FTS SAMHSA

Moderator: Chris Marshall
August 3, 2010
2:00 pm CT

Coordinator: Welcome and thank you for standing by. At this time, all participants are in a listen only mode until the question and answer session. Today's conference is being recorded. If you have any objections you may disconnect at this time.

The Power Point presentation PDF version, the audio recording of the teleconference and a written transcript will be posted to the SAMHSA ADS letter center Web site at www.promoteacceptance.samhsa.gov.

Our presentation today will take place during the first hour and will be followed by a 30-minute question and answer session at which time you may press star 1 to ask a question.

I would now like to go ahead and turn today's call over to Jane Tobler. Thank you. You may begin.

Jane Tobler: Hello and welcome to Mental Health in the Military: the Path to Resilience and Recovery. Today's teleconference is sponsored by the Substance Abuse and Mental Health Services Administration ADS Center also known as the SAMHSA Resource to Promote Acceptance, Dignity and Social Inclusion associated with mental health.

SAMHSA is a lead federal agency on mental health and substance abuse and is located in the US Department of Health and Human Services. SAMHSA has identified military families as one of their top three strategic initiatives. SAMHSA is working to provide support to service men, women, their families and communities by leading efforts to ensure needed behavioral health services are accessible and outcomes are successful.

The views expressed in this teleconference do not necessarily represent the views, policies and positions of the Center for Mental Health Services, the Substance Abuse and Mental Health Services Administration or the US Department of Health and Human Services.

Just a reminder, that after the presentations are finished, we will be taking questions from callers. If you do not wish your entire name to be announced, please just give the operator your first name.

My name is Jane Tobler and I will be moderating the teleconference today. Before we begin today's presentation, we want to make you aware that if you are a veteran or a family member currently experiencing an emotional crisis, help is available. Please call the Veteran's Suicide Prevention Hotline at 1-800-273-TALK. That's 1-800-273-8255. Veterans should press 1. Or you may call the Military One Source at 1-800-342-9647. That's 1-800-342-9647. Both of these numbers are available to you 24 hours a day, seven days a week.

We have three excellent speakers today who will talk about Mental Health for Military Families: the Path to Resilience and Recovery. Our first speaker is Dr. Tom Berger, a life member of the Vietnam Veterans of America, or VVA, and founding member of the VVA Chapter 317 in Kansas City, Missouri. He served as chair of the VVA's National Post Traumatic Stress Disorder and Substance Abuse Committee for almost a decade and was appointed executive director of the VVA Veteran's Health Council in June of 2009.

Tom is a member and former chair of the VA's Mental Health Consumer Liaison Council and is also a member of the VA's Mental Health Quality Enhancement Research Initiative Depression Executive Committee. Tom served as a Navy corpsman with the 3rd Marine Corp Division in Vietnam from 1966 to 1968.

His professional publications include books and research articles on post-traumatic stress disorder or PTSD. Tom now devotes his full efforts to veteran advocacy at the local, state and national levels on behalf of the VVA. Tom will give us a brief history of mental health in the military, its impact on service members and their families as well as the current thinking and recommendations for system levels improvement in a new name for an old story. Tom.

Tom Berger: Jane, thank you. Before I start I'd like to thank the folks at SAMHSA for providing the opportunity and I'd also like to thank everybody who's called in because I think this is going to be a dynamite presentation. And last but not least, I want to thank my colleagues, Steve and Sheri. You're in for a treat today folks. So let's get started.

My first slide really covers a quote that was made by a group back in 2006 that states basically that there's evidence that the high rates of trauma experienced by folks in Southwest Asia theaters of war are going to result in increased demands on DOD, VA and community health care systems as these folks return.

As the number of those veterans grows, their continued care is going to become a national health concern. Well, here we are. It's 2010. We also know that PTSD is a new name for an old story. As you can see in the next slide, war has always had a severe psychological impact on people in immediate and lasting ways.

It has a history that's as significant as the malady itself. It's been with us now for thousands of years. Going back in time, PTSD was called a variety of names. In the 1670s Swiss military doctors described the symptoms as "nostalgia". During the Napoleonic Wars of the early 19th Century, battlefield surgeons began calling it "exhaustion".

And by the time of the American Civil War, it had become as "Soldier's Heart" and the "Effort Syndrome". "Shell Shock" became the term commonly used in World War I and this was succeeded by "combat fatigue" and "battle fatigue" in World War II.

By the time the war in Vietnam was winding down in the early 1970s, the term "post-Vietnam syndrome" was being used to describe veteran's traumatic stress reactions during and after their military service in Southeast Asia. Finally in 1980, the term "post traumatic stress disorder" appeared in the third edition of the APA Diagnostic and Statistical Manual of Mental Disorders which we call the DM- DSM-III. And it's still the name used today.

Research findings have led to a modification in refinement of the diagnostic criteria but many of those criteria found in the DSM-III have remained largely unchanged from that found in the current version of the diagnostic manual, the DSM-IV. Unfortunately the discounting of effects of war related trauma by charging the victim with having ulterior motives was also common in the military reflecting the sentiment that most who suffered signs and symptoms of war trauma were, in fact, malingerers. Unfortunately the attitude that combat veterans with psychological problems are malingerers, trying to gain economically, is still with us today.

Now in the next slide, we should talk briefly about the unseen war - wounds of war. According to RAND studies, about 300,000 U.S. troops are suffering from major depression or post-traumatic stress and another 320,000 have sustained a traumatic brain injury. Many service members and their families will struggle financially and psychologically with the transition from combat to civilian life including the stigma associated with mental health problems.

Our newest veterans are in economic distress. A growing number are severely rent burdened, 500,000 of them paying more then 50% of their income on rent. One in five veterans from Iraq and Afghanistan are unemployed. Complicating matters, the majority of employers recently surveyed admit they don't fully understand the qualifications ex-service members offer.

Despite skills honed in the service, many will need in depth assistance in the form of education, training and job placement just trying to find and transition to civilian jobs. But injured war heroes are wounded in deeper ways too. Many face intense cognitive and psychological issues and they can fall into substance abuse, experience depression and anxiety. These factors of course can lead to homelessness and encounters with the criminal justice system.

Recent figures reveal more then 16,000 Iraq and Afghanistan veterans are dependent upon alcohol, 7,000 more have sought treatment for drug addiction. Intervention is necessary and can be effective but it's time we looked more closely at new methods of prevention that address the trauma that lies at the root of this growing social problem.

Children are also suffering, more then two million kids with parents in the military sought outpatient mental health care last year, twice the number from the start of the Iraq War. That's because children of injured and fallen heroes are prone to feelings and behaviors mainstream school programs cannot always adequately address.

Without special attention, their troubles can affect their schoolwork, relationships, wellness and ultimately their capacity to thrive as adults. More research and training are needed to better understand, diagnose and treat children of those who are injured, who have PTSD or other war related traumas.

Special counseling and intervention developed in collaboration with national experts can work. Through deeper collaboration and more public and private partnerships, we can help more children in more places deal with the damage that lingers long after their parents return from deployment.

Spouses need help too. About half of our nation's service members are married. To them the emotional weight of rehabilitation and transition make just staying together very taxing. Partners of those with hidden injuries face their own grief and depression as they struggle to reunite their families after long separations.

A recent study in the New England Journal of Medicine highlighted the growing effect of deployment on spouses. This includes marital dissatisfaction, divorce and finding emotional health. This is a looming public health issue since most military families will ultimately move outside their military communities, requiring the services of civilian medical and mental professionals.

