Episode 79 Transcription

Welcome to Episode 79 of Behind The Mission, a show that sparks conversation with PsychArmor trusted partners and educational experts. My name is Duane France, and each week I'll be having conversations with podcast guests that will equip you with tools and resources to effectively engage with and support military service members, Veterans, and their families. You can find the show on your podcast player of choice or by going to www.psycharmor.org/podcast.

Thanks again for joining us on Behind The Mission, our work and mission are supported by generous partnerships and sponsors who also believe that education changes lives. This show is brought to you by PsychArmor, the premier education and learning ecosystem, specializing in military culture content. PsychArmor offers an online e-learning laboratory that's free to individual learners as well as custom training options for organizations. 

On today's episode, I'm having a conversation with Dr. Elisa Borah, Research Associate Professor at the Steve Hicks School of Social Work at the University of Texas at Austin and Director of the Institute for Military and Veteran Family Wellness, a joint initiative of the Dell Medical School Department of Health Social Work, and the Steve Hicks School of Social Work. Dr. Borah conducts research to identify, implement, and evaluate treatments, programming and community support for service members, Veterans, spouses, and their families. She also studies self-care practices among military spouses and how to best support their transition needs after military life. You can find out more about Dr. Borah by checking out her bio in our show notes. So let's get into my conversation with her and come back afterwards to talk about some of the key points. 

DUANE: So as a military spouse and research scientist, specializing in the military affiliated population, I'm certain that you have a lot of insight into the unique needs and situations of service members and Veterans and their families. But before we talk about that, I'm interested to hear about how you became involved in research and support for military and Veteran families.

ELISA: Sure. So when I was finishing my PhD at the University of Texas at Austin, my husband, who was an army psychiatrist at the time, mentioned to me that there was this new research happening at Fort Hood called the Strong Star PTSD Research Consortium that was a DOD funded set of studies around effective treatments for PTSD among service members. And so I was putting my hat into all kinds of job searches and put myself into that job search and met the whole Strong Star Team and found a great home for my work, which originally my research focus was on implementation of evidence based practices into practice settings. And so just very briefly.

There's lots of research done in the world, but we don't always get it effectively into practice as quickly as we would like to, or as smoothly as we would like to. And so I was very interested in supporting that, just to make sure that patients and clients receive the best care as soon as possible, as soon as the research is concluded. Then I joined that team up at Fort Hood and I was primarily focused on supporting research for service members at the time. And then when I ultimately, I always say came back to UT Austin, where I had done my final degree and began working more closely or around research to support families.

It was somewhat informed by that work at Fort Hood, where often we heard from spouses calling the clinic to ask us, how can I get my service member, partner, spouse to get care for what they're struggling with. And at the time all we could say was,they're gonna have to come in on their own. We understand that you're dealing with this and you're trying to get them help, but we can't do a referral based on your call. We have to have them come in or get a referral from their provider there at Fort Hood. But that happened often enough that it really got me thinking about how to better engage the family in the care plan and the care access to care, et cetera. And then when I came to UT Austin and started working in the Veteran world, I was very interested in peer support in Veteran Care and just how unique it was in this population that Veterans, so readily identify with each other, can often see another Veteran across the room. They just can tell. And so I was doing an evaluation for the State of Texas, to understand the impact of Veteran peer support. And I always tell this story, because this is how I was led into research and program development for Veteran spouses even though I was a veteran spouse myself. I had to hear it from the community before I really got invested in it, which was, I was doing focus groups around the State of Texas learning about that Veteran peer program and how it was going. What participants were thinking and how it could be improved. And we kept having the spouses of those Veterans showing up to the focus groups, even though the recruitment was primarily for the Veterans, the participants themselves, and the spouses came and said, We think this is a great program. It's so valuable. We see how much it matters, but we need support for ourselves.We need peer support. We need something. Because they were struggling to get what they felt were the needs of their Veterans met, but also their needs that they were going through things that they needed help with. So that's where it all came from. And then that's been our model going forward is we always listen to our stakeholders in the community. Either informally or formally, we will survey or poll our social media followers, which we have a large Veteran spouse network group there. Pr we'll do research studies at the Institute related to listening to our clients or potential clients as to what they need and what's missing in the array of care that they can access.

DUANE: Now I think that aspect of listening and learning is critical. I can imagine that as you're working, and spouses are either coming in or they're picking up the phone, every third phone call, every fourth phone call may be a military spouse, the spouse on the other end of that phone they're in their own life.They don't know that the person in front of them, the person behind them is also asking about the same thing. They're almost very isolated, but being that nexus, you were able to identify that we're getting in a couple different ways, we're getting more and more spouses asking about the same thing. So there has to be something here.

