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 2
HOW COMMUNITIES CAN HELP VETERANS WITH PTSD

Abstract

How can communities better help veterans who are suffering from PTSD? Veterans of

our United States Military have long been affected by their service. What used to be called “shell

shock” or “battle fatigue” is known today as Post-Traumatic Stress Disorder. They face a great

deal of stigma surrounding their PTSD and there are a variety of barriers to getting the care that

they need. Often, family members want to help but don’t know how. This paper looks into the

ways community members and family members of a veteran with PTSD can help him or her

assimilate into civilian life and cope with PTSD. Data collected will include a literature review

on what has already been tried successfully, what therapies are available, and a review of

resources available to help veterans.

Key words: Veterans, Post-Traumatic Stress Disorder

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HOW COMMUNITIES CAN HELP VETERANS WITH PTSD
Trauma

A traumatic event can be a war, natural disaster, rape, a very serious accident, and more,

and often threatens survival. Because of the severe nature of trauma, for many, the event isn’t

over once it’s over. In the words of Bessel Van Der Kolk, an expert in the field, “…trauma is not

just an event that took place sometime in the past; it is also the imprint left by that experience on

the mind, brain, and body” (2015). After a traumatic event, some people cope well and are able

to move on. For many others, trauma impacts their lives severely, and can interfere with day-

today life.

To understand trauma, it’s helpful to look at how the brain reacts when faced with a

traumatic situation. The Polyvagal theory, developed by UNC Psychiatry Professor and trauma

expert Stephen Porges does just that. His theory postulates that our autonomic nervous system

has three branches, each of which is one possible response to trauma (Porges). One is

immobilization, one is fight-or-flight, and the third, found only in mammals, is a social

engagement system that detects signs of safety and communicates them (Porges).

Trauma, while physically invisible, has the power to affect the brain and body of an

individual in many ways. Trauma often involves the release of cortisol and adrenaline,

commonly known as stress hormones, in high doses and over long periods of time, (NICABM

2014) explains Dan Siegel, clinical professor of Psychiatry at UCLA school of medicine. While

these chemicals are meant to prepare our body for flight-or-flight to save us from life-threatening

situations, high doses of these chemicals can be toxic and alter brain function (NICABM 2014).

PTSD in History

Wars have been fought all throughout history, and soldiers have been affected by battle

all throughout history, but Post-Traumatic Stress Disorder, or PTSD, is a relatively new term.
 4
HOW COMMUNITIES CAN HELP VETERANS WITH PTSD
PTSD was always present, but only recently recognized. In the early 1900’s, it was given many

names, most commonly “battle fatigue”, shell shock”, “battle neurosis”, and more. Throughout

history, little was known about how to help returning soldiers suffering from “battle fatigue”, and

soldiers often came home to little help and suffered at the hands of their memories.

World War I produced the first diagnoses of “shell shock”, and the associated symptoms

were paralysis, blindness, and problems with sense of hearing, speech, and memories (Lovelace

2019). By World War II, one researcher described the symptoms of shell-shocked soldiers to be

cognitive disorder, emotional struggles, physical complaints, and hysteria (Lovelace 2019).

During World War I and World War II, it was commonly thought in the military that “battle

fatigue” only required hospitalization once total immobilization had been reached (Lovelace

2019). Another common belief was that a true case of “battle fatigue” rendered a solider

completely out of control in his actions (Lovelace 2019). This led to the unfortunate attitude for

many that soldiers were cowards or were faking “battle fatigue” and wanted an easy out. Soldiers

with a range of mental problems from their military service were all grouped as “shell shock”

and little treatment was available to them.

General George Patton, who served in both World Wars, had a view of shell shock that

was typical of the time. Little information was available, but he did read a French medical review

of shell shock that suggested physical pain as a response to shell shock (Lovelace 2019). General

Patton is widely known for two incidences of slapping a supposedly shell-shocked soldier. The

first soldier, Private Charles Kuhl, was hospitalized after being very nervous, unable to stay on

the front lines, and sensitive to the noise of the weapons (Lovelace 2019). When General Patton

was making rounds on the hospitals, he encountered Private Kuhl, who said he “just couldn’t

take it anymore” (Lovelace 2019). General Patton responded by slapping Private Kuhl across the
 5
HOW COMMUNITIES CAN HELP VETERANS WITH PTSD
face with his gloves and kicking him out of the hospital (Lovelace 2019). Undoubtedly, General

Patton’s actions were a result of the degree of medical knowledge available at the time. Later,

Private Kuhl was diagnosed with diarrhea and Malarial Fever (Lovelace 2019). General Patton

likely mistook Private Kuhl’s malarial fever symptoms for symptoms of hysteria associated with

shell shock. Today, Private Kuhl’s sensitivity to the weapon sounds would be well-known as a

common PTSD symptom.

PTSD Today

In the twenty-first century, Post Traumatic Stress Disorder is defined by the American

Psychological Association as “… a psychiatric disorder that can occur in people who have

experienced or witnessed a traumatic event such as a natural disaster, a serious accident, a

terrorist act, war/combat, rape or other violent personal assault” (American Psychiatric

Association). An estimated 3.5% of American adults have PTSD, and it affects approximately

double the number of men as it does women (American Psychiatric Association).

