.
Generally, well the rates of homelessness
are quite dramatic for veterans.
14% for men of all veterans, 2% for women.
So the number of women veterans who are homeless
is lower but then I went further.
You could tell it was a little obsessional exercise here.
But I went further with this investigation
and in this last year, 21,800 women were homeless.
These are OIF, OEF veterans just in the last few years.
That's a very daunting number
and they're right in our backyard, homeless.
So when you think about the U.S.
and talking about our role in the military
think about the floating display of U.S. pride,
remember that, the "Intrepid?"
And then the sinking display of U.S. pride, homeless vet.
So this is another significant change in the military.
For those of you who know about the reversal
of "Don't ask, don't tell."
Because if you noticed what was missing
in my data analysis there of the demographics,
who knows how many gay and lesbian,
bisexual service members or veterans are there.
We have a better counting for veterans
because they may feel more open to
disclose their sexual orientation.
But again, in order to go through with the reversal of
"Don't ask, don't tell," in April 2011,
President Obama, the Secretary of Defense Leon Panetta,
and the joint Chief of Staff, retired Admiral Mullen.
They certified that the lifting of the ban
would not jeopardize troops.
This is just within the writing of the language, so,
"Yeah, hope I'm not a distraction to you boys.
"No ma'am, we're married, to each other."
So what we don't know right now is really
the experiences of, you can't sort of track
some of the experiences for those service members
and who are identifying as a gay, bisexual, lesbian,
unless we start sort of helping them
to express their identity.
Because even though it's been two years out
into this new world of supposed disclosure,
there are still lots of homophobic and other
harsh experiences that people are subjected to.
Okay, so why do I have this up here,
the biology of traumatic stress?
I'm gonna shift into talking about
different themes that are particularly pertinent
to women in the military then.
I'm not gonna go over the typical reaction
of the traumatic stress response,
I will a little bit just because.
But I think many of you know this.
I'm gonna give you a brief clinical vignette later
in the talk today.
But I'll introduce you to Sergeant Sanchez.
She served in Iraq for a year as a medic
and actually, this is her brain at this moment.
This is Sergeant Sanchez.
During combat, she actually witnessed many explosions
and she was in the direct,
directly involved in an IEV blast of a truck
sort of about 100 meters ahead of her
carrying a number of her buddies in her unit.
A young man who's a Private, who she had taken
under her wing only at 18 years old
was killed at the time.
She ran to the truck, the blazing truck on fire,
and tried to rescue him.
She herself suffered first and second degree burns
in that effort and he died in her arms.
So this represented a horrific experience for her.
But when people think about,
remember when those events occur, the brain,
the thalamus receives stimuli.
It receives stimuli of smells and sounds,
and the feel of the air,
all sorts of visual stimuli that are disturbing.
At the moment, Sergeant Sanchez is overwhelmed.
She's not able to really process the event of the blast.
Even though she's running toward the blast
to try to save him, her body is in full,
sort of state of alert.
So her thalamus is stimulated and you know
that the amygdala is the alarm system that signals the call
for the sympathetic and parasympathetic systems
to activate both the enervation and the innovation.
The revving up and the drawing down at the same time.
For her, the hippocampus was not recording any memories
at the time, she was just on autopilot,
just totally in an adrenaline rush,
rushing to save this young man.
We usually think of this as fight, flight, and freeze.
Remember that's the typical phenomenon we think of
with traumatic stress response.
But there's some research that's been done
for the last numbers of years.
UCLA with Taylor and colleague and
what's interesting is there is a hormone that's released,
that there are studies between gender differences
between men and women
and many women actually
produce higher levels of a hormone,
which is called oxytocin.
Oxytocin induces desire for connection, calm,
tenderness, pro-social behavior, bonding, trust,
and reduced fear and anxiety.
Very interesting, isn't it?
That's different from fight, flight, freeze.
So what was Sergeant Sanchez doing at that time?
There needs to be more research to validate those findings
but it seems pretty evident that she ran toward that.
She did not, she didn't freeze,
she didn't fight, she didn't flee.
Now again, she's a medic,
so you'd say, "Well maybe that's her training."
But it seemed that it might be something
we should think about.
Are there gender differences?
Again when you talk about differences,
you always have to be careful.
Let's not be stereotypical.
I'm not suggesting that men
would not have this similar response as well.
Just thinking of these, some of the research data
that support some of these differences.
Okay, so we think about the effects
for many of these families.
There's no such thing as a deployment cycle any longer.
There's no just one deployment cycle.
There are recurrent deployment cycles.
So particularly, many members of the Guard and Reserves
as well as active duty are all in pre-deployment,
deployment-sustained, and post-deployment
and just think of how that works.
They may be home for a period of month to year or further
but then redeployed, return home, redeployed, return home.
So the multiple separations, reunions, and strains
are enormous in terms of adjustments and reintegration.
You think of, this is gonna be
some of the effects of combat trauma,
this is more universal.
That this is often what people talk about
in terms of some of the fears and stressors
for both men and women in combat.
An unsafe environment, exposure to combat and violence,
exposure to dead and mutilated bodies,
this is an important one, loss of hope, sense of purpose.
That's crucial because that can determine effectiveness
in all these different areas.
Deprivation, that is just not having
some of the same comforts that one would have normally.
One's life separation, this one is very interesting because
when there are a number of reports
that the army does each year.
They actually interview service members
in the field in theater.
They do focus groups
and the separation from family and community is as strong
a stressor as the exposure to combat and violence.
