A need for greater understanding and support
In recent years, increasing attention has focused on the experiences and well-being of U.S. military service members who have deployed since 2001 in support of wars in Afghanistan and Iraq. Compared to previous war eras, these service members were more likely to experience multiple deployments, longer deployments, exposure to potentially traumatic events and conditions, and shorter times at home.
In addition, a larger number of women and National Guard and reserve forces were deployed. All of these factors have repercussions for those who served as well as for their families and their communities. Indeed, the process of reintegration (transitioning back into personal and organizational roles after deployment) has proved challenging for some, and our understanding regarding effective reintegration is incomplete despite a strong national emphasis on the topic.
In 2017, in response to concerns about veteran reintegration, we partnered with guest editors to develop a special issue on veteran reintegration in the American Journal of Orthopsychiatry. Abstracts from the special issue are included in our research highlights below and the introductory editorial is open access.
Listen to this podcast episode with one of the authors from the 2017 AJO special issue, Dr. Joan Griffin, in which she describes the unique challenges facing caregivers of veterans with traumatic brain injury and polytrauma and proposes a model for predicting mental health outcomes in this population.
Recommendations for the Biden/Harris Administration
Read our policy recommendations submitted to the new administration in January 2021.
What can you do?
- Send a letter to a veteran through Operation Gratitude.
- Learn more about PTSD and other trauma-related conditions and consider sponsoring a companion dog for a veteran with PTSD.
- Volunteer at veteran-serving organizations in your community or through an organization such as the National Coalition for Homeless Veterans.
- Provide informal support to individuals and families in your neighborhood and broader community with military ties.
- Help a veteran tell their story through a project such as the Veteran’s History Project. You can download a VHP field kit from the Library of Congress website.
Research on Veterans in AJO
Homelessness is a major public health problem, and serious mental illness (SMI) is highly prevalent in the homeless population. Although supported housing services—which provide permanent housing in the community along with case management—improve housing outcomes, community integration typically remains poor, and little is known about the underlying determinants of poor community integration postresidential placement. The general SMI literature has indicated that motivational and cognitive ability factors are key determinants of successful community integration, which provides a foundation for examining this issue. This study evaluated whether interview- and performance-based assessments of motivation, nonsocial and social–cognitive ability, and psychiatric symptoms were associated with community integration indices in 2 samples of homeless veterans either with (N = 96) or without (N = 80) a psychotic disorder who had recently been admitted to a supported housing program but who had not yet attained housing. Motivation indices, including experiential negative symptoms and defeatist performance attitudes, stood out as the most robust correlates (rs = −.30 to −.69) of community integration across both samples, particularly for social role participation. Demographics, general psychiatric symptoms, and nonsocial cognition showed generally weak relations with community integration, though social cognition showed a few relations. The consistent findings across samples point to the importance of motivational factors for understanding the determinants of poor community integration in this complex population. Further, interventions that target motivational challenges may have widespread usefulness for enhancing community integration outcomes beyond obtaining housing.
Horan, W. P., Wynn, J. K., Gabrielian, S., Glynn, S. M., Hellemann, G. S., Kern, R. S., Lee, J., Marder, S. R., Sugar, C. A., & Green, M. F. (2020). Motivational and cognitive correlates of community integration in homeless veterans entering a permanent supported housing program. American Journal of Orthopsychiatry, 90(2), 181–192.
To address homelessness among Veterans, a growing proportion of permanent supportive housing units supported by the U.S. Departments of Housing and Urban Development and Veterans Affairs Supportive Housing (HUD-VASH) program are allocated to programs where multiple Veterans with a history of homelessness live in a particular building, referred to as single-site housing. This mixed-methods study—including administrative data from Veterans who moved into HUD-VASH housing and qualitative data from focus groups with services providers at 10 single-site programs—describes the characteristics and needs of Veterans who moved into single-site HUD-VASH programs, the rationale for developing single-site HUD-VASH programs, and the services provided in single-site programs that are responsive to Veterans’ needs. Based on quantitative analyses, Veterans who were older and had chronic medical and mental health conditions and sought related care were at increased odds of receiving single-site housing. Qualitatively, we found that HUD-VASH programs developed single-site programs for two reasons: to ensure that the most vulnerable Veterans remained housed through the provision of supportive services and to increase housing options for hard-to-house Veterans, including those who require more support because of medical, mental health, or substance use disorders; physical disabilities; or lack of ability to live independently for other reasons. Due to the high needs of Veterans served by single-site programs, development of these programs should consider both space and staffing needs. Future research should assess the relationship between assignment to housing type and health and housing outcomes for participants as well as service enhancements to address Veterans’ needs.