PTSD has a variety of symptoms, many that lead the individual to avoid any reminders of

the original traumatic event. The American Psychiatric Association divides the symptoms of

PTSD into four categories. The first is intrusive thoughts. A person living with PTSD may often

experience unwanted thoughts and memories surrounding the traumatic event. These can take the

form of very vivid flashbacks that feel realistic to the person with PTSD. The second category is

avoiding reminders of the traumatic event. This could be an avoidance of a person, event, place,

objects, or scenarios. The third category is negative thoughts and feelings. A person with PTSD

may suffer from very negative self-blaming thoughts, as if they believe they could have stopped

the event if they tried hard enough. They may experience a new perception of the world around

them, with much more fear and sense of danger than before. They may have comorbid
 6
HOW COMMUNITIES CAN HELP VETERANS WITH PTSD
depression or anxiety. The fourth category of symptoms is arousal and reactive symptoms.

People with PTSD may become hyperaware of their surroundings and startle at the smallest

noises that are unexpected. Problems with memory and sleep patterns may also occur, as well as

anger, and reckless or self-destructive behaviors.

Because military service often involves exposure to and participation in violent combat

and other scenarios that are highly traumatic, military veterans develop PTSD at an alarmingly

high rate. It’s almost impossible to pin down an exact number, but on average, military veterans

suffer from PTSD at approximately ten times the rate of civilians (Wharton, et al., 2019). While

the number of military veterans seeking care for PTSD has seemed to increase in recent years,

the VA estimated in 2016 that a third of veterans diagnosed with PTSD were treated for it

(Wharton, et al., 2019). Why are so many veterans suffering from PTSD without receiving care?

There are many barriers to receiving adequate care, including stigmatization, lack of support,

gender biases, and more.

Barriers to Care

Stigma

One of the biggest reasons that military veterans do not seek help for their mental health

is the stigma that surrounds mental health care in the Unites States. Veterans do not come home

to a world that understands their trauma and is ready to help them heal. Not every veteran who

serves develops PTSD and needs services, so it is easy for a veteran suffering from PTSD to

compare himself or herself to a fellow veteran and wonder, “Why can’t I be fine? Why do I face

these internal struggles, and he or she doesn’t?”. Veterans may feel ashamed or weak for needing

help, especially if they are comparing themselves to their fellow veterans with different

experiences and diagnoses. Even in a case where two veterans both develop PTSD, they will
 7
HOW COMMUNITIES CAN HELP VETERANS WITH PTSD
likely have a different presentation of symptoms that could lead each to believe that the other

doesn’t have PTSD. This sometimes leads to veterans thinking that it’s “all in their head” and

that they can just “snap out of it”.

In addition to their own insecurities, veterans interviewed reported that the military

culture was one that mocked people who used mental healthcare services and told soldiers to

“suck it up” (Cheney 2018). Veterans were afraid of being labeled “crazy” or being thought of as

weak among their peers for using mental healthcare services. Some expressed a distrust in the

confidentiality of mental healthcare services, afraid of their diagnoses and private details of their

service being leaked, potentially causing embarrassment, lack of security clearance, and other

issues (Cheney 2018). Many veterans struggle to cope with some of their own actions during

their service and do not want anyone to know about them, lest they be judged.

For people suffering from PTSD, having a strong support system is pertinent. Doctors,

therapists, psychiatrists, support groups, sponsors, parents, friends, and spouses can all be

invaluable sources of support and encouragement for a veteran. Professional support persons,

like therapists and doctors, have medical and psychological training that lends an understanding

of PTSD and can offer positive support and healthy coping strategies. Personal support persons,

like friends and spouses, often lack that training and don’t know how to help their loved one. In

some cases, personal support persons may offer well-meaning advice or suggestions that are

actually harmful or discourage care.

In 2019, a study was published by Thompson-Hollands, et al., on the role of support

persons in veterans’ therapies. The study found that not only can a veteran’s relationship with his

or her significant other influence whether or not he or she seeks mental health treatment, but

having a loved one who encourages the veteran to face situations or events that make them
 8
HOW COMMUNITIES CAN HELP VETERANS WITH PTSD
nervous or uncomfortable, veterans were twice as likely to finish their treatment (Prolonged

exposure therapy and cognitive processing therapy were the two therapeutic modalities studied).

In prolonged exposure therapy and cognitive processing therapy, facing things that make the

client uncomfortable and nervous plays a large part in treatment (Thompson-Hollands 2019.

Because of the upsetting nature of the therapies, along with other reasons, veterans sometimes

start treatment but do not finish.

The role of the support person was found to be very important to veterans, and many

veterans wished for increased family participation in their therapy (Thompson-Hollands 2019).

For some veterans, their families or support person may have psychology training or trauma-

informed care training and be able to support their veteran in a helpful way. In some cases,

though, families or support persons may not know how to help their veteran and may end up

supporting negative coping skills or being counterproductive.

Accessibility of Resources

Another barrier that veterans face when accessing mental health care treatment is a lack

of resources. In many rural communities, it can take forty-five minutes or more of travel to reach

a mental health care treatment facility. For some veterans, this can be a barrier if their schedule

does not easily allow for long drives. Often, though, the resources just are not plentiful enough to

keep up with the growing demand for mental health care services. This is true for many facets of

the mental health care industry, from eating disorder treatment to addiction counseling. Many

therapists, both in private practices and in clinical settings, have a full client caseload and have a

lengthy waitlist. The mental health care industry in the US is often overburdened and new clients

cannot find care immediately. For some, this could mean waiting months to receive much-

needed care. In one female-focused study, up to 40% of female veterans reported not always
 9
HOW COMMUNITIES CAN HELP VETERANS WITH PTSD
being able to get an appointment for mental health care as soon as they need it though the VA

(article 6). Six percent of women reported never being able to get an appointment as soon as they

need it, which is a concerning statement.

