Bridge the Gap - Group Therapy Model for Combat Veteran Suicide Prevention
Daniel R. Gaita, MA
October 24th, 2016
Bridging the Gap
Since the recent United States led wars in response to the attacks of September 11th, 2001, American veteran suicides have taken a front and center position on the stage of mental health treatment studies. Veterans Affairs and Department of Defense studies have placed the veterans’ suicide rate between twenty and twenty-two per day (Kemp & Bossarte, 2012; Thompson, 2016). Multitudes of data have been collected across dozens of studies determining the most effective evidence based treatment strategies for Post Traumatic Stress Disorder (Amos, Stein, & Ipser, 2014; Bisson, Roberts, Andrew, Cooper, & Lewis, 2013; Cahill & Foa, 2007; Chard, Resick, Monson, & Kattar, 2009; Dworkin, 2011; IOM, 2008; Monson, Schnurr, Resick, Friedman, Young-Xu, Y & Stevens, 2006) which often accompanies other comorbid symptoms such as depression and substance use disorders which too can lead to suicide (APA, 2013; Kuehn, 2008; Roberts, Roberts, Jones, & Bisson, 2016). While manuals for public access have been produced which provide detailed instructions on implementing trauma focused cognitive processing therapies, session by session (Resick, Monson, Galovski, Chard, & Kattar, 2010), what is missing is more work towards actually getting more veterans interested in seeking treatment in the first place. This “gap” between those needing and seeking mental health services is the focus of our group. This paper will discuss precisely why veterans tend to avoid treatment, how to “bridge the gap” and engage them in the discussion of available modalities, and also provide a template group therapy outline to enable greater engagement by veterans prior to the creeping ideations of suicide that often preempt such self-inflicted and avoidable tragedies.
Analysis of the Gap – Creating the Group Population
The “Gap”, is the term used herein to identify the apparent disconnects between effective evidence based interventions being utilized and those combat veterans that are reluctant, ambivalent, and/or resistant towards their use and implementation. The specific group served will be open only to United States Armed Forces combat veterans. Members will be chosen based on proof of combat service as provided through submission of their Certificate of Discharge, Department of Defense Form DD-214.
Statistics
Veterans that did not use VA mental health services carried out 70% of the reported veterans suicides with 65% of all veteran suicides carried out by those 50 years of age or older (Thompson, 2016). This is of major importance when working to determine more effective engagement strategies that will get veterans to utilize the evidence based interventions that are showing promise through the various Veterans Affairs clinics and affiliated agencies. This is the gap that we must bridge.
Background and Rationale
Veterans that have served in the United States Armed Forces, in combat, were trained to kill the enemy. They are disciplined and effective towards that objective. Weakness in any form or facet of existence is simply not an option for those tasked with killing our enemies. As a result, three elements impact human behavior: Internal Bias, Transference and Cognitive Dissonance, all of which permeate the psyche of a combat veteran, are discussed in greater detail below due to their respective and extraordinary influence over the perceptions veterans hold specific to mental health treatment in the first place. Especially for those whom experienced combat, these veterans were exposed to traumatic events resulting in the taking of the lives of others or having had to watch others being killed. For these men and women, weakness, as perceived in any form is utterly out of the question; thus where the gap emerges. This is the rationale behind the group population selection.
Internal Bias
Internal Bias represents our unconscious and conscious tendency, trend, inclination, and feelings which are often times unreasoned opinions and prejudices about other social groups or individuals based on our life experiences and environments (Robbins, Chatterjee & Canda, 2011). Given this definition, it is then understandable that combat veterans would have a drastically different internal bias toward mental health treatment than their civilian counterparts. Since it requires the combat veteran to conceive that he or she has a weakness or disorder; such a concept is in absolute contradiction to the established “norms” of the warrior mentality.
Transference
Transference represents our unconscious tendency to project onto others both attitudes and feelings that were significant early on in life (Robbins et al., 2011). In many cases this can be of feelings endured as a child with parents or even later on in life through traumatic episodes such as combat. With weakness often times comes death in the combat theatre. Thus strength is not just an essential component of ones identity, but moreover a basic requirement for survival.
