National Caregiver Training Program
National CaregiverCaregiver
Training Workbook
Program
Caregiver Workbook
Module 5: Managing Challenging Behaviors
As a Caregiver, your life has been changed considerably by your new role. The Veteran
that you care for may seem like a different person from the one you knew before his/her
injury. Some injuries, particularly injuries to the brain can cause changes in behavior.
The Veteran may behave impulsively and/or express frustration and anger by behaving
aggressively at times. It is important to remember that his/her feelings, behaviors,
thoughts and beliefs may not be personally directed at you and may not be caused by
anything you did or did not do.
In this module we will discuss some challenging behaviors and strategies to help you
cope as well as what you can do to help the Veteran that you care for.
137
137
www.caregiver.va.gov U.S. Department
of Veterans Affairs
www.caregiver.va.gov
National Caregiver Training Program
National CaregiverCaregiver
Training Workbook
Program
Caregiver Workbook
Coping Tools to Consider
Combat Veterans can suffer wounds that not
only impact their lives; but also the lives of the
people and family around them; symptoms of
stress, depression or anger are not unusual.
You as a Caregiver need to learn about these
symptoms and to manage your responses to
them as well as get the help you need.
Everyone experiences anger from time to time. Anger is a natural emotion, which can
be felt more often or more intensely especially by combat Veterans. When a person
feels vulnerable, anger can allow them to feel more in control. What matters isn’t getting
angry, but rather, how the anger is handled.
The following are some coping tools, you may want to consider:
Find or create a support group of other family members and friends who may be
dealing with the same or similar situations. Talking about your feelings, frustrations and
fears with someone else can help ease your burden and give you the knowledge that
you are not alone.
You may want to seek counseling for yourself independent of any therapy in which you
may be involved in with the Veteran.
You do have the choice and ability to control your own responses to the Veteran’s
behavior. Stay calm in the face of outbursts and aggressive behavior.
Try not to over-react to statements and behaviors. If the Veteran is aggressive or in an
outburst, do not over react by yelling or escalating your behavior. Speak calmly but
firmly without raising your voice or using an excited tone of voice. Sometimes, you may
need to speak slowly and let the Veteran know he/she is in distress. If his/her behavior
begins to get worse, then you may need to slowly walk away telling the Veteran that you
are walking away until he/she calms down.
Avoid challenging the Veteran’s thinking when she/he is obviously in a highly agitated
state. If the Veteran’s anger is at a frightening level, stay safe and keep your children
safe. Back away and keep a safe distance. Get help immediately if you sense that the
Veteran is a danger to himself/herself or others.
Do try to redirect his/her focus by helping him/her attend to something else.
138
138
www.caregiver.va.gov U.S. Department
of Veterans Affairs
www.caregiver.va.gov
National Caregiver Training Program
National CaregiverCaregiver
Training Workbook
Program
Caregiver Workbook
A Veteran who has lost independence in any form, due to an injury in the line of duty,
may find this hard to accept. Imagine needing someone’s help to bathe or to tie your
shoe or not be able to think and express ideas clearly. This can be very frustrating. The
following are ways you, the Caregiver can minimize some of the frustration the Veteran
may be feeling:
Keep things simple.
Minimize the amount of things that can distract the Veteran while engaged in an
activity.
Keep the noise down.
Allow the Veteran plenty of time to do tasks.
Keep a daily routine. Change can increase frustration.
Find tasks that the Veteran can do with little help. This will promote feelings of
independence.
Change activities if the Veteran becomes frustrated.
Communicating with the Veteran
If the Veteran is having difficulty expressing thoughts and ideas, the following
techniques may be helpful:
Tell the Veteran when you do not understand what he/ she said. Ask him/her to
repeat it again more slowly.
Use a consistent cue or gesture to let him/her know you did not understand. For
example, cup your hand over your ear as a
reminder to speak louder.
Help the Veteran start a conversation by asking a
leading question such as, “What do you think
about …?”
Encourage the Veteran to talk about topics of
interest or familiar topics.
Ask open-ended questions (e.g., questions that
cannot be answered with a “yes” or “no”), such as,
“Tell me more about your day.”
Give your full attention to the conversation.
139
139
www.caregiver.va.gov U.S. Department
of Veterans Affairs
www.caregiver.va.gov
National Caregiver Training Program
Caregiver Workbook
National Caregiver Training Program
Caregiver Workbook
Depression
Sometimes people will say that they are sad or feel down and will refer to it as feeling
depressed. Usually these feelings resolve within a few days. If the symptoms continue
or become worse, they could be a sign of clinical depression.
The two most common symptoms of clinical depression are:
Feeling sad or hopeless nearly every day for at least 2 weeks.
Losing interest in or not getting pleasure from most daily activities nearly every day
for at least 2 weeks.