One interview revealed that may veterans don’t have faith in the mental healthcare

provided by the VA (Cheney 2018). One study found that as low as 20% of veterans use VA

healthcare as their primary healthcare provider, (Fuehrlein, B., et al. 2016) demonstrating

veterans’ lack of faith in the system. Interviewees reported having difficulty scheduling

appointments promptly, getting follow-up care, staying at the same facility, or even with the

same provider (VA healthcare facilities are often understaffed with a high turnover rate, possibly

from burnout) which lowered veterans’ confidence in VA mental healthcare. Additionally, many

reported that even before enrolling in VA healthcare, they struggled to understand their insurance

coverage options and steps to enroll. They were not educated on enrollment prior to leaving

service, and did not understand which forms to use to get the care they needed. Once enrolled,

they still experienced trouble understanding their benefits and how to use the system to meet

their needs (Cheney 2018).

Another surprising barrier to care is a concern that veterans voiced about the military’s

policy to deny security clearance to service members who are known to use VA mental

healthcare services (Cheney 2018). This is likely due in part to the military culture of mocking

those who use mental healthcare services and of thinking of people using services as “weak”. It

is possible that higher-up service members create and sustain this culture on purpose to

discourage the use of services for mental healthcare.

Beyond the overburdened mental health care industry struggling to meet the growing

need for services for veterans, there are cultural differences in mental health treatment. Some
 10
HOW COMMUNITIES CAN HELP VETERANS WITH PTSD
cultures view mental healthcare treatment as an admittance of weakness, and this could cause

veterans not to seek the help they need. Another factor is racism—unfortunately, racism can

play a part in getting treatment for those of ethnic minorities in some cases. It has been indicated

that veterans who identify as African American, Latino, and Asian or Pacific Islander are less

likely to receive treatment for PTSD at the same rates as white veterans, even after controlling

for veteran’s individual treatment beliefs, access to treatment, and the scope of treatment needed

(Spoont, et al., 2017).

Steps Toward Better Care

How do we start to tackle the mountain of barriers to mental healthcare for veterans? A

great start would be to dismantle the stigma in the US about mental health. The US has a

negative stigma that those who struggle with their mental health are “making it up” or wanting

attention or are “crazy”. Fear of mental health often comes from a lack of understanding. More

education is needed about mental health disorders, treatments, and care. This isn’t true only for

the US. Some veterans of ethnic minorities come from other countries or are part of cultures that

originated in other countries where there is greater stigma about mental health. Some countries

have the belief that mental health isn’t something to be talked about, and when service members

have those beliefs, it makes it difficult for them to get the care they need. By increasing

awareness and spreading education about mental health worldwide, we can start to change

cultures worldwide to be more accepting of diverse mental health and start increasing treatment

for those who need services.

The younger generations are starting to advocate for more mental health acceptance and

understanding on social media, which may help veterans of the younger generations feel more
 11
HOW COMMUNITIES CAN HELP VETERANS WITH PTSD
encouraged to seek treatment. Posts often circulate on social media sites urging readers to take

care of their mental health, and to see a therapist if they feel it would help.

Simultaneously with destroying the negative stigma of receiving mental healthcare

treatment, the US needs some changes to make the mental healthcare industry better suited to

handle the demand for services. Training more therapists and counselors in different specialties

would decrease waiting lists and make veterans more likely to be able to access a timely

appointment when needed. Opening more clinics and centers for mental health would also

increase service availability. The idea of urgent care clinics, but for mental health, is new. The

development would be invaluable to veterans who are suffering and cannot access timely

appointments.

Another way to help veterans with their mental health is to educate their support persons-

friends, family, significant others, parents, and children of veterans. Since we know that support

persons often want to help their veteran, but don’t know how, we can conclude that support

person education could be beneficial. Greater online resources could be available to support

persons wondering how to help their loved one with a recent diagnosis of depression, anxiety,

PTSD, or any other common mental health problem for veterans. There are already online groups

of military wives and spouses. If we take this idea of a support group and make it an in-person

support group with an instructor/leader trained in trauma informed care, we could help many

veterans’ support persons feel more confident about handling their loved one’s diagnosis and

trauma. This could help support persons feel more connected to their loved veteran, and in turn,

help their veteran feel less alienated and alone in their trauma, and hopefully help them feel more

understood and supported in handling it.

 12
HOW COMMUNITIES CAN HELP VETERANS WITH PTSD
Family members and spouses aren’t the only supportive people in a veteran’s life who

could benefit from additional training. Mental healthcare providers are sometimes uninformed on

military culture and norms, and this could lead to service members and veterans feeling

estranged and misunderstood when trying to seek treatment. For care centers and clinics, hosting

professional development sessions specifically geared toward care of veterans and the unique

struggles they face could increase understanding and ultimately improve treatment for veterans.

Another way to better prepare mental health professionals for unique needs of veterans is

to have classes on veterans’ studies at universities at the undergraduate and graduate levels.

Many of our mental health professionals are coming from 4-year universities that do not have

any specialized classes in veteran’s studies and how to help them with their unique struggles

post-service. Having a specialized concentration available, as well as specialized classes, in

undergraduate and graduate programs would help better prepare mental health professions to

meet the needs of their clients, and perhaps increase the number of mental health professionals

available.

