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On this episode of Behind the Mission, we feature a conversation with Dr. Alex Balbir, Director of Independence Services with the Wounded Warrior Project® (WWP)
Because fewer than 7% of Americans have served in uniform, most Americans are unfamiliar with military service and culture. As a result, members of the military and Veteran community are at greater risk for disconnection and lack of belonging with the civilian community. PsychArmor’s mission is to bridge the military-civilian divide by educating and training a Nation. Each week, Duane France, a combat Veteran and Clinical Mental Health Counselor, will dig deep into the stories “Behind The Mission” - and create a conversation with organizations and leaders on how they are utilizing their expertise and networks to support the military-connected community.
Welcome to Episode 73 of Behind The Mission, a show that sparks conversations 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. Find the show on all the podcast players 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 episode is brought to you by PsychArmor, the premier education and learning ecosystem, specializing in military cultural content. PsychArmor offers an online e-learning laboratory that's free to individual learners as well as custom training options for organizations. You can find more PsychArmor at www.psycharmor.org.
On today's episode, I'm having a conversation with Dr. Alex Balbir, Director for Independent Services for the Wounded Warrior Project. Prior to joining Wounded Warrior Project, he served as a healthcare consultant supporting the Department of Defense Military Health System as the Deputy Director and Chief of Operations for clinical research at the National Intrepid Center of Excellence.
Alex is a Navy Reservist serving as a healthcare administrator in the Medical Service Corps. You can find out more about Dr. Balbir by checking out his bio in our show notes. So let's get him in a conversation with him and come back afterwards to talk about some of the key points.
DUANE: Alex, you've been working with the Wounded Warrior Project for a number of years, as well as formerly serving an active duty and currently serving as an officer in the Navy Reserves. It'd be great to hear your background and what led you to the work that you're doing today?
ALEX: No, absolutely. And thanks for having me on the show here, Duane. So my background, if we go back to my younger days, I was trained as a neurophysiologist, and I focused specifically on sleep disorders and sleep disorder breathing. So I did a lot of work with patients and animal models for obstructive sleep apnea. Really focused, exclusively on the consequences of sleep apnea. And some of the genetic underpinnings of sleep apnea, why people develop sleep apnea, the role of obesity and sleep apnea and other factors that influence or may lead someone to have poor sleep quality. And, as you go in and you're familiar with this going through your academic career, you really love being in the academic medical centers.You love the learning part of it. But sometimes you find yourself really wanting to find something that's mission driven. And, that's when my military career began and I really started to focus more exclusively on sleep disorders and sleep issues in combat active duty personnel and really understanding what happened to them in Iraq and Afghanistan and what sleep issues they were dealing with right now.
And I was fortunate enough to be stationed at Naval Hospital Bethesda, which now is Walter Reed National Military Medical Center after both army and Navy hospitals combined. I had a great opportunity to work in a brain injury and mental health clinic out there really studying and understanding better how to treat patients for sleep disorders.
Those who've come back from combat dealing with post-traumatic stress and traumatic brain injury. I found that to be far more rewarding than anything I had done previously in my academic career. I also wound up, having gone to business school as well and really used that opportunity to understand better how to deliver services for Veterans more carefully, understanding budget principles, finance, accounting. And so that began my career as a Medical Service Corps Officer as a healthcare administrator. But, my passion has always been on the scientific and the clinical side of medicine. Really understanding why things happen to people and really far more rewarding and as you're well aware, sleep disorders are highly probable in active duty service members, as well as our Veterans and really finding the most ideal strategies to meet that because sleep is such an important factor of your life, and it is in my opinion, the, the sort of the window to your soul. And, it doesn't take much to understand whether somebody's who's maybe having a bad day. All you need to do is ask how did you sleep last night? Did you have any cigarettes? Did you have any alcohol? And then you start getting deeper into some issues that may be bothering them.
