As a counselor, you will individualize services for clients. It is important for you to understand how to conduct a needs assessment to help you know how to create new s

Psychiatric Rehabilitation Journal

2012, Volume 35, No. 3, 209–217 Copyright 2012 Trustees of Boston University

DOI: http://dx.doi.org/10.2975/35.3.2012.209.217

Article

Supporting the Education Goals of Post-9/11 Veterans with

Self-Reported PTSD Symptoms: A Needs Assessment

�

Marsha Langer Ellison

Center for Health Quality Outcomes and Economic Research, ENRM Veterans Hospital, Bedford, MA, and University of Massachusetts Medical School

Lisa Mueller

VISN1 Mental Illness Research, Education, and Clinical Center,

ENRM Veterans Hospital, Bedford, MA

David Smelson

National Center for Homeless Veterans–Bedford Node, ENRM Veterans Hospital

Department of Psychiatry, University of Massachusetts Medical School

Patrick W. Corrigan

Illinois Institute of Technology

Rosalie A. Torres Stone

Center for Mental Health Services Research

Department of Psychiatry, University of Massachusetts Medical School

Barbara G. Bokhour

Center for Health Quality, Outcomes & Economic Research, ENRM Veterans Hospital, and Boston University

School of Public Health, Department of Health Policy & Management

Lisa M. Najavits

VA Boston Healthcare System Boston University School of Medicine

Jennifer M. Vessella

Center for Health Quality Outcomes and Economic Research, ENRM Veterans Hospital, Bedford, MA

Charles Drebing

VISN1 Mental Illness Research, Education, and Clinical Center,

ENRM Veterans Hospital, Bedford, MA

Purpose: The influx of young adult veterans with mental health challenges from re- cent wars combined with newly expanded veteran education benefits has high- lighted the need for a supported education service within the Veterans Administration. However, it is unknown how such a service should be designed to best respond to these needs. This study undertook a qualitative needs assess- ment for education supports among veterans with post-9/11 service with self-re- ported PTSD symptoms. Methods: Focus groups were held with 31 veterans, 54% of whom were under age 30. Transcripts were analyzed and interpreted using a thematic approach and a Participatory Action Research team. Results: Findings in- dicate a need for age relevant services that assist with: education planning and ac- cess, counseling for the G.I. Bill, accommodations for PTSD symptoms, community and family re-integration, and outreach and support. Conclusions and Implications for Practice: The veterans recommended that supported education be integrated with the delivery of mental health services, that services have varied intensity, and there be linkages between colleges and the Veterans Health Administration.

Keywords: supported education, young adults, veterans, needs assessment

Introduction

The opportunity to obtain an educa- tion through the Department of Veterans Affairs (VA) benefits is a strong motivation among young people for joining the military (Kleykamp, 2006; Wilson et al., 2000). Given the previous success of the GI Bill program and the recent conflicts in the Middle East, the Post 9/11 GI Bill was passed. This legislation greatly increases veter- ans’ educational tuition and related

benefits (Department of Veterans Affairs, 2011b). There are a rapidly in- creasing number of applicants for GI Bill benefits (Sabo, 2010) as well as a growing number of veterans with psy- chiatric disabilities on college campus- es (Vance & Miller, 2009). However, war related trauma and consequent impairments can hinder educational attainment among veterans with dis- abilities including those with post-

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ahead (Wells et al., 2011). In addition, PTSD is associated with various co- occurring disorders, social role, functional, and cognitive impairments that can impact educational attainment (Thomas et al., 2010; Stein & McAllister, 2009; Najavits, Highley, Dolan, & Fee, in press; Sareen et al. 2007; Vasterling et al. 2008; Vasterling, Verfaellie, & Sullivan, 2009; Kotler, Iancu, Efroni, & Amir, 2001; Church, 2009). Despite recent advances in VA and Department of Defense (DoD) treatments that have resulted in earlier and stronger attempts to address PTSD (National Center for PTSD, 2009), PTSD and its sequelae can be chronic and impairing for a substantial number of veterans.