Financial difficulties exacerbate the stress particularly for spouses who have been forced to give up jobs to act as full time caregivers. The recently signed Caregivers Act will help provide vital financial support but fuller measures are still needed. Nevertheless, no story of war related PTSD is possible without a very brief summary of the complex framework and evolution of the mental health system and policies in America.

As you can see in the next slide, over the past three centuries the complex patchwork of mental health services in the U.S. has become so fragmented that it's often referred to as the "de facto" mental health system by many experts. And its shape has been determined by mentor- many heterogeneous factors rather then by a single guiding set of organizing principles and policies.

This "de facto" system has been characterized by three factors that you see in front of you. Financing refers to the payer of services whether it's public or private. Duration of care is divided between services for the treatment of acute conditions and those devoted to the long term care of chronic conditions such as schizophrenia, bipolar disorder and Alzheimer's.

Settings refer to care and treatment in institutional community based and home based facilities. Now, to confuse you further, these se- these three factors are further subdivided into four sectors.

If I can have the next slide please.

The four sectors include specialty mental health services. These focus on services provided by specialized mental health professionals such as psychologists, psychiatric nurses, psychiatrists and psychiatric social workers. General medical/primary care sector consists of healthcare professionals, your family physicians, nurse practitioners, internists, et cetera and the settings in which they work.

Human sector - human services sector consists of social welfare, criminal justice, educational, religious and charitable services. And lastly, the voluntary support network refers to self-help groups and organizations.

Now, moving to the next slide, you can see an overview in tabular form of the history of mental health services in this country. Obviously the origins of the mental health services system coincide with the colonial settlement of the United States.

The first form of treatment known as moral treatment was not given until the very end of the 18th Century after the Revolutionary War and was introduced from Europe. The term, "moral," had a different connotation from that in which we use it today. At that time it meant the return of the individual to reason by the application of psychologically oriented therapy. The moral treatment period was characterized by the building of private and public asylums.

Shortly after the Civil War, however, the failures of the promise of early treatment were recognized and asylums were built for untreatable chronic patients. The quality of care deteriorated in public institutions where overcrowding and under funding ran rampant. A new form of reform appeared and it was devoted or called the Mental Hygiene Movement. And it began late in the 19th Century.

It combined the newly emerging concepts of public health, scientific medicine and social progressivism. Treatments, however, were not successful. Early treatment was no more effective then - in preventing patients from becoming chronically ill in the early 20th Century then it was in the early years of the previous century. And add to it the financial problems and overcrowding deepened during Depression - the Big Depression and during World War II.

Now enthusiasm for early interventions developed by military mental health services during World War II, however, brought a new sense of optimism about treatment by the middle of the 20th Century. Again, early treatment of mental disorders was championed and a new concept was born - community mental health.

Borrowing some ideas from the mental hygienists and capitalizing on the event of new drugs for treating psychoses and depression, community mental health reformers argued that they could bring mental health services to the public in their communities. But the dual policies of community care and deinstitutionalization, however, were implemented without evidence of effectiveness of treatments and without a social welfare system that was attuned to the needs of those individuals with disabling mental illness.

So a fourth reform era arose that we presently call the Community Support Movement and it grew directly out of the Community Mental Health Movement. Reformers advocated for developing community support systems. At first mental health treatments were deemphasized in favor of social supports but newer medications such as SSRIs and anti-psychotic drugs, more effective psycho-social interventions all facilitated the objectives of community support and recovery in the community.

So the voluntary support network was then expanded with an emphasis on recovery which is a concept introduced by service users or consumers who began to take an active role in their own care and support and in making policy.

So it's within this complex evolutionary framework that I've just tried to describe to you that the current military mental health policies and systems for war related PTSD has evolved. There are now evidenced-based PTSD treatments and a variety of services and programs available to the mental health injured warrior and to his or her partner and children.

For example, in the next slide, the 230-plus readjustment counseling centers, or vet centers, of the VA provide readjustment counseling and outreach services to all veterans who served in any combat zone. I just learned this week that that number of vet centers will be increased to 300 by the end of this calendar year.

Vet centers are closely tied to Vietnam veterans in the sense that when Vietnam veterans came back in the ‘60s and ‘70s, they had nowhere to turn. PTSD had not been officially recognized and so veterans began to gather in groups in libraries and community settings and in storefronts to conduct what we called "rap groups".

And it was from the rap groups that the vet centers were developed. Vet center services are also available for family members for military related issues where local clinical resources permit. As some of you know, there has been some legislation that has authorized the specific hiring of family counselors for each of the 230-plus vet centers across the country. The devil is in the details as to how they're going to implement the hiring and getting these people out to the localities where they needed.

But in any case, that is something new for the vet centers. The vet centers are the most cost efficient mental health service within the VA and over 65% of vet center clinicians are combat veterans themselves.

Next slide please. On the treatment side of things, in early 2006, the Department of Veterans Affairs asked the Institute of the Medicine, the IoM, to conduct a study on the diagnoses and assessment of treatment and compensation for PTSD.

The committee undertook a comprehensive systematic review of the treatment literature dating back to 1980 when PTSD was added to the DSM-III and it included both pharmacologic and psychological therapies in its review. The IoM group reviewed a total of 2,771 published studies conducted since 1980 and determined that only 53 psychotherapy studies and 37 pharmacological studies met scientific methodological criteria.

The committee's conclusion was that the other 2,681 studies did not hold scientific adequacy. So as a result of the review of the 90 studies, the report clearly identified the most efficacious evidence based psychotherapies. You know them as cognitive behavior therapy and exposure therapy.

And they identified a number of pharmacological treatments as well as the protocols necessary for their administration. But both the VA and DoD mental heath services have been extremely slow in recognizing, adopting and implementing the IoM report's eight major recommendations including a call for standardization of treatment.

Despite that, however, to its credit, the army recently announced the initiation of the Mental Health Resiliency Training Program at Fort Stewart and we're given to understand that mental health teams are operational in the combat zones for early intervention. In addition, the VA has hired more mental health clinicians and the military has instituted pre and post deployment mental health screenings for some of its units.

But not everyone returning from the war zones are screened nor do they meet face-to-face with a mental health clinician. Furthermore, we know little about the impact of PTSD when overlaying with co morbid disorders such as military sexual trauma and/or traumatic brain injury.

In addition, there are numerous new modalities of treatment being promoted and treatments du jour seem to be constantly springing up as the latest answer to the PTSD problem for returning combat veterans. A lot of interest has been generated by increased government funding for research for both PTSD and TBI since the start of the wars, particularly in what we call complementary and alternative medicines or CAMs.

A sample of some of these being promoted include virtual reality, bio feedback, Tai Chi, bio energy work, experiential outward bound programs, dance therapy and MDMA which is the party drug ecstasy. Now some of these are promoted in news stories and many veterans have questioned why DoD and the VA have not adopted them for regular use.

The reason is that these modalities have not been proven to be effective via rigorous research studies. In all likelihood, they may be of some benefit for some PTSD symptoms and sufferers because they can in some instances reduce the physiological stress response.

At this point in time, however, they should be considered complimentary to those treatments and stress reduction programs that have been studied scientifically.

Now if I can have the next slide please. This presentation would not be complete without a brief look at the current politics of PTSD. First, VA Secretary General, Eric Shinseki just recently announced the VA policy directive that would affect veterans filing for PTSD compensation claims. For decades, vets applying to the VA for PTSD disability benefits have had to document their claims with details of the specific events that resulted in their condition.