Which I think people don't often think that,
but that's what they're saying out there in the field.
Fear and survivor guilt is often very palpable.
There's another one, I was just citing some of the data.
But there's a new phenomenon that's extremely important,
I should go back to that for a minute,
very important in terms of the effects of combat trauma,
it's called moral injury.
People often are experiencing
the sense of challenge
to their own code of ethics,
if they have their own sense
of their rules of conducts and rules of war,
and either they feel they have violated in some way
or if they feel they see their fellow service members
or command violating certain codes.
They can suffer a tremendous sense of
despair and what's called moral injury.
It's very interesting because actually
in talking with people,
that seems to be more predominant now than PTSD.
Depression, moral injury, and then moral injury,
if that is unrelenting leads to suicidal thinking.
So, okay, I didn't wanna leave you on that note.
Most service members and I would say,
just wanna go back to what we know,
most service members return with
out major mental health outcomes or problems.
It's very important that we focus on
resilience and protected factors.
So that just needs to be the backdrop.
Working with fields for so many years,
I'm so struck by people who
one, two, three, four, five deployments in,
there are those individuals of service members and families
who are, look relatively unscathed from the events.
Meaning that they are not suffering
some of the mental health impact.
I wanna focus briefly on the protective factors
because how do people weather the storms?
Proactive coping, we know about training and leadership.
This is relevant just to military and combat
because we know a lot about survivors
of sexual and physical abuse in childhood
and domestic violence in adult life.
But this is crucial.
For those units who've had more
cohesive training and more of a sense of collaboration
and command that they could really trust and value,
they fare much better.
Much, much better than those who,
it's common sense if they don't trust
their fellow service member,
they're not gonna be in a position of some safety zone,
a psychological safety zone.
Family and social support, those are standard
resilience factors that we know about across the board.
This is crucial because I talk about this topic
in a lot of different settings
and the focus is mostly on individual service members still.
We, our program, we specialize in
a clinical social work practice so
I'm leaning toward talking about the clients
that we're working with who have some
mental health or psycho-social concerns, their issues.
In that realm, the predominant narrative is
individual, individual, individual.
The family and social support,
you have to emphasize regularly.
In the more general communities,
some working on bases or in posts throughout the country,
there is a huge amount of tension
to family and social support more in terms of prevention
and resilience building.
So this is a complex intersecting social identities
and other protective factor.
Basically what that means is if
a service member has a strong sense
of military identity or veteran identity and that is tied in
with whatever their other identities are
in terms of socio-cultural or family identities,
they weather these situations better.
The risk factors you probably know.
They're pretty well known in the field
in dealing with combat.
Those of people, the service members who are younger,
lower socio-economic status, lower ranking, female gender,
and previous mental health issues
have increased risk for mental health outcomes.
Again, that doesn't they're gonna have them
but it's just a risk factor.
It has to be counterbalanced with the protective factors.
This is a tricky one, the previous mental health issue.
Talk about childhood trauma,
there's a lot of talk in the field, military DOD,
Department of Defense settings or VA settings.
Because most of the data suggests
if there's childhood trauma then that's a big risk factor
for mental health problems in the field.
That's been contradicted by some research
that's coming out of Rachel Yehuda,
who works out of the Bronx VA now.
Her research suggests she's comparing
some of the service members who've suffered childhood trauma
and those who haven't
and looking at the differences in combat.
The ones who had childhood trauma who resolved their issues
and demonstrated some mastery and some sense of perspective
do better in combat.
So I think that's a very important finding.
I don't have that right here but it's Rachel Yehuda.
This is an important one, a physical injury.
Any of these service members who've been injured in combat,
they have three times the risk,
three times the risk of developing PTSD.
So you must be familiar with the notion of secondary trauma
because this applies to family members
of people who have been exposed to combat or
but it's not just the family members.
Guess who also is going to be exposed
to listening to narratives of traumatic events
in working in this field.
Or actually any of us here in clinical social work
are dealing with exposure to traumatizing events
hearing about them.
And we are susceptible to developing secondary trauma
meaning that we may develop some symptoms that are
very similar to what the person involved is dealing with
in terms of having been directly traumatized.
So there might be symptoms of hyper-arousal, agitation,
poor sleep, detachment, numbing, all of the above.
I remember Jonathan Shay said
a couple of years ago at our conference,
we had the combat stress conference here in 2008.
He said that he sees it as an occupational hazard
to actually work in this field,
when you're working with traumatized clients
so that every employer should basically provide
health insurance that specifically attends
to secondary trauma and plans.
Part of the insurance plan would be
actually providing for yoga and other regular massages
and other avenues for reducing stress.
So I just thought I'd share that.
Actually, in some settings, I've noticed they've done it
and that's been impressive when you see it in operation.
What does secondary trauma do?
It sets the stage for affecting children and family members.
There are a lot of data, unfortunately,
to support that there are higher rates of marital conflict,
intimate partner violence, and effects on children.
This is an important theme,
which I'm at the caregiving.
Because for caregiving is tremo -
remember that data that I was sharing with you?
On 65% of service members are then
caring for a child or family member.
When they're returning home, they're gonna be dealing with
that responsibility.
So rather than just assuming it's caregiving burden,
which is people often talk about caregiver burden,
which of course is important
because of the secondary trauma.
There's also caregiving satisfaction that there's
more work in that area now,
looking at caregiving satisfaction
and post-traumatic growth.
So it's not just a sense of people really suffering
with some of these difficult situations.
What do we know about some of women in
direct in deployment in combat arenas?