Cognitive Dissonance
Cognitive Dissonance refers to our own internal attitudes and beliefs or behaviors, which are conflicted when we are exposed to other beliefs that are inconsistent with our own. This, often times, results in irrational and sometimes maladaptive behavior due to an internal clash, which creates unpleasant tension (Festinger, 1957). When a combat veteran that has survived by the laws of strength and discipline is confronted with the concept of needing mental health interventions resulting from combat action it creates exactly the type of cognitive dissonance that results in tension and in many cases, maladaptive behavior.
Stigma
The question then remains, how do we shift the perception that can translate enrollment into mental health services from having the attached stigma of weakness, to instead be perceived as a sign as a of great strength. So that the most effected will see themselves as warriors continuing to do battle against a common enemy, rather than proverbial “pussies” that “Can’t handle life”?
Bridging the Gap With Solution Focused Therapy
Reaching out to veterans that do not believe they are amongst the population in need of interventions is precisely how we bridge the gap. This type of effort requires community relationships between the social worker, veteran’s agencies and service organizations. It means tapping into the veteran population that weighs least on the VA system, through local Veterans Tax Benefits Coordinators and Tax Assessors whom know the local veterans population that have withdrawn from the ranks, that tend to live out their days in solitude with a withering sense of life purpose.
We create interest in this group by changing the veterans’ perceptions towards opening oneself up to the possibilities of a brighter future, a better mid-life chapter post combat. It is done by not calling it therapy, but rather camaraderie, while providing these men and women with an opportunity toward purpose rather than treatment. Thus it is modeled after Solution Focused Brief Therapy (SFBT), which is both goal and future oriented, and collaborative (Trepper, 2012).
The basis and rationale of this course of action is not reflective of evidence on its efficacy for this specific population sub group, but rather lack thereof and thru the personal observation of the writer, who is also a combat veteran and who founded a non-profit agency specifically to address the issue of both PTSD and Veteran suicide. SFBT has been left out of most of the recently cited comparison studies and Meta analysis on the treatment of PTSD and its comorbid symptoms (Dworkin, 2011). Yet SFBT has been widely accepted as a best practice for substance abuse (Berg and Miller, 1992) and Depression (Spilsbury, 2012), which are both common comorbid symptoms that accompany PTSD (APA, 2013) and common amongst those who have committed suicide.
Bridge the Gap - The Curriculum
This group will meet weekly for 10 weeks; each meeting will be for one hour and the therapist will be available for up to thirty minutes following each meeting for any needed specific discussion with any group individual.
Week 1: Brotherhood
Terminal Objective: Initial Evaluation and Establishment of Rapport
At a predetermined location (Town hall meeting room, local gym, coffee shop, campfire, BBQ, VFW or American Legion Hall, etc.), our group of 3-10 combat veterans will gather. This first meeting is about gathering our initial evaluation data, establishing rapport and ensuring the privacy and confidentiality of the group.
To do so, we will be seeking information on the number of services the veteran has used since end of enlistment based on personal recall. Simultaneously, the veterans will be rekindling a lost sense of brotherhood amongst the members based on the following rationale.
With shared suffering, hardships and adversity comes lessons in resiliency. One common link that bonds all combat veterans together is that of combat experience. They (combat veterans) have, regardless of branch of service, age or gender a bond that when in common company, emerges a set of conversations that take on a life of their own. Often profane, barbaric, and geared toward inhumane humor, which serve as coping mechanisms that give them light in places that may have long since gone dark.
Enabling Objective: Baseline Measurements & Rekindle Sense of Brotherhood
The therapist hands out a short confidential questionnaire (Appendix A), asking the veteran to list any veteran’s agencies, groups, or services they have used since re-entering the civilian sector. While collecting the questionnaire, the therapist works to encourage dialogue through complimentary and positive observations of shared stories of service, branches served, specific occupations, years of service and by helping each member identify and acknowledge what has been working since becoming a civilian.
Week 2: Camaraderie
Terminal Objective: Building a Group History
This week we will build off of our first introductions and discuss service successes and proud moments as well as others that combat veterans tend to look back at and laugh. This meeting concept is based on the following rationale.
You can take a 100-year-old WWII Veteran, a 70-year-old Vietnam veteran, a 50-year-old Gulf-War veteran and a 23-year-old OIF/OEF veteran, who all share combat service and put them into a room together. Within five minutes of meeting each other, the titles, genders, ages and net-worth of each will be shed off, their current places in society will be erased and all that will matter is the sharing of their service and respective stories or remembrance of events which they each have at least one thing in common, combat. It is surreal to behold, but powerful and useful if harnessed effectively.