The requirements put many vets in the position of reliving and documenting events that many had spent their lives trying to forget and overcome. Then, too, the documentation could be nearly impossible to obtain in some cases. The new regulations would eliminate the requirement, however, the new directive is not without criticism.

It does not allow for diagnoses by non-VA mental health clinicians. In other words, diagnoses by mental health clinicians in the private sector who are not under contract to the VA, those diagnoses will not be accepted. Secondly, the change in the PTSD stressor documentation policy has revived the conflict between those who've seen mental problems resulting from warfare as one of the necessary costs associated with using America's military as an instrument of foreign policy and those who don't want to pay for these costs.

This old argument took a new turn on July 17th of last month with an editorial in the New York Times by Dr. Sally Satel who claims that General Shinseki's policy change lessens the diagnosis of PTSD. And lastly, the DSM-IV is scheduled to be revised in 2012 and PTSD is certain to be one of the hottest topics of the discussion involved with the revision.

So what does this all mean to the future of military mental health policy particularly for soldiers and their families? Next slide please. Although it's going to be cloudy until all the fallout from healthcare reform sells, Vietnam Veterans of America offers the four following recommendations.

We need a system-wide adoption of evidence based assessments, diagnoses and treatments. We need a system-wide recognition and inclusion of recovery philosophy and principles. Too many people use the word recovery without knowing what it really means.

Thirdly, more trans- we need more transparent collaboration among military and veteran mental health agencies and those agencies or organizations in the public and private sectors and they must include a stakeholder's voice. Last but not least, we need more clinical resource - resources and research in these areas.

Thank you and I'll be glad to answer any questions after the presentations of my next two colleagues.

(Jane Tobler): Excellent. Thank you, Tom, for the historical context of mental health in the military and recommendations for system level improvements. Our next presenter is Steve Robinson, a retired non-commissioned officer and Gulf War veteran who served 20 years in the US army.

After retiring in October of 2001, he became a veteran advocate. As a subject matter expert, Robinson has testified numerous times before the U.S. House and Senate on matters pertaining to suicide, PTSD and the mental health and resiliency of U.S. service members. He's served as a military veteran advisor for PBS for an episode on, "This Emotional Life," and wrote and advised them on a yet to be published military family guide.

He continues to serve as an advocate liaison to the Department of Defense, the Department of Veteran Affairs, Congress and the White House. Steve will share challenges that confound care in the military as well as positive steps for self-care that veterans can take to find resilience and wellness at the individual level. Steve.

Steve Robinson: Thank you very much and thank you for allowing me and all of us to talk about the issues that are pressing on us today. And thank you for all the participants.

My presentation is going to focus first on a little bit of issues that confound us and then move more towards what is resiliency and what we can do about it. The majority of people coming home from war incorporate their war experience and they move on with getting back to life without much fanfare.

And many of them find that war was a rewarding experience and something that defines them. But many veterans come back home and find that they are challenged by their wartime experience. And early estimates from this war indicate that the mental health care needs of this generation could potentially rise to the level of 50%. And what I mean by that is 50% of those who serve may turn to the VA and ask for some form of help, and that's a significantly high number and something that we have to pay attention to.

Now one of the things you need to understand about why the military may not be doing quite as good a job as we'd like them to do in terms of mental health which consequently is the reason why perhaps the suicide rate may be as high as it is today, is the fact that the military focuses on mission first.

And what does that mean? Mission first means that nothing supersedes getting the job of war fighting done. And when you understand that mission comes first it begins to explain why issues like redeploying of service members with PTSD can still occur today.

Now in order for the military to do a good job of treating those that return with war injuries, it has to understand and destroy stigma. And the stigma that prevents service members from seeking care still exists in today's military even though there are many studies that help us to understand that witnessing life intense experiences on the battlefield has a physiological and a biological and a spiritual effect on the veterans.

But today I want to put the idea in your mind that the stigma that we talk about is really more discrimination. It's a discrimination against mental health care injuries. Let me put into a perspective that everybody can understand.

We don't have a problem with helping the amputee, the person that we can see just got hit with the IED on the battlefield. We can physically see those injuries and we know that person needs help. But for some reason in our military, we still tend to shun the person who's suffering from repeated exposure to trauma or the injury of the mind, the body and the spirit.

And that's a culture that has to change and it has to change by us teaching the military the occupational exposure of war. Of course, war is not an OSHA approved workplace but we can teach soldiers how the eyes see, how the brain processes, what chemicals are released into the body, what organs are affected and what feeling states occur under life intense experience.

It's important for us to make sure that that information gets into the hands of the individual war fighter, the squad leader, the platoon sergeant, the company commander and the generals in the Pentagon.

One of the other issues that's currently confounding our military and creating a lot of the outcomes that we see today is the operational tempo plus two wars minus a very good doctor/patient ratio equals increased risk. And both Dr. Berger and I met a long time ago back in 2002 with leaders in the Pentagon as we saw these wars beginning to ramp up and suggested that we hire more mental health care professionals.

We're just now getting to the point where that has become a priority even though the military's still having a tough time getting people to fill those positions. Also one of the things that are important is that as Dr. Berger explained, there are not many treatment options for the veterans when they come back.

The military focuses mostly on pharmacological interventions first. They also focus a lot on anger management and group therapy because there's not a lot of time for individual clinicians to help veterans recover. Also, it's important for us to start thinking about that we have to start teaching suicide and prevention and resiliency before soldiers go to war so that we can correct the problems that happen when veterans come home.

The head of all of the problems that the Department of Veterans Affairs, the NGOs, the non-governmental and non-profit services see when the veteran comes back home begin when the veteran returns from war and is transitioned out of the military so we have to do a better job of helping DoD identify the problem, treat it and work on it before the soldier goes to war and then when they come back home.

The next slide that I'm putting up is basically just to tell you that we understand what happens in the daily life of the soldier. This is a graphic timeline that shows the highs and lows of the typical deployment. And at each one of these highs there is usually a series of chemical releases in the body that occurs depending on what's getting ready to happen.

For example, you wake up in the morning, you get your mission brief, it's time for you to get ready to go, you drive your Humvee outside of the wire, you move away from the for operating base and you are on high alert. You - your adrenaline is pumping. Cortisol is being released. And then you roll - and perhaps you have a battle scenario, where again adrenaline and cortisol is released.

And then as you can see, different things occur throughout your 24 hour deployment on this particular day. And then you try to come back to your base and attempt to go to sleep. Now imagine that this cycle continues for 365 days a year, this releasing of chemicals, this dumping of chemicals into the body, this up regulation and down regulation.

Well, because we know the deployed soldier rhythm, we should start creating programs that intervene at each one of these points and provide the service member with something to do when the event occurs. Just like we have battle drills and they are aware situationally(sic) of what's happening around them, we want them to become aware of what's happening inside them - internal awareness.

Now, not everything is doom and gloom even though that there are a lot of problems and issues that remain to be fixed. There is hope if we can change the culture in the military. We do know that proven resiliency techniques exist and as Dr. Berger explained, those - many of those techniques are ancient - ancient 5,000 year old techniques that are scientifically sound such as breath work and visualization and awareness training.

There are many techniques that can help people remain resilient. But there's a problem with low adoption rates because the way that it's being sold to the warrior is that it's a Power Point program or it's a - it's something that comes from a Buddhist practice, you know, or some religious practice. It needs to be sold to them in terms of warrior optimization.