Montgomery, A. E., Szymkowiak, D., Cusack, M. C., Austin, E. L., Vazzano, J. K., Kertesz, S. G., & Gabrielian, S. (2020). Veterans’ assignment to single-site versus scattered-site permanent supportive housing. American Journal of Orthopsychiatry, 90(1), 37–47.
Women veterans in the United States face a disproportionate risk of housing instability (HI) and interpersonal violence (IV), largely perpetrated by intimate partners or involving nonpartner sexual violence, compared to both male veterans and nonveteran women. To explore the ways in which IV and HI intersect in the experiences of women veterans, we analyzed transcripts of in-depth qualitative interviews with 20 women veterans who had screened positive for HI at a Veterans Affairs Medical Center. Three broad themes emerged related to the intersection of IV (specifically intimate partner violence or nonpartner sexual violence) and HI among women veterans: (1) HI can be precipitated by and increase vulnerability to IV, (2) experiences of IV impact women’s definitions of housing safety and security, and (3) IV can pose a barrier to accessing housing services and other support systems. Findings indicate areas for improvement to screening processes and service provision to more effectively address the co-occurring and interacting safety and housing needs of women veterans.
Yu, B., Montgomery, A. E., True, G., Cusack, M., Sorrentino, A., Chhabra, M., & Dichter, M. E. (2020). The intersection of interpersonal violence and housing instability: Perspectives from women veterans. American Journal of Orthopsychiatry, 90(1), 63–69.
Few interventions train homeless consumers in housing-related independent living skills. To inform the development of such interventions for the Department of Veterans Affairs’ Supported Housing consumers with serious mental illness, we examined these consumers’ problem-solving skills and deficits. We performed semistructured interviews and cognitive tests with 20 consumers who retained housing for ≥1 year (“stayers”) and 20 consumers who lost housing in <1 year (“exiters”). Salient types of problems were identified in the qualitative data; we categorized problem-solving approaches by complexity level and identified differences in problem-solving complexity by consumers’ housing outcomes. Instrumental (e.g., money management), interpersonal, and health-related problems were prominent in consumers’ narratives. Cognition was poor among stayers and exiters. Problem-solving approaches were highly relevant to day-to-day functioning in supported housing. There was a trend toward greater problem-solving complexity in stayers versus exiters. These data explore potential challenges faced in supported housing and help inform the development of a Veterans Affairs-based housing-focused skills training intervention.
Gabrielian, S., Bromley, E., Hamilton, A. B., Vu, V. T., Alexandrino, A., Jr., Koosis, E., & Young, A. S. (2019). Problem solving skills and deficits among homeless veterans with serious mental illness. American Journal of Orthopsychiatry, 89(2), 287–295.
Subsequent to the wars in Afghanistan and Iraq, the experiences of military service members (MSVMs) and veterans have garnered increasing attention. A growing body of work has begun to shed light on their reintegration, a process that can bring with it transitions and challenges for service members and their families. Although many families adapt effectively, some have difficulty navigating this process, which can lead to a host of short- and long-term negative consequences for families. The literature to date is not well-developed regarding strategies for supporting successful reintegration of MSVMs and veterans in the context of military families. Guided by the ecological framework, this article summarizes selected evidence regarding factors that influence reintegration and puts forth recommendations for research and practice to promote the wellness of military families. Informed by findings regarding the diverse challenges faced by these families and grounded in the ecological framework, the authors highlight the need to assess both proximal and distal factors related to families’ reintegration experiences and the need to intervene at multiple levels and across multiple contexts. Of primary importance, the authors recommend strategies to enhance the capacity of families’ natural settings and describe selected capacity- and resource- enhancement approaches for families, neighborhoods, schools, and communities that facilitate resilience and promote wellness. Other recommendations include focusing on the accessibility, integration, and coordination of services; considering the long-view and developing strategies for longer-term support; developing mechanisms for family support; and evaluating efforts to address needs of families and promote family resilience.
