![effectiveness of long term, group based therapy, while employing mindfulness techniques to
alleviate symptoms among veterans.
Exposure therapy is another type of effective technique in helping with managing PTSD
symptoms. Exposure therapy decreases distress related to trauma; in this case, war related
trauma. This therapy focuses on approaching trauma-related thoughts, feelings, and situations
veterans have been avoiding due to distress. Repeated exposure to these thoughts, feelings, and
situations helps reduce the symptoms of PTSD ("Prolonged Exposure Therapy - PTSD: National
Center for PTSD", 2014).
Strachan et al. (2012) stated, “[v]eterans with PTSD may require an integrated and
innovative approach to the delivery of exposure techniques. (p.560). Prevalence estimates for
PTSD among U.S. veterans and active-duty service members range between 4% and 17%.
Exposure techniques are usually trauma-focused and ignore the stressors of daily routine in the
civilian life after serving. Strachan (2012) believes that exposure techniques should promote
involvement in positively reinforcing, valued activities even if it does not involve the trauma
itself. These techniques are used in Behavioral Activation (BA), which was originally used for
Major Depressive Disorder. BA strategies may enhance exposure therapy for PTSD by directly
targeting comorbid MDD symptoms and areas of functional impairment. By aligning daily
behaviors and activities with core values, BA strategies may promote community readjustment
among recently post deployed veterans with trauma-related mental health symptoms (Strachan,
Gros, Ruggiero, Lejuez, & Acierno, 2012).
Strachan et al. (2012) had a total of 8 sessions for their integrative approach to combating
PTSD and MDD. The first session focused on psycho-education about common reactions to
traumatic events, development of PTSD and MDD. Session 2 goes in depths about what was
talked about in the first session and goes over the homework assigned on the first session. The
therapists then demonstrate how military values (e.g., commitment, loyalty, courage, and honor)
can translate to the civilian life. Sessions 3 and 4 are used to do exposure exercises like creating
a detailed narrative of a traumatic event. Sessions 5 through 8 develop skills learned in Sessions
1 through 4. Homework, exposure exercises and value-based activities are utilized. The final
session emphasizes relapse prevention. Identifying the behavioral warning signs of PTSD and
MDD symptoms are discussed.
The results provided preliminary evidence that Behavioral Activation (BA) and
Therapeutic Exposure (TE) reduces symptoms of PTSD, MDD, and anxiety in combat-exposed
veterans (Strachan et al, 2012, p. 566). The results that Strachan et al found were consistent with
previous research that concluded that BA strategies and TE therapy minimized PTSD and MDD
symptoms. There was a greater decrease in PTSD symptoms than MDD symptoms when
integrating BA and TE. These results were similar to a previous study Strachan et al utilized in
which 16 sessions of BA-only treatment lead to greater reductions in PTSD symptoms than to
depressive symptoms.
Exposure therapy and MBSR have been shown to help veterans with their PTSD
symptoms. However, there is a host of other problems resulting from PTSD that must be](https://image.slidesharecdn.com/k77h1m9aqjw5cygijdsy-signature-87ba7adba328561d4cf7dd7a61990945a010fc739b67780cc407b51c037ce115-poli-160425011059/85/Comp-9-2-320.jpg)
Comp 9
- 1. The United States’ veteran population faces unique challenges. As a direct result of their military service, many veterans develop physical disabilities as well as mental health issues. These ailments range from minor to severe impairment. According to Veteran’s Affairs latest estimates, there are 21,596,951 veterans, 3.84 million of whom receive VA disability compensation and 1.3 million receiving specialized mental health treatment. A specific and very prominent mental health issue veterans face is posttraumatic stress disorder. In 2013, the total amount of veterans with PTSD diagnoses was 15,620 and a total of 118,829 since 2000. The symptoms of PTSD are complicated and vary with each person. In general, one has PTSD if he/she exhibits memories, dreams, dissociative reactions, or prolonged psychological distress in response to being exposed to a traumatic event. Furthermore, the person will constantly avoid stimuli associated with the event. PTSD can be debilitating and cause great stress. It is estimated that 80% of soldiers with PTSD also suffer from major depression, anxiety disorder, alcohol or chemical abuse/dependency. These co-occurring issues lead to a host of serious problems. Homelessness and suicide are real consequences of untreated PTSD. In 2013, it was estimated that at any given night, there are roughly 58,000 homeless veterans. According to Kemp and Bossarte (2012), who conducted a suicide data report on behalf of Veterans Affairs, veteran suicides comprised 22.2% of all U.S. suicides between 