First of all the environment,
people in environmental stressors,
when people often talk about 125,
almost like last week, 130 degree heat,
that's when it's insufferable.
Sand, blinding sand, insects, all sorts of toxins
that could be problematic.
These are some of the physical environmental stressors
that are very important.
Also, many of the service members coming back
have major sleep problems.
When you think about some of the issues,
one of the major physical issues is insomnia.
If you have insomnia, you cannot sleep
because you have been preoccupied with
all these environmental stressors and also
worried that you're gonna be injured or killed
or your buddies will be injured or killed.
Sleep is not an easy phenomenon.
At Walter Reed, that's what I found fascinating.
That the first thing they do is try to get people,
service members, on a sleep regimen to regulate it.
Because they cannot cope effectively.
Also, lack of adequate sleep enhances
any mental health problems or also can create.
If you don't have adequate deep sleep
and adequate alpha sleep,
it can actually induce some psychotic experiences.
Don't mean to scare people.
It is an important phenomenon.
Then many women, which I'm gonna back to
talking about women in the military.
Majority are in their 20's, 30's, and 40's,
so dealing with menstruation can be very difficult,
hygiene and limited restrooms.
I found this interesting.
There's one study that suggested 20% of the women
who are interviewed, a very large sample
have reported unintended pregnancies.
What happened, is you wonder, "Well why is that."
Well, sometimes birth control
was not available in the same way.
So it was just more difficult to take care of oneself
and be able to manage
basic gynecological care.
I also talked to one woman who's saying,
"Do you know what it's like to go through menopause
"in 130 degree heat?
"And also trying to serve and do your job
"and maintain your fitness
"and do your fitness routine everyday?"
Yeah, okay. Well, no I don't know but I can imagine.
So childbirth and nursing, that's very interesting
because usually when somebody's pregnant,
they're no longer deployable.
But if they're pregnant in theater
then they have to find out they're pregnant
and then they usually are sent home.
Soon as they're sent home,
then other members in the unit resent them
because then somebody else has to do their job.
So if a man and a woman, heterosexual couple,
are dealing with a pregnancy,
the man is not dealing with problems with deployment.
It's the woman in the military who's dealing,
has negative consequences.
The nursing was very interesting.
This is Colonel Richie was talking about at Walter Reed.
When she was on, she was very focused on this effort
in the early 2000's to make sure that nursing
sailors at the time, women sailors,
would be able to provide for nursing for their babies
when they were on ships.
She set up this elaborate program
which was very important.
She said that as long as the command
would provide enough time, you have to have time,
and spacing and support,
that they would allow the mother to be able to express milk,
save it, and actually nurse to baby over time.
This sounds so, it seems so basic, right?
If you think of people who are back home.
But what happens with a nursing mother who then
would have to automatically stop nursing
or not even be with the baby?
In some deployments, the baby is somewhere else
back home with other family members.
So that's a stressor.
Okay, mental health responses.
These are the ones that are familiar to us
who are doing the clinical work.
Here, I do so much, these committees I'm on
are focusing on post-traumatic stress now, PTSD,
over and over and over and over and over.
But as I said, the depression,
moral injury, and suicidal thinking is really
as significant as PTSD.
They're both significant.
The scary thing for women in the military
is that the rates actually are higher for women than men
in terms of post-traumatic stress
and we have that validated now for over years.
With depression and suicidality, that's not the case though.
Women do not suicide at the same rates as men, service men.
However, when you think of just the general data,
we might find this important because it's rather grim,
compelling some meaning
that we should do something about it.
Last year, 349 suicides just in the army.
There were 295 deaths in combat.
The numbers of suicides are higher than
the numbers of death which is pretty daunting.
When you think of the, with every era, any combat era,
there are different issues that are central.
With the conflicts in Iraq and Afghanistan,
the issues that have existed are,
they're called signature injuries.
They're a cluster.
They're not just one.
It's not just congested here for depression.
It's PTSD, I'd say post-traumatic stress or PTSD.
Most people coming back are going to suffer
some post-traumatic stress.
I would argue that any of us
in combat, we're gonna have post-traumatic stress
because it's a normal reaction to abnormal circumstances.
So they're symptoms but it's not full-blown PTSD.
But this cluster of post-traumatic stress, depression,
suicidal thinking, substance abuse, traumatic brain injury,
and intimate partner violence, they go hand in hand
and you see the incendiary effect of that.
This is why we in our field,
we need to be mindful of not just of the service member
but then the impact on the family.
So this, you're familiar probably with PTS,
the clusters of re-experiencing avoidance and hyper-arousal.
If you think of in families, which of these themes
are most difficult for children,
early on in my work here, I thought it'd be hyper-arousal
because that's scary when family members are elevated
and augmented and mad and rage storms and
scary presence, but that's not the case.
Children desperately respond negatively
to the avoidance and numbing.
That's a really powerfully negative effect.
We'll talk a little bit about military sexual trauma.
The Pentagon data of May of this year,
it said 26,000 service members were assaulted
in the last year compared with 19,000 the year before.
Those of you probably know that
it was all the attention that has been paid
in the recent months in the Senate hearings.
The messages are coming forward
and I think there's much more attention,
people are paying attention.
One of three, one of the military assaults
are compared to one in six civilians.
That's sort of a general number at this point.
But again, that's very daunting.
We're talking about assault not harassment.
Harassment, the data on harassment are like in the range
of something like 70% of the people in the military
suggest that they've been harassed, both men and women.
