- [Woman] Good evening, everyone.
- [Audience responds]
- I am delighted that we are here for this lecture
and for Kathryn Basham's giving us a sense
of the richness of the scholarship
and commitment she has made.
This lecture is the result of a sabbatical year,
but a long trajectory of work in the area 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,
Dr. 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.
Dr. Basham earned bother 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, Dr. Basham co-authored four texts
published by the Institute of Medicine,
National Academies of Science.
Titles include, "PTSD: Diagnosis and 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 Ongoing
"Efforts in the Treatment of Posttraumatic 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 Dr. Dennis Miehls
a text entitled "Transforming the Legacy:
"Couples Therapy with Survivors of Childhood Trauma ."
She's also focused her scholarship on intercultural
practice and pedagogy and 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 Corps, Austen Riggs
Institute, and various professional organizations.
Dr. 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 Veteran Family Behavioral Health Providers.
Dr. Basham has been awarded 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, couples
and families, supervision and consultation.
What I would say about Kathryn is, as I really worked on
reinstituting, reengaging 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.
And so, I ask that you join me in welcoming Dr. Basham
to speak on Women and the Military: Rewards and Challenges.
(audience clapping)
- 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.
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.
So I was thinking about this particular topic and I 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 have done a particular support to me in consultation.
Dr. Camille Hall, who is 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 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 I'm 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.
I was reared in a family in New York City, and my father
had served in World War II and the Burmese Chinese 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 worked in a field hospital, which consisted of a tent.
No running water, and was there for two years
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.
Upon return to life in New York,
I was the post-deployment baby.
When we think about what are the effects,
some of the inter-generational effects,
both positive and negative.
Vulnerabilities and strengths.
Rewards and challenges.
That's the talk that I'm offering today as well.
Women in the Military.
My early years were certainly formed by these experiences.
My father never talked about it until I harassed him
at about age 18 and insisted upon hearing about stories.
Then he finally relented and started telling
various experiences that he had had.
His basic message to me was, "Don't push!
"If people do not want to talk
"about these issues, do not insist."
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.
Upon return, his hope was to distill some of
the most positive experiences during the war.
So, growing up in New York, my friends would always
ask me, "Why does everyone in your family, whenever
"we come to visit you, all of the meals are curry,
"Indian curry, and Burmese curry
"and music from the Far East?"
I said, "Well, I have no idea frankly."
This is when I was little.
Then I realized that even though I was
Lithuanian-Hungarian in background, that we had
adopted some different cultural backgrounds.
This was a way of trying to distill some of the really
important features of the legacies of the war.
So I just thought that I would let you know.
I lived in D.C. for 20 years, where I worked in practice
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 can see it,
but it's and MRE, Meals Ready-to-Eat.
As compared with Rosie the Riveter,
she is currently in combat gear.
I'm going to be talking about one of the challenges,
stressors and rewards for women
who have 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.
I was just thinking I will amplify that
as we go throughout this talk.
I want to look at, what are the balance of risk and
protective factors in coping with
deployment and traumatic stressors?
And 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.
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.
Here this picture is depicted in the Civil War.
Disguised as a man on the right, Frances Clayton served many
months in Missouri at the Missouri artillery
and cavalry units in the Civil War.
This was not uncommon.
When detected, actually they usually 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 and Nursing Corps.
Then, 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 had served
as nurses, clerks, typists and telephone operators.
However, when they returned from
the war, they lost their jobs.
Mostly they had lost the 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 of where you know we often
hear the origin of the school in 1918 where social
work students were actually sent to, their internships
were in Eastern Europe and Germany at the time.
It's quite incredible when 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.
Let's fast forward.
In Vietnam, you're all very familiar.
Again, women were serving in many
medical roles and nursing roles.
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 gone through the decades.
Clearly, within the last decade, you see equity
in terms of their experiences.
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.
It was just this year, which is pretty astonishing.
In January of this year, women were basically
acknowledged as serving in combat.
The combat-related ban was lifted
when the Pentagon released news.
Basically what they had to determine was that by
actually allowing women to be in combat roles, that it
would not undermine the readiness of the forces.
The claim was this took a while.
If you hear the history of the women in combat,
this certainly did not make a lot of sense.
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.