Depression is a treatable illness. Anyone can become
depressed but it is important for people with depression to
seek treatment. Family history and stressful life events can
contribute to the development of depression. It is easier to
treat if recognized early. If you are concerned that the
Veteran you care for may be depressed contact the Primary
Care Team at your VAMC.
Tips to Manage Depression
If the Veteran is working with the Treatment Team, using medication as prescribed and
participating in recommended therapy, the following approaches can also be helpful:
Regular physical activity. Studies show improved mood as a result of physical
activity.
Sufficient sleep. A good night's sleep can help mood and stress levels. Avoid
sleeping pills unless your doctor prescribes them.
Stress management. Too much stress can help trigger depression. Some ways to
relieve stress include: meditation, watching funny movies or doing enjoyable
activities. Getting regular exercise also relieves stress.
Avoid substance misuse such as: drinking alcohol, using illegal drugs, or taking
medicines that have not been prescribed for the Veteran. Having a substance abuse
problem makes treating depression more difficult as both problems need to be treated.
140
140
U.S. Department
www.caregiver.va.gov
of Veterans Affairs
www.caregiver.va.gov
National Caregiver Training Program
Caregiver Workbook
National Caregiver Training Program
Caregiver Workbook
How the Caregiver Can Help?
It is important that you work in collaboration with the Veteran’s Primary Care and/or
Treatment Team. As a Caregiver, you are an essential partner the Veteran’s recovery.
Offer emotional support, understanding, patience and encouragement.
Talk with the Veteran and listen carefully.
Acknowledge feelings, point out realities and offer hope.
Be patient, depression does not go away overnight; it takes time to get better.
Involve the Veteran in activities outside the house (e.g., walks, shopping, movies,
religious services, volunteering). If she/he declines, keep making gentle suggestions
but don’t insist.
Signs that a Veteran with Depression May Need Immediate Professional Attention
If the Veteran is depressed and has any of the following
signs or symptoms, this suggests a crisis situation with risk
for suicide. It is an emergency situation.
Talking, reading, writing or drawing about suicide, death
or killing someone else.
Psychotic symptoms (being out of touch with reality,
hearing or seeing things that aren't real).
Speaking in a bizarre way that is not usual.
Trying to get guns or pills or other ways to cause self-
harm.
141
141
U.S. Department
www.caregiver.va.gov
of Veterans Affairs
www.caregiver.va.gov
National Caregiver Training Program
National CaregiverCaregiver
Training Workbook
Program
Caregiver Workbook
Suicide Prevention
Suicide is the taking of one's own life on purpose. There may be warning signs before a
suicide. People thinking about suicide are often depressed, anxious or have low self-
esteem. They are often clinically depressed, anxious or agitated. There may be
problems with sleep and changes in the eating habits of someone who is suicidal. A
Veteran who is suicidal may stop paying attention to hygiene and appearance, and may
withdraw from family and friends. Usually people who are suicidal feel hopeless,
helpless and worthless, and have no sense of life purpose. Suicide may seem like the
only solution for what they are feeling and the only way out.
Suicide Warning Signs
Watch for these key suicide warning signs, and provide the Veterans Crisis Line number
(1-800-273-8255, press 1) to anyone who exhibits these warning signs:
Talking about wanting to hurt or kill oneself.
Trying to get pills, guns or other ways to harm
oneself.
Talking or writing about death, dying or suicide.
Hopelessness.
Rage, uncontrolled anger, seeking revenge.
Acting in a reckless or risky way.
Feeling trapped, like there is no way out.
Saying or feeling there's no reason for living.
Suicide Risk Factors
Risk factors refer to the traits, situations and life events
that have been shown in research to increase the risk
of suicide, compared with people who do not have
such traits or history. Generally, Veterans who are
male, white, younger than 25, have less than a high
school education and E-01 to E-02 rank have a higher
risk of committing suicide.
142
142
www.caregiver.va.gov U.S. Department
of Veterans Affairs
www.caregiver.va.gov
National Caregiver Training Program
National CaregiverCaregiver
Training Workbook
Program
Caregiver Workbook
Other Risk Factors Include:
History of past suicide attempts or problems with violence or extreme anger.
Family history of suicide, violence, mental illness or substance abuse.
Being around others who have attempted suicide.
Chronic medical problems, including chronic pain or mental illness.
Recent or threatened severe loss (especially a marriage or relationship).
Humiliating events or failure.
History of imprisonment.
Difficult times like holidays or anniversaries.
Problems adjusting to new life circumstances.
Poor social and coping skills.
Drug and alcohol abuse.
Personal or Environmental Protective Factors
Protective factors are skills, strengths or resources that help people deal more
effectively with stressful events. Protective factors help a person bounce back from
problems and balance risk factors for suicide. Protective factors can be in the person or
in their environment.