2009-2012. But PTSD is not only correlated with homelessness and suicide, but affects a veteran’s ability to work and maintain stable relationships with family and friends. To provide mental health resources and assistance to veterans, the VA offers many services at various locations. Yet, most programs focus on treating PTSD and do not address the social difficulties associated with family, friends or careers. As of 2011, 13.1% of Operation Iraqi Freedom and Operation Enduring Freedom (OIF/OEF) veterans were unemployed compared to 8.1% of the population (Twamley, Baker, Norman, Pittman, Lohr, & Resnick, 2013). Veterans with PTSD are 10 times more likely to be unemployed than veterans without PTSD and in general, earn 22% less per hour. Comprehensive programs that emphasize group therapy and vocational help are hard to find. Alleviating PTSD symptoms as well as vocational training and assistance are two key components to helping veterans adjust to civilian life. Past Research Much research has been done on the effectiveness of types of therapy on PTSD. Mindfulness-based stress reduction (MBSR) is a standardized class series that is widely available. It has been shown to help manage a many ailments, such as depression, chronic pain, cancer care and anxiety (Kearney, McDermott, Malte, Martinez, & Simpson, 2012). In a trial study using MBSR with heterosexual veterans with PTSD, therapy was conducted in a group setting over the course of 17 months. “MBSR has been described as fostering an enhanced ability to bring sustained, nonjudgmental attention to cognitive, emotional, and physical experiences…” (Kearney et al., 2012, p. 102). Researchers found that after 6 months of treatment, 47.7% of veterans experienced significant improvements in PTSD symptoms. This study highlights the
- 2. effectiveness of long term, group based therapy, while employing mindfulness techniques to alleviate symptoms among veterans. Exposure therapy is another type of effective technique in helping with managing PTSD symptoms. Exposure therapy decreases distress related to trauma; in this case, war related trauma. This therapy focuses on approaching trauma-related thoughts, feelings, and situations veterans have been avoiding due to distress. Repeated exposure to these thoughts, feelings, and situations helps reduce the symptoms of PTSD ("Prolonged Exposure Therapy - PTSD: National Center for PTSD", 2014). Strachan et al. (2012) stated, “[v]eterans with PTSD may require an integrated and innovative approach to the delivery of exposure techniques. (p.560). Prevalence estimates for PTSD among U.S. veterans and active-duty service members range between 4% and 17%. Exposure techniques are usually trauma-focused and ignore the stressors of daily routine in the civilian life after serving. Strachan (2012) believes that exposure techniques should promote involvement in positively reinforcing, valued activities even if it does not involve the trauma itself. These techniques are used in Behavioral Activation (BA), which was originally used for Major Depressive Disorder. BA strategies may enhance exposure therapy for PTSD by directly targeting comorbid MDD symptoms and areas of functional impairment. By aligning daily behaviors and activities with core values, BA strategies may promote community readjustment among recently post deployed veterans with trauma-related mental health symptoms (Strachan, Gros, Ruggiero, Lejuez, & Acierno, 2012). Strachan et al. (2012) had a total of 8 sessions for their integrative approach to combating PTSD and MDD. The first session focused on psycho-education about common reactions to traumatic events, development of PTSD and MDD. Session 2 goes in depths about what was talked about in the first session and goes over the homework assigned on the first session. The therapists then demonstrate how military values (e.g., commitment, loyalty, courage, and honor) can translate to the civilian life. Sessions 3 and 4 are used to do exposure exercises like creating a detailed narrative of a traumatic event. Sessions 5 through 8 develop skills learned in Sessions 1 through 4. Homework, exposure exercises and value-based activities are utilized. The final session emphasizes relapse prevention. Identifying the behavioral warning signs of PTSD and MDD symptoms are discussed. The results provided preliminary evidence that Behavioral Activation (BA) and Therapeutic Exposure (TE) reduces symptoms of PTSD, MDD, and anxiety in combat-exposed veterans (Strachan et al, 2012, p. 566). The results that Strachan et al found were consistent with previous research that concluded that BA strategies and TE therapy minimized PTSD and MDD symptoms. There was a greater decrease in PTSD symptoms than MDD symptoms when integrating BA and TE. These results were similar to a previous study Strachan et al utilized in which 16 sessions of BA-only treatment lead to greater reductions in PTSD symptoms than to depressive symptoms. Exposure therapy and MBSR have been shown to help veterans with their PTSD symptoms. However, there is a host of other problems resulting from PTSD that must be