When you're thinking about do you want to be
completely equal, then is there room for difference?
In the military, one of the most important notions
is that there is a universality of values.
People would often say, why am I
interested in military social work?
Well, if you look at the values in the military,
they're directly compatible with
the 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 parallel with social work values.
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 or differences.
That's when people talk about in esprit de corps.
In the military, on the one hand, is their 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.
It's a both/and 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.
I love this cartoon here.
"Real change.
Women deciding about combat."
Do you see how the pool table has all the
munitions and different activities?
I'll try not to go into too much detail
because it could be mind numbing.
At a 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.
Again, think of the both/and.
There's some similarities between
male and female service members.
There are differences.
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, 15 percent 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 are 15 percent 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.
I am deliberately focused on the OIF/OEF active duty.
Then there's the OND.
This is the group that was in Iraq since 2010, when
troops were withdrawn and the nature of combat changed.
What do you think of this statistic?
60 million family members have been
affected by deployments and combat exposure.
57 percent of active duty service members,
so think of this one again.
57 percent of all active duty service members have
primary family responsibility of a spouse,
children, and/or a dependent.
That's daunting, isn't it?
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.
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 current troops,
70 percent self-define as white,
17 percent as African-American.
That's including Hispanics.
Four percent Asian.
When people are asked to report their ethnicity,
they actually say 18 percent of Hispanic origin.
That's a significant number, and also growing number,
in terms of concentration, when you think of the forces.
That exists in both enlisted as well as officer corps.
In terms of marriages, with active duty men,
59 percent are married in heterosexual marriage.
46 percent of women are married.
If you switch to the National Guard,
50 percent of men are married.
37% of women, do you hear the drop?
Again, just in terms of the data, there are more
women who are single in the military.
They are 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, 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 percent of veterans at this point are
unemployed, compared to the 7.4 percent rate.
If you look at just the age range between 18 and 24,
the percentage of veterans who
are umemployed kicks up to 30 percent.
This is really significant, if you start actually
reviewing the seriousness of these data.
These are unemployment.
These are these service members returning home,
separated from the military, looking for work.
Or it may be the Reservists or the Guard
who had their jobs and have lost their jobs.
Homelessness.
Generally, well the rates of homelessness
are quite dramatic for veterans.
It's 14 percent for men of all veterans,
two percent for women.
So the number of women veterans who are homeless is lower.
Then I went further.
You can tell it was a little obsessional exercise here.
I went further with this investigation.
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.
They are right in our backyard, homeless.
When you think about the U.S. talking
about our role in the military,
sort of at the floating display of U.S. pride.
Remember that, the Intrepid?
Then the sinking display of U.S. pride, homeless vets.
So this is another significant change in the military.
For those of you who know about
the reversal, Don't Ask Don't Tell.
What was missing in my data analysis there of the
demographics, who knows how many gay and lesbian
and 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.
Again, in order to go through with the reversal
of Don't Ask, Don't Tell in April of 2011,
President Obama, the Secretary of Defense
Leon Panetta, and the Joint Chief of Staff,
retired Admiral Mullen, certified that the lifting
of the ban would not jeopardize troops.
This is in the writing of the language.
"Hope I'm not a distraction to you boys."
"No Ma'am, we're married."
"To each other."
What we don't know right now is really the experiences.
You can't sort of track the experiences for
those service members who are identifying
as a gay, bisexual or lesbian unless we start
helping them to express their identity.
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.
So why do I have this up here?
The biology of traumatic stress.
I'm going to shift into talking about different themes
that are particularly pertinent to women in the military.
I'm not going to go over the typical reaction
of the traumatic stress response.
Okay, I will a little bit.
I think many of you know this.
I'm going to give you a brief clinical
vignette later in the talk today.
I'll introduce you to Sergeant Sanchez.
She served in Iraq for a year as a medic.
Actually, this is her brain at this moment.
This is Sergeant Sanchez.
During combat, she actually witnessed many explosions
and she was directly involved in an IED blast of a truck
about 100 meters ahead of her, carrying a number of
her buddies in her unit and a young man, who was a
private who she had taken under her wing,
only 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.
This represented a horrific experience for her.
Remember, when those events occur, the thalamus 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 a full state of alert.
Her thalamus is stimulated.