Knowing these things, understanding these resiliency techniques can help you understand how the brain and body react and more. We're basically wanting to teach them Neurophysiology 101 so that the same way we teach them how to use their weapons they understand what happens when they use it and the impacts on the brain and body once they witness life intense experience.

There are many examples of techniques that can be used, as I said - awareness, breathing, simulation techniques, grief management, acceptance training, even teaching soldiers the 24 hour cycle of operations so that they can conceptualize it.

Now just like we teach the soldier what to do, it's important that we also teach the family what the soldier is going through and what to expect. Military families have to have a formal education and information on what to expect when they are married to someone who operates under the current op tempo that these soldiers do.

There are expected things that they can look out for. One of the things I've been fortunate enough to do with PBS is to help them develop a military family guide which should be released shortly. And the way that we developed it was basically talking to military families. You tell us what you experienced, where you made mistakes, where you did things right, what worked for you. And we took that information and compiled it.

But it's important that the family has the same knowledge about what to do that the service member does. And we have to consider also when the service member deploys, whether or not the family has been trained and understands that they need to have a plan for their children that is age appropriate and ways to help them cope, that the war also impacts the family support network, that moms and dads and brothers and sisters all suffer from fears and need to know what the service member is going through and how to help.

So one of the best ways you can do that is to create a family mentor network. And here're a couple of organizations that you might turn to to get information about how to help a service member while they're deployed or when they come back home.

Now it's important that the knowledge of resiliency and the knowledge of how the brain and body work in war does not reside in the hand of the psychiatrist or the psychologist or the chaplain but that it gets down to the individual user, down - all the way down to the individual user level so that they understand like they never have before what kind of exposures they are having on their brains and bodies.

And there are many effective strategies for self-empowerment. One of those effective strategies is to basically own your experience, to not let it own you. And you do that by understanding how the brain and body work. Another self-empowerment strategy is to develop awareness, become the observer. Once you can observe what is happening, understand the feeling states that are created by working in a wartime environment, then you can look at what you need to do to develop effective strategies and then you put those strategies into action.

Another important thing that you can do to self-empower is to choose a mentor or a peer that you trust that you look up to that's going to be there for you. Dr. Berger can testify that peer-to-peer support networks work and they are often the gateway just by talking to your buddy, somebody that served in war with you is often a gateway for that person to go get help.

And what does the prepared service member and family look like? Well, in the pre-deployment phase, the service member would take care of all of the issues and have all of the discussions about how we're going to communicate, what are we going to do when crisis occurs and we're separated? How are you going to pay the bills? What - how are we going to talk to the children? What kind of strategies are you going to use?

And then in the during deployment phase you execute all of those plans that you made and should you have any problems during the deployment you turn to your peer mentor network. And then once the service member comes home, then the family and those that love the service member watch for signs and symptoms of distress and anything that the service member may be going through that requires attention.

Now we're hearing a lot of the word resilience being bounced around and resilience means a lot of things to a lot of people but for me it's basically the ability to bounce back. And one of the ideas about resilience is that having a resilient capability allows me to maintain neurological functioning when others around me may be falling apart. It allows me to operate in the executive function area of my brain rather then in the survival portion of my brain.

So teaching resilience to people - and this doesn't just include military service members. It also includes police, fire, EMS, anyone that responds to natural disasters or wartime scenarios. Teaching them resilience helps them to be able to function in the environment that they're operating in.

But also resilience - and this is being studied right now through grants at the NIMH - resiliency training appears to reduce anxiety disorders and depression. It certainly isn't a magic bullet. It won't solve all problems but it seems to be able to help people mitigate the stress and the strain of operating in different life intense environments.

It also helps you to maintain emotional stability, health and well being. And there are many differences in resilience when recovering from different types of threats but the one thing why I think it's most important to teach it to people in the military is because we know that we are sending them into traumatic situations. There's no guesswork about it.

It's not as if they're going into the aftermath of an earthquake. We know that they are going to witness life intense experience, and so we have to have a strategy both before they deploy, while they're there and when they come home. And I think resilience is going to be the means by which we try to mitigate some of the problems that we see today.

In order to be resilient you have to have the following - possess the following orientations. You have to be good at problem solving. You have to have a strong inner-self and determination. And you need to be able to become the observer and to create for yourself response tips and assessment tools so that you can identify what's happening and then turn to a tool or a skill to work with it.

For example, if I wake up in the morning and I notice that I'm just not feeling right about this mission, I'm sad, I'm depressed, I'm not feeling well, I feel sluggish. There are many things that I can do to get - I have to go do that job today. I know I'm going to have to get in the Humvee. That mindset is not helpful for me on my mission.

There are many things that I can do, much like Olympic athletes - to get my mind right. I can use visualization. I can use breath work to up regulate. Many soldiers turn to music. It's something that they do without even knowing what it is. They turn to music that motivates them and put them into the parasympathetic or sympathetic nervous system, depending on which direction they want to go. They have music that they already have chosen that puts them in that mood.

So there're many things that you can do to assess and respond. The biggest thing you have to learn is to be the observer, to observe what's happening to you. In the military we call it situational awareness. That's the ability to scan your sector and know what's happening around you. But I want to teach them internal awareness - IA, the ability to scan your body, your mind, your thoughts to recognize feeling states and then to have resiliency tools and techniques to get myself into the optimal performance state.

If we can teach this to them before they go and also teach it to the families back home, I think we can get ahead of many of the problems that soldiers face today so that they can understand and process their experience, so they can own it and know what happened.

Here're some of the key resiliency dimensions. I won't read them all to you. But an important one to maintaining resiliency is having some intimacy and relationships - family and friends. Often the expression of suicide, when someone kills themselves, it's to me the ultimate expression of a loss of help, hope and intimacy and someone to turn to.

And in the military that's inexcusable because everyone in the military has someone who's in charge of them. And no one in the military is responsible for more then five people at any given time. So there's no reason for a service member to feel abandoned or to feel lost or to feel helpless. But often because we haven't trained our military to understand the mental health care injuries are as real as bullet wounds, people with mental health care problems, when they come home, are often ignored or told that they're weak or ridiculed.

And that has to change because if everyone understood what was happening they would not abandoned their buddy on the battlefield like that or when they came back home.

Here're a couple more key resiliency dimensions - humor and laughter, assertiveness, problem solving and decision making, and equanimity. Now this is the definition of equanimity that I got off the Internet. And you'll notice at the very end it says, "A sense of temporal detachment from reality." Well, I don't ever want to detach from reality. Although I know that the brain sometimes can do that as a way to protect me, I never want to detach from reality. I want to know what's happening around me and be able to navigate it and negotiate it.

So while I understand this is the definition off the Internet for equanimity, I certainly hope that what I want soldiers to understand is that when something happens to you to not detach from reality, to be present, whether it's when you get back home and you're grieving or whether you see your buddy get shot. You need to maintain presence. You cannot allow yourself to go into the freeze mode.

So we want to teach them to stay present in the mind and the body when things occur on the battlefield and then when they have - when they're in a safe place and they have time to process, then they can grieve and then they can cry and then they can do the things that they need to do to process the information.

There is certainly some economic gain from creating the situation where your brain and your body are - maintain steady, normal sinus rhythm where you're not too high and you're not too low. And if we can leverage optimal brain functioning to interrupt the damaging effects of stress on the body I think we can create cost savings - not only cost savings but also the health and well being that can occur from employing these techniques.

