Pilot outcomes of a filmmaking intervention designed to enhance treatment entry and social reintegration of veterans.

Military personnel transitioning to civilian life have reported significant challenges in reintegrating into civilian culture. Filmmaking has been used as a therapeutic intervention to enhance the community reintegration of veterans, but there are no published quantitative data documenting its impact. The present study provides outcome data on 40 veterans who participated in the I Was There (IWT) filmmaking workshop. This 3-day (20-hr) group intervention involved veterans working in small teams with a film coach, making short films designed to communicate some aspect of their experience during or after military service, and then creating a screening event to show their films to community members. The sample consisted of community-dwelling veterans who reported at least some mental health symptoms and who were not engaged in mental health treatment for those symptoms. Targeted outcomes included engagement in mental health care, symptoms of posttraumatic stress disorder (PTSD) and depression, and reported perception of community interest in their experience as veterans. Fifty-six percent of participants entered treatment within 4 months of participation. Significant decreases were noted in symptoms of PTSD at 1-month follow-up but not at the 4-month follow-up, while changes in depression were not statistically significant. Participation was related to increased perception of community interest in veterans' experience, and increased interest among community members who viewed the films. These data provide initial support for the conclusion that the IWT film workshop is a potentially effective tool for treatment engagement and for community reintegration among veterans. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

The effects of posttraumatic stress disorder symptoms on educational functioning in student veterans.

Posttraumatic stress disorder (PTSD) occurs at high rates among student veterans and is known to negatively impact educational functioning; however, the unique effects of PTSD are less clear, given that PTSD is highly comorbid with many other conditions that could potentially affect educational functioning. The present study had two objectives: (a) to determine the impact of PTSD symptom severity on educational functioning after accounting for demographic variables, traumatic brain injury, and commonly co-occurring mental health conditions; and (b) to identify which symptom clusters of PTSD have the greatest impact on educational functioning. Educational functioning and other commonly occurring mental health conditions were assessed cross-sectionally among 90 student veterans. Traumatic brain injury and major depressive disorder (MDD) were initially associated with impaired educational functioning; however, after adding PTSD into the final model, only PTSD (ß = .44, p < .001) and MDD (ß = .31, p = .001) remained associated with educational impairment. Follow-up analyses indicated that the reexperiencing symptom cluster was most strongly associated with impaired educational functioning (ß = .28, p = .031). Overall, these results suggest that PTSD symptoms-especially reexperiencing symptoms-may be a driving force behind impaired educational impairment, even after accounting for other commonly co-occurring mental health conditions. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Psychosocial approaches to improving the military-to-civilian transition process.

This special issue of Psychological Services provides a glimpse of some of the most recent work in the arena of psychosocial interventions for military service members who are reintegrating into civilian society and becoming veterans. The psychological effects that can occur as members go through the military-to-civilian transition as they leave the military have been extensively recorded and treated. While psychosocial interventions have been utilized throughout history, we are seeing a new interest and recent renaissance in their use. These psychosocial interventions will help our veterans reintegrate into civilian society not just by focusing on reducing the symptoms from their visible and invisible wounds but by taking a more holistic and integrative perspective that works to improve the veterans' functioning in their surrounding social environments through community reengagement, treatment of the individual and their social environment, and functional improvement. The articles in this special issue illustrate how clinicians and researchers are validating new techniques to improve functioning among those learning to change careers as warriors in their new civilian occupations. (PsycINFO Database Record

Using peer support groups to enhance community integration of veterans in transition.

Peer support groups, also known as "self-help groups," provide a unique tool for helping veterans working through the military-to-civilian transition to achieve higher levels of social support and community integration. The number and variety of community-based peer support groups has grown to the point that there are now more visits to these groups each year than to mental health professionals. The focus of these groups on the provision of social support, the number and variety of groups, the lack of cost, and their availability in the community make them a natural transition tool for building community-based social support. A growing literature suggests that these groups are associated with measurable improvements in social support, clinical symptoms, self-efficacy and coping. For clinical populations, the combination of peer support groups and clinical care results in better outcomes than either alone. Given this evidence, we suggest clinical services use active referral strategies to help veterans engage in peer support groups as a means of improving community reintegration and clinical outcomes. Finally, suggestions for identifying appropriate peer support groups and assisting with active referrals are provided. (PsycINFO Database Record

Effects of social support and resilient coping on violent behavior in military veterans.