Enabling Objective: Rekindle sense of brotherhood
The therapist works to focus on the collective good achieved by the group by building a medals and ribbons bar that reflects the combined service and sacrifice of all the group members. This will serve as a graphic depiction of every award and medal earned by all members of the group, which serves as a powerful, and visual motivational tool for future sessions geared toward the future goals of both purpose and service.
Week 3: Introduction to Purpose
Terminal Objective: Exposition of Resources
This week we will discuss the element of individual purpose while the therapist subtly exposes the members to available resources. This is done through open discussions of members on the topic of purpose, when they may have lost it and how they can get it back by sharing collective positive examples of their most motivating purposes in their life. For many, it will be a reflection of their time in combat.
The rationale for this type of subtle introduction of available resources is grounded in the common observation that this group of combat veterans has not sought help or assistance and may feel ambivalent about it. Therefore the therapist only interjects the availability of a resource when a particular purpose based topic underscores its need.
Enabling Objective: Handout Provided With Resource Listing
While presenting the groups combined ribbons bar (Appendix B), the therapist works to focus on the positive aspects of the members’ recollections of prior or current purpose driven accomplishments, while exposing the entire group to the litany of available resources geared toward making more such purpose driven activities and events possible. Every member receives a complete listing all available resources with websites, contact numbers and brief descriptions of what each is for.
Week 4: Community Needs Assessment
Terminal Objective: Stoking the Flames of Purpose
This week the group will discuss ideas to help the local community. Food drive, toy collection, collaboration with area veterans agencies, feed the poor, drive a vet, Santa’s workshop, fix a house, etc. The group will determine the activity(s) and its purpose(s).
Enabling Objective: Building a Group “Mission”
The therapist works to focus on the abilities of the group to serve the greater good of the local community while understanding it serves the participant combat veterans sense of purpose too. Therapist will then work with the group to coordinate collaborative meetings with local agency officials to iron out logistical details of group mission and community needs.
Week 5: Mission Logistics
Terminal Objective: Enhancement of resource understanding
The therapist works to continue acknowledgement of group work toward purpose while going into greater detail of various modalities being used to assist our other veterans. Conversations on PTSD and SUD may arise and opportunities to introduce concepts may come up throughout planning phases of event.
Enabling Objective: Dates, Times and Places of Community Event
This week we will discuss the logistics of our community based event. Here we will coordinate the event place, time and date to be used for future collaboration and promotion within the community and towards the accomplishment of the purpose driven mission.
The therapist works to focus on the positive aspects of the group’s weekly achievements and contributions while also seeking to locate areas where group members may be demonstrating a specific need or openness toward other interventions or services.
Week 6: Vet Center Introduction
Terminal Objective: Expose Group Members to Area Vet-Center Staff
During this session, the therapist will introduce a special guest, whom is also a combat veteran and director of the area VA Veterans Center. The focus will be on the Vet Center’s interest in the good the group is preparing to do in their upcoming community project while simultaneously fostering a sense of symbiotic collaboration and partnership with the group and its members.
Enabling Objective: Pin Point of Contact For Mezzo Options
Here, the therapist guides the engagement of members with the point of contact at the local community Veterans Center. It is at this point that each member is provided Vet Center brochures and contact cards that they can choose to either use for them or provide to another veteran that may be in need.
Week 7: VA Veterans Service Officer Introduction
Terminal Objective: Expose Group Members to local Veterans Affairs Service Officer
During this session, the therapist will introduce another special guest. This week’s guest will be an area Department of Veterans Affairs Service Officer that specializes in assisting veterans in obtaining valuable services, many of which are often unknown by veterans that have not used the VA since entering the civilian sector.
Here, the therapist guides the engagement of members with the point of contact at the VA. It is at this point that each member is provided valuable information on available VA programs and services that may have peaked an interest during last week’s Vet Center meeting. Again, brochures and contact cards will be provided that they can choose to either use for them or provide to another veteran that may be in need.
Enabling Objective: Expanding Knowledge of Macro Options
The focus will be on the Service Officer’s interest in the good the group is preparing to do in their upcoming camaraderie building, community based project while simultaneously fostering a sense of symbiotic collaboration and partnership with the group and its members. It also serves to add redundancy and layered depth to the previous weeks content.
