Korina Odom1,2*,Shuwen Li1,2,
Laura Zambrano-Vazquez2,Jennifer Bakan2
1 Department of Psychological Sciences, Tarleton State
University, McLennan University Center, Waco, Texas, USA
2 VISN 17 Center of Excellence for Research on Returning
War Veterans, Waco, Texas
Abstract
Posttraumatic Stress Disorder (PTSD) has been estimated to affect about 13% of veterans returning from Operations Iraqi Freedom (OIF) and Operations Enduring Freedom (OEF). For some veterans, the process of transitioning back to civilian life and learning how to reconnect with others can be complicated by PTSD symptoms. The purpose of this literature review is to understand how peer support services can improve a veteran’s psychological functioning and aid PTSD recovery. Reviewing the literature has revealed reports from veterans involved in peer support groups. These peer support groups have helped in the promotion of social bonds, in gaining a sense of acceptance and belonging, as well as a decrease in PTSD symptoms. The results contribute to identifying a process by which peer support services could positively impact veterans with PTSD.
The Relationship between PTSD and Peer Support Among Returning War Veterans
Posttraumatic Stress Disorder (PTSD) is a prevalent mental health diagnosis in returning war veterans. Returning war veterans are impacted by short- and/or long-term effects of functioning in society as a consequence of the extreme stress experienced during combat (Solomon, 2004). This can include symptoms of avoidance and detachment from others, leading to difficulty in establishing or maintaining social connections (Drebing et al., 2018). However, previous findings suggest that social support could lead to improved health outcomes for veterans (Drebing et al., 2018). Thus, individuals seeking and or receiving treatment should consider staying connected and share their struggles with loved ones or friends. Nonetheless there has been little research done on how help from fellow veterans through peer support services could establish connections to mental health services and impact treatment outcomes. Therefore, the purpose of this paper is to review findings on the effectiveness of peer support for veterans with PTSD and the impact on veterans. Furthermore, this review discusses the prevalence of PTSD, common types of treatment for PTSD, types of peer support services, veterans’ perspectives on peer support, and future implications.
PTSD Prevalence and Social Functioning / Social Isolation
PTSD has been estimated to affect about 13% of veterans returning from Operations Iraqi Freedom (OIF) and Operations Enduring Freedom (OEF) (Jain et al., 2013). PTSD has negatively impacted the quality of life across different domains of functioning, like physical, mental, and social-well-being (Schnurr et al., 2009). According to the DSM-5 (American Psychiatric Association, 2013), PTSD is characterized by four primary symptom clusters: 1) re-experiencing of traumatic event, 2) avoidance, 3) negative changes in cognitions and emotions, and 4) hyperarousal, persisting for longer than a month following the traumatic event. Veterans experiencing symptoms of PTSD could experience a diminished interest in doing activities, detachment, and or estrangement from others, which in turn negatively impact veterans social and interpersonal relationships.
When veterans return home from deployment, they must learn how to reconnect and reintegrate into social environments (Tsai et al., 2012). Veterans with PTSD experience difficulties in role performance, including social, interpersonal, and occupational functioning (Schnurr et al., 2009). According to Westwood and colleagues (2010), veterans with PTSD are 10 times more likely to be unemployed and earn 22% less per hour compared to veterans without PTSD. Furthermore, there are elevated rates of domestic violence and divorce for PTSD diagnosed veterans. Hence, there is compelling evidence seen that veterans that experience difficulties interacting with others in social environments could further complicate reintegration into civilian life.
Beyond the impact directly associated with sequelae from PTSD, the change in social contexts during reintegration to civilian life poses a harsh contrast between two cultures: civilian and military culture. When transitioning from military culture, veterans go from tightly connected and interdependent groups to a culture that emphasizes individuality, independence, and choice (Drebing et al., 2018). Research further suggests that when veterans are faced with these reintegration difficulties, they experience something akin to a culture shock, which negatively impacts their mental health and leads to social isolation (Brown, et al., 2016). This social state of limited or no interaction with others is a concern for veterans transitioning back into their communities as it interferes with successful reintegration (Brown, et al., 2016). To prevent social isolation and promote positive social functioning, it is critical for veterans to have access to trauma-focused treatments, resources and support.
