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
Veterans 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 veterans 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 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 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 programs 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 stressrelated 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 groupbased life review process. Enactment is the third stage and the activity for the veterans is to enact specific trauma narratives. Through
the enactment process 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.). Followups 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 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.

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