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Returning Veterans Experiences of a Holistic Therapeutic Program
Elda Kanzki-Veloso, Ph.D. & Angela Yehl, Psy.D.Nova Southeastern University
NSU Collaborators and Community PartnersFt. Lauderdale Vet Center Broward County Elderly and Veterans Services Division Veterans of Foreign Wars Stone of Hope Project Dr. Marcelo Castro, NSU Dr. Kimberly Durham, NSU Dr. James Pann, NSUDr. Ron Chenail, NSUJacob Connolly, M.S., NSU
Wendy Thomson, MSN, RN, NSUSabrina Stern, RN, NSUDr. Tom Kennedy NSURivka Spiro, M.A., NSUDr. Barbara Garcia-Lavin, NSUDr. Timothy Scala, NSUDr. Tommie Boyd, NSU
Operation Iraqi Freedom (OIF)
2003-2010
“Operation New Dawn”(OND) August 31, 2010-Present (U.S. combat mission in Iraq had ended-transitional mission to assist Iraq’s Security Forces)
Operation Enduring Freedom (OEF)
2001-Present
Deployment
Approximately 2 million U.S. troops have been deployed to combat zones since September 2001 (Tan, 2009).
Many of these soldiers have encountered serious challenges readjusting upon their return home since many do not successfully access needed services (Institute of Medicine, 2010; Hoge et al., 2004).
Deployment cont.,
Frequent and lengthy deployments take their toll not only on the soldier but family members and friends as well.
Statement of Need
Several potential consequences to combat exposure, including:
Posttraumatic stress disorder (PTSD)
Depression
Substance abuse
Health problems/Traumatic Brain Injury (Hoge et al., 2004)
Adjustment Concerns: Family Views
In a mixed methods study conducted by Graf, Miller, Feist & Freeman (2011), family members identified the following concerns in their combat veteran family member
Anger and aggression
Distancing and isolation
Emotional numbing
Less consideration for others in the home and negative changes in attitude towards women
Reintegration Concerns
Relationships
Employment
Homelessness
Suicide
Sexual Assault
Health Problems
Barriers to Accessing ServicesStigma associated with mental illness and concern regarding how the soldier/marine would be perceived among peers and superiors was identified as the primary barrier to provision of needed mental health services to military servicemen and women (Hoge et al., 2004)
Barriers to Care
Survey conducted by the National Council for Community Behavioral Healthcare (2009)
Access to Care
Long Distances
Stigma
Lack of Family Involvement
http://www.afterdeployment.org/topics-stigma#videos
Programmatic Needs
The Department of Defense (DoD) has adopted several programs to assist with adjustment following deployment, such as:
Courage to CareMilitary One SourceMilitary HOMEFRONTProject DE-STRESS (Delivery of Self Training and Education for Stressful Situations)
These efforts are helpful for individuals who actively seek these services out; however, what appears to be missing is a centralized proactive program to facilitate patient to provider care (Robinson, 2004).
Most recently the VHA Office of Patient Care Services (2010) has implemented two new programs, Transition Patient Advocates (TPA) and Peer Support Technicians (PST).
Broward County
In Broward County, there are an estimated 114,423 veterans (Florida Department of Veterans Affairs, 2009)
It is projected that Florida will have the largest veteran population before the year 2020. (Florida Department of Veterans Affairs, 2008),
Statement of Need
Current literature calls for “holistic” treatments involving collaboration of support services to address the underutilization of mental health services and inadequacies in current mental health models for veterans (Robinson, 2004).
This study sought to bridge this gap through the investigation of a wraparound treatment program that provided veterans with mental health services, case management, and peer support services. and veterans’report of experiences.
Holistic Therapeutic Program
Intensive case management (Community Partners)- 1 hour every two weeks
Individual therapy- 1 hour/week
Family/marital therapy- 1 hour/week
Group therapy (Community Partners)- 1 hour every two weeks
Brief Strategic Family Therapy
Family is part of a larger social system
Focus on relationships within the family, as well as within contextual frameworks (i.e., school, work, neighbors, etc.) and how these contribute to the development or maintenance of problems
Group Therapy
Group therapy was provided on an “as needed basis” to engage other servicemen and women in the provision of support and encouragement through the often difficult adjustment of returning to civilian life.
Research Methodology
A mixed-methods approach was employed and allowed for the investigation of participants’experience of the holistic therapeutic program while also assessing for changes in symptom presentation (i.e., via pre- and post-treatment PTSD qualitative questionnaires, family satisfaction, and quality of life assessment measures) to triangulate qualitative findings.
A Transcendental Phenomenological approach was used to examine in-depth participants experiences of the program. This approach is concerned with exploring the lived experience of phenomena, “just as we see them and as they appear to us in consciousness” (Moustakas, 1994, p. 49).