It's the assault that is more focused on
in terms of the current congressional hearings.
And then why would you think this?
The reports, you know this I think,
the reports in the Department of Defense are lower than in
VA settings, in the Veterans Administration settings.
Well, if you report one of the significant features of
military sexual trauma is that often the person
who has offended is maybe in your unit,
maybe your superior officer,
maybe the commanding officer.
So then many of the women who are assaulted,
and I say women because men are assaulted as well,
it's not just women.
It's just the focus of this talk is women.
But if they are then not separated from the offending
person who has injured them,
they have to live with that.
So not only is there a deterrent to reporting
because of safety, there's a deterrent
because it would affect one's job standing
and any opportunities for promotion.
What we do know though, is military sexual assault
is directly associated with PTSD.
Ms. Hemofarb conducted a study a few years ago.
It examined the relations between military sexual trauma
and the actual outcomes with PTSD.
It's strongly associated with,
rather than thinking that it's associated with trauma
before the military or after the military,
it's strongly associated with military sexual assault.
That's one of the major reasons
that you have these high number of women
who are presenting with PTSD.
So what I was going to mention,
I'm not going to go into much more detail about that.
Jewish St. George who's an A for T has been organizing
a showing which will occur next Wednesday,
7 o'clock in room 106, Sealy 106.
This is a showing, a viewing, of the Invisible War.
For those of you who may or not be familiar with that,
it's a documentary that won a number of awards
within the last two years
documenting the interviews with women
who have suffered military sexual assault.
It's very powerful, so powerful that it was shown
to a number of the male commanding officers
who had sat in the congressional hearings.
What I have found out since from Deborah Stone
who's the Major, she's the one who is a colleague of mine
who's working in Fort Myer in D.C. now.
She has said that the U.S. Army SHARP training,
that's this training, I have all these.
This website, you can log on and take a look at it.
They actually have implemented
very elaborate training so they're trying to
change the culture in the military.
Some of this is pretty basic.
Both in some basic training as well as just
general conversations and general discourse in the military.
People are often using misogynistic,
bigoted, harsh, sexist language.
That does not set the stage for
a respectful, benevolent environment, shall we say.
This is the challenge to the cultural typing
that the Army has now implemented.
I started looking at some of that today.
I mean that they're taking it seriously,
I hope they keep taking it seriously.
What they were saying, it was all that controversy,
should they have reporting outside of the command structure?
But the conclusion, obviously what they're doing now,
is they think they're trying to change the culture
from the top, not just from the lower ranking.
Top down and mid-rank, so we'll see but
I urge all of you to attend the viewing next Wednesday
if you'd like to see and hear
more about these issues in depth.
So okay, let's see.
I'm going to shift now because
I hope I've given you a lot of these data
about what some of the issues are
that women are coming back with.
As clinical social workers, how do we respond?
These are some of the basic principles
that I think they're all familiar to us
that are critical in any type
of clinical social work encounter.
The value of relationship, therapeutic alliance,
cultural responsiveness, research informed stance,
theoretical grounding, and a social justice perspective.
Let me just introduce you to the
Sanchez family a little better
because then I hope that this will convey,
it's only a clinical and yet, it's a composite.
But I'm hoping that the vignette
will capture some of the issues
that we've just talked about
that are facing many women in the military.
I'm going to urge us to think in a very broad sense.
Don't, think beyond just symptom relief.
Think of the complexity
of this client's situation.
First of all, I need to ask you who's the client
because I've introduced you to Maria.
I've told you a little bit about her so far
but I haven't told you about the whole family yet.
So Maria is 37 and was reared in Puerto Rico
in a family where she's the eldest of four children.
She was reared in poverty
in a very difficult, challenging home life.
Her mother was very physically ill
from very, for her early years onward.
So she was caring for many of the siblings.
Her mother died when she was only four.
Mother died from a septic infection.
So Maria was sent at a very early age.
She was sent to family members in New England to live.
But she was, described herself as really marginalized
because she was taken in by some distant relatives
and they, quote, felt sorry for her.
She, in her home life, that had described that she was
beaten by her older brother regularly.
The father was very neglectful and harsh.
She just had an incredibly difficult early years
and managed to thrive,
when we talk about the nature of resilience,
in her new setting in New England.
She managed to go to school, get through high school
and then met Carlos.
Carlos was reared Puerto Rican ethnicity,
oldest of four children, and his family
had lived in New England
for about 40 years.
Very educationally oriented, solid, socioeconomic,
are you hearing the differences in terms of
some of the socio-cultural background?
When they married, they felt the commonality
in terms of religion, ethnicity, shared values.
They desperately wanted to have three children.
Antonio who's now 16, Delia who's nine, and
Anna who's three.
They've been married 17 years
and Maria was in the Army Reserves for eight years.
She wanted to join because she wanted
to continue with her schooling
and she had a sense of pride because some of the relatives
in her family that adopted her and took her in
had been in the military.
So here are the sense of identification
that was positive for Maria.
This family, basically
you sort of think of where they were
two years before her deployment.
They were basically functioning quite well.
All three kids were doing what they needed
to be doing in school, some thriving.
Carlos was an accountant
and Maria was working in a nursing home as a nurse's aide.
So Maria's unit called up.
She's deployed, goes to Iraq,
this is where you hear the story
that she had been, had the experience of being a medic
and separated from,
at the time 15-year old, eight-year old, two-year old.
Think of the implications.
Again, these are the ordinary stressors of deployment
but the dramatic difference between
the two and three-year old, eight, nine-year old and
15 and 16 year old are considerable.