Veteran Alcohol Use

Veteran returning home face many issues, from mental health, to adjusting to a new

environment and their new role in it, to re-building their social lives, to finding new employment.

This can create a very stressful situation for returning veterans, particularly those with intense

mental health issues. Some veterans cope with these issues by drinking, and while it relieves the

stress temporarily, it often is the start of a much bigger problem that leads to alcohol use

disorder. Having mental health problems even in the general population can lead to an increased

risk of a co-morbid Alcohol or Substance Use Disorder, but especially for veterans who have

spent years immersed in military culture that promotes heavy drinking, it’s easy to see why
 13
HOW COMMUNITIES CAN HELP VETERANS WITH PTSD
veterans are prone to Alcohol Use Disorder. The American Psychological Association reports

that persons with Alcohol Use Disorder have no reliable control over their drinking and often

cannot stop drinking once they’ve started (2012). The APA characterizes alcohol use disorders in

part by a person’s heightened tolerance to alcohol and the presence of withdrawal symptoms

once the person is sober (American Psychological Association 2012).

The lifetime prevalence of Alcohol Use Disorder for veterans is estimated at forty-two

percent (Fuehrlein, B., et al. 2016). This translates to 2 out of 5 veterans having Alcohol Use

Disorder at some point in their lives. For a one-year snapshot, approximately fifteen percent of

veterans have Alcohol Use Disorder. How do these numbers compare to general population

statistics? The lifetime prevalence of Alcohol Use Disorder for the general population is

estimated at thirty percent, a 25% decrease from the rates for veterans (Fuehrlein, B., et al.

2016). In 2018, the National Institute on Alcohol Abuse and Alcoholism estimated that

approximately five percent of adults had Alcohol Use Disorder in a single-year snapshot, and

that it was more prevalent in men than women. The NIAAA’s estimation was conducted from a

sample of adults in the general population, which includes veterans, so the comparison isn’t truly

of veterans to civilians, but it does a good job at showing the increased rate of Alcohol Use

Disorder in veterans.

One important study on veterans’ heightened alcohol use examined common co-morbid

disorders and life factors that are correlated with Alcohol Use Disorder using data from the

National Health and Resilience in Veterans Study (Fuehrlein, B., et al. 2016). The study found

that Alcohol Use Disorder in veterans is associated with higher rates of drug use disorders,

suicidality and suicide attempts, and comorbid psychological disorders, such as Depression,

Post-Traumatic Stress Disorder, and Anxiety disorders. Being younger in age, of the male sex,
 14
HOW COMMUNITIES CAN HELP VETERANS WITH PTSD
and lower education levels were also found to be associated with Alcohol Use Disorder. A

similar study found an association between Substance Use Disorders (including alcohol and

other drugs) and increased suicidality. Going a step further, this study controlled for sex, and

found that the association is even stronger in females than in males (Bohnert 2017). The reason

for the difference in sex is not identified, but the information can be valuable to mental

healthcare professionals and for future research.

How can we help veterans suffering from Alcohol Use Disorder? There isn’t one clear-

cut answer to solve the problem, but several steps that can be taken to help. The first way is to

start at the source, before the Alcohol Use Disorder takes hold. Military culture often normalizes

heavy drinking, and this can be the start of post-service alcohol abuse. Behaviors like binge

drinking and blacking out from drinking occur regularly and aren’t seen as the dangerous

behaviors that they are. Increased education about the dangers of alcohol abuse is a good start for

the military, as well as having substance use counselors more readily available.

Increasing mental healthcare services available while service members are in active duty

could help improve mental health and prevent or slow the course of mental illnesses, to decrease

the chances of veterans self-medicating later in life. Improving mental healthcare available to

veterans both during active duty and post-service has the potential to curb Alcohol Use Disorder

and lessen symptoms in part because other mental illnesses are often co-morbid with Alcohol

Use Disorder, so by treating the comorbid mental health challenges, a more healthy person

overall is created, and this leaves veterans in better health and more able to appropriately address

their problematic drinking.

Alcoholics Anonymous can be a helpful resource for veterans struggling with alcohol

abuse, but we know that veterans are sometimes hesitant to use mental healthcare services
 15
HOW COMMUNITIES CAN HELP VETERANS WITH PTSD
because of the stigma surrounding them. There are a lot of negative stereotypes about alcoholics,

such as them being lazy, uneducated, unwilling to fix themselves, fragile, or weak, and these are

all stereotypes that could deter a veteran from AA services, or make him or her believe that they

don’t “fit in” with the AA crowd, and therefore shouldn’t use their services.

A possible solution is to have an AA group that is meant specifically for veterans. This

could help them feel more as if they belong, and less alone in their struggles, by surrounding

them with fellow veterans facing the same struggle.

Veteran Suicide Rates

Suicide is a leading cause of death among the general population, ranked tenth among the

general US population (Centers for Disease Control and Prevention 2019). For veterans, who we

know have higher rates of mental illnesses, suicide rates are approximately 50% higher than the

general population (Hammond, et al., 2013). In the general population, an individual’s risk for

suicide increases if he or she has mental illnesses, and this is true for the veteran population as

well. Because veterans are prone to service-related disorders, such as depression, anxiety, Post-

Traumatic Stress Disorder, and substance use disorders, among others, this accounts for some of

the difference in suicide rates between the general population and the veteran population.