Violence toward others has been identified as a serious postdeployment adjustment problem in a subset of Iraq- and Afghanistan-era veterans. In the current study, we examined the intricate links between posttraumatic stress disorder (PTSD), commonly cited psychosocial risk and protective factors, and violent behavior using a national randomly selected longitudinal sample of Iraq- and Afghanistan-era United States veterans. A total of 1,090 veterans from the 50 United States and all United States military branches completed 2 waves of self-report survey-data collection 1 year apart (retention rate = 79%). History of severe violent behavior at Wave 1 was the most substantial predictor of subsequent violence. In bivariate analyses, high correlations were observed among risk and protective factors, and between risk and protective factors and severe violence at both time points. In multivariate analyses, baseline violence (OR = 12.43, p < .001), baseline alcohol misuse (OR = 1.06, p < .05), increases in PTSD symptoms between Waves 1 and 2 (OR = 1.01, p < .05), and decreases in social support between Waves 1 and 2 (OR = .83, p < .05) were associated with increased risk for violence at Wave 2. Our findings suggest that rather than focusing specifically on PTSD symptoms, alcohol use, resilience, or social support in isolation, it may be more useful to consider how these risk and protective factors work in combination to convey how military personnel and veterans are managing the transition from wartime military service to civilian life, and at what point it might be most effective to intervene. (PsycINFO Database Record

Promising practices in vocational services for the community reintegration of returning veterans: The individual placement and support model and beyond.

Supporting returning veterans' job-seeking, hiring, and retention issues has become an essential goal for effective community reintegration. Given both the particular strengths and challenges associated with veterans transitioning from military to civilian life, multiple models for supported employment have become integrated into Veterans Affairs health care facilities across the nation. In this article, we review the state of vocational rehabilitation for veterans, with a particular focus on individual placement and support-supported employment (IPS-SE), the current vocational services model that is considered the gold standard of vocational rehabilitation. Various modifications to the IPS-SE model are presented, including additions such as cognitive rehabilitation, contingency management, motivational interviewing, supported self-employment, and transitional work. Finally, recommendations are made about future directions and strategies to expand access to IPS-SE-based programs and to effectively meet the needs of returning veterans for employment in jobs of their choice. (PsycINFO Database Record

Gender differences in associations between DSM-5 posttraumatic stress disorder symptom clusters and functional impairment in war veterans.

Understanding the links between posttraumatic stress disorder (PTSD) symptoms and functional impairment is essential for assisting veterans in transitioning to civilian life. Moreover, there may be differences between men and women in the relationships between PTSD symptoms and functional impairment. However, no prior studies have examined the links between functional impairment and the revised symptom clusters as defined in the Diagnostic and Statistical Manual of Mental Disorders, 5th ed. (DSM-5; American Psychiatric Association, 2013) or whether the associations between PTSD symptom clusters and functional impairment differ by gender. We examined the associations between the DSM-5 PTSD symptom clusters and functional impairment in 252 trauma-exposed Iraq and Afghanistan war veterans (79 females). Regression analyses included demographic factors and exposure to both combat and military sexual trauma as covariates. In the total sample, both the intrusions cluster (ß = .18, p = .045) and the negative alterations in cognition and mood cluster (ß = .45, p < .001) were associated with global functional impairment. Among male veterans, global functional impairment was associated only with negative alterations in cognition and mood (ß = .52, p < .001). However, by contrast, among female veterans, only marked alterations in arousal and reactivity were associated with global functional impairment (ß = .35, p = .027). These findings suggest that there may be important gender differences with respect to the relationship between PTSD symptoms and functional impairment. (PsycINFO Database Record

Executive functioning in TBI from rehabilitation to social reintegration: COMPASS (goal,) a randomized controlled trial (grant: 1I01RX000637-01A3 by the VA ORD RR&D, 2013-2016).