ELISA: Exactly. And so what I took from that, both of those experiences was the need for programming or support that was focused specifically on the spouse in relation to what their service member or Veteran is going through.

So we all know that for example, PTSD, which is the difficulty that most of our spouses are dealing with their Veterans. 70% of people that come to our peer support groups are spouses living with Veterans or partnered with Veterans that have PTSD because it really impacts the relationship that the Veteran has in their lives. And anyone that works in the PTSD world knows that, it's harmful to their relationships. They often isolate, avoid, and have difficulty connecting with others. It's hard to go out and be social as families want to do and couples want to do. And so it really does impact their relationship. So of course the spouses of those individuals with PTSD are struggling and their relationship is struggling. And many of them bring up divorce as an option that if we can't get help, if he or she, the Veteran doesn't get help, I'm not sure how the marriage will survive. And so that also became part of our focus area was how do we address relationship health in our peer support program, which is composed only of Veteran spouses in the group. How do we help them work on their marriages when PTSD is present?

DUANE: Now I hear you obviously, like you'd mentioned you have the experience of being a military spouse, yourself, you have the professional experience of what your clients or potential clients are telling you, but you also have the clinical experience of, like you said, these evidence based program, like research knows what works it's how do we get from the theory and apply that theory to this need. There are programs out there that let's say get military spouses together and let's chat and let's talk, but it doesn't have that evidence based clinical component.

ELISA: Exactly. And that's what we've tried to do throughout the design and testing of the Veteran Spouse Resiliency Group Program, which is the name of our peer sport program. It really started, as I mentioned, through focus groups with Veteran spouses to learn, what would you want in a support group? What are the topics that dealing with, the biggest problems you have, et cetera. We really came into it with no assumptions. We wanted them to tell us what was needed. And part of the reason for that is because my first grant to support the Veteran spouse network was through the patient-centered outcome research Institute or PCORI. It's known as PCORI. And, their focus really helped drive the way I did the work, which was it has to be patient centered. It has to be stakeholder driven. You have to engage those participants throughout your research process, your design process in every step, which I love doing. It's not easy all the time. It's so valuable when you ask the right questions. You learn so much from potential participants than you ever would've thought of as a researcher alone. And so really, I always try to remember that. Don't assume that I know what's next or what's the best program model or next research question, but I really have to fact check it or check with my participants to see if that makes sense before we move forward. And in those focus groups, we learned about the array of topics I've mentioned. But additionally focused on their own careers and their own education. And so some of these are transition focused topics that came up that, okay, now we've left the military life, there's so many things I didn't get to pursue. I didn't get to do fully. I couldn't finish that degree or I never got to advance in my career. So how do I find support for that? And of we don't wanna be that group that provides everything. So what we do is we refer to all those excellent, like you're referring to research informed programs that are great at what they do that know how to get a military spouse, a job, or can help them figure out how to pay for college. If they've never been able to finish a degree or how to get licensed in another state. So we don't assume that we are the case managers for all those issues, but we provide a vetted list of resources and ways to access that’s necessary. And then we also did a really strong program evaluation to understand what impact does a 12 week peer support group have for Veteran spouses on these array of topics. And we measured mental health symptoms, self care practices, social support and quality of life. Those were the first set of measures that we used throughout our pilot, and as a result of that analysis, we learned that we statistically significant changes in all of those areas for all of the spouses, which was amazing. And we realized, okay, we're really onto something. And this was in 2018, 2019. And then ever since then, we're in the sixth edition of our spouse support curriculum and have continued to do the program evaluation, which is not always easy because we're not funded as a study. We're funded as a delivery program. And we do incentivize completion of surveys just because we know people don't love surveys, but it is essential to understanding program outcomes. You have to have the data. And then just recently we were notified that we will be receiving funding to adapt a curriculum for active duty spouses.

And we'll be running that study at Fort Hood next year. And what's cool about that is we learned that we needed to do what we're now calling the Military Spouse Resiliency Group, as opposed to the Veterans Spouse Resiliency Group, because we had military spouses asking to join our Veterans spouse program.They were looking for the same type of peer support. And so once again, we listen to them, what are they looking for? And this is a more structured curriculum based program than most types of peer support, which are very valuable by the way, like having someone to connect with around your career or moving to a new installation, having coffee with them, et cetera, is very valuable and to meet people.

