Community-based laboratories for postdeployment adjustment: A model
By Richard G. Tedeschi and Bret A. Moore, PsyD
Over 14 years of war in Iraq and Afghanistan highlight how harsh combat, environmental conditions and extended separation from loved ones affect the psychological well-being of military personnel and their family members. Although estimates vary, it is generally accepted that up to one-third of Iraq and Afghanistan veterans battle some form of psychological ailment as a result of their service (Hoge, Auchterlonie, & Milliken, 2006 ; Hoge et al., 2004), which translates to roughly 700,000 men and women. More specifically, estimates of post-traumatic stress disorder (PTSD) alone are in the area of 15 percent (Hoge, Terhakopian, Castro, Messer, & Engel, 2007; Tanielian & Jaycox, 2008).
A secondary issue associated with the increase in mental health needs of our veterans is the demand placed on the military and Department of Veterans Affairs (VA) health care systems. Over the past several years, governmental and private organizations issued critical reports on both systems regarding their ability to meet the ever-increasing needs of current and past members of the military. Consequently, there is a greater focus on achieving a better understanding of the difficulties faced by combat veterans and developing more effective approaches to these problems (GAO, 2014).
An additional outcome associated with these concerns, as well as a societal desire to support those who have served their country, is the proliferation of grassroots civilian programs. To date, there are approximately 46,000 veteran-focused organizations in existence that support the variety of needs of veterans and their families (Armstrong, McDonough, & Savage, 2015). Many of these organizations utilize a variety of complementary and alternative treatments such as mindfulness, recreation, art and equine therapies as a means of filling in the gaps within traditional governmental behavioral health care programs. These grassroots civilian programs are often found within local communities and are funded almost exclusively by private citizens, foundations and corporations.
There are several major benefits associated with community-based, nontraditional, grassroots programs. First, these programs have more flexibility with regard to exploring alternative treatment options as opposed to adhering to a relatively rigid menu of manualized treatments. This is by no means an attempt to minimize the importance of evidence-based psychosocial and pharmacological interventions, but rather highlight the idea that many service members and veterans may prefer different treatment options for various reasons (Kearney & Simpson, 2015 ; Steenkamp, Litz, Hoge, & Marmar, 2015). Second, community-based programs can act as “laboratories” or pilot programs, which can be scaled up (or back) as required. And lastly, the grassroots nature of these organizations affords greater opportunity for veterans and their family members, nongovernmental affiliated clinicians and community leaders to bring unique perspectives and renewed passion into the topic of serving the mental health needs of veterans and their families.
However, limitations to this model do exist. As with many nonprofit, community-based organizations, finding funding sources is often a challenge, particularly for those who are unfamiliar with the grant writing process. With little notice, even once-thriving programs can decompose rapidly when funding streams disappear. Also, and inextricably tied to the above-mentioned limitation, is often a paucity of program evaluation and outcome research expertise that is crucial for making the case to the community and donors regarding program success. In an age of tough economic times and skepticism about novel grassroots programs with little scientific support available, well-developed, executed, and articulated outcomes are a necessity.
In this article, we offer the example of Boulder Crest Retreat for Military and Veteran Wellness (BCR), a community-based, nonprofit, private organization in Bluemont, Virginia, as a program that demonstrates many of the strengths of grassroots programs. Although there are many programs in existence that offer critical services to the active duty and veteran populations, we have found BCR to be unique in the level of comprehensive care it provides. We are also impressed with the potential the program has to become a model for establishing and developing effective grassroots, community-based programs for veterans and family members; an approach that is designed to fill the gap in health care services between the Departments of Defense and Veterans Affairs that many veterans experience.
A Model for a Community-Based Program
Veterans in Leadership and Staff Positions
Although we are unaware of any empirical data to support this notion, it appears that many organizations that serve veterans are founded by veterans or their family members. Dedication to this cause is important because developing and sustaining an effective organization is a daunting task. In the case of BCR, the founder, a retired U.S. Navy Master Chief Petty Officer, donated the first million dollars and 37 acres of his family's 200-acre estate on which he lives in the foothills of the Blue Ridge Mountains to create the campus of the retreat center. He also had the leadership and organizational capabilities honed during his time in the military and as a business owner to create the retreat center and attract initial funding. There is much that could be said about his ability to envision what this retreat center is becoming and to attract the right people to help him.