The two gold-standard empirically supported treatments for PTSD are Prolonged Exposure (PE) Therapy (Foa, Hembree, and Rothbaum, 2008), and Cognitive Processing Therapy (CPT) (Resick, 2001). PE therapy has three main therapeutic components to it: psychoeducation, in vivo exposure and imaginal exposure which are targeted at breaking avoidance cycles and has strong support for successfully reducing PTSD symptoms, such as depression, anger, and guilt (Rauch et al., 2009; Smith et al., 2015). CPT, a type of cognitive behavioral therapy, allows for the individual to focus on cognitive challenges (i.e., stimuli, responses, and meaning elements of the event) and repetitive exposure to the traumatic event in a safe environment. CPT has been shown to be effective in treating PTSD for a variety of traumatic experiences with participants showing fewer symptoms months after the event occurring compared to groups receiving routine care (Chard et al., 2011).
Though these treatments help in reducing symptoms of PTSD, comorbid drug abuse and suicidality can potentially cause veterans seeking help to drop from their psychological/pharmacological treatment plans (Jain et al., 2013). Thus, the traditional individual delivery of treatment plans may not be ideally suited to promote interpersonal skills in social settings within the session. Thus, the implementation of peer support services has the potential to serve as a supplemental program that enhances the success of PTSD treatments (Jain et al., 2013).
Peer Support Services
Peer support services have been utilized to help expand reach in accessing existing mental health services (Jain et al., 2013). Peer support is a type of social emotional support, often combined with instrumental support, that is offered by a person who has a mental health condition by sharing their personal experiences in hope to bring about desired social or personal growth to support others (Solomon, 2004). Historically, peers offer services as paraprofessionals, meaning they are not specialized in a core discipline such as psychology, nursing, or social work, and typically have an education below a master’s degree (Jain et al., 2013). Within these groups, the “peers” are individuals who have a shared occupation, community, or mental illness as the person affected. There are six categories of peer support services including: self-help groups, internet online supporting groups, peer delivered services, peer run/operated services, peer partnerships and peer employees (Solomon, 2004). Self-help groups are formed by peers who voluntarily come together to help those in need of overcoming an issue and bring about desired social or personal change. Thus, providers may assist in facilitating the group until someone decides to become a leader. Comparable to self-help groups are internet online support groups but those lack the face-to-face element. These internet support groups allow anyone to join and offer a high degree of anonymity by communicating through online bulletin boards or email. Like self-help groups, peer delivered services are provided by someone having a mental illness and either received or have received mental health services for their diagnosis and deliver services for the purpose of helping others. Peer run or operated, peer partnership and peer employed services are also within the same concept as peer delivered services. The difference between peer operated services and peer partnerships is that peer partnerships have services planned, operated, and evaluated by a volunteer with a psychiatric disorder, while peer operated services have an individual who does not have a psychiatric disorder. Thus, the operated service program lies with a non-peer organization while the administration and regulation of the program are shared with peers and non-peers. Peer employees are hired into a traditional mental health position such as peer companion, peer advocate, peer counselor, and peer specialist. Further, peer employees must meet the requirements of having a mental illness, either received or have received mental health services for their diagnosis and deliver services for the purpose of helping others.
Considering peer employees and fellow peers' similar experiences, peer support has been shown to be beneficial to individuals with various mental illnesses. Research has found improvements in mental, emotional, social and physical health through learning vocational skills, developing trusted interpersonal relationships and re-connecting with their communities (Brown et al., 2016). Thus, the benefits gained through participation in peer support programs can be relevant to helping veterans with reintegration issues by increasing socialization among others, feelings of belongingness, and sense of accountability for others. Overall, peer support services encourage veterans by focusing on emphasizing the individuals’ strengths and receiving mutual support from others alike.