BACKGROUND: Traumatic brain injury is a major health problem that frequently leads to deficits in executive function. Self-regulation processes, such as goal-setting, may become disordered after traumatic brain injury, particularly when the frontal regions of the brain and their connections are involved. Such impairments reduce injured veterans' ability to return to work or school and to regain satisfactory personal lives. Understanding the neurologically disabling effects of brain injury on executive function is necessary for both the accurate diagnosis of impairment and the individual tailoring of rehabilitation processes to help returning service members recover independent function. METHODS/DESIGN: The COMPASS(goal) (Community Participation through Self-Efficacy Skills Development) program develops and tests a novel patient-centered intervention framework for community re-integration psychosocial research in veterans with mild traumatic brain injury. COMPASS(goal) integrates the principles and best practices of goal self-management. Goal setting is a core skill in self-management training by which persons with chronic health conditions learn to improve their status and decrease symptom effects. Over a three-year period, COMPASS(goal) will recruit 110 participants with residual executive dysfunction three months or more post-injury. Inclusion criteria combine both clinical diagnosis and standardized scores that are >1 SD from the normative score on the Frontal Systems Rating Scale. Participants are randomized into two groups: goal-management (intervention) and supported discharge (control). The intervention is administered in eight consecutive, weekly sessions. Assessments occur at enrollment, post-intervention/supported discharge, and three months post-treatment follow-up. DISCUSSION: Goal management is part of the "natural language" of rehabilitation. However, collaborative goal-setting between clinicians/case managers and clients can be hindered by the cognitive deficits that follow brain injury. Re-training returning veterans with brain injury in goal management, with appropriate help and support, would essentially treat deficits in executive function. A structured approach to goal self-management may foster greater independence and self-efficacy, help veterans gain insight into goals that are realistic for them at a given time, and help clinicians and veterans to work more effectively as true collaborators.

Vocational services research: recommendations for next stage of work.

As the field of vocational services (VS) research matures, it is necessary to review its progress and identify any important gaps in measurement and methodology that may hamper future efforts. To encourage progress, we have identified (1) ways to increase consistency in measuring employment outcomes, (2) emerging patterns and lingering gaps in the range of variables and measures commonly used in VS research, (3) broader methodological patterns and needs in the area of study design and sampling, (4) interventions that warrant additional study, and (5) broad strategies to increase the overall amount and quality of VS research. The goal of this article is to assist the field in achieving clearer coherence in shared expectations and standards for research so that the field can consolidate its gains as it helps people successfully return to rewarding jobs in the community.

Pathways to vocational services: factors affecting entry by veterans enrolled in Veterans Health Administration mental health services.

The current study provides naturalistic data documenting the pathways-to-care to vocational services for 155 veterans who were receiving some form of mental health care from the Veterans Health Administration and had a vocational need but were not currently enrolled in vocational services. Of the participants, 94.2% had recognized their vocational need, 80.6% reported that they or someone else had sought help to alleviate the need, and 77.4% had previously received some form of vocational services. The median length of the participants' vocational need was more than 4.2 years. Delays associated with recognition, help-seeking, and treatment entry all contributed to the overall delay in entering appropriate care. Filtering factors associated with quicker recognition, seeking help, and receiving services included diagnosis, level of disability, type of vocational need, and support from primary providers, family, and friends. The results provide information for designing interventions to improve service entry by adults with mental health problems and vocational needs.

Cognitive impairment as barrier to engagement in vocational services among veterans with severe mental illness.

Vocational services (VS), particularly supported employment models, have clear advantages for assisting adults with severe mental illness (SMI) in returning to the workplace, but a majority of eligible individuals with SMI do not receive any type of VS. The reasons for nonparticipation in VS remain poorly understood, and the potential contribution of cognitive impairment as a barrier to entry has not been explored. The present study uses a pathways-to-care design to examine the specific contribution of cognitive functioning to entry into VS among veterans with SMI. We examined 179 veterans with both SMI and un- or underemployment who completed a work history, the Pathways To Care Inventory, and the Trail-Making Test, Part B. Analysis revealed that veterans with SMI and moderate to severe cognitive impairment took significantly longer to progress through pathways-to-care than those with SMI and mild or no cognitive impairment. These results suggest that identifying veterans with SMI and cognitive impairment early and providing them with integrated and adjunct services may help them navigate VS.