The right people at the core of his staff are veterans themselves, along with professionals who clearly understand and believe in the vision and the mission of BCR. All staff are seen as providing services of healing and restoration in their personal interaction with veterans, whether it be while preparing food, working on the grounds or engaging in administrative support. Having veterans as the core of the staff is important for the program to have credibility for participants and to maintain a perspective on what is going to make sense and work for veterans as it undergoes further development. Unlike many clinic-based programs run by mental health professionals, at BCR, there is little sense of separateness between program participants and staff. It is an environment that is often characterized by participants as “being home and surrounded by loved ones.”
An Environment Conducive to Its Methods and Goals
The methodology of the program at BCR is generally meditative, and the activities, environment and interactions with the staff are designed to enhance the reflective focus of the program. For veterans and family members under stress, this peaceful experience allows for greater interpersonal connection, emotional focus and personal discovery. The rural setting is enhanced with the physical structures built of timbers and logs, with warm wood interiors and beautiful views. This physical environment gives a message that participants are going to be cared for and are valued, so the accommodations are part of the process.
In addition, the staff spends virtually all the program time with participants, eating meals together and engaging in the various outdoor activities. The dress is casual, and the interactions are informal. The entire day and evening provides an opportunity for contact and conversation, and this allows participants to settle in to an emotionally safe physical and social environment. In reality, therapy occurs around the clock as opposed to the traditional time limitations of 45 to 50 minutes found within traditional behavioral health facilities.
Short-Term, Intensive Experiences With Follow-Up
The programs at BCR take place over several days and are residential. Because there is much time spent together with other participants and staff, participants are involved in many hours of the program experience that may be comparable to many months of traditional therapeutic interventions. But the difference between this type of program and traditional behavioral health interventions is also qualitative. Although BCR includes in some of their programs therapeutic elements such as interpersonal skill building and cognitive change interventions, overall its approach is based on creating a milieu that emphasizes normalization, mutual support and living skills. Instead of focusing exclusively on the reduction of symptoms, the approach of BCR is one of growth and learning to live a better and more fulfilling life.
One of the biggest challenges to a program like this is extending this experience beyond the time and place of the retreat. There are two approaches to this challenge that are in development at BCR. One is partnering with other organizations that serve veterans back in their hometowns. It is important that these partnerships provide an extension of the basic philosophy of the BCR experience into interactions with organizations that provide support when the veterans and family members return home.
A second approach is technologically based and allows a continued connection via the internet. Through peer and professional support, BCR participants will be able to connect with others who can provide assistance with a variety of issues such as accessing care, transition from military to civilian life and life coaching.
A Growth-Focused Philosophy With a Variety of Specific Programs
Given that there are veterans and families whose needs vary, there needs to be a variety of programs under the overall philosophical umbrella of the organization. Currently, BCR has programs that focus on male and female veterans, military and veteran transitions, veterans' families and mentorships that link older and younger veterans. These programs share a small group approach and a philosophy that veterans have valuable capabilities that are honed in their military experiences and that mutual support emphasizes these capabilities. This philosophy runs counter to a general societal assumption that people who are wounded are broken and instead emphasizes the strengths that can come from stressful and traumatic events if these experiences are treated as catalysts for growth (Tedeschi, 2013).
Using a model that incorporates post-traumatic growth as an assumption rather than a focus on disorder or pathology, participants immediately find themselves treated with respect and encouragement. Veterans themselves tend to value their overall military experience, if not particular traumas. For example, data from Vietnam veterans show that 70 percent reported a mainly positive impact from their military experience (Dohrenwend et al., 2004), and combat exposure was related to greater life satisfaction (Vogt, King, King, Savarese, & Suvak, 2004). Aligning the philosophy of the program with these realities of veterans, creates a sense of being in a place where military experiences are understood. At the same time, it is recognized that participants are coming to the program because there are aspects of these experiences that are traumatizing, and the negative aspects of military service coexist with the positive.
The most important positive aspect of military experience that is recreated in the way the BCR programs are designed is small-unit camaraderie. Intensive, shared experience in the program over several days reminds participants of what has been most valuable in their service, the formation of supportive relationships. Participants also find that they are partners in the process of healing each other. The program encourages this kind of support, rather than implying that the most important aspects of the program are what the staff has to offer. Some veterans who need services have not been able to maintain close contact with their units for various reasons, and the design of a program that recreates that connection is healing in itself.
It is obvious how different a program model this is compared to traditional therapies where veterans come to a clinic individually to receive medication or therapy from a professional. Although these traditional models can be useful and have some positive effects, they do not make use of some of the most powerful aspects of veterans' experiences: being understood by others with similar experiences, an emphasis on the value of military experiences and the sense of personal value and meaning that comes from helping others. BCR participants are truly viewed as individuals who have much to offer each other and the larger society because of their military and combat experiences.
