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A new disability for rehabilitation counselors: Iraq war veterans with traumatic brain injury and post-traumatic stress disorder.

In 2002 and 2003, the George W. Bush Administration stressed that Iraq posed a danger to the safety and security of the United States through the fear that Iraq was developing an arsenal of chemical, biological, and nuclear weapons. The United States and its allies subsequently invaded Iraq in March 2003 and this conflict, commonly referred to as the "Iraq War," continues into its sixth year (Wong, 2008).

The United States has incurred massive human and financial expenditures through its involvement in Iraq. It is estimated that total spending on the Iraq war will cost the United States up to $3 trillion to fund current military operations along with the expenses of paying the long-term disability costs of injured military personnel, death benefits sent to the families of those killed in Iraq, and interest fees paid by the United States Treasury to borrow money to fund current expenditures (Bilmes & Stiglitz, 2008). More importantly, as of October 4, 2008, a total of 4,169 United States military service members have lost their lives in this conflict (U.S. Department of Defense, 2008). Further, the organization "Iraq Body Count" estimates that through mid October 2008, 88,373 to 96,466 Iraq citizens have been killed since the March 2003 invasion (Iraq Body Count, 2008).

The American public as well as rehabilitation professionals are increasingly developing awareness of these realities. In addition to television programs, newspaper stories, and radio shows, an especially effective source of awareness are first-hand accounts of the horrors and aftermaths of combat chronicled in such books as In An Instant: A Family's Journey of Love and Healing (Woodruff & Woodruff, 2007) and Rule Number Two." Lessons I Learned in a Combat Hospital (Kraft, 2007). Such accounts educate readers that those who are fighting in Iraq face the significant potential of incurring a chronic disability or illness. Two of the most common chronic conditions now experienced are traumatic brain injury (TBI) and posttraumatic stress disorder (PTSD).

TBI and PTSD are commonly referred to as the "signature" injuries of military personnel serving in the Iraq War (Fairweather & Garcia, 2007). The need to develop and facilitate specialized care and rehabilitative services for veterans impacted by this modern disability is of paramount importance. An estimated 22% of all Operation Iraqi and Enduring Freedom (OIF/OEF) combat injuries involve some form of brain damage (Summerall, 2008). Also, the California Community Foundation (2008) estimates one in five service members who engaged in OIF/OEF military operations develop PTSD or major depression.

The unique nature of how military personnel incur combatrelated injuries presents the emergence of a new disability for rehabilitation counselors and other health professionals to confront. Many combat-injured military personnel are returning from the Iraqi conflict with the simultaneous onset of both TBI and PTSD. Volatile combat conditions, which frequently entail the infliction of blast-related polytrauma, increase military personnel's likelihood to experience both conditions (Kennedy et al., 2007). Living with both disabilities presents a unique array of challenges that is distinct from singularly living with either TBI or PTSD.

The purpose of this article is to help prepare rehabilitation counselors and other professionals to address the unique needs of this emerging client population for vocational rehabilitation, independent living, and family support. Specifically, we will provide (a) an overview of the injury sequelae of TBI and PTSD, (b) the challenges in living with TBI combined with PTSD, and (c) available interventions and support services.

An Overview of the Injury Sequelae of TBI and PTSD

With over 1.6 million military personnel deployed in coordination with Operations Iraqi and Enduring Freedom (California Community Foundation, 2008), and close to 30,000 troops wounded in action (Defense Link, 2008) the need for optimal, specialized rehabilitation services for veterans impacted by the combination of TBI and PTSD is imperative. Multiple, lengthy deployments to harsh venues of battle have subsequently created a unique set of stresses for numerous active duty, Reservists, and National Guard members and their families.