Participant Recruitment
Convenient sampling was used to target veterans between the ages of 18-40 years of age who served during OIF, OEF or Desert Storm for participation in the program.
Participants were recruited through referrals from the Broward County Commission Elderly and Veterans Services Division, Ft. Lauderdale Vet Center, and VFW Stone of Hope Project
Participants
Sixteen individuals were initially recruited from local veterans’organizations for participation in the study and met with clinicians at NSU to complete an intake assessment.
Of these sixteen individuals, six individuals participated in an initial assessment, at least nine therapy sessions, and a qualitative interview and were therefore able to be included in the final data analysis.
Pre/Post Measures
The instruments that were administered are as follows:
Detailed Assessment of Posttraumatic Stress (DAPS)
Family Environment Scale-Real Form (FES-R)
Quality of Life Inventory (QOLI)
Changes In Trauma SymptomsVeterans’ Total Post trauma Symptoms decreased from pre to post-intervention as measured by the Detailed Assessment of Posttraumatic Stress.
Additionally, decreases were noted among the following symptoms:
Perceptions of Substance Abuse decreased between pre and post-intervention.
Symptoms related to Suicidality decreased between pre and post intervention.
Decreases in symptomatology were also evident in the symptoms of re- experiencing traumatic events, hyper-arousal, and dissociation.
J2
Slide 21
J2 May want to take this out as these were not part of our original data set of interest. Jakers, 1/23/2012
Change in Trauma Symptoms
Table 1. Detailed Assessment of Posttraumatic Stress Pretest and Posttest Subscales Descriptive Statistics
Pretest Posttest Scale n Mean SD Mean SD
DAPS Posttraumatic Stress-Total Scale 6 80.83* 20.87 76.33* 22.95DAPS Substance Abuse Scale 6 61.50 13.34 54.17 7.99DAPS Suicidality Scale 6 52.17 11.32 50.17 6.52
*denotes clinical significance
Change in Perceived Level of Family Cohesion
Perceptions of veterans’level of family cohesion as measured by the Family Environment Scale- Real Form, showed greater family cohesion following the holistic treatment intervention.
Change in Family Cohesion Over Time
Table 2. Family Environmental Scale Real Form Subscale Pretest and Posttest Subscales Descriptive Statistics
Pretest Posttest Scale n Mean SD Mean SD
Family Environmental Scale Real Form-Cohesion 6 48.17 20.32 59.67 6.38
Perceptions of Quality of Life
Veterans’ perceptions of Quality of Life increased in the domains of Health and Self-Esteem following participation in the holistic treatment program as measured by the Quality of Life Inventory (QOLI).
Change in Quality of Life Over Time
Table 5. Quality of Life Pretest and Posttest Subscales Descriptive Statistics
Pretest Posttest Scale n Mean SD Mean SD
Quality of Life Inventory Health 6 0.00 2.45 3.50 2.66 Quality of Life Inventory Self-Esteem 6 3.33 1.63 3.83 2.04
Qualitative Results
Results of the phenomenological analysis revealed five overall themes:
a) the importance of a trusting relationship with the referral source and/or therapist; b) the ability to gain new perspectives or more adaptive coping strategies; c) the importance of maintaining a sense of strength and/or independence; d) difficulty with functional reintegration to civilian life and self-directed identification and access of support services; and e) difficulty with communication and emotional expression in civilian contexts.
Importance of trusting relationships
One participant had this to say about their referral sources, “I listened to people and they are good friends that’s why I came here, ‘cause I respect their opinion.”“From my experience, I thought she (therapist) was great. I know my roommate was doing the same program with some other therapist and [my roommate] didn’t like him, so [my roommate] came to one session and stopped.”“I am not the type of person that likes to talk about my feelings and stuff like that so, but I mean (the therapist) made it, she made it easy, pretty much.” Similarly, another participant reported, “you don’t want no Sigmund Freud or something digging in your brain.”
Gaining new perspectives and coping strategies
When participants were asked what they found helpful within the holistic treatment program, all of the participants indicated that either greater understanding of current problems and/or learning of new coping strategies led toward positive gains in treatment.
Across participants, gains were reported in dealing with issues that ranged from substance abuse, anxiety, past guilt, anger management, and difficulty with assertiveness.
Gaining new perspectives and coping strategies
“I got a better understanding of what I am going through, what the problem has been for the last eight years.” This participant further explained, “I know I ain’t the only person going through this by myself, it felt like that before I started going to therapy and stuff, like I was on my own, but I ain’t, it’s just ah, this is the disorder I have right now.”
Another participant reported that “What has helped the most is, I think, identifying what my problem is and there is ways I can have my mind come out, part seeing what is happening and how to overcome and change it.” Another participant further explained that through therapy they were able to gain “a different point of view, I looked outside of the box about what I think sometimes, sometimes you say stuff and it’s like hey stop, think about it.”