DUANE: No, it's really great. It's really fascinating I think when we talk about the impact that sleep has on not just mental health but physical health is you mentioned. But also just how prevalent it is in the service member and Veteran community. Some of it, I don't want to say necessarily by design, the old slogan is we do more before nine AM than anybody does all day. It's like the, I still get up at the crack of dawn and earlier than the crack of dawn, just because of the military lifestyle. It's not really conducive to good sleep hygiene, let's say. And then you add on top of other things, like the environmental factors, when people do it. So insomnia or sleep disorders and the military and Veteran population could be really complicated.
[00:03:38] audioAlexBalbir11805787784: Yeah, they can be very complicated And it's made more complex because of the work environment. If you're working night shift day shift, if you're in an operational combat tempo and we've seen a lot of this over the last 20 years, your ability to get good quality sleep. It's certainly something that the military is looking at to really understand how to better address the issues in terms of affording Soldiers, Sailors, Airmen, Marines, the opportunity to really get quality sleep. Even though you might be in an operational environment that you might be sleep deprived in, but to get those recovery time periods and it very important because we all know that those are a lack of good sleep and quality sleep are risk factors for not only psychological health issues. They're also extreme risk factors for traumatic brain injury. And the way that normally happens, especially in an operational environment, you're sleepy, you're tired, you're malnourished at times. And you wreck your vehicle. Whether you're coming back from training or you're actually in the training environment or in a combat environment, those accidents do happen or you fall and you hit your head. So you can see that this is an issue, but it's an occupational issue. And I'm certainly appreciative of the military starting to understand this better. It took us a long time to figure that out but, absolutely there. Strategies though, to mitigate some of these risks related to sleep issues and signs we see a lot of the insomnia right now in our Veterans and warriors that we work with. It's highly prevalent and really getting them back on track can certainly unlock the potential for improving their health tremendously. And I highly encourage anyone who's listening to this if you are dealing with the sleep issue, please consult a clinician and get a proper diagnosis.
DUANE: Yeah. And you develop those habits, as you said, there's times when there is a necessity, maybe a mission necessity to engage in some sleep deprived behavior. But you don't have to do that after you've been out of the military for seven years. You don't have to be fueled by six pots of coffee or there's new habits that people can learn and I think we can talk about insomnia for the entire show and probably should at another show. And we'll bring you back for that. But really when I sorta dial into the work that you're doing with the Wounded Warrior Project, as the director of independent services, providing long-term support to catastrophic injured Veterans, that impacts their independence.What can you tell us about the Independent Services Program?
ALEX: Yeah, the Independent Services was something that was born out of necessity. During the height of combat, we had a lot of warriors coming back from the battlefield with significant injuries on moderate severe brain injury, spinal cord injury. You and I both know and many of our fellow Veterans and service members know this as well, good quality health care is available at many military treatment facilities. It's outstanding care, combat casualty care in the military. Some of the best, U.S. military, some of the best in the world. And when I was working at the hospital, our objective was to get that patient in, take care of that patient, stabilize that patient, develop a care plan for them, and then discharge them. None of us really considered what happens when you discharge, when you go back home, or when you discharged from the military as a result of your injury and you wind up going back home.
Especially for someone who sustained a brain injury, and a spinal cord injury. What happens to them when they go home? That care plan sometimes is thrown out the window and there are supports and services that are needed in the home and community to adapt to a different lifestyle, to adapt to maybe different, medical issues that you're dealing with.
And much of that burden has fallen on caregivers. But when Wounded Warrior Project, over 10 years ago, when we saw that gap in that transition where people were coming home and they didn't have the case management, they didn't have access to maybe additional services like physical therapy, recreational therapy, occupational therapy.
They didn't have those because maybe they were still transitioning to the VA or the VA said, you know what? You're already getting enough and you've already hit your max. We say there's more that can be done. And so we developed the Independence Program to provide some of those wraparound services and access to additional support and services, those alternative therapeutic modalities, music therapy, art therapy, equine therapy, the things that we don't normally consider as enablers to our health and wellbeing.
