PTSD in the US.

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