Let me tell you what happened upon return,
return from combat.
Maria was not sleeping.
She had flashbacks.
She wanted to be dead.
She felt that she had no reason to be living.
She was, felt completely detached from the kids.
She didn't know how to engage with them
because she was getting reports from school.
Antonio, the oldest, was getting into trouble.
He was beating up other kids.
Delia was bed-wetting.
She was wetting her bed every night and very anxious
and not able to sleep and Anna would shriek
every time her mother would go to pick her up
and she would start screaming.
So Maria felt like she had lost everything.
She was no longer a decent soldier in her perspective
because she was responsible, this is her word,
she was responsible for the death of that young man.
She was a terrible soldier.
She wasn't a decent mother.
She couldn't be a decent mother to any of these children.
She felt that she failed her husband as a wife
because they were fighting constantly.
She was not only despairing,
but she was not sleeping, angry, irritable,
yelling, yelling at the kids.
He was just, he would try to spend as much time away
from the home as possible.
So, alright.
We have enough of, at least some of the cameo
of the vignette, so what do you do?
Who's the client?
Some of you are familiar with this.
This is my model that I try to use
when thinking about, this is the client.
So who's the client?
Is it just Maria?
And what about Carlos?
What about the whole family?
It could be an individual as a client,
it could be the couple, it could be the family.
I would argue that it was the whole family
that was my client.
With every given client,
we need to pay attention to diversity,
let's see if that shows up here,
health trauma and addictions,
basic developmental themes, family and community,
social policy and research, sociopolitical context,
and ethics.
Does that make sense?
That with every single client,
we need to be mindful of these things
as well as, guess what,
the client is interacting with us.
So as clinicians, we're influencing this
therapeutic alliance at every given moment.
We need to be mindful of all of these factors as well.
So going back to the case,
if you were thinking of what would you do,
how would you assess,
and what theory models would you draw from?
Did you hear in the description with Maria?
With her sense, her nightmares, her flashbacks,
her hopelessness, her irritability, her hyper-arousal?
You're hearing pull for trauma theory right?
Pulls for trauma theory.
Are you hearing the incredible relationship disruptions
and the sense of estrangement that pulls for
attachment theory?
Are you hearing the alienation they have again
with their loved, their families of origin.
They're no longer talking to them.
The family theory comes to mind.
If you think of how we try to use the multiplicity
of theory models, it's not random.
It's actually based on what are the presenting issues
and then pulling from the different theory models.
So why do we care about psycho-dynamic theory?
At least in this line of work,
if we really believe that there are certain patterns
that are established in childhood,
that they're gonna influence
both strengths and vulnerabilities in later life.
That will affect how our female service members
are going to navigate these stressors.
Empowering the unconscious, and then
this is very important,
it's the unique meaning of a narrative of an individual.
Rather than assuming in many settings
the treatment programs are symptom-related.
So if a client has a symptom picture of PTSD,
then they may be recommended to particular protocol
that focuses on PTSD.
It might be cognitive processing treatment, it might be CDT,
which is, would be fine.
Except you need to find out what's the unique meaning
of the experience for the individual,
rather than just focusing on symptom picture,
who's the individual?
Transfer and counter-transference is pivotal
because it tells us how we are reflecting on the work
and what role that has on the work.
I use attachment theory regularly with this population
because it doesn't make sense that
with all the separations and reunions
and disengagements and re-attachments
that under the best of circumstances,
this couple, that couple, had a secure attachment.
It was earned security.
Maria had more of a disorganized attachment.
I'm gonna move through this pretty quickly,
but if those of you who are somewhat familiar
with attachment theory, you realize that there are either
secure or insecure internal attachment models.
This organized and disorganized
what Maria was dealing with as a child.
She had a relatively secure attachment with Carlos
by the time she went off to deployment.
Their attachment systems were disregulated
based on the numbers of stressors that bombarded them.
This is an important construct,
the interference with mentalization.
The part of attachment theory that's a capacity
to actually be aware of one's feelings
and reflect upon them and then be able to attune
to the feelings of other people,
and also reflect upon them so that there's a capacity
to make sense of it in meaning making.
When there are enough combat and deployment stressors,
this process, mentalization, breaks down as well.
Think again, this is what gets interrupted
when you have enough stress,
the care-seeking of attachment breaks down.
People don't always seek care.
Remember with Carlos?
He wasn't seeking any care,
she wasn't seeking any care from each other.
They're not offering a safe haven to each other.
There's no curiosity and this is a crucial one.
The circle of security is broken,
that sense of connecting back to the person
who or people who are most important
in terms of providing comfort and security.
How about another model for a moment?
Why do we care about Winnetka?
First of all, Donald and Claire Winnetka
focused their entire careers in early World War II
in helping children survive the blitz.
They took them to homes outside in the countryside.
One would think, well would they still be traumatized?
Because they were taken away from their families?
No, because they provided homes
that had a good enough holding environment
and good enough mothering, concepts from his model,
that helped to sustain them.
When reunited with their families back in London,
they navigated those separations quite well.
Victim, victimized, or by-stander, why is this relevant?
Anyone who has suffered trauma
would know what it's like to be a victim.
You've had somebody who's offended you
and there's usually a by-stander
who hasn't done much of anything.
Why is that important?
Because in families, if you think of Antonio,
go back to, no, Carlos.
Carlos the husband felt like a helpless victim.
He felt victimized by his partner.
She felt victimized as well.