While mental illnesses are correlated with increased risk for suicide, there is also research

that the correlation works in the opposite direction, too. An article by Cerel, et al., published in

2015, found that half of veterans had been exposed to suicide. Cerel and colleagues found that

those who were exposed to suicide had double the chance of having depression, and more than

twice the risk of having anxiety, compared to their peers who have not been exposed to suicide.

Additionally, having been exposed to suicide made veterans more than twice as likely to report
 16
HOW COMMUNITIES CAN HELP VETERANS WITH PTSD
suicidal ideation than those who were not exposed to suicide. Increased closeness to the person

who committed suicide predicted worse outcomes.

When veteran suicide is discussed, it cannot be thought of in the same way as civilian

suicide. When precipitating factors and risk profiles were analyzed between veteran and non-

veteran populations in relation to suicide, substantial differences were found (Wood, et al., 2020)

that can be helpful in implementing suicide prevention strategies for veterans. Some

recommendations for suicide prevention include increasing economic support to ensure housing

stability, ensure insurance coverage for mental illness treatment, reduced access to means of

suicide, (guns, poison, etc.) increase community engagement, education on positive coping

skills, and strengthening of interpersonal relationships (Centers for Disease Control and

Prevention, 2013).

There are a lot of available resources on the internet for veteran suicide prevention. But,

with any resources available on the internet, some are of higher quality than others. When these

available resources were evaluated for safe messaging, usability, readability, and credibility,

researchers found that many were lacking in readability and credibility and could be improved

with more safety information about lethal means (Chen, et al., 2019).

Because the problem of veteran suicide scaffolds off of other mental health problems

among veterans—like poor access to healthcare, mental health stigma, and substance use and

dependency—the solution to the problem of veteran suicide scaffolds, likewise, off the solutions

to other mental health problems among veterans. If appropriate adjustments are made to improve

veterans’ mental health concerns, in turn, the rate of veteran suicides would decrease.
 17
HOW COMMUNITIES CAN HELP VETERANS WITH PTSD
Therapy Modalities

Because Post-Traumatic Stress Disorder has only in recent years been properly named

and identified, therapy modalities suitable for veterans with PTSD (and possibly other comorbid

mental illnesses) are still being developed and researched.

EMDR Therapy

One of the newest promising therapy modalities is eye-movement desensitization and

reprocessing, or EMDR. The creator of EMDR, Francine Shapiro, was taking a walk in the

woods and happened to notice that her anxiety settled after performing quick side-to-side eye

movements. After trying this technique with her patients and observing success, EMDR was

born. Side-to-side eye movement is the hallmark of EMDR therapy, thought the technique has

grown considerably since its birth in the woods (Whitehouse 2018).

EMDR is an eight-step therapy process, comprised of history and treatment planning,

preparation, assessment, desensitization, installation, body scan, closure, and re-evaluation

(Whitehouse 2018). This is based on the idea that traumatic memories are unique in the way they

are stored and cannot adapt (Whitehouse 2018). There have been claims that EMDR is an

effective therapy for many different types of trauma and mental illnesses, veterans and PTSD

among them. After comparing many different peer-reviewed studies of EMDR being performed,

Whitehouse confirmed that while more research is still needed, particularly in sub-groups of

population who may benefit from EMDR, it has potential to be an effective therapy, if done

correctly (2018).

Even with research supporting EMDR as an effective therapy, there are multiple

competing therapies. One is Cognitive Behavioral Therapy, or CBT. CBT is sometimes thought
 18
HOW COMMUNITIES CAN HELP VETERANS WITH PTSD
of as “traditional” therapy and is one of the most common therapy modalities offered today.

There are subsets of CBT, such as Trauma-Focused CBT (TF-CBT) and Integrated CBT (ICBT).

CBT has proven effective for veterans as well as for children of veterans, who are in a unique

position that leaves them vulnerable to a few traumas and mental illnesses (Ridings, Moreland, &

Petty 2019). One study, however, suggested that ICBT may be less effective for veterans than in

the general population, (Capone, et al. 2018) but since that study was limited to only Iraq and

Afghanistan veterans who has comorbid PTSD and Substance Use disorders, the results of that

study cannot necessarily be generalized to compare the effects of CBT for all veterans to the

effects of CBT for the civilian population. In the interest of finding the superior therapy

modality, Moghadam, et al., set up a study in 2020 designed to test the effectiveness of EMDR

and CBT on veterans with PTSD.

After gathering a sample of eighty veterans who all met the criteria for PTSD based on

the Mississippi Post-Traumatic Stress Disorder Questionnaire, forty subjects were randomly

assigned to receive EMDR therapy, and forty were randomly assigned to receive CBT therapy.

Each group underwent eight weeks of therapy. The treatment methods for both EMDR and CBT

therapy were uniform, to ensure reliable data. The results found that when comparing both

therapy groups to a control group, both therapies were effective in treating PTSD. When

comparing CBT and EMDR directly, EMDR was proven to be more effective in treating PTSD

(Moghadam 2020).

