TY - JOUR
AU - PhD, Jeffrey A. Cully,
AB - ABSTRACT Peer support has been increasingly utilized within the Department of Veterans Affairs and offers an opportunity to augment existing care for posttraumatic stress disorder (PTSD). The current study sought to examine Veterans' perspectives on the potential benefits and drawbacks of peer support for PTSD. A sample of 23 Veterans with substantial treatment experience completed one-time qualitative interviews that were transcribed and coded for thematic content using grounded theory methodology. Results indicated that Veterans identified numerous potential benefits to a peer support program, including social support, purpose and meaning, normalization of symptoms and hope, and therapeutic benefits. Veterans also identified ways that peer support could complement psychotherapy for PTSD by increasing initiation and adherence to treatment and supporting continued use of skills after termination. Results also indicated that Veterans may prefer peer support groups that are separated according to trauma type, gender, and era of service. Other findings highlighted the importance of the leadership and interpersonal skills of a peer support group leader. Overall, Veterans found peer support to be a highly acceptable complement to existing PTSD treatments with few drawbacks. INTRODUCTION Peer support is a model of care in which patients “in recovery” from an illness provide emotional, instrumental, and informational support to patients with the same disorder. Recent reviews of peer support indicate reduced symptoms, fewer hospitalization days, improved functioning, and superiority to usual care.1,2 Peer support providers have increasingly been integrated in military and Veteran mental health treatment3,4 and the Institute of Medicine encouraged peer support for military members.5 In 2013, the president mandated the Department of Veterans Affairs (VA) to hire 800 new peer support providers nationwide. This influx of peer providers provides an opportunity to incorporate peer support into VA treatment of posttraumatic stress disorder (PTSD). For example, peers might encourage treatment-naïve Veterans to engage in challenging but effective treatments like prolonged exposure (PE)6 or cognitive processing therapy (CPT)7 by sharing their stories of recovery.8 Peer support might also provide supportive aftercare to help Veterans maintain skills learned in treatment. Peer support is likely to be particularly helpful for Veterans with PTSD because of the strong bonds among military service members and the importance of Veteran peers in coping with stress.9 Furthermore, Veterans regard peers as more trustworthy than VA providers and combat Veterans in particular are likely to feel greater understanding from fellow combat Veterans.10 Although peer support is increasingly being used in mental health and PTSD outreach programs,11,–13 little research exists on the effectiveness of peer support specifically for PTSD or Veterans' perceptions of how peer support may be helpful. The current study examines Veterans' perspectives on incorporating peer support into existing VA PTSD treatment programs, including perceived benefits, drawbacks, and desired program characteristics. This information can assist future peer programs to increase buy-in and utilization of peer support PTSD services. METHOD Participants We sampled Veterans who had completed at least 8 sessions of PE or CPT in a VA PTSD Clinic and thus had insight on how peer support fits into existing treatment models. We used purposive sampling14 to recruit Veterans of diverse ethnic/racial groups, eras of service, trauma types, and both genders. Consented participants included 23 Veterans. Procedure After obtaining IRB and VA approvals, we obtained a list of patients referred for PTSD treatment between May 2012 and September 2013. Chart reviews were used to determine initial inclusion criteria and a letter was sent to selected patients describing the study and providing a telephone opt-out number. Five to seven days later, a research assistant called patients. Of the 40 letters sent, 23 patients (57%) agreed to participate, 13 (33%) declined participation, and 4 (10%) could not be contacted. Patients were provided the option to participate in a one-time qualitative interview in-person (n = 15) or via telephone (n = 8). All interviews were audio recorded, audio files were password protected on a HIPAA-compliant server. Interviews lasted approximately an hour (M = 59 minutes; range = 42–85 minutes). Guided by the third author (J.A., a medical sociologist trained in qualitative methods), we developed an interview guide querying participants' experiences with PTSD treatment and opinions about PTSD peer support (data regarding treatment