But this one is a bit more curriculum based, is the best word, because we have a structured discussion session every week about a different topic. And like I mentioned before, it's everything from relationships to your career, your education, transitioning out of the military, what that may look like for you and your family. And it's also very family focused. So while we do focus on the spouse, we understand that the spouse is also trying to understand how do I help my Veteran or my service member access care. So we have a lot of psychoeducation for the spouse around all those potential challenges that they're their Veteran may have faced.

DUANE: Now it's very interesting you say, of course it makes sense that military spouses say that I want to join this support group for  spouses but they don't exactly match. You mentioned before we started talking that there are some distinct differences between military spouses and Veteran spouses.One off the top of my head is quite likely, they're just simply younger. I think about my senior leaders. I'm now 10 years older than the old people that I thought were old when I was in the military. And there is a distinct difference between currently serving military spouses and spouses of service members who previously served.

ELISA: That is very true. There's also a big difference related to age in their family stage where the younger military spouses may be starting families have younger kids, which really has different challenges for them related to career education, et cetera, than Veteran spouses, where in most cases they don't have young children anymore.

Although they may, they may have started families later, but in most cases they are older and maybe not as focused or have different ways of focusing on their lives now. Whether it's gonna be, I can now work, I can get out of the home or because my Veteran is no longer moving all over the world.

 I can finally buckle down on my career and focus on it. So those are differences, but then the actual stressors in their lives are different. For example, Veteran spouses, as you mentioned earlier, we've seen lack connection. Unlike the military spouses, where you often have a connection to your unit and the families often form community so that they have each other in difficult times.Whereas in the Veteran families, when they leave military service, the spouses tell us they often feel cut off almost immediately. As soon as the service member gets orders or papers that we're leaving, we're retiring. One spouse told me I was immediately removed from all the email lists. Like I was no longer part of that community. And I had to go find a new community, which is not easy to find in the Veteran space for spouses. Veterans can often find each other because there's a many organizations to go join in their communities, very established VFW, DAV, et cetera. But there isn't anything like that for spouses.

And another differentiation to be aware of is not every spouse that needs support is also a caregiver of a Veteran and very often this, the programming and supports that we see available to spouses post-service are caregiver focused, and that's a small percentage of Veterans that actually need that level of support where a spouse might be in a caregiver program. There are so many spouses that need support for what they're going through. And we like to say that military spouses also transition out of the military, not just the Veterans, because if you've been married to a service member for 20, 30 years and lived the military life and done everything that, that required following that service member around the world as needed as required their lives were not really in their control.And that's one thing that they complain about. I'll put in quotes or recognize as a major stressor in military life is the lack of control they have. Month to month, you may get orders that say, okay, pick up and move. Everything's gotta change. Your kids have to find new schools. You have to find all new healthcare services, everything that you might need, which often is part of the installation, but not always new community groups, new church, et cetera.So that's something that spouses have been doing this entire career. Which now it can feel good after military service ends that, okay. We don't have to pick up and move anymore, but now the whole family has to learn how do we put down roots? And we've heard that before where families will say, yeah, we thought it was gonna be so great. We're finally getting to pick where we live. What kind of house we want, what kind of jobs, et cetera. But then they start to feel antsy after two, three years. Okay. Why are we still here? And the kids feel the same way. Why haven't we started moving yet? It's just a strange pattern that you get used to. And so they do need opportunities to form communities with other people like them. And that's what we've seen with spouses. Very similar to Veterans that when they start connecting with other Veteran spouses in their support groups, they suddenly recognize, oh my gosh, I don't feel alone anymore in my experience. I finally found people that are just like me.

There's something there that we share that lived experience. And it's been really interesting, just that it's so strong of a connection that they feel once they start sharing their stories. And that's what we do in the first couple sessions is just share your story. What was military life like for you? How was it, challenging or difficult, but also how was a positive, rewarding experience, because we don't think it's all bad. We definitely don't. We see a lot of value and many families, despite the challenges, will say I wouldn't do it any other way because I still believe in the commitment and the service that my family gave. Even if the Veteran gets most of the credit, the family recognizes that they also served. And so disconnecting in that support group is an amazing thing. And we have, as researchers, we always measure things like dropout and we have extremely low dropout because once they connect and stay, they really enjoy being with each other. 

DUANE: And I'm curious. if you have some Veteran spouses, that simply don't understand the military because not all Veteran spouses were military spouses. My father was a Vietnam Veteran. He was in Vietnam five years before I was born. I never knew him as a service member. Of course, I only ever knew him as a Veteran. His two wives later. So Veterans go on to build lives after the military, maybe remarriage or things like that. And their spouse has no understanding about what all these acronyms are or why he gets up or she gets up at 3:30 in the morning every morning.