Those were the things that the independent services, our independence program has developed and developed very well over the last seven to ten years. So in the independence program, what every Veteran and their family get, when they're in our program. They get an independence program specialists assigned to them. They get a case manager assigned to them. They get access to all the therapies that I just mentioned as well, music therapy, art therapy, equine therapy, if they want to do that. And also things like transportation. If you sustained a head injury and you're on medication dealing with seizures, dealing with cognitive issues, how do you get to the hospital to get your care?
We provide transportation as well for those folks. So it's all those wraparound services that you normally don't think about that occur in your home and community that allow you to really become functionally independent and in your home. And on top of that, we give you the support and services, to support your social wellbeing, to improve your social capital.
So you get a community support specialist, which is equivalent to a life coach. And it's also a combination of an occupational therapist, breck therapist, and a physical therapist, all in one. We want you to get back out in the community, regardless of your injuries, whether it's a physical injury that you're dealing with, or an invisible wound that you're dealing with, our goal is to get you out there and to become part of the community again. And re-establish your independence, and that's really the essence of the independence program.
DUANE: And I really like how you had identified that there is this gap, like when you were working in acute care in Bethesda, when people are working in that space, you're there to treat the immediate need. And not to move them on before they're ready but once, they've reached a level of stability, you move them out the back door and you've got somebody else coming in the front door. That acute care is necessary for that point in time. But then when that Veteran, like you said, goes back home, if they don't have the wraparound need, they're likely to end back up in that acute care. That's not living independently. You're able to provide those services to allow the Veteran, to not keep cycling through chronic medical conditions where they always need treatment.
ALEX: Yeah, that's absolutely true. That re sedentism piece. Going back into a hospital care facility, that's something we really try to mitigate. And one of the additional things we really tried to mitigate is, institutionalization. We are working with right now, a population in their early forties who are dealing with some significant, cognitive and mental health challenge. Putting them into a facility and a geriatric nursing facility is not appropriate. Having those supports and services in their home and community in their physical home is important. Improves their wellbeing that improves their recovery. But all of that, Duane, is really contingent on not only the services that we provide, but the caregiver and the caregiver support network that the warrior has.
And without that caregiver support network and without some of the services that we provide that risk for institutionalization is really, really high. And so what also we do with the independence services programs also provide support and care for the caregiver. Providing them access to mental health care, providing them respite opportunities, providing them additional comfort items, goods, and services that keep them propped up in order to better support their Veteran. Because we know they're amazing people that do this and they also need a little bit of help and we're here to support them as well. So all those factors come into play to really create an environment of recovery rehabilitation and reintegration into the community.
DUANE: Yeah. I really liked that idea of partnering with the caregivers. Because in many ways my wife is my caregiver, but she's the expert on me, but she's not the expert on all the resources that are out there. And Wounded Warrior Project, in many ways can be the expert of all the resources are out there, but they don't know each individual Veteran's needs.
So partnering with that caregiver to be able to say, we understand what you need and we can provide you those resources. You don't have to jump through 15 pages of Google. But the other thing that the independent services does is continue to support those caregivers. You mentioned you work with a lot of Veterans in their early forties.
There is a high survivability in the global war on terror, but we don't know what the long-term impacts are going to be. And there's some emerging end of life concerns, that you're also helping caregivers with.
ALEX: Yeah, there are. Absolutely. And that's the concept of morbidity, trying to understand better the natural history of a brain injury, natural history of a spinal cord injury, or a neurodegenerative condition. We work with a lot of folks who are dealing with multiple sclerosis, Parkinson's and many of those have been service connected.
And really understanding and working with these families right now is important. And that's what our independence program does right now. But we also have been challenged with helping these families prepare for the future. And how do we do that? It's very complicated.
You're dealing with complex medical issues. You're dealing with family dynamics that aren't always stable and you're dealing with the unknown of the future. So over the last year and a half, we started to roll out some new programming within independent services. It's called the continuous care services model.