- 3. addressed. Job seeking and retention are important components of transitioning to civilian life. Upon examining two large Veteran Health Administration databases of OIF/OEF veterans suffering from PTSD, depression, TBI or substance use disorder, it was found that only 8.4% of them accessed vocational services. Furthermore, retention was low because most veterans only attended one or two appointments (Twamley et al., 2013). This study also looked at the success of supported employment, which is an “…evidence-based practice for helping people with mental health disorders return to competitive work… searching for competitive jobs in an integrated vocational and mental health treatment model” (Twamley et al., 2013, pg. 664). Only 2.2% of veterans received supported employment, but 51% of those veterans acquired competitive work. This study shows that there is high unemployment among veterans, but that can be slowly rectified with certain vocational tools. The overall problem is that there are few programs that integrate both individual/group therapy and vocational rehabilitation. Both methods seem to work and the combination of the two may yield greater success rates. One such program, called the Veterans Transition program (VTP), is a group-based program designed to assist the transition of military personnel back into civilian life. It is a Canadian residential group-based program that helps veterans with their personal and career readjustment. Exposure therapy, trauma focused group therapy, social skills training, family involvement, peer counseling are components of VTP. The program’s main goals are (a) creating a safe, cohesive environment where soldiers can experience mutual support, understanding from others who have ‘‘been there’’ and process their reactions (b) normalizing of the soldiers’ military experiences overseas and the difficulties with re-entry back to civilian life (c) offering critical knowledge to understand trauma and its origins, symptoms, impact on self and others along with provision of specific relational and self-regulation strategies for trauma symptom management (d) reducing the symptoms of the stress-related issues arising from their military experiences; (e) teaching of interpersonal communication skills to help manage difficult interactions or enhance relationships with others (e.g., spouses, friends, co workers)(f) generating life goals and learning how to initiate career exploration; and (g) involving spouses and other family members in family awareness sessions (Westwood, McLean, Cave, Borgen, & Slakov, 2010, p. 47-48). There would be a para-professional soldier that has previously participated in the VTP and have received additional training; they assist by modeling caring and supportive behavior and by engaging in the expected behavioral outcomes of the program. There are 21 steps in the VTP program that are broken into 5-stage model. The first stage is assessment and preparation which focuses on establishing a solid working group, which is prepared by the professionals. The second stage is called group building. The counselors assist veterans to address symptoms and begin the work of trauma repair. The veterans share life- narratives through a group-based life review process. Enactment is the third stage and the activity for the veterans is to enact specific trauma narratives. Through the enactment process
- 4. group members are able to learn about their triggers, stressors, and patterns of activation, relapse and regression. The fourth stage is called Sharing, Reconnection, Closure; it integrates what the veterans have learned and create new clear and achievable goals. The final stage, Integration and Transfer, helps veterans reconnect with their community (family, friends etc.). Follow-ups by the clinicians are done after six months of the program. Then a year later after the six-month follows up. Method The proposed program is designed to integrate both therapeutic aspects as well as vocational rehabilitation. The program is preventative in nature. The goal is to minimize PTSD symptoms, while incorporating vocational rehabilitation. This two-pronged approach can help reduce hospitalizations and co-occurring conditions (such as depression and substance abuse). Furthermore, it can increase job retention. Therefore, the program is designed to be cost and time effective. Participants The program would be in the United States and focused in New York State. New York state has a high density of veterans, between 650,001- 950,000 (Veteran Affairs, 2014). There will be a total of 20 veterans, consisting of both men and women. The veterans must meet certain criteria in order to participate. Each veteran must be referred to the program by the Bronx VA Medical Center and, therefore, have a documented diagnosis of PTSD. The veteran must have been discharged in the past 10 years. The discharge time frame was decided based on