Re tur ning Ve te r ans E xpe r ie nc e s of a Holistic T he r - - PowerPoint PPT Presentation

Re tur ning Ve te r ans E xpe r ie nc e s

• f a Holistic T

he r ape utic Pr

• gr

am

Elda Kanzki-Veloso, Ph.D. & Angela Yehl, Psy.D.

Nova Southeastern University

NSU Co lla b o ra to rs a nd Co mmunity Pa rtne rs

F

• t. L

a ude rda le Ve t Ce nte r

Bro wa rd Co unty E

lde rly a nd Ve te ra ns Se rvic e s Divisio n

Ve te ra ns o f F

• re ig n Wa rs

Sto ne o f Ho pe Pro je c t

• Dr. Ma rc e lo Ca stro , NSU
• Dr. K

imb e rly Durha m, NSU

• Dr. Ja me s Pa nn, NSU
• Dr. Ro n Che na il, NSU

Ja c o b Co nno lly, M.S., NSU We ndy T

ho mso n, MSN, RN, NSU

Sa b rina Ste rn, RN, NSU

• Dr. T
• m K

e nne dy NSU

Rivka Spiro , M.A., NSU

• Dr. Ba rb a ra Ga rc ia -

L a vin, NSU

• Dr. T

imo thy Sc a la , NSU

• Dr. T
• mmie Bo yd, NSU

Operation Iraqi Freedom (OIF) 2003-2010 “Operation New Dawn” (OND) August 31, 2010-Present (U.S. combat mission in Iraq had ended- transitional mission to assist Iraq’s Security Forces) Operation Enduring Freedom (OEF) 2001-Present

De plo yme nt

Appro xima te ly 2 millio n U.S. tro o ps ha ve b e e n de plo ye d

to c o mb a t zo ne s sinc e Se pte mb e r 2001 (T a n, 2009).

Ma ny o f the se so ldie rs ha ve e nc o unte re d se rio us

c ha lle ng e s re a djusting upo n the ir re turn ho me sinc e ma ny do no t suc c e ssfully a c c e ss ne e de d se rvic e s (I nstitute o f Me dic ine , 2010; Ho g e e t a l., 2004).

De plo yme nt c o nt.,

F

re q ue nt a nd le ng thy de plo yme nts ta ke the ir to ll no t o nly

• n the so ldie r b ut fa mily me mb e rs a nd frie nds a s we ll.

Sta te me nt o f Ne e d

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

Re inte g ra tio n Co nc e rns

Re la tio nships E

mplo yme nt

Ho me le ssne ss Suic ide Se xua l Assa ult He a lth Pro b le ms

Ba rrie rs to Ac c e ssing Se rvic e s

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

Pro g ra mma tic Ne e ds

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

• ut; 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

I

n Bro wa rd Co unty, the re a re a n e stima te d 114,423 ve te ra ns (F lo rida De pa rtme nt o f Ve te ra ns Affa irs, 2009)

I

t is pro je c te d tha t F lo rida will ha ve the la rg e st ve te ra n po pula tio n b e fo re the ye a r 2020. (F lo rida De pa rtme nt o f Ve te ra ns Affa irs, 2008),

Sta te me nt o f Ne e d

Curre nt lite ra ture c a lls fo r “ho listic ” tre a tme nts invo lving

c o lla b o ra tio n o f suppo rt se rvic e s to a ddre ss the unde rutiliza tio n o f me nta l he a lth se rvic e s a nd ina de q ua c ie s in c urre nt me nta l he a lth mo de ls fo r ve te ra ns (Ro b inso n, 2004).

T

his study so ug ht to b ridg e this g a p thro ug h the inve stig a tio n o f a wra pa ro und tre a tme nt pro g ra m tha t pro vide d ve te ra ns with me nta l he a lth se rvic e s, c a se ma na g e me nt, a nd pe e r suppo rt se rvic e s. a nd ve te ra ns’

re po rt o f e xpe rie nc e s.