Peer Support Services for Veterans
Research suggests peer support among veterans is associated with measurable improvements such as increased social support, decreased clinical symptoms, and enhanced self-efficacy (Drebring et al., 2018). The unique camaraderie that often emerges among veterans as a result of shared combat and deployment experiences, is a characteristic that may favor the use of peer support services among veterans (Luchsinger, 2016). This camaraderie can help veterans quickly assimilate and identify with other peers, with some reported success in treating different disorders through diverse program structures of peer support services. When compared to receiving support from staff, veterans at a residential rehabilitation program for PTSD perceived greater support from other veterans through the “Big Brother” program, where someone who is further along in their PTSD treatment offers support to their designated “Little Brother” who recently started their treatment (Jain et al., 2016). In Vet-to-Vet programs, veterans consistently show improved daily functioning, and a general sense of empowerment (Resnick and Rosenheck, 2008). Research also suggests that the benefits of peer support can be observed in shorter intervals such as peer support-based weekend retreats. The Vet4Vet Weekend Retreat Program aids in addressing PTSD symptoms to improve psychological well-being in returning OEF/OIF veterans (MacEachron and Gustavsson, 2012). Vet4Vet Weekend retreats allow veterans to have intensive bonding experiences within a short time frame, similar to veterans experiencing camaraderie during deployment (MacEachron and Gustavsson, 2012). Additionally, community involvement, the veterans age, and points of contact made throughout the course of peer support can influence engagement for the first six months of treatment with veterans who were previously homeless, have co-occurring mental health conditions, or a history of substance abuse (Ellison et al., 2016). These findings suggest that peer support services could positively impact veteran’s well-being. However, it is important to consider how these services could be integrated into existing healthcare systems, treatments, and clinical settings.
Beehler and colleagues (2014) compared veterans experiences in response to peer-facilitated relative to clinician-facilitated groups. Across both group settings, the within group interactions among members were associated with a decrease in feelings of isolation, with veterans reporting feeling more positively valued and socially engaged in their everyday roles (Beehler et al., 2014). Peer facilitated groups participants reported discussing their experiences with the military or mental illness comfortably, which contributed to the veterans valuing others participation. Regardless of whether the facilitator was a clinician or a peer, both could play a unique role in promoting mental health recovery in veterans. However, veterans did indicate the significance in having a facilitator who specialized in mental health or someone who could relate to their experiences. In a recent study, Hundt and colleagues (2015) researched both veterans who had prior experience with peer support groups versus veterans with no experience. Both groups reported positive and hopeful feedback about future peer support programs being implemented in Veteran Affairs PTSD-based treatments. Some veterans expressed unwillingness to attend peer support programs due to social anxiety, mistrust, and the feeling of hopelessness when it comes to seeking help (Hundt et al., 2015).The credibility associated with fellow peers, peer support services within this population could enhance access to traditional mental health services (Brown et al., 2016). These studies exhibit how the concept of peer support could help and encourage fellow veterans in connecting with others, which in turn reflects on the relationships among veterans, PTSD and complementary treatments. Further, the peer support services could enhance veterans’ engagement in mental health services by de-stigmatizing seeking out mental health care.
How Peer Support Impacts PTSD Symptoms
In order for peer support services to be effective for veterans, it has been theorized that there are three mechanisms of action by which peer support could improve veterans with PTSD outcomes: promotion of social bonds, wellbeing/recovery, and knowledge regarding the healthcare system (Jain et al., 2013; Brown et al., 2016). Indeed, peer support programs could directly address symptoms clusters of PTSD such as avoidance and isolation. Caddick and colleagues (2015) revealed veterans participating in a peer support group had initially reported feelings of social isolation in relation to PTSD. However, through veterans sharing their experiences with PTSD and being able to relate to one’s suffering, the veterans’ bonds with one another increased, as well as their sense of acceptance and belonging (Caddick et al., 2015). Additionally, they reported being more trusting of others, and more confident in asking for help (Westwood et al., 2010). Ultimately, these improvements contributed to healthier relationships with their spouses, children, friends, and colleagues (Westwood et al., 2010). However, further research is needed to examine the processes that affect PTSD via relationships with other people and correlating factors.
When veterans participate in peer support services, they are continuously involved in an interdependent-like group that can in turn promote positive reintegration. Reintegration is a perceived component to improve psychological well-being and social relationships. Peer supports core components of military culture and camaraderie can play a critical role in reintegration by utilizing resources from the civilian culture and increasing veterans self-efficacy that was once developed during their time in services to be able to approach the daunting task of returning to civilian life (MacEachron and Gustavsson, 2012). Further, veterans reported peer support played a significant role in reintegration because they worked alongside students, community members, and fellow veterans while sharing the experiences of being involved in the community (Brown et al., 2016). The peer support model contributes to veterans progress towards positive reintegration by keeping them “one step away” from isolation and “one step closer” to social solidarity through enhancing their individual strengths and building the familiar culture of camaraderie amongst veterans (Brown et al., 2016). Overall, peer support can help veterans with successful reintegration through social support, connectedness with others, and wellness through encouragement to seek professional help.