143
143
www.caregiver.va.gov U.S. Department
of Veterans Affairs
www.caregiver.va.gov
National Caregiver Training Program
National CaregiverCaregiver
Training Workbook
Program
Caregiver Workbook
Personal and Environmental Protective Factors Checklist
Take stock of the protective factors in the Veteran you care for.
Yes No
Believing in the value of life and that suicide is wrong.
Good social skills, such as making decisions, solving problems and managing
anger.
Feeling connected to friends and family.
Hope for the future; optimism.
Following doctors’ orders and advice.
Strong sense of self-worth or self-esteem or determination.
Ability to cope and adapt (resiliency).
Ability to control impulses.
Reasons for living.
Being married or a parent.
Being sober.
Strong relationships, particularly with family members and/or significant other.
Chances to be involved in family projects and activities.
A safe and stable environment.
No access to guns, pills or other means to harm self.
Responsibilities to others.
Pets.
144
144
www.caregiver.va.gov U.S. Department
of Veterans Affairs
www.caregiver.va.gov
National Caregiver Training Program
National CaregiverCaregiver
Training Workbook
Program
Caregiver Workbook
Things Someone Thinking About Suicide May Say
“It would be better if I wasn’t here.”
“You would be better off without me.”
“I want out.”
“I'm going away on a real long trip.”
“You don't have to worry about me anymore.”
“I just want to go to sleep and never wake up.”
“Don't worry if you don't see me for a while.”
“There is no way out.”
Possible Suicide Warning Signs
A Veteran who is thinking about suicide may demonstrate these behaviors. Do any of
these apply to the Veteran you care for?
Yes No
Talk about feeling trapped – like there is no way out of a situation.
Talk of a suicide plan or make a serious attempt.
Talk, write or draw pictures about death, dying or suicide.
Talk about suicide in a vague or indirect way.
Give away things that are special.
Put affairs in order, tie up loose ends or make out a will.
Try to get guns, pills or other means of harming oneself.
Call old friends, particularly military friends, to say goodbye.
Clean a weapon that they may have as a souvenir.
Become obsessed with news coverage of the war, or the military channel.
Talk about how honorable it is to be a soldier.
Become overprotective of children and the home.
Act recklessly or violently, such as punching holes in walls, getting into fights.
Suddenly change, for example changing from being very sad to being very calm
or appearing to be happy, as if suddenly everything is okay.
Use more alcohol, tobacco, or pain pills.
145
145
www.caregiver.va.gov U.S. Department
of Veterans Affairs
www.caregiver.va.gov
National Caregiver Training Program
Caregiver Workbook
National Caregiver Training Program
Caregiver Workbook
What Should You Do if You Think the Veteran is Considering Suicide?
Trust your instincts that the Veteran may be in trouble.
Talk with the Veteran about your concerns.
Listen to what the Veteran says.
Ask direct questions without being judgmental
"Are you thinking about killing yourself?"
"Have you ever tried to hurt yourself before?"
"Do you think you might try to hurt
yourself today?"
Find out whether the Veteran has a suicide plan. The more detailed the plan, the
greater the risk:
"Have you thought about ways that you
might hurt yourself?"
"Do you have pills or a gun?"
Do not leave the Veteran alone.
Do not swear to secrecy.
Do not act shocked or judgmental.
Do not counsel the Veteran yourself.
Get professional help, even if the Veteran resists.
146
146
U.S. Department
www.caregiver.va.gov of Veterans Affairs
www.caregiver.va.gov
National Caregiver Training Program
National CaregiverCaregiver
Training Workbook
Program
Caregiver Workbook
Suicide Prevention Resources for Veterans and Their Families
The VA is committed to addressing the issue of suicide among our Veterans and offers
a network of support available to those who have served our country. VA provides a
confidential 24/7 Veterans Crisis Line for Veterans in crisis and their families. Trained
VA professionals are available at all times to assist Veterans and their family members.
Veterans and their families do not have to be enrolled in VA to use the free, confidential
Veterans Crisis Line.
Veterans Crisis Line 1-800-273-8255
Veterans Crisis Line|Hotline and Online Chat at: http://www.Veteranscrisisline.net
Locate Your Local Suicide Prevention Coordinator at:
http://www.Veteranscrisisline.net/GetHelp/
Each VA Medical Center has a suicide prevention coordinator to make sure Veterans
receive needed counseling and services. Calls from the Lifeline are referred to those
coordinators.
DoD/VA Suicide Outreach: Resources for Suicide Prevention at:
http://www.suicideoutreach.org/
This site is a comprehensive resource- you will find ready access to hotlines,
treatments, professional resources, forums and multiple media designed to link you to
others. This site supports all Service Branches, the National Guard and the Reserves,
our Veterans, families and providers.