Ho listic T he ra pe utic Pro g ra m

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

Brie f Stra te g ic F a mily T he ra py

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

Gro up T he ra py

Gro up the ra py wa s pro vide d o n a n “a s ne e de d b a sis” to

e ng a g e o the r se rvic e me n a nd wo me n in the pro visio n o f suppo rt a nd e nc o ura g e me nt thro ug h the o fte n diffic ult a djustme nt o f re turning to c ivilia n life .

Re se a rc h Me tho do lo g y

A mixe d-me tho ds a ppro a c h wa s e mplo ye d a nd

a llo we d fo r the inve stig a tio n o f pa rtic ipa nts’ e xpe rie nc e o f the ho listic the ra pe utic pro g ra m while a lso a sse ssing fo r c ha ng e s in sympto m pre se nta tio n (i.e ., via pre - a nd po st-tre a tme nt PT SD q ua lita tive q ue stio nna ire s, fa mily sa tisfa c tio n, a nd q ua lity o f life a sse ssme nt me a sure s) to tria ng ula te q ua lita tive finding s.

A T

ra nsc e nde nta l Phe no me no lo g ic a l a ppro a c h wa s use d to e xa mine in-de pth pa rtic ipa nts e xpe rie nc e s o f the pro g ra m. T his a ppro a c h is c o nc e rne d with e xplo ring the live d e xpe rie nc e o f phe no me na , “just a s we se e the m a nd a s the y a ppe a r to us in c o nsc io usne ss” (Mo usta ka s, 1994, p. 49).

Pa rtic ipa nt Re c ruitme nt

Co nve nie nt sa mpling wa s use d to ta rg e t ve te ra ns

b e twe e n the a g e s o f 18-40 ye a rs o f a g e who se rve d during OI F , OE F

• r De se rt Sto rm fo r pa rtic ipa tio n in the

pro g ra m.

Pa rtic ipa nts we re re c ruite d thro ug h re fe rra ls fro m the

Bro wa rd Co unty Co mmissio n E lde rly a nd Ve te ra ns Se rvic e s Divisio n, F

• t. L

a ude rda le Ve t Ce nte r, a nd VF W Sto ne o f Ho pe Pro je c t

Pa rtic ipa nts

Sixte e n individua ls we re initia lly re c ruite d fro m lo c a l ve te ra ns’

• rg a niza tio ns fo r pa rtic ipa tio n in the study a nd me t with

c linic ia ns a t NSU to c o mple te a n inta ke a sse ssme nt.

Of the se sixte e n individua ls, six individua ls pa rtic ipa te d in a n

initia l a sse ssme nt, a t le a st nine the ra py se ssio ns, a nd a q ua lita tive inte rvie w a nd we re the re fo re a b le to b e inc lude d in the fina l da ta a na lysis.

Pre / Po st Me a sure s

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)

Cha ng e s I n T ra uma Sympto ms

Ve te ra ns’ T

• ta l Po st tra uma Sympto ms de c re a se d fro m pre to

po st-inte rve ntio n a s me a sure d b y the De ta ile d Asse ssme nt o f Po sttra uma tic Stre ss.

Additio na lly, de c re a se s we re no te d a mo ng the fo llo wing

sympto ms:

Pe rc e ptio ns o f Sub sta nc e Ab use de c re a se d b e twe e n pre a nd po st-

inte rve ntio n.

Sympto ms re la te d to Suic ida lity de c re a se d b e twe e n pre a nd po st

inte rve ntio n.

De c re a se s in sympto ma to lo g y we re a lso e vide nt in the sympto ms

• f re - e xpe rie nc ing tra uma tic e ve nts, hype r-a ro usa l, a nd

disso c ia tio n.

J2

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

Cha ng e in T ra uma Sympto ms

Table 1. Detailed Assessment of Posttraumatic Stress Pretest and Posttest Subscales Descriptive Statistics Pretest Posttest Scale n Mean SD Mean SD DAPS Posttraumatic Stress- Total 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

Cha ng e in Pe rc e ive d L e ve l o f F a mily Co he sio n

Pe rc e ptio ns o f ve te ra ns’

le ve l o f fa mily c o he sio n a s me a sure d b y the F a mily E nviro nme nt Sc a le - Re a l F

• rm, sho we d g re a te r fa mily

c o he sio n fo llo wing the ho listic tre a tme nt inte rve ntio n.