Maintaining a sense of strength and independence
Several participants indicated a reluctance to seek help, relating a strong sense of independence and self-perceived ability to effectively solve their own problems. There was a sense among participants that to seek help would characterize them as “weak” and thus it “took a lot of courage” for many of the veterans to seek help.
One participant indicated that coming in for therapy “took a lot of courage” and further stated that, “I never asked for any help” and “I don’t talk to people about the problems I have, so it’s a big step.”
Maintaining a sense of strength and independence
“At first I was like, oh my God, I am gonna go see a shrink, and then it was like, this is cool, you just come and talk.”
Difficulty with reintegration into civilian life and identification of services
Difficulties encountered during reintegration following post-deployment varied among participants.
One participant related problems sustaining employment and financial difficulties stating, “I can’t hold a job... just can’t hold ‘em down, I go through 5, 6, 7 jobs a year. Well, I guess it’s my attitude. I just don’t like people telling me what to do.”
“The community’s different programs and things, I am unaware, I am totally unaware of what they are”
Difficulty with communication and emotional expression in civilian contexts
Several of the participants who completed the interview also identified difficulty with communication and emotional expression in civilian contexts following their reintegration into civilian life following their experiences in the military.
Difficulty with communication and emotional expression in civilian contexts
Expressions of anger were described as being especially difficult to express in assertive ways. For example, one participant indicated, “I feel that when I try and talk to people, normal, civilian people, sociably, amicably I don’t get anywhere. When that aggressive side comes out, either because I strike fear or because they realize I am not messing around that I mean what I say, now things get done. And that is pretty much been a serious problem with me since I have got out of the military.”
Implications for Practice
Trusting and comfortable relationship with referral source and provider-facilitated access to care
Frequent personal communication, follow-up with clients and coordination of care
Need for immediate delivery of something “tangible”
Initial paperwork may have contributed to attrition
Responded to structure in referring for ancillary services and in therapeutic approach
Recommendations for Future ResearchStudies with greater breadth of scope and larger sample sizes would allow for the utilization of inferential statistics and the increased ability to generalize the results. Further study of the individuals leaving programs prematurely need to be conducted to enhance quality improvement.
Future research should explore alternative methods to recruitment to target returning servicemen and women who may not seek services through the VA.
Sustainability
Manuscript submitted for publication
Submitted for presentation at the American Psychological Association 2012 annual meeting
Additional funding (United Way of Broward County)
Program evaluation
Abramowitz, E. G., Barak, Y., Ben-Avi, I., & Knobler, H. Y. (2008). Hypnotherapy in the treatment of chronic combat-related PTSD patients suffering from insomnia: A RCT. International Journal of Clinical and Experimental Hypnosis, 56, 270–280.
Amdur, D., Batres, A., Belisle, J., Brown, J.H., Cornis-Pop, M., Mathewson-Chapman, M., Harms,
G., Hunt, S.C., & Kennedy, P. (2011). VA integrated post-combat care: A systemic approach to caring for returning combat veterans. Social Work in Health Care, 50, 564-575.
Armed Forces Health Surveillance Center. (2011, September). Associations between Repeated Deployments to Iraq (OIF/OND) and Afghanistan (OEF) and Post-deployment Illnesses and
Injuries, Active Component, U.S. Armed Forces, 2003-2010 Part II. Mental Disorders, by Gender, Age Group, Military Occupation, and “Dwell Times” Prior to Repeat (Second through Fifth) Deployments. Retrieved from http://afhsc.army.mil/viewMSMR?file=2011/v18_n09.pdf#Page=02
Bleiberg, K. L., & Markowitz, J. C. (2005). A pilot study of interpersonal psychotherapy for posttraumatic stress disorder. American Journal of Psychiatry, 162, 181–183.
Cahill, S. P., Rothbaum, B. O., Resick, P. A., & Follette, V. M. (2008). Cognitive-behavioral therapy for adults. In E. B. Foa, T. M. Keane, M. Terence, M. J. Friedman, & J. A. Cohen, (Eds), Effective treatments for PTSD: Practice guidelines from the International Society for Traumatic Stress Studies (2nd ed., pp. 139–222). New York: Guilford Press. Department of Veterans Affairs. (2004, June). Iraq war clinician guide.
Cardeña, E., Maldonado, J. R., van der Hart, O., & Spiegel, D. (2008). Hypnosis. In E. B. Foa, T. M. Keane, M. Terence, M. J. Friedman, & J. A. Cohen, (Eds), Effective treatments for PTSD: Practice guidelines from the International Society for Traumatic Stress Studies (2nd ed., pp. 427–457). New York: Guilford Press.