Methods

Participants and Data Collection This needs assessment collected data pri- marily through focus groups held in 2009 – 2010. Study participants were recruited from the housing and mental health services at the Bedford, Massachusetts VA Medical Center (VAMC) and Boston area Veterans Upward Bound programs (a federally funded program that provides academ- ic preparation services for veterans in the community). The study was ap- proved by the Institutional Review Board of the VAMC and all participants were compensated $25 for their partici- pation. Eligibility criteria for the study included: (a) military service since 2001 and deployment in the Middle East; and (b) an educational goal (to ei- ther continue education if enrolled or to begin or go back to school or train- ing). In the interest of preserving a very brief screen on entry to the study, we used the following questions to deter- mine likely presence of PTSD: “Do you consider yourself to have war related problems that may be signs of PTSD (for example: having flashbacks, trou-

ble sleeping, feeling edgy or easily angry, feeling numb or withdrawn)”; and “Have you even been diagnosed as having PTSD by a mental health profes- sional?” Although we do not presume these self-report questions to be equiv- alent to an actual diagnostic interview for PTSD, it indicates a notable pres- ence of likely PTSD in our sample.

A total of 29 veterans participated in eight focus groups and two veterans participated in individual interviews (for reasons of scheduling at their con- venience) using identical questions.

The focus group protocol and interview guide was developed by the research team and brought to the PAR team (de- scribed below) for review. During each data collection session, participants were asked about their military service, their educational background and goals, steps they had taken to pursue their education, facilitators and barri- ers in pursuing their education and/or goals, and what types of VA services would help them to achieve education- al goals.

The study also used a Participatory Action Research (PAR) approach in which a team of stakeholders collabo- rated with researchers in a “co-learn- ing” context that can ensure relevant, meaningful and actionable findings (Danley & Ellison, 1999; Rogers & Palmer-Erbs, 1994; Minkler & Wallerstein, 2003). A PAR team was convened of 12 individuals consisting of 7 veterans (3 were young adults and all were employed as service providers to other veterans in varying capacities), a VA mental health practitioner, 2 com- munity college academic Deans and 1 administrator, and another state veter- an service provider. The PAR team met with Investigators of this study as a group five different times in person or via phone. Meetings were used to re- view project procedures and materials,

traumatic stress disorder (PTSD) (Kraus, 2010). Supported education (SEd) is an emerging evidence-based practice that has successfully ad- dressed disability-related educational challenges for adult civilians with seri- ous mental illnesses (Cook & Solomon, 1993; Hoffman & Mastrianni, 1993; Mowbray, Collins, & Bybee, 1999; Nuechterlein et al., 2008). However, lit- tle is known about how such a service should be designed or adapted from civilian models to be used in the VA. Also unknown are the educational bar- riers that veterans with PTSD symp- toms perceive themselves to need. This study attempted to fill this knowledge gap by performing qualitative inter- views to examine the perceived educa- tional needs of younger (age 18 – 29) and older adult veterans (age 30+) with self-reported PTSD, and to thus inform consideration of an age-tailored sup- ported education service in the VA.

This research pays specific attention to young adult veterans and does so for two reasons: 1) their substantial pro- portion (41%) among post-9/11 veterans who are seeking VA health care (Dept. of Veterans Affairs, 2011a; VA Office of Public Health and Environmental Hazards, February, 2010); and 2) literature and research supports that young adults differ from mature adults in treatment needs and responses (Arnett, 2000; Davis 2003; Haddock et al., 2006; Uggen, 1999; Rice, Longabaugh, Beatties, & Noel, 1993; Clark & Unruh, 2009). This re- search includes Veterans with self- reported PTSD symptoms because studies have shown elevated rates of PTSD among recently returning service members (Hoge et al., 2004), with the youngest among these being at great- est risk for receiving a PTSD diagnosis (Seal, Bertenthal, Miner, Saunak, & Marmar, 2007). It is anticipated that the mental health needs of veterans will be substantial in the decades

Psychiatric Rehabilitation Journal Supporting the Education Goals of Post-9/11 Veterans

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Portions of transcripts and coding cate- gories were distributed to the PAR team and discussed in team meetings to fi- nalize interpretation. Subsequently, axial categories were then grouped into three larger headings: 1) barriers to educational attainment, 2) recom- mendations for supported education services, and 3) other needs related to educational support.

Results

Demographics of focus group participants The demographic data on the participants are displayed in Table 1. Slightly more than half of the total sample was under age 30, (54%, n=17). Most young adults were male (88%),

data analysis and interpretation, and recommendations.

Data Analysis Focus groups were audio recorded and transcribed by a profes- sional transcription service and re- viewed for accuracy. The research investigators and PAR team reviewed the transcriptions to code passages and organize categories. Initially each passage was “open coded” to identify the concept it represented using QSR NVIvo (ver. 8) software. Researchers met to review the transcripts, and con- sensus meetings were held with three independent coders in order to estab- lish the open codes for the first three transcripts. Subsequently, consensus meetings with two coders were held for the remainder of the open coding process. This process resulted in 23 codes (e.g., education strategies, rein- tegration to civilian life, unmet educa- tion needs).