EMDR is a relatively new therapy modality but shows promise in treating PTSD in

veterans. While more research is needed to support effectiveness claims and find the best

deliverance, making the therapy more accessible to veterans could certainly help those suffering

from PTSD.
 19
HOW COMMUNITIES CAN HELP VETERANS WITH PTSD
Prolonged Exposure Therapy

Prolonged exposure therapy is another fairly recent therapy modality that has shown

some promise in treating clients with trauma. According to the American Psychological

Association, prolonged exposure therapy is based on the idea that symptoms of PTSD can be

reduced by changing the client’s response to fearful stimuli. Many people with PTSD avoid any

reminder of their trauma that occurs in their environment, because they interpret the stimuli as

fearsome (American Psychological Association 2017). A famous example is trauma surgeon

Owen Hunt of Grey’s Anatomy. The combat veteran from Iraq suffered from PTSD and actively

avoided stimuli that reminded him of his trauma. One night, Owen awoke to the blades of the

ceiling fan spinning, and the stimuli reminded him of a helicopter in Iraq. Because he interpreted

the stimuli as fearsome, he reacted by choking his sleeping partner (McKee, 2009). If the client’s

response to these stimuli can be neutralized, the symptoms of PTSD have been shown to

decrease. In the case of Owen Hunt, the goal would be for him to be faced with the fearful

stimuli (the blades of the ceiling fan spinning) and to not have a fearful reaction (American

Psychological Association 2017).

Initial sessions typically involve psychoeducation, where a background of trauma and the

prolonged exposure process is explained to the client (American Psychological Association

2017) (Tuerk, et al., 2011). A trustful therapeutic relationship is important, given the nature and

difficulty of the therapy. The prolonged exposure comes in two forms, imaginal exposure, and in

vivo exposure. Imaginal exposure is done in session with the client and therapist together. The

client vividly pictures the traumatic experience as if they are re-living it, and describes it in

detail. Together, the therapist and client talk about emotions that occur as the client is imagining

the traumatic experience, and process the emotions as they come up. Sessions are audio recorded
 20
HOW COMMUNITIES CAN HELP VETERANS WITH PTSD
so that they client has access to them at home to continue processing emotions (American

Psychological Association 2017).

In vivo exposure is the at-home counterpart of imaginal exposure. The client and

therapist together come up with possible stimuli to confront that are relevant to the client’s

trauma. Exposure should be gradual so as to set the client up for success and to have a positive

experience (American Psychological Association 2017). In the case of Owen Hunt, the stimuli

would the fan blades spinning, perhaps on a low setting, and to face the stimuli during the day in

a calm setting to retain control over his emotions and make it a positive experience (McKee

2009) (American Psychological Association 2017). These at-home confrontations of fearsome

stimuli are assigned as “homework” between therapy sessions.

One study in 2011 sought to analyze the effectiveness of prolonged exposure therapy

specific to Afghanistan and Iraq veterans (Tuerk, et al). The study treated 65 veterans from

Operation Enduring Freedom and Operation Iraqi Freedom and used a self-assessment before

and after therapy measuring PTSD symptoms as they’re listed in the DSM-IV. Results showed

that the treatment significantly reduced PTSD symptoms, and that the therapy could be used

effectively (Tuerk, et al 2011). Their participation rates suggested that it could be a preferred

therapy modality, as the dropout rate was relatively low (Tuerk, et al 2011).

Studying dropout rates of different therapy modalities is important to help clinicians

understand what makes a client more likely to dropout. Using this information, hopefully therapy

modalities can be improved to be more accessible and to minimize dropout rates and help more

veterans who need it. A recent study examining dropout rates of prolonged exposure therapy

defined “dropout” as attending fewer than the minimum number of sessions to be considered

adequate, which is 8 (Eftekhari, et al. 2020). When clinicians were asked to report dropout rates
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HOW COMMUNITIES CAN HELP VETERANS WITH PTSD
and reasons, numbers showed that the client’s amount of progress made was not a predictor of

dropping out. A majority of dropouts were unable to tolerate treatment or avoided treatment.

This category made up the largest group of dropouts. Being younger in age presented a higher

chance of dropping out, and interestingly, clients being treated for childhood traumas were less

likely to dropout than those being treated for combat trauma (Eftekhari, et al. 2020).

Prolonged Exposure therapy shows promise for treating trauma, and has been shown to

help veterans suffering from PTSD. Given the intense and difficult nature, it will not be ideal for

all veterans. The homework assignments could be another barrier that inhibits success with PE

therapy. Despite this, it is a great tool for those who can commit to homework assignments to

help reduce their PTSD symptoms.

Therapeutic Horsemanship

Veterans are as diverse a group as the civilian population, and different therapies suit

different personality types. For those who may have hesitations about traditional talking therapy

modalities or who feel the stigma of going to a therapist or mental health center, therapeutic

horsemanship offers a different approach.

PATH, INTL, stands for the Professional Association of Therapeutic Horsemanship

International. Therapeutic horsemanship can take place through therapeutic riding lessons,

driving lessons, hippotherapy, and equine facilitated learning and psychotherapy. Therapeutic

horsemanship benefits a diverse range of clients, and certainly, veterans suffering from PTSD. A

qualitative review of one therapeutic horsemanship program found that the veterans liked it for

three main reasons- the horses, the connections formed with other veteran participants, and the

difference from traditional talking therapy in an office (Krob 2016). Evidence supported the
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HOW COMMUNITIES CAN HELP VETERANS WITH PTSD
possibility for a positive, transformative experience for not just the veterans, but the instructors

and volunteers as well (Krob 2016). As for the participating equines, their body language

expressed that they were content, and veterans seemed to enjoy the connection with them (Krob

2016). The healing properties of horses are difficult to express on a page but are felt by veterans

and vulnerable populations.