ELISA: You have brought up a really important point, which is something that when we first got into developing the curriculum, because I had the bias as a military spouse that, oh, I just didn't even think about it. I thought, okay of course we're gonna be serving spouses that were part of that military life. But then my program coordinator married her Marine after his service. And she kept saying, but I don't know anything about this and I need support. That's why I wanted to have this job, because this is so needed. And we realized, and a lot of spouses were coming to us that were exactly that type of spouse where they did not have.They weren't married during military life. They were struggling because they didn't know what was going on. Why does my Veteran act the way they do? I don't understand the acronyms. I want to help them navigate the VA. I don't have no idea how, where to start. And so then we did adapt the curriculum to include discussion questions that could work for either group, whether they had been a part of that military life, or they had married the Veteran after. So that is an essential distinction that we've really focused on. And. we've just started a new program during COVID actually called the Veteran Spouse Network Social Club. And those are just more informal one time sessions where we could get together on zoom and talk about anything it's less structured.

And that is one that we're putting together now because there's been so much interest is let's get a bunch of people together that need support around marrying a Veteran post-service. And then we'll have those military spouses that were there the whole time offer guidance and thoughts on, maybe what is going on is the following or what he, or she means by that term is this, you know, kind of a mentorship program. 

DUANE: My wife knew what I was like before Iraq and Afghanistan, twice and all that but others, somebody who, you know, your colleague who married her Marine after his service, she didn't know what he was like before he went to Fallujah or wherever. And so that's one of the things, and I think that, especially if we think about the changes that the Veteran experiences related to trauma, traumatic stress reaction and exposure, for example, is there's a before and after, but their children don't know the before, or maybe their spouse doesn't know the, before they only know them and love them and struggle sometimes. Sure. because of the after.

ELISA: That's so true. And so for example, when we do clinical research around PTSD, we often try to understand is this person different than before the deployment? And that's a good sign that perhaps PTSD is present. But when we rely on family members to support, help us understand that. They may or may not know who this person was, are they different? And really that doesn't matter so much. It's really, how do we help the family and the couple now where they're at and how do they understand each other? And there's some really great work with couples based PTSD therapy. For example, cognitive behavioral conjoint therapy, we call it CBCT, and what's so cool about it. And we tried to implement this in three community based clinics and it went extremely well. We just need to find new funding to do it again. But couples loved being in peer groups with other couples who were going through PTSD. And the focus there was, it's not just the service member or Veteran that's has PTSD. Instead, they made PTSD the target so that they could shrink its impact on their marriage because that's what they were working towards is how can we be happier?How can we work together? And the spouses really wanna be involved in supporting service members and Veterans in any psychological health problems. That's something that we're really focused on is how do we engage the family? How do we promote program models and practices that support that? So it's not just falling on the shoulders of that person with PTSD because they're not in isolation. They live in a family. They're often married to people that love them and want to help them. And so how do we open up treatment models to support that? So that's one example that was extremely well received and it does require clinicians to become trained and certified to deliver couples based PTSD care.

But it's a really exciting development. and one area of work that we hope the VA adopts someday hopefully is to promote more family based care with Veterans. So it's not just the Veteran on their own, going to the VA, trying to figure everything out. And this also applies to suicide prevention. We had a project also by patient-centered outcome research institute, about a year and a half ago called All Hands On Deck. And it was a community convening to focus on Veteran suicide prevention with concerned significant others. And so we had a fantastic turnout of over 80 people coming to four different working groups to figure out from their point of view, what can we do to better engage concern significant others in suicide prevention because they want to be involved. They don't wanna be bystanders. They don't wanna, just be in the dark at home. They  want to do anything they can to help the Veteran. And my colleagues and I always consider family members to be the most untapped resource for Veteran suicide prevention and that if we can develop better practices and ways that providers can coordinate with family members, I really think there's some, potential there.

DUANE: And I think, and I know, perhaps from my own personal experience, that a strong social support network, especially a family support network, is critical. Before my clinical work, I was working in a homeless Veterans program and there was another Veteran who was a member of the program. He was a participant in the program, same rank as me, same age as me deploy Iraq did the same job as me, but I'm running the program and he's a participant. The only difference was I had control over my substance use. And I didn't come home to an empty house. For better or worse, my wife, my family, I still have a good supportive network with my family. And I think that's one thing that a lot of people don't really understand is that a significant protective factor are those strong bonds. I really appreciate the work that you're doing. If people wanted to find out more about the Veteran Spouse Network or the Institute for Military and Veteran Family Wellness, how can they do that?