The science of behavioral health and emotional regulation, I like to use those - the three Cs. Many of you maybe have seen these. Basically a sense of control over our response to life events, that we have an internal locust of control, that we own our experience rather then being owned by it. And what I mean by that is there are many veterans that come - have come back home from war and have been haunted forever from their experience.

And I think ultimately what I want to see them be able to do is to use that experience. Whatever happened to you, use it, incorporate it into your life. Make it part of your advocacy. Make it part of who you are. I don't want you to let it go away from you but I do want you to be able to own it and not let it own you where it drives you to dysfunction, drives you to suicide, drives you to alcohol, drives you to depression and drug use.

And I think that's happening to this generation. They're turning to drugs. They're turning to alcohol. It's an old story like Dr. Berger said. But there're things we can do to help them.

One of the other C's is a sense of commitment, it's a focus on being there for yourself and for the people that love you, a focus on meaningful work which is a problem in this environment today, and a focus on relationships.

And lastly, a sense of challenge and learning that no matter what happens to you, no matter what you're confronted with, that while it make suck in the moment, there's an opportunity for growth. There's an opportunity for growth. And you have two paths and one of the paths is - can lead you to dysfunction and despair, alcoholism, drug abuse, loneliness. And another path is to try to negotiate it and to navigate it. And it takes help to do it.

It takes communities and it takes partnerships. And that's what my last slide is about. In a perfect world, if we were doing our job in the military and we were training people the way we're supposed to, we would have programs that teach soldiers how the brain and body function. They would be subject matter experts on what happens when you go to war, rather then trying to figure it out after they've gotten back home.

That knowledge would be incorporated into integrative health and wellness that includes the best and the newest treatment models. One cookie cutter model or two cookie cutter models in the DoD and the VA are not going to be appropriate for this generation. There are many models and paths to recovery. And we're going to have to look at all of them.

Finally the family has to be in the loop. And when all of those things are together what we end up getting is a resilient community when the warrior comes home because everybody is prepared and everybody understands what happens to soldiers when they deploy. And we've got a battle plan for them before they go. We know what we're going to do while they're gone. And when they come back home we put our arms around them and get them the care if they need it.

That's my presentation. Thank you very much for listening.

Jane Tobler: Thanks Steve. That was great. We really appreciate you sharing information on the Path to Resiliency and Recovery and what people need to do to improve it.

Our final presenter today is Sheri Hall. Sheri has been a military spouse for 19 years. She was a family readiness group advisor for two year-long deployments in support of Operation Iraqi Freedom. She and her husband, Jeff, attended the deployment health clinical centers Specialized Care Program, Track II to address the effects of PTSD.

They have also participated in many conferences for the Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury. Both Sheri and Jeff have been involved as panelists with the Theater of War and they also work closely with the Real Warriors Campaign to break down the walls of stigma associated with getting treatment for PTSD and traumatic brain injury.

Sheri will share her personal perspective on mental health problems faced by service members and their families. Sheri.

Sheri Hall: Thank you Jane. And I would like to thank SAMHSA for asking me to be here today to tell the family portion of this story. I'll start off by giving a little bit of background. Jeff and I are high school sweethearts. We've been married for 19 years and we have two teenage daughters.

I can tell you that from early on in our relationship, I knew that Jeff wanted a career in the military. He had been enlisted for three years after he graduated from high school. After that he went on to college on a National Guard scholarship. He graduated from college in 1997 receiving his commission as a field artillery officer. I fully supported his career from the beginning because I knew it's what he always wanted to do and I could see the drive in his eyes.

Before deployment, I can tell you September the 11th of 2001, Jeff was ready to roll. He was - unfortunately he was in school at Fort Sill and he couldn't get to a unit quick enough. But he was very excited when we got our assignment to Fort Riley because he knew that at that point he would deploy out of here as quickly as possible. He was very committed to victory and he was fearless - he had no fear in his eyes at all. He was ready to go and represent his country and fight for our freedom and stand strong.

We expected long deployments even though, you know, they told us a year, just as worst case scenario, 18 months. So in preparing for his deployments, we talked as a family. We sat around and we helped him pack his bags. And we tried to explain to the kids as much as possible that this was a dangerous job and that there was a possibility that dad could not come home or come home, you know, severely wounded in most - in some case.

But we - we even went as - you know, Jeff laid out what he wanted for his funeral. One thing that we never discussed was the possibility of a psychological injury. That's not something, knowing Jeff for as long as I did, I never in a million years imagined that that would be the case.

As a family we - you know, we knew we'd probably face more then one deployment. I was very confident that Jeff could take care of himself. He trained very well. He not only trained himself well but he trained his soldiers under him very well to always have eyes in the back of your head as well as in the front of your head.

He was deployed - he was redeployed ten months after his first deployment and I continued through the second deployment to stay strong with my faith. That to me was an important part of getting through that year and dealing with the things that I had to deal with back here as being two parents. But I just kind of put, you know, all of my concern and worry in God's hands and went - you know, went on about my daily business. Not that I wasn't worried or concerned for him but I knew that God would take care of him.

His preparation for the second deployment, it did begin almost immediately. He had his two weeks of block leave and then they were right back in the field training. And that included a trip to the national training center in California where they were gone for I believe anywhere from four to six weeks for that.

So we just stayed in a constant deployment mode after the first deployment. We never stood down. We never - I guess you could say we never really reconnected as a family. We stayed on guard constantly. He was actually deployed a total of 24 months from 2003 to 2005. And during that time we figured out that he was only home about seven months in there.

And in that seven months there was some time where he was preparing for his deployments, like I say, constant field training and things like that. As a family readiness group advisor I had about 30 wives under me and those included mothers also. And like I said, trying to stay motivated and stay strong in doing the two parenting thing at home kind of wore me down a little bit after the second deployment.

Jeff came home in December of 2005 from his second deployment and as he walked in the door of the hangar for the ceremony that evening I could tell immediately that there was something different. He had a thousand yard stare on his face. And that's what we call it now. At the time I could just tell that he just looked like he was staring off into space and he was glad to be home but at the same time there was something deeply wrong.

I could see this - he just had a deep look in his eye. I did encourage him to get help and he, you know, he just - he said, "No. I think I'll be fine. Everything will be okay." But finally one day he did go talk to somebody who just explained that, you know, you're just angry and those feelings will go away and everything will be okay.

And we did – we thought that, well, maybe she's right. Maybe things will be better as we move onto our next duty station which was Fort Polk, Louisiana where Jeff was assigned to the joint readiness training center. And he would come home and he would tell me about the things that they would do while they were training.

And it just seemed to me like it was from one battlefield to the next which, as a spouse, you watch all of this happening and the anger continues to build. It doesn't go away. He becomes very distant from the family. He has the strong desire to just be alone. And he would say some hurtful things, never to the children but always to me. He would just say some hurtful things and then never really remember what he said afterwards.

And I just kind of thought, well, if I just stand strong and encourage help maybe he will eventually get that help. But, again, he was just reluctant to do that. He did not want to be on any type of medication, although he did go speak to a psychiatrist at Fort Polk and was immediately after 15 minutes prescribed, you know, four bottles of pills and sent on his way, pills that he just didn't feel comfortable with taking because he didn't want to alter - he didn't - he wanted to be better but he didn't want to alter his mental state in another way where he knew he may be constantly just groggy or feeling drugged out.