Discussion
Taken together, the literature suggests that veterans with PTSD symptoms can benefit from participating in peer support programs. Peer support programs encourage veterans to communicate their difficulties knowing that members of the group have experienced events similar to them. The group dynamic offers each member a sense of belonging, assistance, vulnerability, and positive feedback when actively listening to other members personal experiences, suggestions, and different methods of coping. Participants in peer support groups reported that once trust and rapport was established within the group, veterans were able to speak freely about their past experiences and were able to learn new skills from each other (Azevedo et al., 2020). Furthermore, lessons and experiences discussed during peer support services allowed veterans to implement advice received into their everyday lives in hopes of increasing positive social interactions with others.
Several limitations from multiple studies reviewed are worth noting. There is still limited understanding on how peer support models impact PTSD symptoms in returning war veterans due to the absence of evidence supporting the effectiveness in peer support improving PTSD outcomes in veterans. . This could be in part of not having a way to formally evaluate how to optimize the potential of peer support programs as an additional component of healthcare for veterans with PTSD (Jain et al., 2016). The lack of testing within peer-group context therapies can make it difficult for more of these peer support programs to employ and contribute to more literature. This could be due to service elements of peer provided services being antithetical to the employment of randomized designs, whereas characteristics of peer providers and system principles rely on observations of investigators of peer provided service interventions (Solomon, 2004). This lack of categorical evidence hinders implementing peer support programs in the clinical setting (Jain et al., 2016). It is essential for a trained professional who is better equipped to handle crises or provide treatment to be present during peer support group meetings. Professionals can be involved in the groups if they do not facilitate conversation or attempt to control the session, however, if their help is needed, they can aid in addressing issues or treatment related concerns.
To remedy these concerns, future research can analyze how mechanisms within peer support could improve PTSD outcomes, specifically analyzing the promotion of social bonds, recovery, and knowledge about the healthcare system (Jain et al., 2013). First, researchers must analyze theoretical mechanisms of action on how peer led sessions could contribute to the decrease of PTSD symptoms. For example, a peer support program using a recovery-oriented approach or peer support interventions with the target sample being veterans with PTSD symptoms could be used to theorize a conceptual model (Jain et al., 2013). Thus, future research needs to thoroughly define the differences between social support and experiential learning processes, and a continuation of rigorous research is needed to thoroughly analyze the impact of peer support services on PTSD symptoms (Solomon, 2004). Despite these limitations, this review points to a few areas of peer support programs that may improve social functioning and overall life satisfaction among veterans with PTSD symptoms (Tsai et al., 2012). When addressing concerns for more innovative healthcare programs, it is essential to pursue these efforts as more OEF/OIF veterans with PTSD symptoms seek further help and treatments beyond symptomatic relief to social functioning.
One of peer support services' key role is to have peers share their experiences of not only having difficulties with symptoms of PTSD and social relationships, but to share their experiences of seeking further care which allows the individual to develop a sense of security, which is necessary for coping with PTSD (Jain et al., 2012). Thus, peers are able to destigmatize negative attitudes towards mental health treatments through sharing their experiences of seeking care which in turn, promotes treatment accessibility (Jain et al., 2013). Indeed, research has shown that perceived peer support from receptive veterans was associated with positive attitudes towards recovery from PTSD (Jain et al., 2016). Having peers may help aid fellow veterans navigating the mental healthcare system for the first time, and thus can in turn encourage reluctant veterans with PTSD symptoms to seek help and begin building trust towards mental health professionals (Jain et al., 2013). Peers from these programs can also assist fellow veterans by utilizing the opportunity in promoting their knowledge and their own personal experience in regard to the healthcare system (Tsai et al., 2012). Veterans reported an increase in self-awareness and being more open to address mental health problems and seek further professional help. Peer support programs can further be utilized in connecting veterans with other mental health providers. One study observed veterans who received a referral from their clinicians due to veterans having low levels of social support as a way to get veterans connected to peer support to address that need (Drebing et al., 2018). By receiving clinical care and support from peer groups, participants reported there being potential for added value in the combination of the two services (Drebing et al., 2018). Additionally, peer support services aid with the demand of mental health services, but it can serve as a connection to either a treatment program or a complementary service additional to the veterans PTSD treatment. Self-help groups can be helpful in reducing the utilization of traditional mental health services and the low cost of implementing these programs help the health care system save in total dollar savings (Solomon, 2004). Peer support services have the potential to further extend enhancement of access to mental health treatment secondary to the credibility associated with trained peers (Jain et al., 2013). Through knowledge and understanding the mental healthcare system, mental health professionals, and related treatment process, levels of engagement and satisfaction of mental healthcare could increase (Jain et al., 2013). Taken together, participation in both clinical care and peer support can essentially be associated with better outcomes for peers than clinical programs alone.