Blast injuries from improvised explosive devices (IED) in the Iraq War are the most frequent causal agent of combat casualties (Levin, 2008). The consequences of IED caused blasts include primary, secondary, tertiary (Taber, Warden, & Hurley, 2006; Warden, 2006), and quaternary injuries (DePalma, Burris, Champion, & Hodgson, 2005). Primary injuries refer to the effects of the wave-induced changes in atmospheric pressure following the blast, resulting in possible damage to body parts with air-fluid interfaces, such as lungs, the bowels, and the middle ear. Secondary injuries refer to damage caused by objects put into motion following the blast and then hitting people. Tertiary injuries result from persons hitting an object or the ground following the blast. Quaternary injuries refer to complications or worsening of existing conditions. Quaternary injuries are caused by toxic inhalation, burns (chemical or thermal), exposure to radiation, asphyxiation (includes carbon monoxide and cyanide after incomplete material combustion, and breathing in dust from coal or asbestos; DePalma et al., p. 1338). One example of how quaternary injuries are caused occurs when IEDs are constructed with ball bearings coated with various poisons (M. McDonough, personal communication, March 18, 2008).

The National Center on Posttraumatic Stress Disorder estimates that 60-80% of solders who experience an lED attack blast also acquire a TBI (Summerall, 2008). Warden (2006) noted that blast-related secondary and tertiary injuries result in TBI much like this injury occurs in the civilian world through such causes as falls and motor vehicle accidents. However, the connection between primary injuries and TBI is much less clear.

TBI is characterized by trauma to the head, resulting in concussive, or closed, and penetrating injuries (Defense and Veterans Brain Injury Center, 2007). Ranging in severity from mild to severe, symptoms related to TBI comprise cognitive, somatic and behavioral problems, including concentration, attention, and memory setbacks, sleep dysfunction, headache, anxiety, depression, and irritability (Degeneffe, 2001). Persons with TBI sometimes experience anxiety-related symptoms such as extreme apprehension, interpersonal sensitivity and social alienation (Rao & Lyketsos, 2002). Mild traumatic brain injuries encompass approximately 80% of all TBIs (Summerall, 2008).

Studies also indicate that troops who have survived IED-caused blasts in Iraq report elevated rates of PTSD (Hoge et al., 2008). Given the high incidence of blast explosion attacks paired with urban combat conditions, veterans of the Iraq war often experience co-occurring TBI and PTSD, as memory of the incident, which resulted in the TBI, persists (Fairweather & Garcia, 2008). Veterans may incur PTSD due to events that precede or follow loss of consciousness, in addition to the possibility of experiencing PTSD after learning information or details about their traumatic event while in recovery (Summerall, 2008). Warden (2006) also noted that individuals with mild TBI are at an elevated risk of developing PTSD in comparison with severe TBIs, especially in instances of blast-related injury.

PTSD results after an individual experiences intense distress and trauma, commonly present in combat scenarios. Common symptoms include reliving the traumatic event, avoidance of anything associated with the traumatic event, and feelings of hypervigilance and irritability (Force Health Protection and Readiness, n.d.). Deployments into volatile combat conditions in Iraq, in which the rules of engagement are often strained due to concern of collateral damage (Hoge et al., 2008), can result in a prolonged experience of stress and anxiety (Litz, n.d.). These environmental elements can result in disproportionate release of stress hormones with likely detrimental consequences impacting coping ability, health preservation and restitution (Litz). Individuals may experience PTSD and TBI from two mutually exclusive experiences, in which recovery from both disorders could be complicated (Summerall, 2008).

The progression of PTSD symptoms can be impacted by the occurrence of a TBI (Summerall, 2008). Individuals diagnosed with both TBI and PTSD experience fewer intrusive memories than individuals with PTSD exclusively (Summerall). Furthermore, studies have indicated that PTSD can aggravate cognitive symptoms occurring in cases of mild TBI (Kennedy et al., 2007).

A biologically based model suggests that co-occurring TBI and PTSD may affect the functioning of the neural systems that regulate anxiety, which may serve to further impair the ability to control one's tear reaction (Levin, 2008). Cognitive model dynamics suggest that mild TBI debilitates cognitive assets resulting in a diminished ability to employ suitable cognitive strategies, which may lead to an amplified occurrence of PTSD (Levin).

Neurobiological research identifies the hippocampus and amygdala, common locations of injuries correlated with TBI, in the maturation of PTSD related symptoms (Summerall, 2008). Studies have indicated that the structural, endocrine, genetic and neurochemical changes associated with TBI seem to parallel changes associated with PTSD pathophysiology. These correlated changes are suspected to possibly increase the likelihood of PTSD development for an individual diagnosed with TBI. Further research is suggested and needed in the examination of neurobiological links regarding TBI and PTSD (Kennedy et al., 2007). Finally, physiological signs and consequences resulting from TBI and PTSD can entail blurred vision, frequent headaches, auditory disturbances, dizziness, fatigue, sleep disturbances, environmental sensitivities, delayed cognitive processing, including memory and concentration difficulties, hyper-arousal, and increased startle response (Force Health Protection and Readiness, n.d.).