Veterans Health Administration Transitional work experience vs. job placement in veterans with co-morbid substance use and non-psychotic psychiatric disorders.

OBJECTIVE: This study seeks to compare the effectiveness of Veterans Health Administration's (VHA) transitional work experience (TWE) services and a minimal but common intervention-job placement (JP) services, for veterans with co-morbid substance and psychiatric disorders. METHODS: We conducted a random clinical trial comparing work outcomes for 89 veterans with co-morbid psychiatric and substance use disorders (SUD) who were randomly assigned to participate in VHA TWE services with those assigned to simple JP services provided by state vocational rehabilitation professionals. Participants were enrolled at the time of application to VHA TWE services and then randomly assigned to the two treatment groups and followed for 12 months. RESULTS: VHA TWE participants were more likely to engage in paid activity, to work more total hours, to work more weeks and to earn more in total wages. The groups were not significantly different with respect to competitive employment, in terms of the percentage acquiring competitive jobs, the number of hours worked, or wages earned. CONCLUSIONS: These data suggest that the primary benefit of VHA TWE services is in rapidly engaging participants in paid activity and that these services are not effective at helping dually diagnosed veterans obtain competitive employment.

Adding contingency management intervention to vocational rehabilitation: outcomes for dually diagnosed veterans.

In this random-assignment trial, we evaluated the efficacy of using a contingency management (CM) intervention to enhance job acquisition and tenure among participants of a vocational rehabilitation (VR) program. The CM intervention offered participants cash incentives up to $1,170 for completing tasks related to sobriety and job search and maintenance. Participants were 100 veterans with comorbid psychiatric disorders and substance dependence who were randomly assigned either to VR only or VR + CM. Relative to participants in the VR-only group, those in the VR + CM group showed more intense job searches and transitioned to competitive employment faster and at higher rates. No significant difference was found in job tenure, though this may be due to the limited follow-up period. Abstinence rates were significantly better in the VR + CM group during the first 16 weeks of follow-up but not significantly different in subsequent follow-ups. No relationship was found between relapse and employment. These results suggest that rehabilitation outcomes may be enhanced by adding CM to current programming or by restructuring traditional work-for-pay contingencies to include direct financial rewards for achievement of clinical goals.

The illness burden of alcohol-related disorders among VA patients: the veterans health study.

Little is known about the illness burden associated with alcohol-related disorders (ie, problem drinking, alcohol abuse, and alcohol dependence) among patients in outpatient medical care. The objective of this study was to examine several aspects of illness burden-medical comorbidities, patterns of health services use, and functional status-among Veterans Health Administration (VA) ambulatory care patients with alcohol-related disorders. Male participants (N = 2425) were recruited at 1 of 4 Boston-area VA outpatient clinics. They completed self-report screening measures of current alcohol-related disorders (CAGE score > or =2 with past year alcohol consumption), health behaviors, medical comorbidities, and functional status (SF-36). A medical history interview, which assessed comorbid conditions and use of recent health services, was also administered. Screening criteria for current alcohol-related disorders were satisfied by 12%; however, only 40% of these reported ever receiving treatment specifically for alcohol-related disorders. Patients who screened positive for alcohol-related disorders reported significantly greater limitations in mental health function, longer hospitalizations for medical care in the prior year, and fewer outpatient medical visits in the previous 3 months. Findings suggest considerable illness burden associated with alcohol-related disorders among VA ambulatory care patients. Efforts to increase detection and treatment of alcohol-related disorders may lessen the illness burden and cost of alcohol-related disorders.

The impact of enhanced incentives on vocational rehabilitation outcomes for dually diagnosed veterans.