Conclusion
In this literature review, summation of previous studies on peer support were used to gain a better understanding on the effectiveness of peer support services for veterans with PTSD and how these services can impact veterans’ outcomes. Overall, the literature review suggests that participation in peer support groups can be associated with positive outcomes such as enhanced personal well-being, improvement in attitudes towards mental healthcare, social bonds, and social functioning. Thus, leading to an increase in community involvement and improving their relationships with significant others, family members, friends, and civilians. Given the positive feedback from veterans with PTSD and veterans who prefer to not seek treatment, as well as the evidence indicating the effectiveness of peer support programs and the military population, the need for innovative, community-based, recovery-oriented, informal-evidence-based approaches of peer support services are critical (Brown et al., 2016). The diversity of peer support programs can aid in both bridging gaps and connecting the mental healthcare system and veterans (Solomon, 2004). Furthermore, the flexibility in the structure of peer support programs as the field continues to evolve, allowing future research to adapt and expand peer programs if necessary (Bernardy et al., 2011). Because veterans are in the unique position of understanding each other in a way civilians cannot, peer support programs can provide accountability, trust, and relatedness to impact peers in a positive manner that can last a lifetime.
Conflicts of Interest: The authors do not have any conflicts of interest to report.
Acknowledgments
This material is the result of work supported with resources and the use of facilities at the VISN 17 Center of Excellence for Research on Returning War Veterans and the Central Texas Healthcare System through the VA Center of Excellence Program (VA-CERP). The authors of this paper would like to thank Psychology Technicians of Project SERVE, Corina Mendoza, and Lisa Corcoran, for their support and feedback during the VA-CERP internship through which this review was developed. The views and opinions of authors expressed herein do not necessarily state or reflect those of the United States Government.
References
Association, A. P. (2013). Diagnostic and statistical manual of mental disorders: DSM-5. American Psychiatric Association, 5-5.
Azevedo, K. J., Ramirez, J. C., Kumar, A., Lefevre, A., Factor, A., Hailu, E., Lindley, S., Jain, E. and S. (2020). Rethinking violence prevention in rural and underserved communities: How veteran peer support groups help participants deal with sequelae from violent traumatic experiences. The Journal of Rural Health, 36(2), 266-73.
Beehler, S., Clark, J. A. and Eisen, S. V. (2014). Participant experiences in Peer- and Clinician-facilitated mental health recovery groups for veterans. Psychiatric Rehabilitation Journal, 36(1), 43-50.
Bernardy, N. C., Hamblen, J. L., Friedman, M. J., Ruzek, J. I. and Mcfall, M. E. (2011). Implementation of a posttraumatic stress disorder mentoring program to improve treatment services. Psychological Trauma: Theory, Research, Practice, and Policy, 3(3), 292-99.
Brown, C., Besterman-Dahan, K., Chavez, M., Njoh, E. and Smith, W. (2016). It gave me an excuse to get out into society again: decreasing veteran isolation through a community agricultural peer support model. Journal of Veterans Studies, 1(1), 163-163.
Caddick, N., Phoenix, C. and Smith, B. (2015). Collective stories and well-being: using a dialogical narrative approach to understand peer relationships among combat veterans experiencing post-traumatic stress disorder. Journal of Health Psychology, 20(3), 286-99.