You know the amygdala is the alarm system that signals
the call for the sympathetic and parasympathetic systems
to activate both the enervation and the innervation.
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 this is the typical phenomenon
we think of with traumatic stress response.
There's some research that's been done over the last
number of years at UCLA with Taylor and colleagues.
What's interesting is there is a hormone that's released.
There are studies between gender
differences between men and women.
Many women actually produce higher levels
of the hormone, which is called oxytocin.
Oxytocin induces desire for connection,
calm, tenderness, prosocial behavior,
bonding, trust and reduced fear and anxiety.
That's 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 didn't freeze, she didn't fight, she didn't flee.
Now, again, she's a medic, so you
would say maybe that's her training.
It seemed that it might be something we should think about.
Are there gender differences?
Again, when we talk about differences,
we always have to be careful.
Let's not be stereotypical.
I'm not suggesting that men would
not have this similar response as well.
I'm just thinking of some of the research
data that supports some of these differences.
We think about the effects for many of these families.
There's no such thing as a deployment cycle any longer.
There's just one deployment cycle.
They're recurrent deployment cycles, so particularly
many members of the Guard and Reserve as well as
active duty are all in pre-deployment,
deployment, sustainment, post-deployment.
Just think of how that works.
They may be home for a period of a month
to a year or further, but then re-deploy, return home.
So the multiple separations, reunions and strains
are enormous in terms of adjustments and reintegration.
Some of the effects of combat trauma,
this is more universal.
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 and sense of purpose.
That's crucial because that can determine
effectiveness in all these other areas.
Deprivation.
That is just not having some of the same comforts
that one would have normally in one's life.
Separation.
This one is very interesting.
There are a number of reports that the army does each year.
They actually interview service members
in the field and theater, and they do focus groups.
The separation from family and community is as strong
a stressor as the exposure to combat and violence.
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.
There's a new phenomenon that's extremely important.
Very important in terms of the effects of combat trauma.
It's called moral injury, that people are often experiencing
in the sense of challenge to their own code of ethics.
If they have their own sense of their rules of conduct
and the 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 in talking with people,
that seems to be more predominant now
than PTSD, depression, moral injury.
Moral injury, if that is unrelenting,
leads to suicidal thinking.
I didn't want to leave you on that note.
Most service members, I would say,
just want to go back to what we know.
Most service members return without major
mental health outcomes, or problems.
It's very important that we focus
on resilience and protective factors.
So that needs to be the backdrop.
Working this field for so many years,
I'm so struck by people.
One, two, three, four, five deployments.
There are those individuals, service members and
families who look relatively unscathed from the events.
Meaning, they are not suffering
some of the mental health impact.
I'm going to focus briefly on the protective factors.
How do people weather these storms?
Proactive coping.
We know that.
Training and leadership.
This is relevant just to military and combat.
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 can really
trust and value, they fare much better, much much better.
It's common sense.
If they don't trust their fellow service members,
they're not going to 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 are a program that specializes in clinical social
work practice, so I'm leaning toward talking about
the clients that we're working with who have some
mental health or psychosocial concerns.
They're issues.
In that realm, the predominant narrative is individual.
Individual.
The family and social support
you have to emphasize regularly.
In the more general communities, I'm working
on bases or in posts throughout the country.
There is a huge amount of attention
to family and social support.
More in terms of prevention than resilience building.
So this is a complex intersecting social identities.
Another 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 sociocultural 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.
The service members who are younger,
lower socioeconomic status, lower ranking,
female gender, and previous mental health issues
have increased risk for mental health outcomes.
Again, that doesn't mean they're going to have them.
It's just a risk factor.
It has to be counterbalanced with the protective factors.
This is a tricky one.
The previous mental health issues,
we talked about childhood trauma.
There's a lot of talk in this field, military DOD,
Department of Defense settings, or VA settings.
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.
Rachel Yehuda, she's working at the Bronx VA now.
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.
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.
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.
This applies to family members of people
who have been exposed to combat.
It's not just the family members.
Guess who also is going to be exposed to listening to the
narratives of traumatic events and working in this field.
Actually, any of us here in clinical social work are dealing
with exposure to traumatizing events, hearing about them.
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 the Combat Stress Conference here in 2008 that he sees it
as an occupational hazard to actually work in this field.