This study evaluated the efficacy of adding contingency management techniques to vocational rehabilitation (VR) to improve treatment outcome as measured by entry into competitive employment. Nineteen dually diagnosed veterans who entered VR in the Veterans' Administration's compensated work therapy (CWT) program were randomly assigned to CWT (n = 8) or to CWT with enhanced incentives (n = 11). Over the first 16 weeks of rehabilitation, those in the incentives condition could earn up to dollar 1,006 in cash for meeting two sets of clinical goals: (a) remaining abstinent from drugs and alcohol and (b) taking steps to obtain and maintain a competitive job. Results indicate that relative to participants in the CWT-only group, those in the incentives condition engaged in more job-search activities, were more likely to remain abstinent from drugs and alcohol, were more likely to obtain competitive employment, and earned an average of 68% more in wages. These results suggest that rehabilitation outcomes may be enhanced by restructuring traditional work-for-pay contingencies to include direct financial rewards for meeting clinical goals.

Housing preferences of homeless veterans with dual diagnoses.

Previous research indicates that most homeless persons with mental illness prefer independent living, while most clinicians recommend group housing. This study compared residential preferences of 141 homeless veterans with dual diagnoses with those of 62 homeless nonveterans with dual diagnoses. Clinicians rated both groups while they were in transitional shelters before they were placed in housing. Both samples strongly rejected group home living, but a majority of nonveterans desired staff support. Clinicians recommended staffed group homes for most veterans and nonveterans. This survey underscores the disjuncture between consumers' and clinicians' preferences as well as the need to provide a range of housing options to accommodate varied preferences.

Twelve-week outcomes from an investigation of high-dose nicotine patch therapy for heavy smokers with a past history of alcohol dependence.

This study reports findings from an investigation of the efficacy of high-dose nicotine patch (NP) therapy for heavy smokers with a past history of alcohol dependence. One hundred thirty participants were randomly assigned to 42 mg or 21 mg of transdermal nicotine for 4 weeks, followed by an 8-week dose titration. Follow-up assessments were conducted at 4 and 12 weeks. Differences between dose conditions were nonsignificant, although unexpectedly, outcomes favored participants in the 21-mg NP condition. Nicotine abstinence at follow-up was related to longer length of alcohol abstinence at time of enrollment. Future research should investigate ways to improve smoking quit rates in this population, including more frequent counseling sessions and/or other pharmacotherapies. These investigations should focus primarily on smokers in early alcohol recovery.

Building the future: psychosocial rehabilitation with a Veterans Construction Team.

The Veterans Construction Team (VCT) is an innovative form of Compensated Work Therapy (CWT) for unemployed, homeless veterans who have had a history of substance abuse and/or a serious mental or medical illness. The VCT model builds social support and self-esteem, while delivering tangible services to public entities and providing a relatively high rate of pay and exceptional opportunities for skill development. This brief report outlines the VCT model, reviews VCTs development and operations, and describes participant reactions. Data were collected by interviewing program managers and office staff, field supervisors and VCT participants, as well as through archival data on VCT projects and VA intake data.

Predictive validity of the ASAM Patient Placement Criteria for hospital utilization.

We tested the validity of the ASAM Patient Placement Criteria (PPC) using the first complete and reliable computerized implementation of these criteria. Adult U.S. veterans (N = 95) seeking substance abuse treatment were blindly assessed for level of care need according to the PPC but were naturalistically assigned by counselors to residential rehabilitation (Level III) without knowledge of the PPC recommendation. Analyses compared subjects across three levels of recommended care, based on the algorithm, for utilization outcomes of VA hospital admissions and bed days of care. Subjects who were mismatched to lesser level of care than recommended utilized nearly twice as many hospital bed-days over the subsequent year (F (2;92) = 3.88; p < .05); this was unrelated to differential pre-assessment chronicity. The computerized algorithm is a promising new tool for facilitating field trials of the validity of the ASAM Criteria. A comprehensive implementation is an important methodologic requirement. These preliminary results support predictive validity for the ASAM Criteria, in that mismatching may be associated with excessive hospital utilization.