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

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