Cha ng e in F a mily Co he sio n Ove r T ime

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

Pe rc e ptio ns o f Qua lity o f L ife

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).

Cha ng e in Qua lity o f L ife Ove r T ime

Table 5. Quality of Life Pretest and Posttest Subscales Descriptive Statistics Pretest Posttest Scale n Mean SD Mean SD Quality of Life Inventory Health 6 0.00 2.45 3.50 2.66 Quality of Life Inventory Self- Esteem 6 3.33 1.63 3.83 2.04

Qua lita tive Re sults

Re sults o f the phe no me no lo g ic a l a na lysis re ve a le d five

• ve ra ll the me s:

a ) the impo rta nc e o f a trusting re la tio nship with the re fe rra l

so urc e a nd/ o r the ra pist;

b ) the a b ility to g a in ne w pe rspe c tive s o r mo re a da ptive

c o ping stra te g ie s;

c ) the impo rta nc e o f ma inta ining a se nse o f stre ng th a nd/ o r

inde pe nde nc e ;

d) diffic ulty with func tio na l re inte g ra tio n to c ivilia n life a nd se lf-

dire c te d ide ntific a tio n a nd a c c e ss o f suppo rt se rvic e s; a nd

e ) diffic ulty with c o mmunic a tio n a nd e mo tio na l e xpre ssio n in

c ivilia n c o nte xts.

I mpo rta nc e o f trusting re la tio nships

One pa rtic ipa nt ha d this to sa y a b o ut the ir re fe rra l so urc e s, “I

liste ne d to pe ople and the y ar e good fr ie nds that’s why I c ame he r e , ‘c ause I r e spe c t the ir

• pinion.”

“F

r

• m my e xpe r

ie nc e , I thought she (the r apist) was gr e at. I know my r

• ommate was doing the same pr
• gr

am with some othe r the r apist and [my r

• ommate ] didn’t like him, so [my r
• ommate ]

c ame to one se ssion and stoppe d.”

“I am not the type of pe r

son that like s to talk about my fe e lings and stuff like that so, but I me an (the the r apist) made it, she made it e asy, pr e tty muc h.” Simila rly, a no the r pa rtic ipa nt re po rte d, “you don’t want no Sigmund F r e ud or some thing digging in your br ain.”

Ga ining ne w pe rspe c tive s a nd c o ping stra te g ie s

Whe n pa rtic ipa nts we re a ske d wha t the y fo und he lpful

within the ho listic tre a tme nt pro g ra m, a ll o f the pa rtic ipa nts indic a te d tha t e ithe r g re a te r unde rsta nding

• f c urre nt pro b le ms a nd/ o r le a rning o f ne w c o ping

stra te g ie s le d to wa rd po sitive g a ins in tre a tme nt.

Ac ro ss pa rtic ipa nts, g a ins we re re po rte d in de a ling with

issue s tha t ra ng e d fro m sub sta nc e a b use , a nxie ty, pa st g uilt, a ng e r ma na g e me nt, a nd diffic ulty with a sse rtive ne ss.

Ga ining ne w pe rspe c tive s a nd c o ping stra te g ie s

“I got a be tte r

unde r standing of what I am going thr

• ugh, what

the pr

• ble m has be e n for

the last e ight ye ar s.” T

his pa rtic ipa nt furthe r e xpla ine d , “I know I ain’t the only pe r

son going thr

• ugh

this by myse lf, it fe lt like that be for e I star te d going to the r apy and stuff, like I was on my own, but I ain’t, it’s just ah, this is the disor de r I have r ight now.”

Ano the r pa rtic ipa nt re po rte d tha t “What has he lpe d the most

is, I think, ide ntifying what my pr

• ble m is and the r

e is ways I c an have my mind c ome out, par t se e ing what is happe ning and how to ove r c ome and c hange it.” Ano the r pa rtic ipa nt

furthe r e xpla ine d tha t thro ug h the ra py the y we re a b le to g a in

“a diffe r e nt point of vie w, I looke d outside of the box about what I think some time s, some time s you say stuff and it’s like he y stop, think about it.”