Gil-Rivas, V., Kilmer, R. P., Larson, J. C., & Armstrong, L. M. (2017). Facilitating successful reintegration: Attending to the needs of military families. American Journal of Orthopsychiatry, 87(2), 176-184.
Many returning OIF/OEF/OND Veterans are seeking higher education in an effort to develop a meaningful career and financial stability. Evidence suggests that student service members/veterans (SSM/Vs) are experiencing less academic success than other students. The purpose of this review is to identify the unique challenges of SSM/Vs and evaluate current campus efforts to facilitate their retention and academic performance. With a focus on SSM/Vs attending colleges and universities, we obtained 57 peer-reviewed and 73 gray literature records published between 2001 and 2015. The current SSM/V literature contains an abundance of gray literature, and the empirical research tends to be limited by cross-sectional design and small sample sizes. SSM/Vs encounter significant personal and environmental challenges when transitioning from the military to college campuses. A variety of services have been developed to address the needs of the SSM/V population, but the efficacy of these services remains largely unknown. In conclusion, there is a clear need to provide education to faculty, students, and staff regarding the experiences of SSM/Vs. Efforts to enhance screening for, availability of, and SSM/V engagement in mental health services would also be beneficial, as would improved availability of and SSM/V access to academic support. All future programs designed to address the unique challenges of SSM/Vs in the academic environment should also be systematically implemented and evaluated.
Borsari, B., Yurasek, A., Miller, M. B., Murphy, J. G., McDevitt-Murphy, M. E., Martens, M. P., . . . Carey, K. B. (2017). Student service members/veterans on campus: Challenges for reintegration. American Journal of Orthopsychiatry, 87(2), 166-175.
As service members return from active duty and, in some cases, exit the military, they face a process of reintegration (also referred to as community reintegration) as they seek to resume participation in their life roles as civilians. Facilitating this dynamic process of reintegration for service members, veterans, and their families—including outlining potential strategies for supporting this return to civilian life and its demands, roles, and responsibilities—is the focus of this Special Issue. Reintegration has been framed as a national priority (U.S. Department of Veterans Affairs, 2015) and has been a point of emphasis of efforts at federal, state, and local levels. As the articles in this issue suggest, multiple public, private, and voluntary systems and the communities to which service members, veterans, and their families return can help influence their health outcomes and, ultimately, their reintegration.
Elnitsky, C. A., & Kilmer, R. P. (2017). Facilitating reintegration for military service personnel, veterans, and their families: An introduction to the special issue. American Journal of Orthopsychiatry, 87(2), 109-113.
Returning military service members and veterans (MSMVs) experience a wide range of stress-related disorders in addition to social and occupational difficulties when reintegrating to the community. Facilitating reintegration of MSMVs following deployment is a societal priority. With an objective of identifying challenges and facilitators for reintegration of MSMVs of the current war era, we critically review and identify gaps in the literature. We searched 8 electronic databases and identified 1,764 articles. Screening of abstracts and full-text review based on our inclusion/exclusion criteria, yielded 186 articles for review. Two investigators evaluating relevant articles independently found a lack of clear definition or comprehensive theorizing about MSMV reintegration. To address these gaps, we linked the findings from the literature to provide a unified definition of reintegration and adapted the social ecological systems theory to guide research and practice aimed at MSMV reintegration. Furthermore, we identified individual, interpersonal, community, and societal challenges related to reintegration. The 186 studies published from 2001 (the start of the current war era) to 2015 included 6 experimental studies or clinical trials. Most studies do not adequately account for context or more than a narrow set of potential influences on MSMV reintegration. Little evidence was found that evaluated interventions for health conditions, rehabilitation, and employment, or effective models of integrated delivery systems. We recommend an ecological model of MSMV reintegration to advance research and practice processes and outcomes at 4 levels (individual, interpersonal, organizational, and societal).