Medal of Honor Recipients: Speak Out! Save Lives at:
http://www.medalofhonorspeakout.org/
Our nation's greatest heroes – Medal of Honor recipients – speak out to save lives by
encouraging America's military to seek help when adjusting to life after combat.
147
147
www.caregiver.va.gov U.S. Department
of Veterans Affairs
www.caregiver.va.gov
National Caregiver Training Program
Caregiver Workbook
National Caregiver Training Program
Caregiver Workbook
Substance Abuse (Alcohol and Drugs)
Substance abuse is a major concern among
Veterans returning from combat. Prescription drug
abuse doubled among U.S. military personnel from
2002 to 2005 and almost tripled between 2005 and
2008. If you believe that substance use or abuse
has become a problem for the Veteran then it is
worth discussing with a health professional.
If the Veteran has had a TBI or has any mental health issue such as PTSD or
depression, substance abuse will further impair their thinking. While intoxication may
provide immediate relief of symptoms such as anxiety, it may start and/or worsen
symptoms of several kinds of mental illnesses that are already present and may lead to
using alcohol or drugs more persistently.
Opioid pain killers and medications known as benzodiazepines (e.g., Valium) when
taken with alcohol, work together to create greater negative effects than if taken alone,
posing risks for function, impulsive behavior, serious overdose and possibly death. In
addition, painkillers that combine acetaminophen and narcotics, such as Vicodin, could
cause severe liver damage when mixed with alcohol.
Signs of Drug Misuse
If you as a Caregiver suspect that the Veteran is using illegal drugs or misusing
medications that are prescribed, the following are common signs and symptoms:
Intoxication, incoherency, bloodshot eyes or dilated pupils, smell of substances and
other physical indications that the person is under the influence.
Loss of interest in hobbies, sports and other favorite activities.
Changed sleeping patterns: up all night and sleeping all day.
Mood swings; irritable and grumpy and then suddenly happy and bright.
A sudden change in personality. A few keys signs to watch for are: lying, moodiness,
oversensitivity, forgetfulness and a sudden lack of motivation.
Carelessness about personal grooming.
148
148
U.S. Department
www.caregiver.va.gov of Veterans Affairs
www.caregiver.va.gov
National Caregiver Training Program
Caregiver Workbook
National Caregiver Training Program
Caregiver Workbook
Signs of Alcohol Misuse
Possible signs of alcohol misuse include:
Continuing to drink even though the Veteran’s alcohol
use is causing problems in your relationship.
Drinking more than intended―the Veteran may want
to quit drinking, but can’t.
The Veteran has given up other activities, including
physical rehabilitation, because of alcohol.
Downplaying the negative consequences of drinking.
Complaining that family and friends are exaggerating
the problem.
Blaming drinking or drinking-related problems on
others.
Taking Care of Yourself and Your Family
Often, Caregivers, family and friends feel the need to
cover for the person with the drinking problem. Pretending that nothing is wrong and
hiding away all of your fears and anger can cause you more stress.
Seek counseling for yourself and family in order to help you manage the stress of
your relationship with the Veteran and to prepare you for helping him/her change.
Get assertive: learn effective communication skills.
Build a support network: speak to supportive people in your community about ways
to get help.
Protect yourself as alcohol and drugs can increase the likelihood of aggression. If
you are experiencing domestic violence, take action to protect yourself by calling
your local law enforcement.
149
149
U.S. Department
www.caregiver.va.gov of Veterans Affairs
www.caregiver.va.gov
National Caregiver Training Program
Caregiver Workbook
National Caregiver Training Program
Caregiver Workbook
Gaining Trust with the Veteran
Unfortunately, Veterans are often reluctant to discuss misuse of prescribed and non-
prescribed substances during their recovery. Ways that you can help include:
Establish open and honest communication with the Veteran.
Develop a family support network to provide stability around the Veteran.
Limit the Veteran’s access to alcohol and prescription drugs, particularly to opioid
pain relievers and benzodiazepine anti-anxiety medications.
Stay in contact and coordinate with members of the Healthcare Team.
Substance Abuse Resources
Resources where the Caregiver and other family member can get help with dealing with
addiction in their family:
Speak with the existing Primary Care Team
Contact the OEF/OIF/OND Program at your local VA Medical Center
Substance Abuse and Mental Health Services Administration (SAMHSA) at:
Website: http://www.samhsa.gov/vets
Call 1-800-827-1000, VA's general information hotline
Al-Anon Family Groups at: http://www.al-anon.org
Nar-Anon Family Groups at: http://www.nar-anon.org
150
150
U.S. Department
www.caregiver.va.gov
of Veterans Affairs
www.caregiver.va.gov