are presented in Hundt et al15). The first author (N.H.) and another member of this research team conducted all interviews. Recruitment ended at data saturation, defined a priori as the point when 3 consecutive transcripts rendered no new thematic concepts.16 Data Analysis Interviews were transcribed by a professional service. We used grounded theory analysis to develop coding categories based on emergent themes in the data.14 After reviewing transcripts to establish a “codebook” with definitions and examples, the first and second authors coded each transcript and resolved discrepancies through discussion. We linked quotations to multiple codes as appropriate and utilized the qualitative data management software Atlas.ti V6.0. RESULTS Table I presents demographic characteristics. Results revealed Veterans' perceptions of benefits, drawbacks, and preferred peer program characteristics. TABLE I. Veterans' Demographic Characteristics    No. of Participants (N = 23)  %  Gender   Female  6  26.1   Male  17  73.9  Race/Ethnic   Non-Hispanic White  8  34.8   African–American  10  43.5   Hispanic  2  8.7   Native American  1  4.3   Asian  2  8.7  Service Era   OEF/OIF  9  39.1   Vietnam  9  39.1   Persian Gulf  3  13.0   Noncombat era  2  8.7  Mean Age  53.74 (SD = 12.23)     No. of Participants (N = 23)  %  Gender   Female  6  26.1   Male  17  73.9  Race/Ethnic   Non-Hispanic White  8  34.8   African–American  10  43.5   Hispanic  2  8.7   Native American  1  4.3   Asian  2  8.7  Service Era   OEF/OIF  9  39.1   Vietnam  9  39.1   Persian Gulf  3  13.0   Noncombat era  2  8.7  Mean Age  53.74 (SD = 12.23)  OEF/OIF, Operation Enduring Freedom (Afghanistan)/Operation Iraqi Freedom (Iraq). View Large TABLE I. Veterans' Demographic Characteristics    No. of Participants (N = 23)  %  Gender   Female  6  26.1   Male  17  73.9  Race/Ethnic   Non-Hispanic White  8  34.8   African–American  10  43.5   Hispanic  2  8.7   Native American  1  4.3   Asian  2  8.7  Service Era   OEF/OIF  9  39.1   Vietnam  9  39.1   Persian Gulf  3  13.0   Noncombat era  2  8.7  Mean Age  53.74 (SD = 12.23)     No. of Participants (N = 23)  %  Gender   Female  6  26.1   Male  17  73.9  Race/Ethnic   Non-Hispanic White  8  34.8   African–American  10  43.5   Hispanic  2  8.7   Native American  1  4.3   Asian  2  8.7  Service Era   OEF/OIF  9  39.1   Vietnam  9  39.1   Persian Gulf  3  13.0   Noncombat era  2  8.7  Mean Age  53.74 (SD = 12.23)  OEF/OIF, Operation Enduring Freedom (Afghanistan)/Operation Iraqi Freedom (Iraq). View Large Perceived Benefits of Peer Support Approximately a quarter had prior peer support experience, chiefly through 12-step groups and two with community PTSD peer support groups. Veterans reported primarily positive experiences and hopefulness about future peer groups. “If they tried I think they'll love it. Even if they sit there and just listen.” (Female Veteran with military sexual trauma [MST] and experience with a church-run sexual assault support group) Others had no experience with peer support but thought the idea sounded promising: “To me it would be highly recommended…You're going to get a lot of mileage out of it.” (Male Vietnam Veteran) Only a few expressed unwillingness to attend peer support. Reasons included social anxiety, difficulty trusting others, and for one, hopelessness that he could get better. Despite their reluctance to personally attend, all believed peer support might help other Veterans. Specifically, Veterans noted that potential benefits included social support, purpose and meaning, normalization, hope, therapeutic benefits, and linkage to care. Social Support and Understanding The most commonly cited potential benefit was that Veterans understand each other in a way that civilians cannot, and Veterans are more willing to open up to other Veterans. “My friends, they don't—I don't expect them to understand what I've been through. When I'm around veterans, like-minded veterans, I don't have to explain myself. They already know.” (Male Operation Enduring Freedom (OEF)/ Operation Iraqi Freedom (OIF) Veteran) This shared understanding and valuable social support is crucial to addressing the social isolation that often accompanies PTSD. Some expressed that having this support from fellow Veterans could relieve stress from family caregivers. “Just having somebody that you can lean on besides your spouse and your family because to be honest with you that (expletive) gets old after a while.” (Male OEF/OIF Veteran) The two senior noncommissioned officers (NCOs) in our sample both reported that some Veterans struggle to transition to civilian life without the structure and support provided by the military and often seek out informal peer support from higher-ranking Veterans. “The military is