Ma inta ining a se nse o f stre ng th a nd inde pe nde nc e

Se ve ra l pa rtic ipa nts indic a te d a re luc ta nc e to se e k

he lp, re la ting a stro ng se nse o f inde pe nde nc e a nd se lf- pe rc e ive d a b ility to e ffe c tive ly so lve the ir o wn pro b le ms. T he re wa s a se nse a mo ng pa rtic ipa nts tha t to se e k he lp wo uld c ha ra c te rize the m a s “we ak” a nd thus

it “took a lot of c our age ” fo r ma ny o f the ve te ra ns to

se e k he lp.

One pa rtic ipa nt indic a te d tha t c o ming in fo r

the ra py “took a lot of c our

age” a nd furthe r sta te d

tha t, “I ne ve r

aske d for any he lp” and “I don’t talk to pe ople about the pr

• ble ms I have , so it’s a big

ste p.”

Ma inta ining a se nse o f stre ng th a nd inde pe nde nc e

“At fir

st I was like , oh my God, I am gonna go se e a shr ink, and the n it was like , this is c ool, you just c ome and talk.”

Diffic ulty with re inte g ra tio n into c ivilia n life a nd ide ntific a tio n o f se rvic e s

Diffic ultie s e nc o unte re d during re inte g ra tio n fo llo wing

po st-de plo yme nt va rie d a mo ng pa rtic ipa nts.

One pa rtic ipa nt re la te d pro b le ms susta ining e mplo yme nt

a nd fina nc ia l diffic ultie s sta ting , “I c an’t hold a job... just

c an’t hold ‘e m down, I go thr

• ugh 5, 6, 7 jobs a ye ar

. We ll, I gue ss it’s my attitude . I just don’t like pe ople te lling me what to do.”

“T

he c ommunity’s diffe r e nt pr

• gr

ams and things, I am unawar e , I am totally unawar e of what the y ar e ”

Diffic ulty with c o mmunic a tio n a nd e mo tio na l e xpre ssio n in c ivilia n c o nte xts

Se ve ra l o f the pa rtic ipa nts who c o mple te d the

inte rvie w a lso ide ntifie d diffic ulty with c o mmunic a tio n a nd e mo tio na l e xpre ssio n in c ivilia n c o nte xts fo llo wing the ir re inte g ra tio n into c ivilia n life fo llo wing the ir e xpe rie nc e s in the milita ry.

Diffic ulty with c o mmunic a tio n a nd e mo tio na l e xpre ssio n in c ivilia n c o nte xts

E

xpre ssio ns o f a ng e r we re de sc rib e d a s b e ing e spe c ia lly diffic ult to e xpre ss in a sse rtive wa ys. F

• r e xa mple , o ne

pa rtic ipa nt indic a te d, “I fe e l that whe n I tr

y and talk to pe ople , nor mal, c ivilian pe ople , soc iably, amic ably I don’t ge t anywhe r e . Whe n that aggr e ssive side c ome s out, e ithe r be c ause I str ike fe ar

• r

be c ause the y r e alize I am not me ssing ar

• und that I me an what I say, now things ge t done .

And that is pr e tty muc h be e n a se r ious pr

• ble m with me sinc e

I have got out of the militar y.”

I mplic a tio ns fo r Pra c tic e

T

rusting a nd c o mfo rta b le re la tio nship with re fe rra l so urc e a nd pro vide r-fa c ilita te d a c c e ss to c a re

F

re q ue nt pe rso na l c o mmunic a tio n, fo llo w-up with c lie nts a nd c o o rdina tio n o f c a re

Ne e d fo r imme dia te de live ry o f so me thing “ta ng ib le ” I

nitia l pa pe rwo rk ma y ha ve c o ntrib ute d to a ttritio n

Re spo nde d to struc ture in re fe rring fo r a nc illa ry se rvic e s a nd

in the ra pe utic a ppro a c h

Re c o mme nda tio ns fo r F uture Re se a rc h

Studie s with g re a te r b re a dth o f sc o pe a nd la rg e r sa mple

size s wo uld a llo w fo r the utiliza tio n o f infe re ntia l sta tistic s a nd the inc re a se d a b ility to g e ne ra lize the re sults. F urthe r study o f the individua ls le a ving pro g ra ms pre ma ture ly ne e d to b e c o nduc te d to e nha nc e q ua lity impro ve me nt.