Our interest was to understand the unique needs of younger veterans as well as issues that were common to both age cohorts. We chose a cut-off of age 30 for age group division. The actu- al age of stabilization of developmental changes among young adults is an em- pirical question and is unknown for young adult veterans. However, this cut-off is consistent with developmen- tal psychology that suggests that early adulthood launches adult role function- ing and is completed by age 30 (Arnett, 2000). Initial open coding was across age groups because transcripts were de-identified for the name or the age of the veteran speaking. Open codes were then classified as belonging either uniquely to younger veterans that were not expressed by older veterans, to older adults, or as ones that were com- mon to both groups. For the next step codes were organized into larger or axial categories of meaning (e.g., clini- cal related issues, reintegration con- text, school related challenges).

white (82%), single (64%), and roughly half (47%) had a high school diploma only. In contrast, older adult partici- pants (46%, n = 14) had a smaller pro- portion that were single (29%) and that had only a high school diploma (36%). For both age groups roughly one quar- ter were currently enrolled in school, the remaining had a goal to begin or return to school. In keeping with our in- clusion criteria, all veterans were on active duty since 2001 with 30 out of 31 having served in Iraq or Afghanistan.

Barriers to educational attainment among potential GI Bill beneficiaries The barriers to education centered on four codes, two of which were especial- ly relevant to young adults: educational planning and reintegration challenges.

winter 2012—Volume 35 Number 3

Table 1–Veteran Focus Group Demographics by Age Group (Total N=31)

Under age 30 Over age 30 (n=17) (n=14)

Gender

Male 88% (n=15) 100% (n=14)

Female 12% (n=2) 0% (n=0)

Race

White 82% (n=14) 79% (n=11)

African American 6% (n=1) 14% (n=2)

Other 12% (n=2) 7% (n=1)

Hispanic Ethnicity

Yes 12% (n=2) 14% (n=2)

Marital Status

Single 64% (n=11) 29% (n=4)

Married 12% (n=2) 36% (n=5)

Divorced/Separated 24% (n=4) 36% (n=5)

Educational Attainment

High School 47% (n=8) 36% (n=5)

Some College 35% (n=6) 36% (n=5)

Associate or College Degree 18% (n=3) 29% (n=4)

Currently Enrolled in School

Yes 23% (n=4) 29% (n=4)

Branch of Service

Army/Marines/Air Force 76% (n=13) 86% (n=12)

National Guard/Other 24% (n=4) 14% (n=2)

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cial/psychological/environmental con- texts that were less pronounced for older veterans. This included home- lessness, disintegrating family sup- port, urgent clinical needs such as addiction relapses, physical injury and disability, and an adjustment process to civilian life that was at times over- whelming. For example, one veteran said:

I know four vets, they just got into school and couldn’t handle it, and ended up in a major depression be- cause they dropped out of school and had no support. And here they are back, needing to go back inpatient because they got so overwhelmed at school they couldn’t handle it and had no one to talk to… a lot of these vets end up ei- ther hitting the bottle or drugs or what- ever the case may be and they end up here [hospital inpatient services].

Financial issues were pressing for these veterans and many were unsure how they could balance their education goals with their living needs. As one veteran said:

Mostly everybody who is just out of the military…you’re probably not going to want to go home and live with mom and dad, so you’ve gotta get your own place to live. … it all comes down to having a stable place to live, transportation, bills… Because you can’t focus on school if you’re worrying about how you’re gonna make your car payment, or how are you going to feed yourself tonight, you can’t do it.

GI Bill Education benefits and VA Benefits counseling. A theme across both age groups was difficulties with accessing and using the GI Bill and re- lated VA rehabilitation supports. Both younger and older veterans described difficulties such as: reaching a live per- son on the phone to ask questions, not having a knowledgeable person to an- swer questions or to assist with the application, not understanding the var- ious types of GI Bill or other VA bene-

fits or the ramifications of choosing one over another. A related barrier that was described is the current GI Bill re- quirement for nearly full-time credit load. The veterans told stories of hav- ing to start with a full-time caseload which turned out to be too much, and then having to drop classes and finally dropping out of school altogether as stress mounted. For some of the older veterans an added difficulty was mak- ing the forced choice between the Montgomery education benefits and the Post 9/11 GI Bill as there were differing requirements and benefit packages.