Elnitsky, C. A., Blevins, C. L., Fisher, M. P., & Magruder, K. (2017). Military service member and veteran reintegration: A critical review and adapted ecological model. American Journal of Orthopsychiatry, 87(2), 114–128
For veterans separated from the military as a result of acquired mild traumatic brain injury (mTBI), the transition from a military identity to a civilian one is complicated by health, cognitive, and psychosocial factors. We conducted in-depth interviews with 8 veterans with mTBI to understand how they perceived the experience of departure from the military, rehabilitation services provided at a Department of Veterans Affairs (VA) Polytrauma Network Site, and reentry into civilian life. Two distinct patterns of thinking about community reintegration emerged. The first pattern was characterized by the perception of a need to fade one’s military identity. The second pattern, conversely, advanced the perception of a need to maintain the integrity of one’s military identity though living in a civilian world. These perceptions may be linked to individuals’ roles while in the military and whether violent acts were committed in carrying out the mission of service, acts not consonant with positive self-appraisal in the civilian world. The crisis of unplanned, involuntary separation from the military was universally perceived as a crisis equal to that of the precipitating injury itself. The perception that civilians lacked understanding of veterans’ military past and their current transition set up expectations for interactions with health care providers, as well as greatly impacting relationships with friend and family. Our veterans’ shared perceptions support existing mandates for greater dissemination of military culture training to health care providers serving veterans both at VA and military facilities as well as in the civilian community at large.
Perspectives of veterans with mild traumatic brain injury on community reintegration: Making Libin, A. V., Schladen, M. M., Danford, E., Cichon, S., Bruner, D., Scholten, J., Llorente, M., Zapata, S., Dromerick, A. W., Blackman, M. R., & Magruder, K. M. (2017). Perspectives of veterans with mild traumatic brain injury on community reintegration: Making sense of unplanned separation from service. American Journal of Orthopsychiatry, 87(2), 129–138.
Veterans who survive multiple traumatic injuries, including traumatic brain injuries (TBI), must often rely on family caregivers for ongoing care and support with reintegration. Understanding factors associated with caregiving that help or harm caregivers’ health is critical for identifying appropriate and effective interventions that support caregiver health and promote the provision of quality care to veterans. This study utilized cross-sectional data from the Family and Caregiver Experiences Study, a survey of 564 caregivers caring for veterans who served after September 11, 2001, survived TBI/polytrauma during service, and received inpatient rehabilitation care in a Veterans Affairs Polytrauma Rehabilitation Center. Structural equation modeling was used to examine the relationship between caregiver stress (i.e., veterans’ neurobehavioral problems and intensity of care required), and caregiver well-being (i.e., caregiver burden and mental health). Analyses also examined how intrapersonal, family or social, and financial resources mediate and moderate the relationship between caregiver stress and well-being. Results indicate that veterans’ neurobehavioral problems and intensity of required care were associated with more caregiver burden, and more burden was associated with poor mental health. Intrapersonal and family or social resources mediated the relationship between veteran functioning and mental health. Family or social resources also moderated the relationship between care intensity and burden. The model explained a moderate amount of variability in burden (59%) and a substantial amount in mental health (75%). We conclude that caregivers of veterans with neurobehavioral problems who require intense care are at risk for burden and poor mental health. Increasing resources to bolster family or social resources may reduce risks.
Griffin, J. M., Lee, M. K., Bangerter, L. R., Van Houtven, C. H., Friedemann-Sánchez, G., Phelan, S. M., Carlson, K. F., & Meis, L. A. (2017). Burden and mental health among caregivers of veterans with traumatic brain injury/polytrauma. American Journal of Orthopsychiatry, 87(2), 139–148.