F

uture re se a rc h sho uld e xplo re a lte rna tive me tho ds to re c ruitme nt to ta rg e t re turning se rvic e me n a nd wo me n who ma y no t se e k se rvic e s thro ug h the VA.

Susta ina b ility

Ma nusc ript sub mitte d fo r pub lic a tio n Sub mitte d fo r pre se nta tio n a t the Ame ric a n Psyc ho lo g ic a l

Asso c ia tio n 2012 a nnua l me e ting

Additio na l funding (Unite d Wa y o f Bro wa rd Co unty) Pro g ra m e va lua tio n

• Abramowitz, E. G., Barak, Y., Ben-Avi, I., & Knobler, H. Y. (2008). Hypnotherapy in the treatment of

chronic combat-related PTSD patients suffering from insomnia: A RCT. International Journal of Clinical and Experimental Hypnosis, 56, 270–280.

• Amdur, D., Batres, A., Belisle, J., Brown, J.H., Cornis-Pop, M., Mathewson-Chapman, M., Harms,

G., Hunt, S.C., & Kennedy, P. (2011). VA integrated post-combat care: A systemic approach to caring for returning combat veterans. Social Work in Health Care, 50, 564-575.

• Armed Forces Health Surveillance Center. (2011, September). Associations between Repeated

Deployments to Iraq (OIF/OND) and Afghanistan (OEF) and Post-deployment Illnesses and Injuries, Active Component, U.S. Armed Forces, 2003-2010 Part II. Mental Disorders, by Gender, Age Group, Military Occupation, and “Dwell Times” Prior to Repeat (Second through Fifth) Deployments. Retrieved from http://afhsc.army.mil/viewMSMR?file=2011/v18_n09.pdf#Page=02

• Bleiberg, K. L., & Markowitz, J. C. (2005). A pilot study of interpersonal psychotherapy for

posttraumatic stress disorder. American Journal of Psychiatry, 162, 181–183.

• Cahill, S. P., Rothbaum, B. O., Resick, P. A., & Follette, V

. M. (2008). Cognitive-behavioral therapy for adults. In E. B. Foa, T. M. Keane, M. Terence, M. J. Friedman, & J. A. Cohen, (Eds), Effective treatments for PTSD: Practice guidelines from the International Society for Traumatic Stress Studies (2nd ed., pp. 139–222). New York: Guilford Press. Department

• f Veterans Affairs. (2004, June). Iraq war clinician guide.
• Cardeña, E., Maldonado, J. R., van der Hart, O., & Spiegel, D. (2008). Hypnosis. In E. B. Foa, T. M.

Keane, M. Terence, M. J. Friedman, & J. A. Cohen, (Eds), Effective treatments for PTSD: Practice guidelines from the International Society for Traumatic Stress Studies (2nd ed.,

• pp. 427–457). New York: Guilford Press.

Re fe re nc e s

• Christensen, A., Atkins, D.C., Berns, S., Wheeler, J., Baucom, D.H. & Simpson, L.E. (2004). Taditional versus integrative

behavioral couples therapy for significantly and chronically distressed married couples. Journal of Consulting and Clinical Psychology, 72, 176-191.

• Defense Science Board. (2008, December). Challenges to military operations in support of US interests:2007 summer
• study. Retrieved from http://www.acq.osd.mil/dsb/reports/

ADA495353.pdf

• DOD Task Force on Mental Health. (2007). An achievable vision: Report of the DOD task force on

mental

• health. Falls Church, VA: Defense Health Board
• Edes, T. (2008). Progress in VA home-based primary care. Retrieved from

http://www.cfmc.org/value/files/HBPC%20CMS%201-3-08f36.pdf

• French, L.M. & Parkinson, G.W. (2008). Assessing and treating veterans with traumatic brain injury. Journal of Clinical

Psychology, 64 (8), 1004-1013.