a study that compared therapy dropout rates of OIF/OEF veterans and Vietnam veterans. The results showed that OIF/OEF veterans were attending sessions significantly less than Vietnam veterans. Furthermore, dropout rates all together were higher than Vietnam veterans (Erbes, Curry, & Leskela, 2009). These results show that it is important to focus on more recently discharged veterans. Veterans cannot be homeless and must show proof of suitable housing. Lastly, veterans must start the program from the beginning; no participants will be allowed to begin after the first session. Program Specifications The VTP will be 3 hours long every Saturday for 16 weeks from 12 to 3pm. It will be held at the Bronx VA Medical Center in New York. Two facilitators, one with military background and one mental health counselor, will run the sessions. The program will follow the stages of Westwood et al, group-based approach. Throughout the 16 weeks, VTP will focus on minimizing PTSD symptoms using exposure therapy with the group-based approach of Westwood et al. Creating a support system for the veterans is needed in order to have a successful transition to civilian life. Additionally, a vocational component to the program is added in order to help veterans understand and effectively navigate the current job market.The vocational component will include translating military skill sets to a civilian job, resume building and interview skills. The counselor with the military background will lead the vocational component.The last part of the vocational
- 5. component will be career assessing.This involves asking the veterans what career interests they have and assigning the veterans to research the requirements of the career(s). In order to evaluate the veterans, the PTSD CheckList – Civilian Version (PCL-C) will be handed out at Assessment and Preparation stage of the program and also at the conclusion of the program. Doing a pretest and posttest evaluation like the PCL-C is a requirement of the VA hospital in order to see if PTSD symptoms were minimized. Furthermore, a follow up will be conducted 6 months and 12 months after the program. This is to assess the long-term effectiveness of the interventions. The follow up will be a phone conversation with the veteran, where the counselor will note how the veteran has been managing his/her PTSD symptoms. Job placement, retention, housing and no recurring hospitalization will be indicators of progress. Limitations This program aims to alleviate veteran PTSD symptoms, while helping them transition into civilian life by finding a job. This complicated process has various limitations. Insurance may not cover the program, so funding will be essential. The program is based on individual studies done on therapy and vocational rehabilitation separately. No research has been done on the combination of the two with the use of group counseling as the main form of therapy. Therefore, there are no previous trials the program can build on and prevent mistakes. Since veterans must be referred to us by the VA hospital, the program excludes all those who do not have access to health care. The veterans participating in the program will come from the same referral source. They might know each other and already have relationships in place. This can be a hindrance to group therapy and progress. Follow up might be difficult because the counselors might not be able to get in touch with the veterans (who might have moved or changed their contact information). In addition, counselors will be assessing progress solely on the testimony of the veterans. This testimony is very important, but can also be misleading since the veteran might not divulge accurate information. Funding For a pilot program of this type, funding is inherent due to the likely possibility that health care will not cover the 16 sessions for the veterans. The websites used to find funding were Grants.gov, foundationcenter.org/newyork and google.com searches for grants. The Department of Labor (DOL) provided grants under programs like Veterans Workforce Investment Program and Stand Down. JPMorgan Chase also offer grants through programs called Veterans for Hire and Wounded Warriors. The Veterans Affairs website lists grants as well. Fundraising and donations will be included in the process.
- 6. Prolonged Exposure Therapy - PTSD: National Center for PTSD. (2014, January 1). Retrieved June 30, 2014, from http://www.ptsd.va.gov/public/treatment/therapymed/ prolonged-exposure-therapy.asp Strachan, M., Gros, D. F., Ruggiero, K. J., Lejuez, C. W., & Acierno, R. (2012). An Integrated Approach to Delivering Exposure-Based Treatment for Symptoms of PTSD and Depression in OIF/OEF Veterans: Preliminary Findings. Behavior Therapy, 43, 560- 569. doi:10.1016/j.beth.2011.03.003 Westwood, M. J., McLean, H., Cave, D., Borgen, W., & Slakov, P. (2010). Coming Home: A Group-Based Approach for Assisting Military Veterans in Transition. The Journal for Specialists in Group Work. doi:10.1080/01933920903466059