And what we've done there is really been able to afford these families and their caregivers an opportunity to help better prepare for the future. And the question we're trying to address here, Duane, is what happens to my warrior when something happens to me as the caregiver. When that caregiver and that caregiver support network is no longer in the picture, what happens to that warrior in the absence of that caregiver. As I mentioned earlier, the risk for institutionalization is very high. And what we're trying to do is prevent that from happening for the warriors. And we have our continuous care services model where we provide a very thorough review of their VA benefits. We have senior staff members on our team that go through line by line of all of their diagnoses to figure out if they're maximizing and optimizing their benefits. We also have access to nurse life care planners that help for the actual disease process or the physical changes that may occur in the next 10, 15, 20 years. And what's going to be the best environment for you. We also have estate planning and legal guidance and legal counsel helps you prepare for all those things.
Your will. Directives, any sort of power of attorney, what happens to you physically and especially in the eyes of the law, if your caregiver is not there. Who owns the property, whose name is your house currently in, is it in your spouse's name or you living in with your parents? These are all things that normally we don't consider when we talk about planning for the future, but that's a very critical one. And finally, we really work with these families on their financial plans. They're each assigned a financial planner, a certified financial planner, that helps them look at their current financial situation and prepare for the future in order to maximize their independence in their home and community right now, but into the future as well.
So we are not going to run the risk of premature institutionalization for these warriors in those facilities that are likely to be not appropriate for them. There'll be able to afford the opportunity to remain in their homes and communities for as long as possible, as long as it's an appropriate fit for them.
DUANE: No. I really like, again, there's this idea of identifying a gap and then being responsive enough to fill that gap, right. As you were talking about the longstanding, independent services we're supporting health care, right? When you were talking about the occupational therapist and the physical therapist, and so on social supports, talking about recreational therapy and things like that.
So you were doing that for a very long time, but then you have these adult logistics, things like financial planning and estate planning. That, to be honest, I'm not even paying that much of attention to, it's not something that normally in, in even maybe as you said in this early middle age, people aren't necessarily considering.
But again, being able to provide that support, it sounds like it's really beneficial and will be able to bring a lot of benefit to Veterans in the program. But another key aspect of support that Wounded Warrior Project provides is partnerships with other organizations to do these kinds of things.
Wounded Warrior Project has been partnering with PsychArmor you've collaborated to produce a series of trainings focused on these topics. So people understand more about TBI, Resilience and suicide prevention.
ALEX: Yeah, that's been a great partnership for us with PsychArmor is really leading the way on, on these educational modules for companies that work with Veterans, for staff members that work with Veterans who may not have had previous experience with Veterans. I think you and I both know that the value of educating individuals, not only individuals working with members, but also educating service members and Veterans on what issues they might be dealing with. So understanding what happens in a traumatic brain injury or what is a traumatic brain injury, is absolutely important. If I'm your provider at Wounded Warrior Project or another organization, I want to be best prepared to understand that. You're not calling me back because you're avoiding me. You're not calling me back because of a cognitive issue.
You don't remember to call me back. And so to being able to manage that relationship much better, having known or being trained on what some of those symptoms are, and those symptoms are consistent with brain injury, post-traumatic stress, complex family dynamics that maybe, I have to take a different approach with you if I'm your service provider.
But also we know that, having access to this content and these modules developed with PsychArmor, functions to educate Veterans and their families better. They become a better, more informed healthcare consumer. I can't begin to tell you the amount of times when a Veteran or service member has come up to me and said, I'm having problems sleeping, I'm lethargic.
There are issues with intimacy with my spouse, And a few questions that I ask, If you sustained a brain injury, are you on any medication? And you've come slowly to realize that they may be talking about a male may be talking about low testosterone and they don't understand why they might have low testosterone. Recommendation is to go see a specialist, but what I've also found effective Duane was is that level of education. So when we create those modules, a Veteran watches those modules, learns a little bit of something, or has an experience already with working with a provider and getting the care that they need. They'll go and have that conversation with another Veteran. So it's not coming to the expert to ask a question of why am I feeling this way? Veterans become their own peer support leaders and their own educators to improve that healthcare knowledge consumption and to make them a better healthcare consumer, as well.