When you're working with traumatized clients,
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.
I just thought I would share that.
Actually, in some settings, I noticed they've done it.
It'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.
Remember that data I was sharing with you?
Like 65 percent of service members are
then caring for a child or family member.
When they're returning home, they're going
to be dealing with that responsibility.
Rather than just assuming it's caregiving burden.
People often talk about caregiver burden, which is
important because of the secondary trauma.
There's also caregiving satisfaction.
There's more work in that area now, looking at
caregiving satisfaction and post-traumatic growth.
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
deployment or in combat arenas?
First of all, the environment.
Environmental stressors.
People often talk about, how about 125, 130 degree heat?
That's insufferable.
Sand, blinding sand.
Insects.
All sorts of toxins that could be problematic.
These are 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 of these environmental
stressors and also worried that you are going to be injured
or killed, or your buddies would be injured or killed.
Sleep is not an easy phenomenon.
At Walter Reed, that's what I found fascinating.
The first thing they do is try to get service
members on a sleep regimen, to regulate it,
because they cannot cope effectively.
Also, lack of adequate sleep
enhances any mental health problems.
It also can create.
If you don't have adequate deep sleep and adequate
alpha sleep, it can actually do some psychotic experiences.
Don't mean to scare people.
It is an important phenomenon.
Many women, the majority are in their 20's, 30's and 40's.
Dealing with menstruation can be difficult.
Hygiene.
Limited restrooms.
I found this interesting.
There's one study that suggests that 20 percent of the
women who are interviewed, a very large sample,
reported unintended pregnancies.
Why is that?
Well, sometimes birth control was not available
in the same way, so it was more difficult to
take care of oneself and be able to
manage basic gynecological care.
I also talked to one women who was 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 every day?"
No, I don't know, but I can imagine.
Childbirth and nursing.
That's very interesting because usually when
somebody's pregnant, they're no longer deployable.
If they're pregnant in theater, then they have to find
out they're pregnant, and usually they're sent home.
Sometimes when they're sent home,
then other members in the unit resent them,
because then somebody else has to do their job.
If a man and a woman, a heterosexual couple,
are dealing with a pregnancy, the man is not
dealing with problems with deployment.
It's the woman in the military
who has negative consequences.
The nursing was very interesting.
This is Colonel Ritchie, who I was
telling you about at Walter Reed.
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 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, and spacing and support, that would allow
the mother to be able to express milk,
save it, and actually nurse the baby over time.
This sounds so basic, if you
think of people who are back home.
What happens with a nursing mother who
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.
That's a stressor.
Mental health responses.
These are the ones that are familiar
to us who are doing the clinical work.
These committees I'm on, I'm focusing
on post-traumatic stress now, PTSD.
Over and over and over and over.
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.
We have that validated now over years.
With depression and suicidality,
that's not the case though.
Women do not suicide at the same rates as men.
Service women.
However, when you think of just the general data,
you might find this important, because it's rather grim,
compelling some meaning that we
should do something about it.
Last year, there were 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 any combat era,
there are different issues that are central.
With the conflicts in Iraq and Afghanistan, the issues
that have existed are called signature injuries.
They're a cluster.
They're not just one.
It's not just PTSD or depression.
It's PTSD.
I 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 going to have post traumatic stress.
It's a normal reaction to abnormal circumstances.
There's symptoms, but it's not full blown PTSD.
This cluster of post traumatic stress, depression,
suicidal thinking, substance abuse, traumatic
brain injury, and intimate partner violence,
they go hand in hand.
You see the incendiary effect of that.
This is why we, in our field, need to be mindful
not just of the service member,
but then the impact on the family.
You're familiar probably with the clusters of
re-experiencing, avoidance and hyperarousal.
If you think of families, which of these
themes are most difficult for children?
Early on in my work here, I thought it would be
hyperarousal, because that's scary when family
members are elevated and augmented and
mad and rage storms, and a really scary presence.
That's not the case.
Children desperately respond
negatively to the avoidance and numbing.
It has a really powerfully negative effect.
We'll talk a little about military sexual trauma.
The Pentagon data of May of this year, said 26,000
service members were assaulted in the last year,
compared with 19,000 the year before.
