Download Returning Veterans Experiences of a Holistic Therapeutic Program

Returning Veterans Experiences
of a Holistic Therapeutic
Program
Elda Kanzki-Veloso, Ph.D. & Angela Yehl, Psy.D.
Nova Southeastern University
NSU Collaborators and Community
Partners
† Ft. Lauderdale Vet Center
† Broward County Elderly and
Veterans Services Division
† Wendy Thomson, MSN,
RN, NSU
† Sabrina Stern, RN, NSU
† Veterans of Foreign Wars
Stone of Hope Project
† Dr. Tom Kennedy NSU
† Dr. Marcelo Castro, NSU
† Dr. Kimberly Durham, NSU
† Dr. Barbara GarciaLavin, NSU
† Dr. James Pann, NSU
† Dr. Timothy Scala, NSU
† Dr. Ron Chenail, NSU
† Dr. Tommie Boyd, NSU
† Jacob Connolly, M.S., NSU
† Rivka Spiro, M.A., NSU
† Operation Iraqi Freedom
(OIF)
† 2003-2010
“Operation New Dawn”
(OND) August 31,
2010-Present (U.S.
combat mission in
Iraq had endedtransitional 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 Services
Stigma 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 Care
Military One Source
Military HOMEFRONT
Project 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 Symptoms
€ Veterans’ 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 postintervention.
† Symptoms related to Suicidality decreased between pre and post
intervention.
J2
x Decreases in symptomatology were also evident in the symptoms
of re- experiencing traumatic events, hyper-arousal, and
dissociation.
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 StressTotal Scale
6
80.83*
20.87
76.33*
22.95
DAPS Substance Abuse Scale
6
61.50
13.34
54.17
7.99
DAPS 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
Quality of Life Inventory SelfEsteem
6
0.00
2.45
3.50
2.66
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 selfdirected 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 selfperceived 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
Research
† Studies 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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