• Graf, N.M., Miller, E., Feist, A., & Freeman, S. (2011). Returning veterans’ adjustment concerns:

family

• views. Journal of Applied Rehabilitation Counseling, 42, 13-23.
• Hicken, B.L. & Plowhead, A. (2010). A model for home-based psychology from the veteran health administration.

Professional Psychology: Research and Practice, 41 (4), 340-346.

• Lester, P., Peterson, K., Reeves, J., Knauss, D.G., Mogil, C., Duan, N.,…Beardslee, W. (2010).

The long war and parental combat deployment: effects on military children and at-home spouses. American Academy of Child & Adolescent Psychiatry, 49, 310-320.

• Linehan, M. (1993). Cognitive-behavioral treatment of borderline personality disorder. New York:

Guilford Press.

• Makin-Bryd, K., Gifford, E., McCutcheon, S., & Glynn, S. (2011). Family and couples treatment for newly returning
• veterans. Professional Psychology: Research and Practice, 42 (1), 47-55.

Re fe re nc e s

• Markowitz, J. C., Milrod, B., Bleiberg, K., & Marshall, R. D. (2009). Interpersonal factors in

understanding and treating

• PTSD. Journal of Psychiatric Practice, 15, 133–140.
• Miller, W.R., & Rollnick, S. (2002). Motivational interviewing: Preparing people for change (2nd

ed.). New York, NY: Guilford.

• Reddy, M.K., Meis, L.A., Erbes, C.R., Polusny, M.A., & Comptom, J.S. (2011). Associations among

experiential avoidance, couple adjustment, and interpersonal aggression in returning Iraqi war veterans and their partners. Journal of Consulting and Clinical Psychology, 79 (4), 515-520.

• Rizzo, A., Reger, G., Gahm, G., Difede, J., & Rothbaum, B. O. (2009). Virtual reality exposure

therapy for combat-related

• PTSD. In P. J. Shiromani et al.’s (Eds), post-traumatic stress

disorder: Basic science and clinical practice. New York: Humana Press.

• Sautter, F.J., Armelie, A.P., Glynn, S.M., and Wielt, D.B. (2011). The development of a couple-

based treatment for PTSD in returning veterans. Professional Psychology: Research and Practice, 42 (1), 63-69.

• Schnurr, P. P., Friedman, M. J., Foy, D. W., Shea, M. T., Hsieh, F. Y., Lavori, P. W., & Bernardy, N. C.

(2003). Randomized trial of trauma focused group therapy for PTSD: Results from a Veterans Affairs Cooperative Study. Archives of General Psychiatry, 60, 481– 489.

• Sharpless, B.A. & Barber, J.P. (2011). A clinician’s guide to PTSD treatments for returning
• veterans. Professional

Psychology: Research and Practice, 42 (1), 8-15.

• Sher, L. & Yehuda, R. (2011). Preventing suicide among returning combat veterans: A moral
• perspective. Military

Medicine, 176 (6), 601-602.

• Skidmore, W.C., & Roy, M. (2011). Practical considerations for addressing substance use

disorders in veterans and service members. Social Work in Health Care, 50, 85-107.

Re fe re nc e s

Re fe re nc e s

• Stahre, M.A., Brewer, R.D., Fonseca, V

.P., & Naimi, T.S. (2009). Binge drinking among US active- duty military personnel. American Journal of Preventive Medicine, 36, 208–217.

• Tanielian, T. & Jaycox, L.H. (2008). Invisible wounds of war: Psychological and cognitive

injuries, their consequences and services to assist recovery. Arlington, VA: RAND Corporation

• Walker, R.L., Clark, M.E., & Sanders, S.H. (2010). The “postdeployment multi-symptom

disorder”: an emerging syndrome in need of a new treatment paradigm. Psychological Services, 7, 136-147.

• Wolfe, J.W

., Keane, T.M., & Young, B.L. (1996). From soldier to civilian: Acute adjustment patterns

• f returned Persian Gulf veterans. In R.J. Ursano & A.E. Norwood

(Eds.), Emotional aftermath of the Persian Gulf War: Veterans, families, communities, and nations (pp. 477-499). Washington, DC: American Psychiatric Press.