a support system … basically I'm taking care of forty kids is what it boils down to, you know. So they look up to somebody. They need that support. When they leave the Army there's nobody out here in this world that could give them that support …. they're reaching out to a senior NCO.” (Male OEF/OIF Veteran) Purpose and Meaning For many, helping other Veterans through peer support provides purpose and meaning, as the duty to fellow service members endures even after discharge: “That helped me because I felt like I was helping someone else. So if I get to help another combat brother, that's not a blessing, that's not a gift, that's an obligation.” (Male Vietnam Veteran) Normalization and Hope Peer support might normalize PTSD symptoms and thus reduce self-stigma. Veterans often blamed themselves or felt “weak” for not being able to deal with their traumas, but seeing that their problems were common helped reduce these feelings. “I think it would help you feel like you're not alone and what happened to you happens to a lot of others.” (Female Veteran with MST) Veterans also noted that the positive example of a peer provider in recovery would instill hope and help modify beliefs that they would never “recover” from PTSD. “That it's possible to get through it and there is light at the end of the tunnel … if you saw someone who could show you it's possible, I think that might be a real motivational thing.” (Female Veteran with MST) Therapeutic Benefits A few pointed out that engaging in a peer support group might be therapeutic in and of itself. Opening up to others might serve as an exposure task or corrective learning experience for Veterans who have difficulty trusting others or forming relationships. “The camaraderie will take on a whole new meaning for people once they get involved. It would be like, ‘Hey I can get close to people. I don't have to be afraid to have a relationship.’” (Male Vietnam Veteran) Peer support might also help Veterans change how they think about the trauma. For example, some noted that hearing that they were not at fault from fellow Veterans who had “been there, done that” was more meaningful than hearing it from a non-Veteran therapist. “It helps you to get further even past it because you're able to talk about it…you'll be like, ‘Oh wow I didn't think of it like that.’” (Female Veteran with MST and experience with peer support) Many expressed the need for help regaining social and recreational functioning. Peer support could provide Veterans with positive, healthy activities, consistent with a behavioral activation approach. “They need some outlet … they don't have nowhere else to go … ” (Male Vietnam Veteran) Link to Care Finally, Veterans expressed that peer support could be a link to professional treatment. Several were more willing to reach out to peers than to traditional providers when in crisis, and peers could facilitate contact with professionals. “I wish like hell I had somebody to call … for me to call 1-800 save my life (referring to the Veterans' Crisis Line)—I ain't doing that. No, if I ever get ready to have a crisis like that, I ain't calling nobody. But I would call another Veteran.” (Male OEF/OIF Veteran) Peer support could increase initiation of psychotherapy, as reluctant Veterans may be more willing to attend peer support, and positive experiences may then facilitate entering psychotherapy. “When I was first diagnosed with PTSD if you had told me I had a group of guys who had PTSD to go to talk to I might've done that. Even back when I wasn't ready to come to therapy.” (Male Vietnam Veteran) Veterans reported that they were more likely to initiate evidence-based psychotherapy at the recommendation of fellow Veterans. Some suggested that having peer support during psychotherapy could encourage treatment adherence: “Because you're going to have the people who've completed it are going to say, ‘Stay with it man. Don't quit before the miracle happens’ and hearing that from another Veteran makes me want to go back.” (Male Vietnam Veteran) Others preferred that peer support primarily function as supportive aftercare because peer support could encourage continued practice of therapy skills: “Something to keep us on track … if no one reminds of you of something you forget. And you may not have worked on everything. Like that list my therapist wrote out that I'm supposed to work on. I haven't done all of them.” (Male Vietnam Veteran) Overall, Veterans were very positive about PTSD peer support and noted a variety of potential benefits. DRAWBACKS OF PEER SUPPORT Veterans noted that potential drawbacks were primarily related to the individual personalities of the group members. “There's one person that just has to talk and talk and talk and talk. And you're