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Co-Occurring Disorders in Veterans and Military Service Members

Treatment Models for Veterans and Service Members with Co-Occurring Disorders

Treatment models for veterans and service members have focused almost exclusively on co-occurring PTSD and substance use disorders. Examples of models below that show promising results for:

Examples of Peer-based Models are also included.

Post-traumatic stress disorder

Post-traumatic stress disorder, or PTSD, is an anxiety disorder that may occur following a traumatic event. Only some of the people who experience a traumatic event will develop PTSD, although many may experience some of the symptoms. Several treatments have been found to be effective for PTSD among veterans.

Prolonged exposure therapy for PTSD is a cognitive behavioral treatment program that focuses on thoughts, feelings, and situations related to the traumatic event. Prolonged exposure has four components:

  • Education about the nature of trauma and trauma reactions
  • Training in controlled breathing
  • Repeated discussion and talking over of the traumatic event
  • Exposure practice in situations that are safe but the individual has been avoiding as a result of the traumatic event

Most people who receive prolonged exposure therapy attend between eight and fifteen session of 90 minutes. In a multisite randomized controlled trial of prolonged exposure with female veterans and active-duty personnel with PTSD, those who received prolonged exposure experienced a greater reduction in symptoms than women who received a present-focused therapy.

Cognitive Processing Therapy is a cognitive behavioral treatment for PTSD that targets the coping strategies people develop in response to a traumatic experience but can extend the symptoms and related problems. It helps individuals identify and question stuck points and problematic thinking as well as associated problems such as guilt and anger.

Cognitive processing therapy has been found to be effective for people with PTSD as a result of sexual assault, physical assault, and combat. The therapy includes a psychoeducation component about PTSD and the affect it can have on an individual's attitudes, thinking, and beliefs.

Eye Movement Desensitization and Reprocessing is a therapy intended to help individual learn from traumatic experiences, desensitize triggers, and resolve distress that is experienced physically and through emotions. The focus is on past memories, present disturbance, and future actions, replacing negative with positive emotions, feelings, and behaviors. Part of the therapy involves focusing on external stimuli, such as eye movement or hand tapping. There are eight phases to the therapy.

  • Preparation, where the focus is on building trust with the practitioner, psychoeducation, and learning relaxation techniques.
  • Assessment, where negative self-beliefs associated with the traumatic event are articulated, disturbance is rated, and positive self-beliefs are developed.
  • Desensitization, where the therapy focuses on reducing the disturbance resulting from the memory of the traumatic event is reduced.
  • Installation, where the goal is to replace the negative self-belief with the positive self-belief.
  • Body scan, which addresses remaining physical responses to unresolved thoughts.
  • Closure, which focuses on self-calming.
  • Reevaluation, where the practitioner considers whether progress has been maintained.

Trauma-Specific Services

Trauma-specific services are designed to help individuals manage the aftereffects of traumatic experiences. Such services may offer grounding techniques for handling dissociative symptoms as well as cognitive and behavioral approaches.

Many trauma-specific service models are not designed with the sole focus on veterans. One model, Seeking Safety, has been found to be effective for veterans, and the Trauma Empowerment Model is being adapted for veterans.

Seeking Safety is a present-focused intervention to aid in the recovery of people with histories of trauma, primary post-traumatic stress disorder, and substance abuse. The therapy is focused on building individual safety, integrated treatment, a focus on ideals, and pays attention to practitioner processes. The therapy's content addresses cognition, behavior, interpersonal relations, and case management.

Seeking Safety consists of 25 modules with no set order. The topics range from learning grounding techniques to self-care and from recovery thinking to coping with triggers. The therapy can be provided to individuals or groups and in outpatient, residential, and inpatient settings. The therapy has been found to be effective for male and female veterans and for people in correctional settings.

Trauma Recovery and Empowerment is a manual-based group intervention designed to facilitate trauma recovery among women and men with histories of exposure to sexual and physical abuse. The model employs cognitive restructuring, psychoeducational, and skills-training techniques in a gender-specific group format.

Individuals take part in up to 29 group sessions. The model addresses coping skills, social support, mental health, and substance abuse. It has been employed in criminal justice settings.

The model has been adapted to be more effective for men and veterans. A study of the model found it to be effective in decreasing symptoms and reduced severity of substance abuse.

Distinguishing Trauma-Specific from Trauma-Informed

Unlike the trauma-specific services described above, trauma-informed services promote safety and avoid retraumatization. Trauma-informed care is as essential as trauma-specific services given the prevalence of trauma among women and men with mental and substance use disorders in the justice system. People who have experienced trauma are also vulnerable to victimization and ongoing abuse. The key principles of trauma-informed services are:

  • Safety: Ensuring physical and emotional safety
  • Trustworthiness: Maximizing trustworthiness, making tasks clear, and maintaining appropriate boundaries
  • Choice: Prioritizing consumer choice and control
  • Collaboration: Maximizing collaboration and sharing of power with consumers
  • Empowerment: Prioritizing consumer empowerment and skill-building

Peer-Based Services

Peer-based services expand the continuum of services available to veterans with co-occurring disorders. It is essential that the peer also be a veteran. Peer-based services provide individuals with co-occurring disorders a unique opportunity to develop linkages and relationships with other peers who have similar lived experience and develop options for involvement in new communities of hope.

Peer-based services may be:

  • Independent and community based
  • Part of the Department of Veterans Affairs
  • Employees of community-based behavioral health services
  • Mentors organized as part of a veteran's treatment court program or other jail diversion initiatives

Research shows that peer services improve social functioning, self-esteem and social support, and reduce impatient utilization and substance use for individuals with mental illness and substance use disorder.

Consumer-operated services are peer run service programs that are administrative by individuals with mental and substance use disorders. Consumer-operated services offer opportunities for people to receive services, build mutual support, and develop new community networks and memberships. Services vary across consumer-operated services and may include:

  • Drop-in centers
  • Peer counseling
  • Linkages to services, housing, employment and education
  • Social opportunities
  • Crisis responses
  • Outreach

Vet-to-Vet is a consumer organization that is administered by veterans who have lived experience with co-occurring disorders. This organization was designed to provide peer-counseling services for veterans expanding the services provided by the VA and allowing peer providers to receive supervision from professional staff, while remaining independent. Vet-to-Vet provides peer-facilitator training programs that teach veterans how to facilitate group sessions.

Veterans Affairs: Peer Support Services. In 2005, the Department of Veterans Affairs (VA) began hiring consumer positions, individuals with mental and substance use disorders as part of their clinical team. In 2008 the role of peer support specialists was added to the VA's Handbook on Uniformed Mental Health Services in VA Medical Centers and Clinics. Peer support staff working in the VA have a variety of roles including:

  • Serving as role models for showing other veterans that recovery is possible
  • Teaching other veterans how to set goals and about recovery tools 
  • Empowering other veterans to help identify their strengths, resources and skills
  • Advocating for social support and community resources

Mentors/ Peer Specialists. Some mentors and peer specialists are paid positions within behavioral health centers or as part of a jail diversion initiative, while other positions are volunteers. Mentors/peer specialist work directly with the participants. They serve are facilitators, sponsors, coaches and supports. Peers work with the veteran to set goals, and develop action plans while providing support that only veterans can provide. A peer serves as part of the treatment team and offers insights on the veterans and his/her needs.


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