Another study examined the effectiveness of equine-facilitated cognitive processing

therapy for veterans and yielded impressive results (Wharton, et al. 2019). Combining the talking

component of cognitive processing therapy with the horse’s natural ability to reflect human

emotions, EF-CPT is a powerful combination of therapies. Below is an example exercise from

EF-CPT that was used in the study.

Example session 4: Focuses on the participant telling a story of trauma, with as much

sensory detail, and emotional recall as possible. The individual will be coached and

supported in feeling emotions related to the event and continuing in the telling of the

story.

Suggested equine exercise: The participant selects and grooms a horse from the prior

sessions. As before, the horse will be held or tied as per the horse handler’s safety-based

decision and the individual will be given a curry comb as well as a soft brush and

instructed briefly on the use of these items. The participant will curry in a circular motion

and brush in lengthwise strokes during the session. Participant is aske Socratic questions

by the therapist as they groom the horse. If the participant has difficulty with the Socratic

questions about his/her memories of the event, the participant will be asked to

anthropomorphize the behavior of the horses as observed in the previous sessions, and

this can be a springboard to relate to the participant’s own memories of his/her event.
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HOW COMMUNITIES CAN HELP VETERANS WITH PTSD
(Wharton, et al. 2019).

Two pre- and post-tests were used to assess PTSD symptoms and trauma-related guilt,

and veteran participants in the EF-CPT showed improvement in both categories after completing

therapy, as well as demonstrating good bonds with their equine partners (Wharton, et al. 2019).

Equine facilitated therapy is a great alternative to traditional talk therapy, from which some

veterans are discouraged by the stigma around mental health in the US. Therapeutic riding is also

a great way for veterans to re-connect with their bodies, as it requires a keen awareness of the

rider’s body and the way it is used to give cues to the horse.

Resources Available to Veterans

The VA

One of the most well-known resources available to veterans is the United States

Department of Veteran Affairs, or the VA. The VA follows a mission statement as follows: “To

fulfill President Lincon’s promise ‘To care for him who shall have borne the battle, and for his

widow, and for his orphan’ by serving and honoring the men and women who are America’s

veterans” (United States Department of Veteran Affairs). The VA strives to meet this goal by

providing four avenues of care: a healthcare networking that serves over nine million veterans

annually, a benefits package and assistance with education, loans, and insurance, a special burial

and the maintenance of cemeteries for veterans, and to prepare the nation to respond to war and

national emergencies (United States Department of Veteran Affairs). The VA has a crisis line at

1-800-273-8255.

National Center for PTSD

The National Center for PTSD is a smaller organization that is part of the VA. It is very

informational and contains the definition and symptoms of PTSD, available treatment methods
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HOW COMMUNITIES CAN HELP VETERANS WITH PTSD
and their success rates, and an informational database to support the treatment of PTSD (United

States Department of Veteran Affairs). Through their website, a veteran can request a

consultation, as well as find information about local counselors, support groups, and coping

skills (United States Department of Veteran Affairs). Veterans aren’t the only group who can

benefit from the website- there is information for healthcare providers, as well as for friends and

family (United States Department of Veteran Affairs). The information for friends and family

makes the National Center for PTSD a particularly valuable resource because not many

resources also help friends and family. Additionally, the website has general information on

PTSD and treatment, not just information for Veterans specifically.

Liberty House

The Liberty House is a transitional living facility for homeless veterans in Manchester,

New Hampshire. It offers housing, meals, clothing, and assistance to those getting back on their

feet after serving our country. Drug tests are required and there is a zero-tolerance policy for any

substance use. Residents follow the Liberty House’s four-step model, which consists of recovery,

health and wellness, employment, and housing (Liberty House). As veterans get back on their

feet, they give half of their pay to the Liberty house from their job, if they work. When they

leave, they get their earnings back, to help jump start them into an independent life.

The Liberty House takes no federal or state funding, and relies on community donations.

These donations often come from fellow veterans, some former residents. The food pantry is

well stocked and the clothing section is quite plentiful with donated clothing items of all seasons

and sizes for those in need.

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HOW COMMUNITIES CAN HELP VETERANS WITH PTSD
Swim with a Mission

Swim with a Mission is a non-profit organization started by Phil and Julie Taub to raise money

for veterans who are in need. Their primary fundraising event is a swim across Newfound Lake

that raises money and draws a crowd of swimmers and volunteers (Swim with a Mission). Since

then, additional events have been added, like a team-building day led by Navy SEALs, followed

by a paint-ball exercise (Swim with a Mission). Focusing on changing to meet the changing

needs of veterans, the organization has shifted to focus on securing service dogs for veterans and

hosting informational fundraising events surrounding dogs at work (Swim with a Mission). The

organization conducts photoshoots and interviews with veterans to be featured on their website,

and sells merchandise as an additional fundraising effort (Swim with a Mission).

Military One Source

Military One Source is a resource for military families funded by the Department of Defense.

They do not charge for services and are available twenty-four hours a day, seven days a week

(Military One Source). Services include relationship and financial counseling, mental health

counseling, childcare assistance, document translation, access to a digital library, health and

wellness coaching, and education and career benefits for military spouses and guidance on how

to use these benefits. (Military One Source). They also have a live chat available and a crisis

line, as well as confidential help (Military One Source). This is a resource with a great deal of

knowledge for military families and can help locate resources families need.