Over the next couple of years these problems just continued to become more and more serious. We tried to carry on as normal as we could as a family. And it just - you know, the girls were getting older and they were starting to notice more things. But as a mother I tried to shield them and protect them as much as I could. But Jeff just become more and more distant from us.

In April of 2008, he became just totally - just really hit rock bottom, if you will. He became suicidal. He really just thought that that would be the only thing that would fix what was wrong. He felt like if he just laid down and just died everybody would be better.

And he wanted - just wanted nothing to do with the things that mattered to him before. He's a wonderful woodworker. He builds beautiful furniture and things like that. And he had no desire to do any of that anymore. He had no desire to ride his motorcycle anymore. He just wanted to just be alone, lay in the front yard. He felt very useless.

And he tried very often to get me and the girls to leave but I just couldn't leave him alone even for 30 minutes to go pick the girls up from the school. I was extremely worried that he would do something to himself while I was gone, to the point where we'd get home and I would jump out of the car before the kids and run into the house to make sure that he was still alive.

I finally told him - I asked him one day, I said, "Who benefits from your death, because I don't see, you know, how anybody can benefit from you leaving or killing yourself." And Jeff said he - he said, "I'll be better. I'll be fine. And you guys will be okay without me." And I said, "How do I explain you taking your life to your children and our family when I can't explain it to myself?"

And I really think that that may have been a turning point for Jeff. Even though the family was asking questions and we were struggling with, you know, the things that were going on and with constant prayer, and I prayed everyday but I knew that just prayer alone wasn't going to solve these problems.

So I actually went to Jeff's - to his boss and he and I helped (Jeff) find the right help. He went to see somebody at Fort Polk and when he re- when that therapist realized that Jeff's issue was over his head, we were referred to a program at Walter Reed. It's a specialized treatment program for those suffering from PTSD and TBI.

In July of 2008, Jeff went out for a week long evaluation where they check you out from head to toe. It's not just a psychological check. You also see an internal medicine doctor and they check on everything to see what your aches and your pains are.

He came home at the end of that week and he really felt a little bit of hope which gave me some hope. And he no longer felt suicidal which was a great stride for me to see in him. He asked me that if he got accepted in this program if I would go with him. And in August of 2008, we left for three weeks from Louisiana and went out to Washington, DC.

And it was kind of our first step in healing together. And for the first time since Jeff came home in December of 2005, I felt that there was some hope and that there was a solution and that we could start to fix this even though everything that I had read on PTSD I knew that it was not going to be something that went away overnight.

A little bit about the Specialized Care Track II Program. It is an intensive three week treatment program. They touch on not just, you know, your PTSD issues or what you're dealing with mentally. They explain these things to you. They teach you what causes it, what it's - how it all comes about. And, you know, you're - you just - you sit in group therapy and you get to talk.

It's that peer-to-peer where you get to - you get to talk to your peers back and forth and you realize, you know, you're not the only one that's dealing with this. There's also some physical reactivation that you go through with a physical therapist and you do pool therapy and you do outside activities and then you do individual things, whether it's on a treadmill or, you know, something of that nature.

You learn some stress management through relaxation training, breathing techniques and yoga which was very good for us. And like I said, you have your education based self-care focus where you learn what is wrong with you, you learn how to cope with - like Jeff would say, he could see the impending doom. He could see the dark cloud coming.

Well after this program, he could see that dark cloud coming but he knew how to deal with it. He knew what was coming and he knew what he could do. There's a 30, 60 and 90 day follow up when you leave so you're never alone. They call to check on you to see how you're doing. And that really helped us out a lot also.

It gave us a sense of security that if we had something that we needed to discuss, either one of us could call back and we could get the help that we needed.

After our treatment when we went home we were really concerned about coming back to Fort Polk and starting back through, you know, getting back into the normal part of life but we did come home and we did apply what we had learned. And like I said, if Jeff saw that dark cloud coming, you know, he knew what to do to cope with it.

But we both realized that in three weeks you're not cured of this. And that was something that we did have to explain to our family and Jeff had to take that to work with him and explain that to his peers at work as well as to his boss.

Everything is one day at a time and that's the way we had to take it. I did become more aware of certain triggers and I knew how to cope with those and I knew how to help. Communication was a huge - a huge thing for us and that's how we got through it. But again, the most important thing is that Jeff was no longer suicidal.

When he did go back to work, his boss was very understanding and he eased him back into it. It just didn't throw him back into the fire which I think really helped Jeff a lot to continue on with his treatment.

About a month after we came back we were asked to come and speak at the National Institute of Health and tell a little bit of our story and tell what we learned at the DHCC at Walter Reed and to be able to spread that message that there is hope and there is help. And since then, as Jane said, we are participants of the Theater of War and with the Real Warriors Campaign. Again, we're just trying to help soldiers and their families understand that there is help out there for you and that there is no reason that you shouldn't accept that help. That stigma - the stigma that's attached to PTSD really does need to go away.

In February of 2010 after we got back to Fort Riley - we've been back here a year - and Jeff was picked to be the director of the Resilience Training Program here at Fort Riley. And he's working very hard to help create a program that will help soldiers and their families that are coping with deployment and redeployment, especially the reintegration of that.

You know, getting help isn't the end of your career. It hasn't been for Jeff. He has strived in the last couple of years. And I'm very proud of him. I will tell you that we have made it our mission, our personal mission, to help families and soldiers to get the care that is deserved of them as they deal with trying to heal.

It's not easy - it wasn't easy for us to find what we needed but once we did we got on the right path to healing. And like I said, healing is an every day process for us. The psychological trauma due to combat takes time to heal for both the soldier and the family because those wounds are very deep. But we feel that with the proper knowledge and care the right path can be found and that healing can begin.

And again, I thank you very much for having me today.

Jane Tobler: Thank you Sheri for sharing your personal story. I'm sure there are many people on this teleconference who can relate well to your experience, so we really appreciate you bringing it home.

At this point in time the presentations are over and I would like to just point out to the participants that there are many excellent resources on Slides 51 through 54. In the interest of time we will not go through them because you may access them later. But they're for families and for use and for returning vets and for mental health providers, so I encourage you to check them out.

And we will be starting questions in just a minute, so we've received many through email. You may go ahead and email them to that - us or press star 1 on your telephone keypad to be placed in the queue. If you do not wish your full name to be announced by the operator, please only state your first name.

Upon hearing the conference operator announce your name, please ask your question. After you've asked your question, your line will be muted to allow the presenters an opportunity to respond. If you have additional questions that we are unable to get to today you are welcome to follow up with our presenters whose contact information is on Slide 56. Or you can also contact the SAMHSA at promoteacceptance@samhsa.hhs.gov. This address and contact information are also listed. The information for the ad center is on Slide 62.

Today we are lucky to have two additional speakers from SAMHSA who can field your questions. The first is Dr. R. Thomas Deloe, a senior public health advisor in the Center for Substance Abuse and Prevention within SAMHSA. Dr. Deloe, a veteran, is part of the task force in SAMHSA that focuses on the needs of returning veterans and their families. He joins us today as a resource to answer any questions about substance abuse prevention.

Our second presenter is Dr. Ruby Neville who is the lead coordinator on military families and disabilities within the Center for Substance Abuse Treatment in SAMHSA. She serves as a primary contact for issues and questions in the area of returning veterans and military families. Ruby joins us today as another resource to answer any questions about substance abuse treatment issues.