Week 8: Introduction to Mobile Applications
Terminal Objective: Expose Group Members to Electronic Mobile Applications for Self Help
During this session, the therapist will guide discussion around the benefits of self-help applications that can be downloaded onto mobile devices.
Enabling Objective: Expanding Knowledge of Mobile and Micro Options
The therapist will briefly discuss multiple downloadable and free mobile applications that can either be used or shared with their fellow veterans. We are arming them with the knowledge of available treatment modalities without attempting to force their use. If they have an interest in any of these applications, or modalities they will now be able to peruse them in private. The following applications will be introduced:
PTSD Coach. This is a downloadable Veterans Affairs and Department of Defense project. It serves as a tool for self-management of PTSD, and includes: a self-assessment tool, educational materials about PTSD symptoms, related conditions, treatments, relaxation and meditation exercises, crisis resources, personal support, and professional mental healthcare contacts. It was released in 2013 and has been downloaded 86,000 times in 87 countries. (Thompson, 2016).
ACT Coach. Another downloadable application specifically targeted for depression that was released in 2014 and has been downloaded 23,000 times in 93 countries. It works in conjunction with Acceptance and Commitment Therapy (ACT) in an effort to bring the practice into daily life (Thompson, 2016).
Mindfulness Coach. Another mobile tool to assist users in practicing mindfulness meditation. This application was released in 2014 and has been downloaded 39,000 times throughout 95 countries (Thompson, 2016).
Moving Forward. Another 2014 released application that teaches problem solving skills. It can be used by itself or in conjunction with participation in Problem Solving training. It has already been downloaded 5,400 times in 54 countries (Thompson, 2016)
Week 9: Community Project
Terminal Objective: Engage Members in Purpose Driven Activity
During this session, the therapist will guide discussion around the actual event. How it feels to help, to serve a purpose, and expand upon the natural happening of the camaraderie based community event. Whether it is a food drive, community clean up project; or a clothing or toy collection for needy children, the group members will feel a renewed sense of purpose and achievement. The therapist merely serves to point out observations of successes and accomplishments throughout the event.
Enabling Objective: Doing Good for Others in the Community
Through their own action and participation in their coordinated community event, the group members will exhibit a renewed sense of self worth, purpose, and identity. For some, this will be a feeling that has been absent for years or perhaps decades.
As can be observed by those that have left a motivational seminar, the group members will be eager to share their experiences with others that may not be aware such a group program ever existed. They will be expanding community awareness of the program while fostering the brotherhood and camaraderie they knew they missed and are now aware still exists but now it is in a much more healthy and far different environment.
Week 10: Outcome Evaluation and Future Consideration
Terminal Objective: Measure Outcome
During this session, the therapist will reflect back upon the previous week’s accomplishments through dialogue and discussion of the event, and gather participant feedback and guidance specific to future collaborations.
Enabling Objective: Individual Questionnaire
Participants will be handed the same questionnaire they completed in week one. The objective is to measure week one answers with week ten answers to learn if the group curriculum has resulted in a bridging of the gap between available services and utilization of services by the group participants.
An increase in participation rates amongst group members demonstrates that the purpose of the group, “Bridging the Gap”, has been served. Knowing that veterans whom participate in the available programs and services provided through the VA and other affiliated agencies are less likely to commit suicide should result in an overall reduction in both suicidal ideation, depression rates and suicides amongst group participants.
Appendix A
Combat Veteran Questionnaire of Utilized Services
Please do not put your name on this questionnaire
Dear fellow Combat Veteran,
Thank you for taking your time to participate in this group. All participating members here today have served in the combat theatre and represent multiple branches of the United States Armed Forces that have served during different combat operations. Each participating members combat action has been verified via submission of their respective DD-214’s.
Confidentiality
Please note that this is a private and closed group. Everything we share is confidential. No personal identifying information or other personal information shared herein will be shared with any other individuals or agencies with the following exceptions: written permission from client to share information; and second, unless release of identifying information is determined to be necessary to prevent harm to yourself or others, as we are mandated by law to report such instances.
Initial Services Questionnaire
On the attached blank page, please list any veteran’s services that you have used or currently use since your discharge or retirement from the Armed Forces. Feel free to share any non-veteran related services that you may have used too. Such services may include but are not limited to: Health and fitness related products or services, mental health services, nutritional services, disability services etc.
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