Those of you probably know that with all the attention
that has been paid in recent months in the Senate hearings,
the messages are coming forward and I think
there's much more attention.
People are paying attention.
One in three women in the military are assaulted,
compared to one in six civilians.
That's sort of a general number at this point.
Again, that's very daunting.
Which I meant assault, not harassment.
The data on harassment are like in the range
of something like 70 percent of people in the
military suggest that they've been harassed.
Both men and women.
It's the assault they're focused on.
in terms of the current congressional hearings.
The reports in the Department of Defense
are lower than in VA settings,
the Veterans Administrations settings.
If you report, one of the significant features in
military sexual traumas is that often the person
who has offended is maybe in your unit,
maybe your superior officer,
maybe your commanding officer.
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.
If they are then not separated from the offending person
who has injured them, they have to live with that.
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.
Himelfarb 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
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.
I'm not going to go into much more detail with that,
but Julius St. George has been organizing
a showing which will occur next Wednesday.
Seven o'clock.
Room 106.
Seelye 106.
This is a viewing of "The Invisible War."
For those of you who may or may 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 commanding
officers who sat in the congressional hearings.
What I have found out since from
Deborah Stone, who is a major.
She is a colleague of mine who
is working in Fort Myer in D.C. now.
She has said that the U.S. Army SHARP training,
that's this training.
This website, you can view.
You can sort of log on and take a look at it.
They actually have implemented very elaborate training.
It's about trying to change the culture in the military.
Some of it's pretty basic.
Both in some basic training as well as just general
conversation 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 was looking at some of that today.
They're taking it seriously.
I hope they keep taking it seriously.
What they were saying is with all that controversy
should they have reporting outside of the command structure?
The conclusion with 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-range.
So we'll see.
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.
Let's see.
We're going to shift now.
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 are
all familiar to us, that are critical in any
type of clinical social work encounter.
The value of relationship, therapeutic alliance,
cultural responsiveness, a 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 vignette, it's a composite.
I'm hoping that the vignette will capture some of the
issues that we have 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.
So first of all, I didn't ask you who's the client.
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.
Maria is 37, was reared in Puerto Rico in a family
where she was the eldest of four children.
She was reared in poverty in a
very difficult, challenging home life.
Her mother was very physically
ill from her early years onward.
So she was caring for many of the siblings.
Her mother died when she was only four.
Her mother died from a septic infection.
So Maria was sent at a very early age to
family members in New England to live.
She 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, 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, we talked 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.
His family had lived in New England for about 40 years.
Very educationally oriented, solid socioeconomically.
Are you hearing the differences in
terms of some of the sociocultural background?
When they married, they felt the commonality
in terms of religion, ethnicity, shared values.
They desperately wanted to have three children.
Antonio who is now 16, Delia who's 9, and Anna who's 3.
So they had 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 you hear the sense of identification
that was positive for Maria.
So 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, thriving.
Carlos was an accountant and Maria was working in
a nursing home as a nurse's aide.
Maria's unit's called up, she's deployed, goes to Iraq.
This is where you hear the story.
Then she then had the experience of being
a medic, and separated from at the time
a 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, and eight and nine year old,
and 15 and 16 year old is considerable.
Let me tell you what happened upon 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 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.
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 words.
She was responsible for the death of that young man.
So she was a terrible soldier.
She wasn't a decent mother.
She couldn't be a decent mother to any of these children.
Then 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 distant.
He tried to spend as much time
away from the home as possible.
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.
This is the client.
So who's the client?
Is it just Maria?
Or 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, health trauma and addictions, basic
developmental themes, family and community, social
policy and research, sociopolitical context and ethics.
Does that make sense?
With every single client, we need to be mindful of
these things as well as, guess what,
the client is interacting with us.
As clinicians, we're influencing this
therapeutic alliance at any given moment.
We need to be mindful of all of these factors as well.
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
nightmares, her flashbacks, her hopelessness,
her irritability, her hyperarousal?
Are you hearing poles for trauma theory?
Poles for trauma theory.
Are you hearing the incredible relationship disruptions
and the sense of estrangement and
the poles for attachment theory?
You're hearing the alienation they
have again with families of origin.
They're no longer talking to them.
The family theory comes to mind.
When 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 psychodynamic theory?