Matching Participants to Programming
We do know that one size does not fit all. Understanding who can benefit most from the programming available is important in making sure that the participants who attend will benefit from their experience. Staff members need to understand for whom the programs are designed and built and not assume their methodology will suit every veteran. For example, BCR does not accept participants who are active substance abusers as the facility and staff is not able to manage possible withdrawal reactions, and useful participation is not possible while intoxicated. In the variety of programs offered, there is a process of screening and preparation, with BCR staff starting the development of a supportive relationship before veterans are accepted for participation.
Balancing Innovation and Empirically Based Approaches to Intervention
While BCR is not a treatment center or clinic, it shares goals of traditional clinical treatment centers, of enhancing the functioning of veterans and families in their communities. Being privately funded and using small group programming, BCR acts as a laboratory for exploring the effectiveness of alternative approaches to helping veterans and families achieve post-traumatic growth. Although there is a variety of activities involved in the programming, all have a common element of meditative, reflective experience that they share. Walking a labyrinth, yoga, kayaking, and archery, working with horses and similar activities, help to reduce anxiety and encourage a more mindful self-awareness that helps in allowing participants to consider their emotional wounds and to create a positive idea for their future selves.
Traditional therapies are not offered in these short-term programs, but elements of empirically based therapies are introduced and integrated throughout the activities of the programs. Cognitive-behavioral approaches are represented in how veterans are encouraged to think about themselves and their experiences; relaxation and meditative techniques are emphasized in many activities. Group psychoeducational sessions introduce participants to more accurate ways to understand symptoms, family dynamics, communications and practical living skills.
Evaluation of Outcomes
Because of the integrative nature of this program, it is difficult to determine which elements of programs are responsible for gains. Dismantling procedures could be used to understand which elements operate to produce positive outcomes, but that strategy is hard for programs designed primarily to serve. Good program evaluation is a challenge for community-based programs that have staff that are not necessarily trained in research methodology. Therefore, it is important that community-based programs link with resources that can help them establish an ongoing evaluation process if they are to be credible laboratories for innovation.
Most community programs have access to local colleges and universities that may be able to help with evaluation and making sure there is clear ongoing investment and, in this process, may involve an ability to fund grants and contracts specifically for this purpose. However, there may be routine measurements that can be incorporated into the programming so that at least some data exist that can be utilized to determine overall effectiveness, if not an in-depth understanding of how program components are working. Well-validated measures of symptoms related to PTSD are obvious choices. BCR uses such measures in tracking their participants over time and plans to continue this process to understand the long-term trajectories of veterans who have attended their programs. BCR utilizes the PTSD Checklist-Military version, The World Health Organization Disability Assessment Schedule, The World Health Organization Quality of Life Instrument and The Beck Depression Inventory Version 2. However, attention should also be paid to other outcomes beside symptom reduction.
In programs such as those at BCR, the philosophy and emphasis are on strength and growth; the development of meaningful living, enhanced relationships; and other outcomes that involve the presence of positive aspects of living rather than the absence of negative experiences such as symptoms of post-traumatic stress. Therefore, adding measures of post-traumatic growth, resilience and meaning may demonstrate more clearly the strength of programs that have these concepts as a foundation for their design. BCR is currently in the process of designing a comprehensive program evaluation that measures the concept and process of post-traumatic growth, quality of life and clinical symptoms over an 18-month period.
Despite the fact that BCR has served over 2,000 veterans and family members in just over two years, it is obviously limited in the degree to which it can serve the needs of the larger veteran community. Therefore, the stated vision of BCR is to replicate this approach around the nation, establishing similar retreat centers in locations that have large veteran populations. The practical challenges of such an undertaking are obvious. A less obvious challenge is to preserve the nature of an intimate healing experience for program participants within a large organization. Maintaining a multisite organization's philosophy and programming requires consistency and clarity that only comes from collaboration with experts in curriculum development and program evaluation.
As the need for effective behavioral health care for our veterans and military personnel and their families continues to grow, community based, grassroots organizations like BCR will play an integral role in healing the men and women who have sacrificed so much for our country. Few people who are familiar with the military and VA health care systems believe that these institutions alone can address the myriad needs of those they serve. Civilian organizations that have the flexibility, passion and innovative spirit to champion programs that provide an alternative to traditional behavioral health care will fill these gaps.
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For further information, please contact Richard G. Tedeschi.