Neither of them were really recognizing
that they were aggressive in victimizing each other.
These themes are important in families as well as for us.
As long as we reflect,
we have a better chance of helping our clients.
Back to the practice approaches
that those of you who work in the Department of Defense
and VA settings, these are probably familiar to you.
These are considered the gold standard treatments
for PTSD and depression, cognitive behavioral work,
cognitive processing treatment, prolonged exposure.
They're all CBT models.
They all have very strong validity.
However, imagine with Carlos and Maria.
Can you imagine them focusing exclusively
on these models without paying attention
to couple and family therapy and other methods.
What I want to, well let me go back to this for a moment.
Just propose why would we want to work with families
because I'm arguing with this need
for actually working with this entire family.
And that's to promote secure attachments.
We help them reconnect,
reduce the mental health symptomotology,
minimize secondary trauma,
help them with learning more,
and then restoring a sense of reconnection,
social vindication.
So this is a trauma informed model that I've been working on
that's geared to military and veteran families.
It's similar to a lot of trauma inform models
where the first stage if safety, stabilization.
Second, reflection on the trauma narrative.
Third, consolidation of new perspectives.
But what I'm going to emphasize is the attachment piece
because getting back to the case of Carlos and Maria.
They needed to have a sense
that there was a safe environment at home
because you hear the volatility?
Wasn't clear to me
if there was intimate partner violence or not.
Had to do a risk assessment to establish safety.
The whole realm of self-care was crucial.
The affect regulation was just thrown off
not only for Maria who was the combat veteran.
but for her husband.
Does that make sense?
In their years where they had more stability,
they were able to relate in really harmonious ways
and to be able to self-soothe
and to be able to manage their emotions
without having these incredible ups and down, rage storms.
This feature was absolutely critical.
The bio-behavioral strategies for stress reduction,
that's repeated there, I guess I'm trying to make the point.
Stress reduction, self-soothing after regulation.
This couple was completely disregulated
so this was the major focus of the self-care.
In addition, in this early phase of the work,
remember the physical health?
Neither of them were sleeping.
Not just Maria.
Carlos wasn't sleeping
and the little one, Anna, wasn't sleeping.
Delia was wetting her bed.
The only one sleeping was Antonio.
The whole household had problems with physical health.
Mental health, you heard the issues.
Maria needed to have a referral for a psychiatrist
to see if she needed help with sleep, depression,
check out any possible suicidality.
She was also drinking several glasses of wine,
two or three, four glasses of wine a night.
So had to be checked.
This is where you can pull in, if you are the clinician
who's actually providing the support.
At this moment, you're providing
a supportive psychotherapy role.
You're doing a extended assessment
and building a therapeutic alliance
while connecting with this whole cast of characters.
The psychiatrist, physicians, nutritionists,
other clinicians who are working.
The school system who are the school counselors
who are dealing with the children who are suffering.
Psycho-education regarding post-deployment.
This is also a piece of this for many of couples then,
the partners need just basic understanding
of some of the stressors
that they may have been dealing with.
So once again, it's understanding safety
and developing in attachment theory language.
What they were doing is developing
secure attachments and re-connections once again
so they're able to move on.
Moving on means actually trying to address
some of the traumatic experiences.
At that point, Maria is ready for being,
for entering cognitive processing treatment.
She's in a position where she's stable enough
to be able to withstand recalling the content
of the horrific traumatic events.
So Maria gets her own individual therapist.
But what do we do in couples therapy?
She starts to talk about how devastated she was
of being lost and not having any role in her family,
of losing her husband, losing her children,
losing her sense of being a soldier, wanting to be dead.
He then becomes Carlos, much more compassionate because
at this point, they are starting to talk to each other
and talk about how they've missed each other,
how they've lost each other.
The grieving, this is a phase of grieving and
it's not just sharing of trauma events,
it's the grieving of those experiences
and the grieving of whatever was lost during the deployment,
the lost years with these children.
So this couple was actually able to go
from a sense of bitter estrangement
to really connecting with each other in a powerful way.
Why does this matter?
The pattern of victim, victimized, by-stander?
They were each blaming the other.
She kept saying to him that he seemed so passive
and hopeless and helpless and she couldn't stand it.
He kept saying she was so agitated and angry
and furious and hard to be around, he couldn't stand it.
So they were unable to tolerate the other's qualities
and they were victimizing each other constantly
back-and-forth, back-and-forth, back-and-forth,
back-and-forth and ultimately as they were talking about
what they had lost, what they felt they had grieved,
they were able to then actually
establish more of a connection.
He said to her that he hated her bitterness.
That she'd become a bitter old woman, old, she's like 38.
Bitter old woman who he just couldn't stand
being around anymore.
And she also, another part of this that happens
with a lot of combat veterans, and I think it's this
important phenomenon, she had a lot of,
she just hadn't sounded so racist and bigoted before.
But she certainly did after combat.
She only had vicious things to say about anybody
who looked as if they had Middle-Eastern ancestry,
ethnicity, and family background.
She would hurl all these nasty comments
and really sound quite vicious.
He said he couldn't live with somebody
who was so vile and so hateful.
As she kept talking about what happened
when she saw this young man killed in holding her,
in her arms, she said, "I hate all of them.
"I hate them, I hate them."
Then he said to her,
"Why are you hating an entire group of people?
"When one person, one person, killed?
"And even that one person is just a human
"who was fighting just the way you were fighting?"