ELISA: Yeah, we just updated our website. So it's super easy. It's www.VeteranSpouseNetwork.org, and at the University of Texas Austin, where we are housed. I direct the Institute for Military and Veteran Family Wellness, and that website is a little more complicated, but it https://sites.utexas.edu/imvfw/. And I just wanna put in a plug that, we're gonna be offering our military social work and behavioral health conference in June of 2023 in person at UT Austin. So obviously pre COVID it was always in person. Then in 2020, we, like the rest of the world, we made everything virtual, but we really value that in person networking and we're working closely with D O D and the VA, so that many of their providers will be there. And it's an amazing conference that has cross disciplinary and cross-sector dialogue about how we support the entire family on all kinds of behavioral health needs.

DUANE: That's great. I will make sure that all of those links are in the show notes.Thank you so much for coming on the show today. 

ELISA: Thank you. I really appreciate it.

Once again, we would like to thank this week's sponsor PsychArmor. PsychArmor is the premier education and learning ecosystem specializing in military culture content. PsychArmor offers an online e-learning laboratory that is free to individual learners, as well as custom training options for organizations. 

There's so much in this conversation with Dr. Borah that I would love to share some thoughts about from interested organizations being a nexus and collector of common events to the different type of military connected spouses be they currently serving military spouses, Veterans spouses who have military experience and those who haven't or supporting spouses who weren't caregivers incorporating evidence-based practices and research methodology to program development. 

This is definitely a conversation that can benefit from a good relisten because I could talk for another 20 minutes just about the entire conversation. But I had to discipline myself to stick to two main points as I usually do. And these are the ones that I wanted to bring up for your consideration. 

The first is Dr. Borah’s point about how important it was for her and her team to include the participants of the programs in the development of the programs, what she called patient centered program development. I recently attended an event that focused on community coalition, building and social impact efforts. 

This was a significant theme throughout the week, including those with lived experience and the ones we are trying to quote unquote help in the planning, development and delivery of programs. One of the speakers said something that has stuck with me that which has done for me, if it is done without me is done to me. It may even be that those who are planning and developing a program do have lived experience as Elisa does as a military and Veteran spouse. But even as she said in our conversation, certain aspects of the need for spouse and Veteran peer support hadn't occurred to her. Even those of us with lived experience have limited experience that's sometimes the trap of lived experience is that we don't always recognize its limitations. But including the members of the group or community you're trying to serve in your planning and development is significantly important. Not only do you get feedback on how you're designing the program as in whether or not it'll work or whether or not it resonates with the constituents, but you will also find things that you had not considered.  You will learn from the voices and with the words of those, you were trying to help how best to partner with them. This is something that I often saw in supporting Veterans who were unhoused. There were people who served in organizations in the community who saw themselves on one level and saw the people they served on a different level. 

That's a transactional interaction, not a collaborative relationship. And again, without collaboration, if you're doing something for someone you're actually doing it to them, which does much more harm than any good that you're trying to do. 

The other point that I'd like to bring up is when she mentioned the work that she had done piloting therapy groups with military families, experiencing PTSD. When I was working as a therapist, I would have clients who would describe constant struggles with their spouse or partner arguments or friction or whatever. And often it was because that other person was seen as an adversary, the partner becomes the problem, or the partner sees the Veteran as the problem. They're playing chess. You have two people on either side of the chess board in each of them are trying to win the game. But I talk to clients about how both of them should come to one side of the board and focus on the problem, which is the chess game, not the opponent. And that's what Elisa was talking about when she said they helped the couple make PTSD the target instead of making each other the target. 

And this is applicable to many types of problems. There's a conflict or a challenge happening and people take up different sides of the issue and then start opposing or defending against the other, rather than focusing on what the actual problem is and how it can be solved. If in any relationship like a domestic partnership or a work collaboration, if we can agree on some basic things that we're in this together, we have the same goals, we're passionate about the same thing.  Then we can make the problem, the central issue that we're working to solve rather than making the other person, the central issue that we're working to solve. We stopped playing tug of war against each other. And we use the rope in a way that it's intended to lift a pool to drag, to exert force on whatever we're trying to move and do it together rather than opposition. 

It goes back to that person centered program development concept. If we all work together, there's no limit to what we may be able to do. So I'm glad that I was able to share this conversation with Dr. Borah with you. If you enjoy the show, let us know by dropping a review on your podcast player of choice, or by sending us an email at info@psycharmor.org. 

For this week PsychArmor resource of the week, I'd like to share the link to the PsychArmor course, Making Connections and Networking. This is one of the things that Dr. Borah and her group were doing establishing connections between military and Veteran spouses. Regardless of your military background or previous work experience this course can help service members, Veterans and their families learn how to network in their new communities. You can find a link to the resource in the show notes.