The Challenges in Living with TBI and PTSD

Physical, psychological, and systematic barriers often impact returning combat veterans with TBI and PTSD. A combat veteran's transition to civilian society from combat is fraught with complications in familial and interpersonal relations, vocational endeavors, and, at times, adherence to societal and legal boundaries (Fairweather & Garcia, 2007). In addition to the physiological changes post-injury, functioning and societal integration can be complicated by behavioral symptoms as well, including social withdrawal and isolation, changes in sexual interest and behavior, impulsiveness, (Kennedy et al., 2007), and dependence on drugs and alcohol (Fairweather & Garcia).

Physiological and cognitive difficulties, paired with the varied psychological symptoms facing returning veterans who have a combination of TBI and PTSD create an elaborate and complex set of hurdles to overcome in pursuit of rehabilitation and maximized functioning. Anxiety and depression, inciting feelings of irritability, anger, and intense sadness, are associated with TBI and PTSD (Kennedy et al., 2007). Further, indicative of their coping struggles, Iraq war veterans with TBI and PTSD as well as the general military population are at greater risk for committing suicide (Harben, 2006).

The Military Mental Health Advisory Team III (Harben, 2006) found that the suicide rate for military personnel serving in Iraq and Kuwait in 2005 was 19.9 per 100,000 members compared to the 18.8 rate in 2003 and the 13.0 rate in 2004. The greatest suicide risk factors included problems with fellow military members, military job performance, issues with legal actions, and personal relationship difficulties. Also, an investigation conducted by CBS News (2007) determined how many veterans (i.e., not specific to service in the Iraq war) nationwide commit suicide. CBS commissioned the study since they were not able to obtain suicide incidence data from the United States Department of Veterans Affairs (VA). CBS News found that in 2005 veterans committed suicide at a rate of 18.7 to 20.8 per 100,000 citizens. Comparatively, non-veterans in 2005 killed themselves at a rate of 8.9 per 100,000.

System-based challenges

Stigma. The stigma associated with receiving medical assistance within the military community, especially in regards to mental health concerns, commonly inhibits service members from seeking and receiving treatment and rehabilitation (Fairweather & Garcia, 2007). According to the Army's Mental Health Advisory Team, 59% of Army personnel and 48% of Marines thought that military leaders would treat them differently if they sought mental health care. Subsequently, only 42% of Army soldiers and 38% of Marines requested treatment after screening positive for mental health problems (Willis, 2007). The potential negative impact to service member's career, paired with shame and fear of judgment is a concerning barrier to treatment and rehabilitation (Fairweather & Garcia).

Reintegration. Difficulties in transition and reintegration experienced by veterans can lead to financial distress resulting from inability to maintain employment (Fairweather & Garcia, 2007). Combined with antisocial and hazardous behavior frequently exhibited by individuals diagnosed with TBI and PTSD, many combat veterans impacted by this new disability are engaging in behavior resulting in legal repercussions, such as domestic violence, child abuse and substance abuse related charges. As a result, many of these veterans are given a discharge status that precludes them from receiving VA compensation and health care. Engagements in hazardous and disruptive behavior are frequent symptoms causing service members impacted by TBI and/or PTSD to incur criminal and legal problems, which can lead to a dishonorable military discharge. A service member receiving a dishonorable discharge is ineligible for veteran benefits, which includes service connected disability financial supports as well as VA coordinated medical care, to include the Polytrauma System of Care (Fairweather & Garcia).

Another troubling trend entails the application of a personality disorder diagnosis. Whereas TBI and/or PTSD are classified as service-related injuries, personality disorders are considered preexisting conditions, and, as such, they disqualify service personnel from receiving VA benefits and care (Fairweather & Garcia, 2007). Lee (2008) noted for example that the diagnosis of adjustment disorder renders a smaller disability payment than would be provided to a veteran with PTSD, further reducing the likelihood of appropriate care and treatment.