Impact of PTSD on educational attainment. Veterans in both age groups reported that PTSD symptoms posed additional challenges. They de- scribed feeling overwhelming anxiety during some class time. This was set off by differing circumstances such as loud and sudden noises, encountering roadwork reminiscent of scouring for roadside bombs, or other reminders of recent combat. Some reported using substances to alleviate the anxiety, or coping by always sitting at the back of the class where no one can come up from behind. Veterans voiced a need for classes with fewer students, isolat- ed settings for test taking, and evening or online classes to reduce anxiety. For example one veteran stated:

I couldn’t be in some classrooms. It was too hard being around some people … I dropped out because it was too much anxiety, especially during tests – be- cause I was already stressed out, then I’d have added stress, and I wouldn’t have enough time to finish what I was doing. I figured I can’t do this [school] so I’d stop.

Another common issue involved diffi- culties with perceived impairments in memory and concentration, and an overwhelming flow of information. The veterans reported a need for accommo- dations such as tape recording classes

Two codes were common to both age groups including: using GI Bill educa- tion benefits, and coping with PTSD symptoms.

Educational planning. For the younger veterans, education meant starting post-secondary schooling and this pre- sented numerous challenges. Several noted worry about meeting the de- mands of the academic environment and both desired and were anxious about initial assessments for academic readiness. As one veteran noted, “Let’s face it, many of these guys went into the service because they were no good at school.” Others didn’t know what kind of program to enroll in, or where. There were discussions about the rami- fications and requirements of one de- gree vs. another. They had not the opportunity to receive counseling about these questions; as one said, “no one ever asked him before” about his education goal. One young veteran noted how he found by chance a web- site about a veteran-friendly campus and moved cross county to enroll with little other information or preparation. Among the older veterans in the groups, educational planning needs were less expressed. Many had a clear occupational goal and understood the education requirements they needed to achieve that goal, and many were plan- ning to return to schooling that had already begun.

Education goals occur in a challenging context of re-integration into civilian life. Reintegration difficulties were pro- nounced for the younger veterans be- cause many went into the service straight from high school and then re- turned as young adults, but without having learned the skills needed for liv- ing independently as a civilian. We heard from the participants that there was no “basic training” for getting back to civilian life. The younger veter- ans described rapidly changing so-

Psychiatric Rehabilitation Journal Supporting the Education Goals of Post-9/11 Veterans

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I had gone to a couple of Vietnam veter- an groups and I’m like ‘Oh my G-d.’ Big room. Big people. Big and loud. I didn’t just go once and get a lousy opinion of it and not come back. I went a few times and it was – it was tough.

Younger veterans voiced interest in having access to technology to get in- formation on school and benefits, par- ticularly at VA hospitals. The veterans who were residing at the hospital or shelters complained that they did not have access to computers except under highly restrictive and monitored sessions.

Peer Support. The veterans we spoke to both young and old voiced the need to hear information and get help from other veterans who have overcome similar problems. The value of peer support is reflected here:

…when I first came to the VA I had seri- ous problems, I was thinking, there’s no help here, until a peer said they had the same problems. That was the first time I thought, well, there might be something to this … We went to hockey games and it’s comfortable because you’re around people like yourself so if you have anything going on, there’s support right there. It would be nice if there was someone that went through the college experience and they can say, “here’s a bunch of information, this is what I had to do, this is what I went through, and this is how I got past that.” Peer support is just huge be- cause they understand… It would help a lot to make veterans feel more comfort- able and more willing to go through school… I think everybody would be more comfortable with a fellow veteran.

Veterans turned to each other for infor- mation through word of mouth. Often the focus group itself turned into infor- mation-sharing activities among the veterans present. There is an immedi- ate extension of trust between veterans who may not know each other but who have both been in combat situations. The veterans expressed an interest in

or extensions of time for assignments. As one veteran stated:

For me, you know, my mind don’t work normal anymore, it’s hard for me to live in a normal situation. I always need more time because my brain works slower. In the normal case scenario, say, well, you got a term paper due Friday and you just learned about it on Monday. It’s gonna take a couple of weeks for me to get that done because, you know, my brain don’t function fast anymore.

Veteran recommendations for supported education and rehabilitation services. The veterans had numerous sugges- tions about the context and types of services that would be beneficial to them in reaching their educational goals. Some suggestions mirrored the needs previously described (i.e., pro- vide benefits counseling). Other addi- tional recommendations are described below. The first of these, “outreach and services” pertained to the younger group of veterans we talked with, while the remaining recommendations were common to both groups.

Outreach and services to young veter- ans. Several veterans noted how existing VA services were not age ap- propriate for them. They reported find- ing it hard to relate to clinical groups composed of veterans

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