Well at least in this line of work, if we really believe
that there are certain patterns that are established
in childhood, that they're going to influence both
strengths and vulnerabilities in later life,
then that will affect how our female service
members are going to navigate these stressors.
Power of the unconscious.
This is very important.
This 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 a particular
protocol that focuses on PTSD.
So it might be cognitive processing treatment.
It might be CDT, which would be fine except you need to find
out the unique meaning of the experience for the individual,
rather than just focusing on symptom picture.
Who is the individual?
Transference, countertransference,
is pivotal because it tells us how we are
reflecting on the work and what role it has in 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
reattachments that under the best of circumstances,
this couple had a secure attachment.
It was earned security.
Maria had more of a disorganized attachment.
I'm going to move through this pretty quickly.
Those of you who are somewhat familiar
with attachment theory, you realize that there are
either secure or insecure internal attachment models.
Disorganized and disoriented is 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.
A part of attachment theory that's a capacity to
actually be aware of one's feeling and reflect upon
them, and 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 and, meaning-making.
When enough combat and deployment stressors,
this process, mentalization, breaks down as well.
And 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.
This is a crucial one.
The circle of security is broken.
That sense of connecting back to the person,
or people, who are most important in terms of
providing comfort and security.
So, how about another model for a moment?
Why do we care about Winnicott?
First of all, Donald and Claire Winnicott
focused their entire careers in World War II
in helping children survive the Blitz.
They took them to homes outside in the countryside.
One would think, well were these children traumatized
because they're taken away from their families?
No.
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-victimizer-bystander.
Why is this relevant?
Anyone who has suffered trauma will
know what it's like to be a victim.
You've had somebody who's offended you, and there's
usually a bystander who hasn't done much of anything.
Why is that important?
Because in families, if you think of Carlos
the husband, he 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 and 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.
Those of you that work in the Department of Defense,
in 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 CDT 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, 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.
It's to promote secure attachments.
We help them reconnect, reduce mental health
symptomatology, minimize secondary trauma, help
them with learning more, and then restoring a sense
of re-connection and social vindication.
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-informed models,
where the first phase is safety, stabilization.
Second, a reflection on the trauma narrative.
Third, consolidation of new perspectives.
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.
You hear the volatility.
It wasn't clear to me if there was
intimate partner violence or not.
How 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 is 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 downs, rage storms.
This feature was absolutely critical.
The biobehavioral strategies for stress reduction.
That's repeated there.
I guess I'm trying to make the point.
Stress reduction, self-soothing, affect regulation.
This couple was completely disregulated.
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.
So the whole household had problems with physical health.
Mental health.
You heard the issues.
Maria needed to have a referral to 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 or four glasses of wine a night.
She had to be checked.
This is where you can pull in.
If you are the clinician who's actually providing
the support, at the moment you're providing a
supportive psychotherapy role.
You're doing an extended assessment
and building a therapeutic alliance,
connecting with this whole cast of characters.
The psychiatrists, physicians, nutritionists,
other clinicians who are working.
The school counselors who are dealing
with the children who are suffering.
Psychoeducation regarding post-deployment.
This is also a piece of this.
For many couples, the partners need a basic
understanding of some of these stressors
that they may have been dealing with.
Once again, it's understanding, safety
and developingt in attachment theory line.
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 entering
cognitive process and treatment.
She's in a position where she's stable enough
to be able to withstand recalling the
content of the horrific, traumatic events.
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, 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.
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.
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-victimizer-bystander?
Well, they were each blaming the other.
She kept saying to him that he seems so passive
and hopeless and helpless, and she couldn't stand him.
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 others' qualities.
They were victimizing each other constantly.
Back and forth, back and forth, back and forth.
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 had become a bitter old woman.
Old?
She was like 38.
Bitter old woman who he couldn't
stand being around anymore.
Another part of this that happens with a lot of
combat veterans, and I think it's an important
phenomenon, she 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, family background.
She would hurl all these nasty comments
and really sounded quite vicious.
He said he couldn't live with
somebody so vile and so hateful.
As she kept talking about what happened when she
saw this young man killed and holding her hand
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 killed?
"And even that one person 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.
She re-owned what had been projected onto him
as being helpless and frightened and insecure.
Do you hear the unpacking of racialized hatred?