Chard, K. M., Schumm, J. A., Mcilvain, S., Bailey, M., G, Parkinson, W. and R, B. (2011). Exploring the efficacy of a residential treatment program incorporating cognitive processing therapy-cognitive for veterans with PTSD and traumatic brain injury. Journal of Traumatic Stress, 24(3), 347-51.
Drebing, C. E., Reilly, E., Henze, K., Kelly, T., Russo, M., Smolinsky, A., Gorman, J., Penk, J., E and W. (2018). Using peer support groups to enhance community integration of veterans in transition. Psychological Services, 15(2), 135-180.
Ellison, M. L., Schutt, R. K., Glickman, M. E., Schultz, M. R., Chinman, M., Jensen, K., Mitchell-Miland, C., Smelson, D. and Eisen, S. (2016). Patterns and predictors of engagement in peer support among homeless veterans with mental health conditions and substance use histories. Psychiatric Rehabilitation Journal, 39(3), 266-73.
Foa, E. B., Hembree, E. A. and Rothbaum, B. O. (2008). Prolonged exposure therapy for PTSD: emotional processing of traumatic experiences therapist guide,. USA: Oxford University Press.
Hundt, N. E., Robinson, A., Arney, J., Stanley, M. A. and Cully, J. A. (2015). Veterans’ perspectives on benefits and drawbacks of peer support for posttraumatic stress disorder. Military Medicine, 180(8), 851-56.
Jain, S., Mclean, C., Adler, E., Lindley, S. and Rosen, C. (2013). Does the integration of peers into the treatment of adults with posttraumatic stress disorder improve access to mental health care? A literature review and conceptual model. Journal of Traumatic Stress Disorders & Treatment, 2(3), 1-9.
Jain, S., Mclean, C., Adler, E., Lindley, S. and Rosen, C. (2016). Peer support and outcome for veterans with posttraumatic stress disorder (PTSD) in a residential rehabilitation program. Community Mental Health Journal, 52(8), 1089-92.
Jain, S., Mclean, C. and Rosen, C. (2012). Is there a role for peer support delivered interventions in the treatment of veterans with post-traumatic stress disorder? . Military Medicine, 177, 481-83. Luchsinger, A. (2016). Veterans seeking veterans through interpersonal communication. International Journal of Communication, 8, 1-9.
Maceachron, A., and Gustavsson, N. (2012). Peer support, self-efficacy, and combat-related trauma symptoms among returning OIF/OEF veterans. Advances in Social Work, 13(3), 586-602.
Rauch, S. A. M., Defever, E., Favorite, T., Duroe, A., Garrity, C., Martis, B. and Liberzon, I. (2009). Prolonged exposure for PTSD in a veterans health administration PTSD clinic. Journal of Traumatic Stress, 22(1), 60-64.
Resick, P. A. (2001). Cognitive processing therapy: generic manual.,. Unpublished manuscript.
Resnick, S., and Rosenheck, R. (2008). Integrating peer-provided services: a quasi-experimental study of recovery orientation, confidence, and empowerment. Psychiatric Services, 59(11), 1307-1321.
Schnurr, P. P., Lunney, C. A., Bovin, M. J. and Marx, B. P. (2009). Posttraumatic stress disorder and quality of life: extension of findings to veterans of the wars in Iraq and Afghanistan. Clinical Psychology Review, 29(8), 727-762.
Smith, E. R., Porter, K. E., Messina, M. G., Beyer, J. A., Defever, M. E., Foa, E. B. and Rauch, S. A. M. (2015). Prolonged exposure for PTSD in a veteran group: a pilot effectiveness study. Journal of Anxiety Disorders, 30, 23-27.
Solomon, P. (2004). Peer support/peer provided services underlying processes, benefits, and critical ingredients. Psychiatric Rehabilitation Journal, 27(4), 392-401.
Tsai, J., Harpaz-Rotem, I., Pietrzak, R. H. and Southwick, S. M. (2012). The role of coping, resilience, and social support in mediating the relation between PTSD and social functioning in veterans returning from Iraq and Afghanistan. Psychiatry: Interpersonal and Biological Processes, 75(2), 135-149.
Westwood, M. J., Mclean, H., Cave, D., Borgen, W. and Slakov, P. (2010). Coming home: a group-based approach for assisting military veterans in transition. The Journal for Specialists in Group Work, 35(1), 44-68.