She then sank into a state of tremendous sadness
and helplessness and powerlessness and fear and anxiety
and reowned, she reowned what had been projected onto him
as being helpless and frightened and insecure.
So do you hear the unpacking of the,
there was an unpacking of racialized hatred.
Because if people are trained to see the enemy
as bad and evil, and good and bad, and you kill the enemy,
don't expect that to change necessarily
automatically upon homecoming.
Some of those, sort of, deep-seeded beliefs
can really settle in.
Fortunately hers was not that deep-seeded.
It was the unpacking, the hatred, was tying in with her
inability to stick with her powerlessness.
For him, what was interesting, what was he disowning?
He was disowning his aggression.
He couldn't recognize how furious he was with her.
He was sick of having this wife
who had seemed so unavailable to him
and he was furious, from his perspective,
stuck with having to take care of the three children
while she was gone and nobody complimented him
on what a good job he had done.
So this period then continued on with a lot of discussion
about the rage, his rage, and his frustration.
So do you see the unpacking
and the levels of shared expression of their feelings
which are absolutely critical for them
to be able to move to a more of a state of reconnection?
So their attachments were beginning to rebuilt.
They began to empathize more with each other,
grieve together and one of the healing rituals
had to do with her openness to accept.
She was awarded a medal, a Purple Heart,
for some of her, said of her heroism.
She said, "I'm not a hero.
"Not a hero at all.
"I don't want it, throw it out."
So ultimately they had long conversations
about what that might mean
and moving along to another phase of the work
where her social identity,
this is where she could sense that as a veteran,
that she was going to move from being the service member
to veteran, that she would feel honored by actually
accepting her award.
This is something to think about.
See where we are?
Maybe all of the above might be in terms of doing this work.
But what I would like to say at the end here,
to think of this, just thinking of
why do we focus on this work and why is it so important?
It seemed to me that
as long as we just recognize that a client is what,
Winnetka would just say there's no such thing as a baby,
that's just a nursing couple.
There's no such thing as just a solitary service member.
There's always, the service member always
has to be understood in the context to
whoever his or her family would be
or people who are important to her.
The context is absolutely crucial.
If we can be holding onto complexity
and thoughtfulness in working with this population,
we can recognize the need to have
the relationship as the underpinning of the work.
That allows for us to move slowly, going back to the idea,
if we could wait for the client
to tell us what the clients really need
and the pacing of the work.
So that they will then help to define,
what do they need first?
It's always self-care, safety,
stabilization first and then moving into different layers
and different levels of complexity that they can bear.
So that they can reconnect in ways
that will really be powerful.
I would say, I would say that that's our charge
with this population
and I think we will make quite a difference
for many success of generations of children if we do so.
So, I thank you.
(applause)
So are there any comments or questions or reactions?
Yeah, Seth?
(audience member speaking inaudibly)
Yeah, well I'd be curious and
if there are ideas from the group as well.
But my senses, even with this case,
I didn't highlight that.
But actually for her, as a reservist,
she was cut off from the members of her union.
Part of that was her detachment.
She didn't wanna talk with people.
It was part of her avoidance.
So a good part of the work was for her to think about
how important those people were to her
during deployment and she started to reconnect.
But then, if there are some people
who are not gonna be reconnecting with their,
the people they actually cared about, but even
the connection with other veterans can be so powerful.
That that's early on.
People often think that before people enter into treatment,
if they need different types of psychotherapies,
they often do very well to that.
Then that often had a sense of shared experience,
even if they weren't deployed together.
But I'm curious, are there anybody in the audience
who would speak to that?
For those of you who have?
Okay, any other?
(audience member speaking inaudibly)
Oh okay, well that part of the
victim, victimized, or by-stander scenario
is one to think about because that's,
that resonates regularly
with working with traumatized clients.
Just to give you an example,
my work, mine was the work as a couple,
family therapist, and again, it's disguised in composite
but it has elements of the actual case.
So I would reverberate back and forth
from feeling a sense of helplessness
in thinking this family seems so devastated.
The children were so, they were suffering so badly,
that I was glad that I had listened to the history
and that's always important, to get a full history
because that's what made me realize
they had tremendous promise.
So I was struggling with should I just give up?
Or I could send this couple or family to another client,
send the clients to another clinician.
That's the typical helplessness that we can resonate with.
Then the sense of victimizing.
Just feeling really frustrated,
I would get very angry with her when she would start making
really, she would curse all the time really nasty, bigoted,
offensive remarks and I would get annoyed with her.
Then I would think, alright, unpack it.
You need to pay attention, what is she really saying?
What's beneath the vitreal?
The by-stander, as the social workers,
we have to be careful.
We don't just try to jump in and rescue people
and try to make nice and have it all be taken care of.
So that's a typical counter-transference response.
Then the more detached by-stander is a scary one
because we can be susceptible to secondary trauma.
I talked about so, that zoning out detachment.
If you're planning your next vacation
while you're sitting working with a family like this,
that's a clue of counter-transference enactments.
So usually enactments have to have an action component to it
of doing something.
Usually if we just sit quietly and have the experience
then we could try to catch it.
That was part of the self-reflection
so we don't inflict it on the clients.
But even when there's an enactment,
sometimes that can be helpful.
Because I remember when I was annoyed with her a few times,
she said, "Why are you so judgmental, Kathryn?"
That's just because I didn't like her, some of her language.
So she caught it, she realized I was acting on my
counter-transference.
I wasn't just quietly sitting there.
So you can use that regularly
to try to understand the clients better
and then also when necessary, repair the rupture.