If people are trained to see the enemy as bad and evil and
good and bad, and you kill the enemy, you don't expect that
to change necessarily automatically upon homecoming.
Some of those deep-seated beliefs can really settle in.
Fortunately, her's was not that deep-seated.
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 was so unavailable to him.
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.
This period then continued on with a lot of
discussion about his rage and his frustration.
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 more of a state of reconnection.
Their attachments were beginning to rebuild.
They began to empathize more with each other.
Grieve together.
One of the healing rituals had to do with her
openness to accept, she was rewarded a medal,
a Purple Heart, for some of her heroism.
She said, "I'm not a hero.
"I'm not a hero at all.
"I don't want it.
"Throw it out."
So ultimately they had long conversations
about what that might mean.
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 a 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.
What I would like to say at the end here,
is why do we focus on this work
and why is it so important?
What seemed to me that as long as we just
recognize that a client is what Winnicott would say
there's no such thing as a baby.
There's just a nursing couple.
There's no such thing as a solitary service member.
The service member always has to be understood
in the context of whoever his or her family
would be or people who are important to her.
The context is absolutely crucial.
Also, 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 of wait for the client to tell us
what the clients really need and the pacing of
the work so that then they will help to define
what do they need first?
It's always self-care, safety, stabilization first.
Then, moving into different layers and levels of
complexity that they can bear so that they can
reconnect in different ways that will really be powerful.
I would say that that's our charge with this population.
I think we will make quite a difference for
many successive generations of children if we do so.
So, I thank you.
(audience clapping)
Are there any comments or questions?
Reactions?
Yes?
- [Man] How do we help returning veterans who are
very fond of keeping their identity?
I've done some work in the military.
(inaudible)
They really get tight.
They feel like family.
So that's really important (inaudible).
Then when they come back to the United States
(inaudible)
I'd be curious in their ideas from the group as well,
but my sense is with this case, I didn't highlight that,
but actually for her, as a reservist, she was cut off
from other members of her unit.
Part of that was her detachment.
She didn't want to talk with people.
It was part of her avoidance.
A good part of the work was for her to think about
how important those people were to her during deployment.
She started to reconnect.
But then, if there are some people who are not
going to be reconnecting with the people they
actually cared about, but even the connection
with other veterans can be so powerful.
Early on, people often think of that before
people enter into treatment.
If they need different types of psychotherapies,
they often do very well, vet-to-vet, often have a sense of
shared experience, even if they weren't deployed together.
I'm curious, is there anybody in
the audience who would speak to that?
Or those of you have...?
Okay, any other...?
(audience member asks question)
Okay, well, part of the victimizer-bystander
scenario is one to think about because that's
one that resonates regularly with working
with traumatized clients.
Just to give you an example, mine was that
work as a couple family therapist.
Again, it's disguised and composite,
but it has elements of the actual case.
I would reverberate back and forth from feeling a
sense of helplessness, of thinking this family seems
so devastated, the children are suffering so badly,
that I was glad that I had listened to the history.
That's always important, to get a full history.
That's what made me realize they had tremendous promise.
I was struggling with, should I just give up,
could I send the clients to another clinician?
That's a typical helplessness that we can resonate with.
And then the sense of victimizing.
Just feeling really frustrated.
I would get very angry with her.
She would curse all the time, really nasty, bigoted
offensive remarks, and I would get annoyed with her.
Then I would think, "All right, unpack it.
"You need to pay attention.
"What is she really saying?
"What's beneath the vitriol?"
As 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.
That's a typical countertransference response.
The more detached bystander is a scary one because
we can be susceptible to secondary trauma.
That zoning out detachment, if you're planning
your next vacation while you're sitting and
working with the family like this.
That's a clue of countertransference enactment.
Usually the enactments have to have an action
component to it, of doing something.
Usually if we just sit quietly and have
the experience, and we try to catch it.
That was part of the self-reflection.
So we don't inflict it on the clients.
Even when there's an enactment,
sometimes it can be helpful.
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 some of her language.
So she caught it.
She realized I was acting on my countertransference.
I wasn't just quietly sitting there.
So you can use that regularly to try to
understand the clients better and also
when necessary, repair the rupture.
I could have lost them if I didn't figure out...
I said I did find it hard to listen to,
because it was so nasty.