like, ‘Okay, you say the same thing every time. Can somebody else talk?’” (Female Veteran with MST) Some feared that Veterans may attend peer groups for reasons of secondary gain or having a social outlet rather than focus on recovery, or would only sporadically attend thus compromising group cohesion. Many expressed that a strong group leader could reduce these problems. “Let it be known it's no BS and you know if you're coming, you're coming to get better. You're coming to get treatment.” (Male OEF/OIF Veteran) Several felt that social anxiety or difficulty trusting others would make them reluctant to attend. However, some also recognized that this is part of why peer support groups could be so helpful: “I think that would be a good thing to have, even though I hate to go to groups. It's just getting to know a whole new group of people and it's hard, but I think that would be something that would probably help me more.” (Male OEF/OIF Veteran) Two Veterans expressed that racial, religious, or sexual orientation prejudices could become problematic unless a group leader clearly indicated that intolerance would be unacceptable: “It's an underlying pink elephant on the floor that doesn't get addressed … the releaser is, ‘Am I safe? Am I safe against being judged?’” (Female Veteran with MST) Overall, Veterans foresaw few drawbacks to peer support. PREFERRED PROGRAM CHARACTERISTICS Preferences for Peer Support Group Composition A nearly complete consensus emerged that separate groups should exist for combat and sexual trauma survivors. Unfortunately, the minority of Veterans with PTSD from other types of events (i.e., accidents) do not fit into either category. Combat Veterans in particular often rejected being in a group with Veterans who had noncombat trauma: “I do believe I'm a little bit different because I was in combat … And because of that there are certain people I don't think I can talk to about certain things.” (Male Vietnam Veteran) The majority of male Veterans and combat Veterans were supportive of mixed-gender groups, stating that females could bring in broader perspectives and that combat status trumped gender as a marker of belongingness. Female Veterans, however, strongly felt the option of separate gender groups was necessary. “I think some people may be so uncomfortable in a mixed environment that they'll just shut down.” (Female Veteran with MST) One potentially problematic issue may be the intersection of gender and trauma type. Female Veterans with MST expressed both pros and cons of having an MST group with both males and females. For example, not all women felt safe in a group with men. On the other hand, some pointed out benefits to gender integration. “It would be welcome to learn how a man deals with things like (MST) … I wouldn't mind being in a group with some understanding men.” (Female Veteran with MST) Most Vietnam Veterans were in favor of including Veterans of all eras in the same group: “There's no camaraderie like combat camaraderie. And it doesn't matter what branch of service; it doesn't matter how old you are; it doesn't matter what war you were in.” (Male Vietnam Veteran) Vietnam Veterans were interested in using their own experiences as a cautionary tale: “I would tell them: ‘Don't do it like I did—if you don't want the same results, don't do it like I did.’” (Male Vietnam Veteran) Although some OEF/OIF Veterans agreed, they were more likely to prefer to segregate by service era, citing the likelihood of competition between Veterans of different war eras. “It just creates this environment where they want to say, ‘Well we did this and you guys didn't have to because you’ and it always ends up like that.” (Male OEF/OIF Veteran) Overall, it appears that Veterans with MST, female Veterans, and OEF/OIF Veterans may benefit from the option of separate groups. Preferred Peer Provider Characteristics All Veterans agreed that group leaders should have a similar trauma type to group members. Although some preferred having groups jointly led by peer providers and professional providers, most felt the opposite: “They need to be Veterans first; professionals second” (Male Vietnam Veteran). Veterans hoped that the peer provider would be able to share information about their own trauma and recovery, but also emphasized the difference between peer providers and therapists. “You're not sharing your education; you're sharing your experience…there is a place for both of them” (Male Vietnam Veteran). Many also expressed that the provider would have to find the balance such that they could “lead and not dictate … kind of easy going but can still stay on track.” (Female Veteran with MST) Finally, Veterans hoped that the peer provider would be someone who is a natural leader, “charismatic,” “positive,” who