Veterans with family support have better functional recovery and reintegration outcomes. However, families’ ability to support the veteran with PTSD’s rehabilitation and reintegration oftentimes is hindered by interpersonal challenges. We report findings of a qualitative study that examined OEF/OIF veterans with PTSD/TBI and their significant others’ (SOs’) perceptions of family functioning. We conducted 24 in-depth interviews with 12 veteran/SO dyads using an adapted version of the Family Assessment Device Structured Interview. Descriptive qualitative analytic methods were used to analyze the data. Data show that the impact of deployment and the resulting changes in the individuals and the family dynamics lingered years after the veterans returned home and had a lasting influence on veterans’ and SOs’ perceptions of family functioning. Most couples acknowledged growth in their relationships several years postdeployment. However, many continued to struggle with disruptions generated by deployment. Four themes emerged from the data: individual changes, coping strategies, relationship changes, and a “new normal.” Postdeployment family functioning was influenced by a dynamic interplay of individual and relationship factors and the development of coping strategies and a new normal. This study contributes to the understanding of the prolonged postdeployment family reintegration experiences of veterans and their SOs. Findings underscore the importance of continuing to advance the current knowledge base about the long-term impact of deployment on veterans and their families, especially factors that contribute to positive postdeployment family functioning. Additional empirical studies are needed to provide more in-depth understanding of the long-term postdeployment reintegration experiences of veterans and their families.
Freytes, I. M., LeLaurin, J. H., Zickmund, S. L., Resende, R. D., & Uphold, C. R. (2017). Exploring the post-deployment reintegration experiences of veterans with PTSD and their significant others. American Journal of Orthopsychiatry, 87(2), 149–156.
Military service members have an increased risk of developing mental health (MH) problems following deployment to Iraq or Afghanistan, yet only a small percentage seek mental health treatment. The aim of the present study was to explore patterns of MH service utilization within the first 12 months following return from combat deployment. Participants were 169 service members who had returned from war-zone deployment in either Iraq or Afghanistan and had assessments covering a 12-month period following their homecoming. The authors first examined the prevalence of mental health diagnoses and engagement with mental health treatment (e.g., visits to the emergency room, inpatient hospitalization, individual therapy, group therapy, family or couple therapy, medication appointments, and self-help). Regression analyses explored whether distress, functioning, diagnoses, or social support predicted treatment use. Findings indicated that 28 of 50 military service members (56%) who met diagnostic criteria for a mental health disorder accessed services in the year following their return from deployment. Individual treatment was the most common modality, and those with major depressive disorder (MDD) reported the most treatment contacts. Social support was not associated with use of mental health services. Baseline functioning and psychiatric distress predicted entry into treatment whereas only psychiatric distress predicted amount of mental health service use in the 12-month postdeployment period. Findings highlight the need for enhanced strategies to link those reporting psychiatric distress with MH treatment services and increase community connectedness regardless of whether they meet full criteria for a mental health diagnosis
Primack, J. M., Borsari, B., Benz, M. B., Reddy, M. K., & Shea, M. T. (2017). Mental health treatment utilization in OIF/OEF National Guard and Reserve troops with and without DSM diagnoses. American Journal of Orthopsychiatry, 87(2), 157–165.
Military deployment of a parent is a risk factor for children’s internalizing and externalizing problems. This risk may be heightened in National Guard and Reserve (NG/R) families who tend to be isolated from other NG/R families and do not benefit from the centralized support system available to active duty families living on military bases. Isolation and trauma-related disorders may complicate the adjustment of military families during reintegration. An evidence-based parent training intervention was modified to meet the unique needs of recently deployed NG/R parents and their spouses, and the modified program was evaluated in a randomized controlled trial. The current study examines engagement and satisfaction with the program. Modifications such as employment of military-connected facilitators sought to maximize engagement in and satisfaction with the program. Engagement and satisfaction were examined between mothers and fathers, as well as between groups led by a military-connected facilitator and those led by civilian facilitators. Significantly greater engagement was noted for groups that were led by a military-connected facilitator (p = .01). There were no differences between genders in attendance rates, though greater positive group experiences were reported by mothers versus fathers (p = .01). Results are discussed in the context of engagement and satisfaction reported for similar programs. Implications for working with military families are also considered.
Pinna, K. L. M., Hanson, S., Zhang, N., & Gewirtz, A. H. (2017). Fostering resilience in National Guard and Reserve families: A contextual adaptation of an evidence-based parenting program. American Journal of Orthopsychiatry, 87(2), 185–193.