I could've lost them if I didn't figure out.
I said I was really trying to,
I did find it hard to listen to because it was so nasty.
But I was trying to understand what it meant to her
and did she always have those feelings?
"No, I din't have those feelings.
"I've only had it since I was in Iraq and back."
So that was the clue.
So does that, thank you for asking that
because I didn't amplify that.
Yeah?
(audience member speaking inaudibly)
Did everyone hear that?
Just the question that,
so this is one family, one deployment and actually,
that you see what can happen sometimes with one deployment.
But some families, four, five, six
types of reunions of this sort, what do you do with that?
Some of them actually do not have these difficulties.
But others do.
That's something we need to be mindful of
in doing this work.
I would say proceed nonetheless because if the family
has that history of strength and desire to be together
and they've had those experiences of strong connection,
then some of these complex models can be very useful.
But it raises the question about
what are we doing in our country
when we constantly redeploy, redeploy, redeploy, redeploy,
when we know the data suggests that this is harmful.
If there are enough times of this,
that it's the people in the minority
maybe who have no effects,
who suffer no negative effects.
(audience member speaking inaudibly)
Yeah, mhmm.
(audience member speaking inaudibly)
So you're saying that the service member
might not actually have some difficulties
in the integration, but the families sometimes can.
I would hope that we, particularly in our field,
that's why I primarily talk and work with the families.
I'm focusing on the women in the military because
that's an area that I'm interested in nowadays as well.
But the families are pivotal as sources of support
and also they need assistance, our assistance,
when they're suffering.
So, we just have. Yeah. Take you there first.
(audience member speaking inaudibly)
The moral injury?
Well it usually occurs around some event
where the service member has experienced
something that they had felt,
that their sense of ethics,
they've betrayed their own sense of ethics.
What's interesting is even though for her,
this was very clear cut.
She felt that she should've been able to save this young man
and so she felt that she let herself down
and it was just completely morally corrupt.
But that was her view of it.
Sometimes people, other people can actually
observe something they consider egregious.
Often the killings of children or
whether deliberate or instead of
the so-called non-combatants who get killed
in the process of war.
That can feel horrific.
Just as being a bystander who's watching.
Sometimes the feeling of moral injury
can be almost as profound
as having done something one-self.
So inviting that type, that conversation I think
is what's important but usually again,
the timing, the pacing is so crucial
because that is such delicate territory.
People have to be ready to do that.
If you noticed with this couple,
I was deliberately trying to convey
you have to work with that first phase.
Which is really both strings strengths
helping them reconnect, re-establish attachments
and then each of them had a sturdier base.
They could also regulate their moods better, each of them,
so they could withstand the discussion of,
because it brings up such shame and guilt.
Not just guilt, shame.
For her, she was able to get to a point
where she could then see that
she was human and mortal and humble
and she could not do it.
She just had tremendous valability and she hated that.
But that's different from so-called ethical defect.
Yeah, Ruth, did you?
(audience member speaking inaudibly)
How long to get to stabilization?
For this particular family, just a couple of months.
Because I think if that's your goal,
if your goal is to pay attention
to what the pressing issues are,
and then work, it's interdisciplinary work though,
you're coordinating with this cast of characters.
You are the anchor trying to then provide
its clinical case management that's best
with old Winnetka and clinical case management.
Where we can be in touch with a whole range of people
and so you're creating this circle of security.
It's not just the partners.
It's the children, it's the school.
It's all the cast of characters in the professional network
that need to be included as well.
So, go ahead.
(audience member speaking inaudibly)
It's mostly military sexual trauma.
That's what they're saying.
That that's a direct association with why
those rates are significantly higher for women.
Because otherwise they're exposed then
to some of the same combat stressors as men,
the male counterparts.
So it's not as if they're...
Yeah, any thoughts about that?
Anybody have thoughts about that?
Of why they would, women would have more risk factors?
One thing is that if people are then deployed
with different units, they haven't trained with the unit,
and if there's a sense of insecurity then
with the other service members or the command.
That's a very, that's not necessarily gonna cause PTSD.
But you have to look at the risk factors
and the protective factors.
That's the balance of the two.
Yeah.
(audience member speaking inaudibly)
You're just talking about the continuation
of the mass analyzed culture?
I didn't hear the last...
(audience member speaking inaudibly)
Oh okay, yeah.
(audience member speaking inaudibly)
So you're saying, so you're hearing pockets of mysogyny?
That's what I think some of the brass are talking about now.
That there's certainly going to be
ongoing misogynistic attitudes.
But now there's some effort to tell people
you don't talk that way.
This is what harassment is.
This is rape.
This is assault.
This is abusive talk.
But, yeah, it seems like that persists.
Maybe just one more comment and then we're gonna wrap up.
Yeah, go ahead.
(audience member speaking inaudibly)
Mhmm, yeah.
(audience member speaking inaudibly)
Yeah, that's a very good point
that sometimes that's become part of the training
if you've heard about some of the basic training
and it's yeah, that's nasty stuff.
It's misogynistic, it's racist, it's bigoted.
It's all the above.
But it's what we might think of as abusive language.
But they are suggesting that one of the high rates
of military sexual assault has something to do with that
sort of that generalized acceptance.
That the language then can translate into behavior.
That's sort of like it becomes, words become the behavior
so that type of harsh treatment doesn't,
you have to set the limit and the boundary
between the words and behavior
and then also adjust the language.
No easy feat here, but..
So I wish us all the best in working with this population.
So thank you very much.
(applause)