In a moment we will take our first caller. First we'll have a question that was sent to us via email. This question is for Steve. Your resiliency training seems to be a good way to prevent mental health problems. Is the program being implemented and/or studied, and if not, how can we get these types of holistic approaches implemented?

Steve Robinson: Well, the Department of Defense does have a program that it has begun where it's teaching some individuals who then return back to their units called Comprehensive Soldier Fitness. I looked at their program. I don't know that it is as extensive as some of the programs that myself and Dr. Berger have worked on.

But there are many ways for us to try and get those programs into the Department of Defense through talking to your local congressman, reaching out to people who are on key positions, key committees. For example, I'm waiting for the Department of Defense to release a training program that I worked on that taught resiliency techniques to soldiers before they deploy to war.

We created a movie around this idea and eventually I assume they will release it and it will be used but there are many different ways to get these programs. The one thing I would say is that you can - even if a program isn't in your area, there are many ways to access these programs by contacting some of the organizations that are listed in the resource list - Real Warriors, the Coalition for Iraq and Afghanistan Veterans. There are many great organizations that will take a veteran at no cost, send them to wherever they need to go at no cost, put them through a three week or four week program at no cost and let them return back to the military.

Jane Tobler: Excellent. Thanks so much Steve. Our next question is what issues do you feel are the most important to discuss with the wives of veterans? Sheri, would you answer that please?

Sheri Hall: What issues are most important to discuss with the wives of veterans?

Jane Tobler: Correct.

Sheri Hall: I think when I talk to spouses, I just encourage them to stand strong in the fact that there is help for their soldier, that, you know, don't back down and then, you know, I always encourage them to check into the resources that I have, whether it's Real Warriors or Military Family Life, though Military Family Life Association has some great resources also.

But I also encourage them to, you know, talk to their other - talk to their peers, talk to the other wives around them, though you would be surprised at how many will actually - actually say, "Hey, you know, I've seen that in my husband and how do you handle that?" And for them also if they can find a great support group to join and be a part of, one where they can just talk about what they're dealing with at home and ways that they can learn to cope. Those are just some of the things that I like to do for spouses of veterans.

Jane Tobler: Excellent. Thanks Sheri. Operator, will you please give us our first caller?

Coordinator: One moment.

Jane Tobler: Thank you.

Coordinator: First question comes from Sally Miller. Your line is open.

Sally Miller: Thank you. I would like to know how we can get the excellent statistics that Dr. Berger gave at the beginning of his presentation. He was speaking too fast to be able to write them down as he went. Is there a slide or resource available?

Jane Tobler: Tom? Tom, if you're speaking you're on mute.

Tom Berger: Okay, mute off.

Jane Tobler: Thank you.

Tom Berger: I believe that the presentation will be posted and you can get the figures directly from there. If you want the sources, specific sources, my contact information is on the screen and give me a holler and what sources do you want?

Sally Miller: Thank you.

Tom Berger: I'll be glad to share them with you.

Sally Miller: Great. Thanks.

Jane Tobler: Excellent. And this is Jane Tobler again. Just a reminder that the - this training teleconference is being recorded so the Power Point presentation, a PDF version and a recording will be available, along with the transcript, posted to the SAMHSA ADS Center at promoteacceptance.samhsa.gov.

Operator, could you go to our next question please?

Coordinator: Next question comes from Sam Coleman. Your line is open.

Sam Coleman: Thank you very much and thanks to all the presenters too. Question especially for Dr. Berger. Some social workers now are talking about the possibility of applying techniques from restorative justice to vets experiencing PTSD. Have you heard anything about this?

Tom Berger: Just a little bit about it. I don't know. I'm not aware of any studies that are taking a look at it. I am familiar with one person who - and it had an impact on them. But really there's not a lot of information out there about it yet.

Sam Coleman: Well, thank you.

Jane Tobler: Next caller please operator.

Coordinator: Next question comes from Linda Weber. Your line is open.

Linda Weber: My question is for any of you that would be able to answer this. I have been recently in touch with a number of veterans who - OEF, OIF - who have been involved with the law. And some of them are going to be incarcerated or are incarcerated. I understand that there are some states that are looking to alternative kinds of lock up facilities. Do you know of any? Do you know of any resources? Anywhere I could look?

Tom Berger: This is Tom Berger.

Linda Weber: Hi Tom.

Tom Berger: I'm not aware of alternative lock ups. I am aware of alternative sentencing programs which, along a continuum, could be anything from certain kinds of supervised habitats or communities, but not - I'm not aware of being organized in the fashion that in the words that you used.

Ruby Neville: This is Ruby Neville who'd like to make a comment on that. I work at SAMHSA, the Substances Mental Health Services Administration, and the Center for Substance Abuse Treatment.

We do fund a drug court. We say - it's what we - they - call them, and basically instead of sentencing the person as the gentleman just mentioned to incarceration, we - they are sentenced to treatment, to refined treatment. I don't know if you're aware of this but there's a Judge Russell in Buffalo, New York who started the first veteran's court and it has been very successful. It's been all over the news. We've used him in our National Returning Veterans Conference to inform states about the drug courts.

And there is funding - there has been funding and I think there continues to be some funding in that area - for mental health as well as for treatment. And then we have people in our criminal justice office who work on - in that area and they are working with the Department of Justice as well. So stay tuned. You know, continue to look on our SAMHSA Web site to see if you see any announcements relating to that.

But (Ken Robinson) is the person in our center who's in charge of that criminal justice office and they do work with the drug courts and it is available for veterans as well.

Steve Robinson: And this is Steve Robinson. I'd like to just add one thing to that. It's an important issue that's being raised about veterans and the justice system because, for example, in the military because we don't really have a good - the military doesn't have a good grasp of what the symptoms of mental issues are, they often view them as a lack of moral character or a lack of discipline.

And so they often may punish mental health care symptoms with the uniform code of military justice which denies people treatment and programs from having an injury that they sustained while at war. So we're trying to educate them on that. That education is extending to the courts so that the courts also understand that we've got to look at the whole veteran, the whole picture when they come back. And, you know, they should take into account their honorable service when they sentence them, try to help them before they just drop them into a jail forever.

Tom Berger: This is Tom Berger again. This is really important what Steve said - the whole picture. For those of you who are unfamiliar with the criminal justice system, if you can visualize it as a continuum from the point where the veteran encounters the criminal justice system - that is the police officer - until the other end of the justice system or continuum is when he or she is released.

There are things that can be done at every step on the continuum, not just alternative sentencing or modifying a drug court to fit a veteran's particular circumstance. There are what they call crisis intervention teams that have been started in several large localities, notably Chicago and Memphis, where police department leaders have taken the ini- and these fellows are veterans themselves - have taken the initiative that within the pol- their respective police departments, have trained veterans who've come to the police force to handle crisis situations involving veterans because when you encounter a veteran in a highly charged situation the could involve violent behaviors and/or weapons, police officers and veterans are sort of like two bulls in a China shop.

One - neither one of them is going to give up. So what I'm saying here is that these crisis intervention programs train the police officer in ways to approach the veteran in terms of that first encounter. So that's just an example but what I'm - what Steve said is very important. We need to look at the whole continuum that we call the criminal justice system and there're very places - very - many places on that continuum where there can be interventions that specifically take into account veteran's circumstances.

Ruby Neville: And this is Ruby. I just want to briefly add to that. Just - yes, and we preach that all the time within SAMHSA. There's a continuum in almost everything we do as far as treatment and, you know, helping folks. But I also wanted to mention that, you know, that's part of our - all of grantees who receive funding from us, including criminal - the drug court or mental health court because it's not just about drugs. It's about giving people the mental health care that they need as well.