could “motivate folks.” Preferred Topics Discussed in Peer Support Veterans believed that peer support group content should be guided by the leader but also organically from the group members. The majority of Veterans were interested in discussing traumatic experiences, hoping that feedback from others would help them process or relieve guilt. However, many agreed that no Veteran should feel pressured to share trauma details, and a minority preferred not to discuss trauma. Several Veterans hoped that the peer support program would involve social events or outings: “Something where Veterans can meet up instead of just coming to the VA and sitting around. They need to go out and do things: go to a park, go to the zoo, go to a ball game.” (Male OEF/OIF Veteran) Others believed that these needs could be met by having the encouragement provided by a peer group to attain life goals. “I think the approach should be like, what do you think is important for you? Where do you see yourself three years, five years from now?… and then come up with different ways to help you get there. And then come back and bring what you accomplished or what you're still working on.” (Male OEF/OIF Veteran) Finally, some hoped that a peer support group might be a place to share information and resources, such as employment leads, Veterans' community events or programs, or filing for disability. DISCUSSION This study indicates strong Veteran interest in peer support, noting a variety of potential benefits consistent with prior peer support research: providing social support, normalization and hope, and purpose and meaning.10,13 Veterans also believed that peer support might complement treatment at three time points: before entry into care, to increase initiation of psychotherapy; during care, to encourage adherence; and after care, to provide for maintenance of skills learned. These peer provider roles are particularly important given the reluctance of some Veterans to initiate treatment due to stigma and treatment-discouraging beliefs,17 attrition rates for psychotherapy, including PTSD treatments,9 and the fact that many Veterans who complete effective PTSD treatments often remain symptomatic.9 Veterans foresaw few drawbacks to peer support, and highlighted the need for a peer leader skilled at managing groups to mitigate these potential drawbacks. They expressed a variety of preferences about program characteristics, suggesting that Veterans with MST, female Veterans, and OEF/OIF Veterans may benefit from separate groups. Many wanted to discuss both traumatic experiences and nontrauma topics, including current life goals. Limitations and Future Directions This qualitative study was limited to Veterans treated for PTSD in a VA PTSD clinic to provide insight into how peer support might fit into existing treatment programs. However, it is possible that other Veterans might have a different perspective. Although peer support is a promising direction valued by Veterans, more research is needed to examine patient satisfaction with peer support and its effectiveness, as well as the most effective structure and format of peer groups. ACKNOWLEDGMENTS This research was supported by a pilot grant from the Department of Veterans Affairs South Central Mental Illness Research Education and Clinical Center (MIRECC) and partially supported by the Office of Academic Affiliations VA Advanced Fellowship Program in Mental Illness Research and Treatment and the VA HSR&D Houston Center for Innovations in Quality, Effectiveness and Safety (No. CIN 13-413), Michael E. DeBakey VA Medical Center, Houston, Texas. REFERENCES 1. Miyamoto Y, Sono T Lessons from peer support among individuals with mental health difficulties: a review of the literature. Clin Pract Epidemiol Ment  2012; 8: 22– 9. Google Scholar CrossRef Search ADS   2. Pfeiffer PN, Heisler M, Piette JD, Rogers MA, Valenstein M Efficacy of peer support interventions for depression: a meta-analysis. Gen Hosp Psychiat  2011; 33( 1): 29– 36. Google Scholar CrossRef Search ADS   3. 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Stecker T, Shiner B, Watts BV, Jones M, Conner KR Treatment-seeking barriers for Veterans of the Iraq and Afghanistan conflicts who screen positive for PTSD. Psychiatr Serv  2013; 64( 3): 280– 3. Google Scholar CrossRef Search ADS PubMed  Reprint & Copyright © Association of Military Surgeons of the U.S.
TI - Veterans' Perspectives on Benefits and Drawbacks of Peer Support for Posttraumatic Stress Disorder
JF - Military Medicine
DO - 10.7205/MILMED-D-14-00536
DA - 2015-08-01
UR - https://www.deepdyve.com/lp/oxford-university-press/veterans-perspectives-on-benefits-and-drawbacks-of-peer-support-for-a4O2pwqDh0
SP - 851
EP - 856
VL - 180
IS - 8
DP - DeepDyve
ER -