But I was trying to understand what it meant to her.
Did she always have those feelings?
"No, I didn't have those feelings.
"I've only had it since I was in Iraq and back."
So that was the clue.
Thank you for asking that because I didn't amplify that.
Yeah?
(audience member asks question)
Did everyone hear that?
So this is one family.
This is one deployment.
See what happens with one deployment.
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.
Others do and that's something we need
to be mindful of in doing this work.
I would say proceed nonetheless, because if the family
has the history of strength and the desire to be together,
and they've had those experiences and strong connections,
then some of these complex models can be very useful.
It raises the question about what are we doing in our
country when we constantly, redeploy, redeploy, redeploy?
When we know the data suggests that this
is harmful if there are enough times of this.
It's the people in the minority who have no effects,
who suffer no negative effects.
(audience member asks question)
Yeah.
A service member might not have difficulties in
reintegration, 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 mean, I'm focusing on the women in the military.
It's an area that I'm interested in nowadays as well,
but the families are pivotal as sources of support,
and also they need our assistance when they're suffering.
(audience member asks question)
The moral injury?
It usually occurs around some event where the service
member has experienced something that they felt
that they betrayed their own sense of ethics.
What's interesting is, even though,
for her, this was very clear cut.
She felt that she should have
been able to save this young man.
So she felt that she let herself down
and was just completely morally corrupt.
But that was her view of it.
Sometimes other people can actually
observe something they consider egregious.
Often the killings of children, whether deliberate,
or the so-called noncombatants who
get killed in the process of war.
That can feel horrific.
That's the bystander who's watching.
Sometimes the moral injury can be almost
as profound as having done something oneself.
Inviting that conversation, I think, is what's important.
Usually the timing, the pacing is so crucial.
The site of such delicate territory.
That people have to be ready to do that.
If you notice, with this couple, I was trying to
deliberately convey, you have to work with that
first phase, which is really both the restraints.
Helping them reconnect, reestablish 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, 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 fallibility.
She hated that.
That's different from a so-called ethical defect.
(audience member asking question)
How long to get to stabilization?
With this particular family?
Just a couple of months.
If that's your goal, if your goal is to pay attention
to what the pressing issues are, it's interdisciplinary.
You're coordinating with this cast of characters.
You're the anchor trying to then provide the
clinical clinical case management.
It's best, I think, with Winnicott
and clinical case management.
We can be in touch with a whole range of people.
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 and professionals
at work that need to be included as well.
Go ahead.
(audience member asks question)
It's mostly military sexual trauma.
That's what they're saying.
And that's a direct association with why those
rates are significantly higher for women.
Otherwise they're re-exposed then to some of the
same combat stressors as men, the male counterparts.
It's not as if they're...
Any thoughts about that?
Anybody have thoughts about why
women would have more risk factors?
One thing is that if people are
then deployed with different units, they haven't
trained with a different unit.
And if there's a sense of insecurity, then with the
other service members or the command,
that's not necessarily going to cause PTSD.
You have to look at the risk
factors and the protective factors.
That's the balance of the two.
Yeah?
(audience member asks question)
So just at the continuation of the masculinized culture?
I didn't hear the last...
So you're hearing pockets of misogyny.
That's what I think some of
the brass we're talking about now.
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."
It seems like that persists.
Maybe just one more comment and then we're going to wrap up.
- [Woman] I was just going to say that maybe one
of the reasons why Maria was using that kind of
language is that as well in the military it's
very, very, common for soldiers to go away (inaudible)
Even men, my husband included, he never talked
that way before he went on a deployment.
When he came back, they get used to
using certain language over there.
It's all understood between the soldiers,
but when they come back it does not...
That's a very good point.
Because sometimes it's become part of the training.
You've heard about some of the basic training.
It's nasty stuff.
It's misogynistic.
It's racist.
It's bigoted.
It's all of the above.
It's what we might think of as abusive language,
but they are suggesting that one of the high rates
of the military sexual assault has something to do
with that generalized acceptance.
That the language can then be translated into behavior.
Words become the behavior.
That type of harsh treatment, you have to set the limit
between the boundary and the word's
behavior and adjust the language.
No easy feat here.
I wish us all the best in working with this population.
Thank you very much.
(clapping)