Suicide Prevention Lifeline

For veterans who are facing a mental health crisis, the Suicide Prevention Lifeline can

offer immediate support via their crisis hotline at 1-800-273-8255. What makes the Suicide
 26
HOW COMMUNITIES CAN HELP VETERANS WITH PTSD
Prevention Lifeline a great resource is the accessibility that most resources lack. Not only does it

have the typical crisis hotline, but it caters to deaf and hard of hearing clients with a chat option

as well (Suicide Prevention Lifeline). This is a great addition, as some veterans partially or fully

lose their hearing ability in the line of duty. They also have help available in Spanish, further

increasing accessibility for those who either do not speak English or feel more comfortable

speaking Spanish (Suicide Prevention Lifeline).

The Suicide Prevention Lifeline is well prepared to help with a variety of life challenges

that callers may be struggling to cope with. They have specific resources and information

available for youth considering suicide, survivors of disasters, Native Americans, Veterans, those

who have experienced loss, LGBTQ+ individuals, and suicide attempt survivors (Suicide

Prevention Lifeline). Having these nuanced resources makes the site a great resource as veterans

may fall into several of these categories and need help coping with the culmination of them.

To help those who are struggling feel less alone, the website has a section called “Stories

of Hope and Recovery” (Suicide Prevention Lifeline). There are multiple categories of heart-

warming stories, including addiction, military sexual trauma, serious mental illnesses, anxiety,

gender identity, sexuality, borderline personality disorder, PTSD, depression, recent suicide

attempts, eating disorders, self-harm, suicidal thoughts, suicide loss survivor, and Traumatic

Brain Injury (Suicide Prevention Lifeline). This is valuable because those who suffer from

mental health problems often feel heavily stigma that may prevent them from getting help, and

these stories of hope can help them feel less alone. Visitors to the site can even find stories of

people overcoming the same thing they are struggling with, and hopefully, fell less alone and

better able to cope.

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HOW COMMUNITIES CAN HELP VETERANS WITH PTSD
Veterans Count: A Program of Easterseals

Veterans Count is a smaller organization belonging to the Easterseals Military and

Veterans Services organization, with chapters located in the Lakes Region, Manchester, Nashua,

the Seacoast, and the Upper Valley (Veterans Count). Veterans Count has partner organizations

in Massachusetts, Maine, Vermont, and Rhode Island. The organization helps with many facets

of military and veteran life, and provides substantial financial assistance for car repairs, food,

medical and dental procedures, rent and utility payments, and other needed assistance. In January

of 2020, Veterans Count provided over $28,000 in financial relief to struggling veterans and their

families (Veterans Count).

Fallen Patriots

Fallen Patriots is an organization that aspires to honor service members killed in the line

of duty by offering tuition assistance and educational counseling to the children of fallen service

members (Fallen Patriots). Fallen Patriots believes that a college education is the greatest gift

they can give to children who have lost a parent in the line of duty, and that that is the best way

to honor fallen service members. When the founder of Fallen Patriots watched a service member

die during duty just days before Christmas, and after research showed that many families of

fallen veterans struggle to make ends meet and often make less than $50,00 a year, Fallen

Patriots was founded. Affording a college degree on $50,000 per year can be very challenging,

so Fallen Patriots gives over $6,000 per year to each student (Fallen Patriots). This is a great

resource for families of veterans to help secure a brighter future for children who lost a parent in

the line of duty.

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HOW COMMUNITIES CAN HELP VETERANS WITH PTSD
Operation FINALLY HOME

For many service members, finding housing can be a challenge, especially affordable

housing for veterans who may be unable to work due to injuries sustained in the line of duty.

Operation FINALLY HOME seeks to aid these veterans by building mortgage-free homes for

veterans and their families. Most of the veterans who receive homes have been wounded or

became ill, or are families of deceased veterans, but veterans who were not injured or ill from

their service are eligible as well, as long as they were honorably discharged and have financial

need (Operation FINALLY HOME). Also on their website is a list of past families homes that

were built and stories of each veteran’s sacrifice (Operation FINALLY HOME). This is a great

resource for veterans who have a financial need for a home and who are adjusting back into

civilian life with their families.

CreatiVets

For veterans who struggle to express their feelings with words, CreatiVets offers an

artistic expression instead, through songwriting, visual arts, songwriting, and music. This can be

a great tool for those suffering from PTSD, as they are often unable to express themselves with

words, and artistic methods can be a great substitute expression. The work done at CreatiVets

has been shown to help reduce symptoms of PTSD and is accessible because it allows veterans to

seek help while avoiding the stigma associated with seeking mental health treatment

(CreatiVets).

War Paints

Created by a Navy SEAL in 2016, War Paints is an organization that encourages veterans

to use their artistic abilities to express themselves, and to develop these abilities thoroughly (War

Paints). The organization seeks to help veterans re-integrate themselves into civilian life while
 29
HOW COMMUNITIES CAN HELP VETERANS WITH PTSD
focusing on their strengths and artistic abilities rather than their limitations or struggles (War

Paints). The organization seeks to host classes and skill development workshops for veterans, as

well as accepting donation of artistic supplies. On the website, buyers can browse and purchase

art created by veterans in many artistic expressions, including photography, painting, drawing,

woodworking, and more (War Paints).

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HOW COMMUNITIES CAN HELP VETERANS WITH PTSD
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