So that's the brilliance behind these types of partnerships, Wounded Warrior Project and PsychArmor building these modules, for Traumatic Brain Injury, Post-Traumatic Stress, understanding resilience, helping us better serve, but also helping Veterans educate themselves to go on, to be advocates for themselves and advocates for each other as well. I think that's critically important for the success of these types of partnerships.
DUANE: Yeah, no, I can imagine. Like you said, there's a lot of people that want to help Veterans. You have a lot of financial planners that say, yeah, I want to come help, especially with these new programs. But, just like you need to be able to help a physical therapist understand why somebody doesn't sleep very well because they had to get up at 5:30 every morning for 20 something years, that someone who grew up with, to be honest, not a lot of money in the military doesn't really understand. Hey, when I retired, it took me probably months to figure out how not to get paid on the first and the 15th. It's just a different lifestyle that these support personnel can take these courses and understand more about the Veterans that they're serving. And that seems to be one really beneficial, piece as you had talked.
ALEX: It does. And it provides for an even greater bond. That's what's developed between the service provider, organization, our staff, working with Veterans in the community or any other company that, company organization that goes on, the internet finds those modules and really starts to educate themselves.
I think it's important to know, but it's not just it's not an interaction or a transaction between a service provider and a Veteran or a company. It's also a transaction between an employee and a manager. They could better understand that relationship, or if you're out at the restaurant, with friends and stuff, and there's some Veterans in there, you know how to maybe better address an issue now, because you're familiar with some of these Veterans issues related to mental health or brain injury. So you can start to become an advocate in your community as well and make those interactions and transactions count, count towards the greater good of society. And I think that's important and it's all through education knowledge, very critical for this population to thrive and for all of us to engage better with that.
DUANE: No, I absolutely agree. And, I speaking from the folks at PsychArmor, they obviously are very supportive of the work that Wounded Warrior Project is doing. So if people wanted to find out more about the Wounded Warrior Project Independent Services and the work that you're doing, how can they find that?
ALEX: I would encourage them to go to our website, www.woundedwarriorproject.org. It has a great interactive website that has all of our programs, all of our areas that we work in. And we have a wide variety of programs and we all work together. Our goal has always been to treat these Veterans and their families holistically in a comprehensive way. And to really engage with them. They earn this and we are happy to serve them.
DUANE: Absolutely. I'll make sure to add those links in the show notes. Thanks for coming on the show today, Alex.
ALEX: Absolutely. Thank you for having me, Duane. It is always a pleasure.
Once again, this show is brought to you by PsychArmor. the premier education and learning ecosystem, specializing in military culture content. sarcoma offers an online e-learning laboratory that's free to individual learners as well as custom training options for organizations. You can find out more about what they're doing at www.psycharmor.org.
It was great to have Alex on the show as a guest representing Wounded Warrior Project. One of the largest national organizations supporting the needs of post 9/11 Veterans. WWP does a lot of different stuff and we could do a whole series of shows on the organization. They could have their own podcast, to be honest with you.
But one of the points that I'd like to highlight that came up for me during the conversation is the importance of covering the gaps that exist in support for catastrophic injuries. That's what the independent services at WWP are all about. As Alex mentioned, the military has developed significant cutting edge expertise in medical care, especially in the last 20 years.
It's had to both with combat and non-combat injury sustained during global war on terror, as well as the wide range of environmental impacts in the forms of illnesses and pathogens. Where there's traumatic brain injury, the psychological impacts of military service burden care, chronic disease, diagnosis and treatment. The military medical system is amazing.