We have as an objective, that folks would have to do well in as far as working with these people, decreasing criminal justice activities as well as building social connectedness. We think that, along with some other measurements, we measure success of our grantees because we want them to work well and do a really great job as far as working with any veterans who might show up at their door, as well as the Access to Recovery Program.

That's supported recovery, whether it's mental health and substance abuse together or substance abuse by itself. We want people to maintain or to sustain recovery. So our Access to Recovery Program is a wonderful program. I just want to mention if you want to find about out the mental health or substance abuse courts that got started in Buffalo, just Google Judge Russell and he's been very, very conservative as far as helping people and channeling states to step up these types of programs.

Jane Tobler: Thank you very much. The next question comes via email. The army reported record numbers of suicides for June. What can we do? What messages can we develop to combat the issue? Tom, do you want to take a stab at that?

Tom Berger: Sure. I'll start with it and then I'm going to turn it over to Steve. Just last week I testified on the Hill about the effectiveness of the VA's Suicide Hotline Program. On some ca- in some cases, it's been very effective in the sense of stopping any suicide, of course, is great.

The difficulty is that there's no long term program. And that was evidenced in my testimony last week. Two years ago, just prior to when former Secretary Pete left the VA, he established - he commissioned a blue ribbon suicide panel. These were - these included some of the top suicide people in the country.

And he charged them with developing some recommendations which in turn would be acted upon individually by the VA. There were eight major recommendations plus I think 14 I call them minor recommendations that were turned over to the VA.

Last week, in testimony, two years later, we asked the VA for the plan. In response to that, they do not have one yet. Steve?

Steve Robinson: Well, I know that Tom and I and others, when we saw that we were going to war back in 2001 began meeting with people in the Department of Defense with congress and others saying that if we were going to have urban combat in the way in which it has played out that we were going to see a different kind of war then the first Gulf War which was limited long range tank battles and a really entrenched warfare where there was going to be face-to-face contact, up close battle which scientifically we understand can create lots of trauma in people and requires a certain response.

After eight-plus years of war, the Department is now - the Department of Defense is just now pushing out its study on what it thinks the problems are related to suicide. And having read the 330 page-plus document, I find that it's, from my humble opinion, missing some very important things.

One is the fact that we, in the military, because of our lack of understanding about mental health care issues are part of the problem. That's the first thing. We've got to point the finger at ourselves. Two, they don't address very well in the report the fact that the military's first choice for dealing with people with mental health care problems is pharmacological intervention, handing them bags and bags of medication.

Tom and I and others know, and I think maybe even Sheri, you can attest to this, that sometimes some veterans are on as many as from six to 15 different medications without being monitored. That's a problem.

So we're happy that they're starting to look at it. There's another report that's going to come out very soon that is a Department of Defense report, not an army report, but a Department of Defense report, that has consumers, family members, the people who have dealt with suicide, and I think their recommendations are going to be more spot on then the one we've just seen.

Ruby Neville: This is Ruby Neville. I also wanted to mention, even though I'm not involved in this specifically, but Eileen Zeller who comes from the VA who's been working with the lead at SAMHSA, Kathryn Power, she's the lead on returning veterans.

They have been having some conversations with the VA relating to suicide prevention. They also put out a few years ago a wonderful protocol on preventing suicide. And the VA took a look at that from my understanding and they thought it was very - you know, it was a very powerful document. And - well, protocol I should say. And it was a manual that was released.

But there ha- I know there has been some conversations that have started and they have been conferring with SAMHSA because SAMHSA has taken a leading role as it relates to preventing, you know, mental health issues and suicide problems.

So I can't tell you too much more about that but I know Eileen Zeller has been working on that for a long time and she continues to work on that with the VA.

Steve Robinson: If I may just to add to my comments, we just recently sent six recommendations to the White House, to Congress, the Department of Defense and the Department of Veteran's Affairs basically it goes like this that, number one, we have to implement pre-deployment, during deployment and post-deployment screenings with mental health care professionals.

That - believe it or not, that doesn't happen. They do get screenings - pre-deployment, during deployment and post-deployment but those screenings are paper surveys and if you indicate in the affirmative that you need help you may or may not get a referral.

There is no nationwide consistent anti-stigma campaign that's delivered from the White House, that's delivered from the Department of Defense. There - Real Warriors is the first step in that direction. We like it. But there needs to be more. There're many, many other recommendations that have been made. Suicide's a big problem. It's not going to go away. There are many things we can do to at least allow ourselves to go to sleep at night knowing we've done everything that we humanly know is possible. Right now we're not doing that.

Tom Berger: Exactly Steve. This is Tom Berger again. I would just point out - that the VA was given the appropriation to develop, which they did, a series - a video presentation which utilized Gary Sinise, some of you may know or remember him from the For- the movie, "Forest Gump." He's also on one of the television crime shows.

But in any case, Gary was recruited and participated in and developed a suicide prevention video. It ran for several months and then the VA pulled it. And they could not answer Congress's questions as to why it was pulled. So, you know, as Steve said, there's a lot of stuff out there. We need to start doing it to reduce or slow down that rate.

Jane Tobler: Excellent. Thank you so much. Because of time we're going to just take this last question. It is for Sheri. Sheri, what was the children's school involvement? Did you let their teachers know about Jeff's deployment? And if so, were the teachers supportive? Sheri, you're on mute. If you're speaking we can't hear you.

And I do have to tell you that Sheri was having some technical difficulties earlier today. So I'm going to guess that she still is. So this is going to - so we'll just end here.

Ruby Neville: May I say something quickly? This is Ruby Neville and I think everybody is familiar with the military families initiative that's going on throughout the country at the - and I can't recall the exact name of the program now, but if anyone needs to, I can give it to them later sent to you by email. But anyway, I will say this. If you - there are some programs that are looking at parents in the military who may have also kids with special needs. And there's one out of Washington State called the STOMP Program.

And I will tell people, you know, to be familiar with that because in addition to all the other stressors, if a parent has a special needs child and they're going from state to state with that special needs child and there's no coordination of individual's - the IEP plan and getting the kids the right education, that can - that creates additional stress for the parent. So this program is wonderful. It's a national program.

They're available to have any parent who may be going through any crisis as far as kids with special needs or kids who may have learning disabilities and requiring an IEP. And that's an individual educational plan. I just wanted to mention that.

Jane Tobler: Thanks. Thanks Ruby. Thanks for sharing that. And I just want to thank all of our speakers today - Tom, Steve, Sheri and Ruby for your work on this important issue and for sharing your professional and personal experiences and insights today. Also thanks to all of our listeners for caring about this topic and taking time out of your afternoon to learn more.

Tomorrow you'll receive an email request to participate in a short anonymous online survey about today's training. It'll take you about five minutes to complete. Please do take the survey and share your feedback with us. This information will be used to help us determine what resources and topic areas need to be addressed by future training events.

The conference has been recorded and the audio recording and transcription will be available in late August on the SAMHSA ADS Center Web site. I want to thank everyone once more for joining us and to let you know that on Slide 56 you have the contact information for all of the speakers including Ruby Neville and R. Thomas Deloe. Thanks so much and have a great rest of your day.

Coordinator: Thank you so much for participating in today's conference call. You may disconnect your lines at this time. Thank you and have a great day.

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