References
Christensen, A., Atkins, D.C., Berns, S., Wheeler, J., Baucom, D.H. & Simpson, L.E. (2004). Taditional versus integrative behavioral couples therapy for significantly and chronically distressed married couples. Journal of Consulting and Clinical Psychology, 72, 176-191.
Defense Science Board. (2008, December). Challenges to military operations in support of US interests:2007 summer study. Retrieved from http://www.acq.osd.mil/dsb/reports/ ADA495353.pdf
DOD Task Force on Mental Health. (2007). An achievable vision: Report of the DOD task force on mental health. Falls Church, VA: Defense Health Board
Edes, T. (2008). Progress in VA home-based primary care. Retrieved from http://www.cfmc.org/value/files/HBPC%20CMS%201-3-08f36.pdf
French, L.M. & Parkinson, G.W. (2008). Assessing and treating veterans with traumatic brain injury. Journal of Clinical Psychology, 64 (8), 1004-1013.
Graf, N.M., Miller, E., Feist, A., & Freeman, S. (2011). Returning veterans’ adjustment concerns: family views. Journal of Applied Rehabilitation Counseling, 42, 13-23.
Hicken, B.L. & Plowhead, A. (2010). A model for home-based psychology from the veteran health administration. Professional Psychology: Research and Practice, 41 (4), 340-346.Lester, P., Peterson, K., Reeves, J., Knauss, D.G., Mogil, C., Duan, N.,…Beardslee, W. (2010). The long war and parental combat deployment: effects on military children and at-home spouses. American Academy of Child & Adolescent Psychiatry, 49, 310-320.Linehan, M. (1993). Cognitive-behavioral treatment of borderline personality disorder. New York: Guilford Press.Makin-Bryd, K., Gifford, E., McCutcheon, S., & Glynn, S. (2011). Family and couples treatment for newly returning veterans. Professional Psychology: Research and Practice, 42 (1), 47-55.
References
Markowitz, J. C., Milrod, B., Bleiberg, K., & Marshall, R. D. (2009). Interpersonal factors in understanding and treating PTSD. Journal of Psychiatric Practice, 15, 133–140.
Miller, W.R., & Rollnick, S. (2002). Motivational interviewing: Preparing people for change (2nd ed.). New York, NY: Guilford.
Reddy, M.K., Meis, L.A., Erbes, C.R., Polusny, M.A., & Comptom, J.S. (2011). Associations among experiential avoidance, couple adjustment, and interpersonal aggression in returning Iraqi war veterans and their partners. Journal of Consulting and Clinical Psychology, 79 (4), 515-520.
Rizzo, A., Reger, G., Gahm, G., Difede, J., & Rothbaum, B. O. (2009). Virtual reality exposure therapy for combat-related PTSD. In P. J. Shiromani et al.’s (Eds), post-traumatic stress disorder: Basic science and clinical practice. New York: Humana Press.
Sautter, F.J., Armelie, A.P., Glynn, S.M., and Wielt, D.B. (2011). The development of a couple- based treatment for PTSD in returning veterans. Professional Psychology: Research and Practice, 42 (1), 63-69.
Schnurr, P. P., Friedman, M. J., Foy, D. W., Shea, M. T., Hsieh, F. Y., Lavori, P. W., & Bernardy, N. C. (2003). Randomized trial of trauma focused group therapy for PTSD: Results from a Veterans Affairs Cooperative Study. Archives of General Psychiatry, 60, 481–489.
Sharpless, B.A. & Barber, J.P. (2011). A clinician’s guide to PTSD treatments for returning veterans. Professional Psychology: Research and Practice, 42 (1), 8-15.
Sher, L. & Yehuda, R. (2011). Preventing suicide among returning combat veterans: A moral perspective. Military Medicine, 176 (6), 601-602.
Skidmore, W.C., & Roy, M. (2011). Practical considerations for addressing substance use disorders in veterans and service members. Social Work in Health Care, 50, 85-107.
References
References
Stahre, M.A., Brewer, R.D., Fonseca, V.P., & Naimi, T.S. (2009). Binge drinking among US active- duty military personnel. American Journal of Preventive Medicine, 36, 208–217.
Tanielian, T. & Jaycox, L.H. (2008). Invisible wounds of war: Psychological and cognitive injuries, their consequences and services to assist recovery. Arlington, VA: RAND Corporation
Walker, R.L., Clark, M.E., & Sanders, S.H. (2010). The “postdeployment multi-symptom disorder”: an emerging syndrome in need of a new treatment paradigm.
Psychological Services, 7, 136-147.
Wolfe, J.W., Keane, T.M., & Young, B.L. (1996). From soldier to civilian: Acute adjustment patterns of returned Persian Gulf veterans. In R.J. Ursano & A.E. Norwood (Eds.), Emotional aftermath of the Persian Gulf War: Veterans, families, communities, and nations (pp. 477-499). Washington, DC: American Psychiatric Press.