And it's not just for service members themselves but family members. Both of my children were part of the exceptional family member program due to health concerns as babies. And the skills of a pediatric neurologist for my son and a pediatric cardiologist for my daughter, both doctors who were active duty service member station in Germany were literally life altering for my family. I've always said whatever I gave to the Army, the two things that I will always value that the Army gave me is the educational opportunities and the healthcare that it provided for my family. At the same time, however, as great as the care at Walter Reed or Brooke Army Medical Center or Landstuhl Regional Medical Center are at some point, the patient is treated, stabilized and leaves the facility. And then there's a lifetime of ongoing care that's needed. And that care doesn't mean that the service member or Veteran needs to be wholly dependent on the healthcare system for survival.
The advances and support for people with disabilities in the past 30 years has ensured that Veterans who are catastrophic, wounded, illed, or injured can live productive, meaningful lives in whatever way that is for the Veteran. Living where I do in Colorado Springs, there are a number of combat and non-combat injured Veterans who have won multiple medals at the Paralympic Games.
A colleague of mine, a former Apache pilot, is the first Colorado law maker known to use a wheelchair after surviving a catastrophic helicopter crash in Afghanistan. Just because of Veteran is catastrophic injured doesn't mean that they can't and shouldn't live independent lives to the fullest extent. And this is where the support from WWP independent services comes in.
Those of us who don't have to overcome obstacles related to our health may not consider how our health allows us to live and thrive in an environment of our choosing. Considering this morning, how I've been able to do every single thing from getting out of bed to making my coffee, to coming downstairs, recording this episode of the podcast, going for the run a bit later, all of these things are possible as a result of my ability.
And or something that can easily be taken for granted because they're not all easily accessible for those that don't have my level of ability. That's not to say that a Veteran who may have mobility limitations, loss of eyesight or hearing or missing an arm and a leg, can't get out of bed, get coffee, go downstairs, do a podcast, go for a run.
They just have to adapt to their environment and adapt their environment. After a Veteran leaves the hospital, they have the rest of their lives to live and is great to know the organizations like WWP are there to support them in doing that in whatever way they want to live their lives.
The other point that I'd like to make is related to this and it's the increased necessity to consider the needs of catastrophical wounded, ill and injured Veterans. Because of advances in both immediate and longterm medical care, advanced equipment and increased training, the mortality rate of the most recent conflicts in the global run terror are significantly less than the mortality rate in 20th century conflicts. Injuries sustained in combat or even in training that would have been fatal 30 years ago are now survivable. That decreased mortality rate and increased survivability, however, comes at the cost of an increased catastrophic injury rate.
Just because a service member does not die from an injury does not mean that they're not impacted by the injury. The increase in traumatic brain injuries is especially linked to the survivability of combat. Those incidences that would have caused traumatic brain injury in Vietnam, or even the Gulf War in the early nineties would have been fatal at that time. And with greater survivability with catastrophic physical injuries also come service members who have survived significant traumatic events, which means more psychological impacts of trauma. This is one of the reasons that post-traumatic stress disorder and traumatic brain injury are so closely linked. A single incident can cause both.
The word trauma and traumatic brain injury describes a physical trauma to the brain, but the word trauma and post-traumatic stress describes a psychological trauma that impacts the mind and the brain as well as it impacts neuro-plasticity and causes physical changes to the brain. But that's an entirely different episode.
The point that I'm trying to make here is there are more Veterans now that have survived with catastrophic injuries and illnesses than there were 30 years ago. And while advances in healthcare have ensured survivability advances in social support and independence care must also occur to ensure livability.
Again, when we say caring for those who served in those who cared for them. That doesn't mean just caring for those of us who came out of the military with some dents in our fenders. That means caring for those who came out of the military with some serious structural damage to the vehicle.
It's not easy, but it's necessary. And it's good to know that organizations like WWP and individuals like Dr. Balbir are taking on the cause. So, hopefully you enjoy my conversation with Alex. If you did 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.
This week's PsychArmor resource of the week, I'd like to share the link to the PsychArmor course, How To Talk To Someone With A Disability. As you've heard in this episode, a significant number of service members leave the military as a result of catastrophic injuries or illnesses. And this course is designed to equip volunteers with the knowledge and tools necessary to effectively and confidently communicate with someone who has a disability. You can find a link to the course in our show notes.