Veterans are entitled to request a discharge review or engage in an appeals process regarding their discharge status or disability claims. However, the process is very complex and presents difficult challenges for veterans with the diagnosis of TBI and PTSD to navigate independently. As a result of changes in Veteran Affairs laws and procedures, service members were recently granted permission to obtain legal representation when dealing with discharge procedures; however few lawyers are knowledgeable in this specialized area (Fairweather & Garcia, 2007).

Stress on Family Unit. Families of returning combat veterans who have TBI and PTSD are undeniably affected by common transition difficulties. Domestic violence is more common among veterans with PTSD or severe depression, putting families of veterans diagnosed with PTSD and TBI at an elevated risk (Sherman, 2006). Additionally, spouses may be reluctant to report domestic abuse due to the potential negative consequences such as loss of rank, limited career advancement, and loss of future pay increases for the veteran (Hall, 2008).

Hall (2008) noted the United States Department of Defense recognizes the problem of family violence in the military. In 1981 the Department of Defense required each military branch to establish a Family Advocacy Program (FAP), which was designed to prevent and/or intervene in cases of spousal abuse and child maltreatment. However, Hall also noted significant problems with the FAP including: (a) services are not available to ex-spouses and unmarried cohabitating and dating partners, (b) FAP counseling services are not confidential (e.g., only chaplains maintain confidentiality), (c) allegations of domestic violence must be first reported to the abuser's superior, and (d) domestic violence is only defined as abuse when the abuse results in temporary or permanent disability/disfigurement or inpatient medical care.

Available Interventions and Support Programs

Intervention strategies

The importance of effective, reliable screening methods as a component of diagnosis and subsequent treatment for TBI and PTSD cannot be overstated. TBI scanning tools utilized by military health care facilities most frequently include magnetic resonance imaging (MRI) and computed tomography, with the military vowing to administer a MRI to any service member requesting a TBI scan or displaying symptoms indicative of TBI. Unfortunately, accessibility impediments, including extensive delays and waiting times for scans, negatively impact the effectiveness of this governmental policy (Willis, 2007). In addition, the VA asserts that no available screening instruments can dependably diagnose TBI and PTSD preferring instead to defer to a clinician for diagnosis based on an interview (Summerall, 2008).

For injuries that are not imminently threatening and apparent, such as mild TBI, treatment and subsequent disability rating procedures are convoluted and place the burden of proof on the injured service member to establish that his/her injuries are combat related (Willis, 2007). In order to better assist the veteran in self-diagnosis, the Army has introduced a chain-teaching program to help soldiers and their families identify symptoms of PTSD and TBI. The program includes a script and audiovisual materials used by program leaders to educate soldiers and their families regarding the signs and associated symptoms of behavioral and mental health issues, including TBI and PTSD (Army News Service, 2007).

Cognitive Behavior Therapy. Cognitive behavior therapy often garners scientific support in treatment of individuals with a diagnosis of PTSD and TBI. Trauma-focused cognitive behavior therapy involves a combination of non-trauma focused therapy, eye movement desensitization and reprocessing (EMDR), and exposure therapy (Kennedy et al., 2007). Non-trauma focused therapy does not directly address the underlying traumatic event that caused the PTSD reaction but rather involves the use of techniques such as relaxation and non-directive counseling (Patient UK, 2007). EMDR entails identifying a traumatic memory, having the individual articulate a negative and positive thought associated with the targeted memory, and then tracking the therapist's fingers back and forth as they moved in front of their eyes while focusing on the negative memory. Assessment of belief of the positive or negative thought would be recorded and the procedure repeats until positive beliefs increased and anguish decreased (McNally, 1999).

The cognitive behavioral technique of exposure therapy has been found to be effective in treating panic disorders, phobias and PTSD in a wide range of populations including combat veterans (Wood et al., 2007), survivors of automobile accidents (Walshe, Lewis, Kim, O'Sullivan, & Wiederhold, 2003), and refugees (Paunovic, 2001). Exposure therapy involves gradual exposure of the traumatized person to the stimuli that trigger a fear reaction while in a safe and supportive environment. Creative uses of exposure techniques using computer technology have proven to be both practical and effective. For example, Wood and his colleagues (2007) have successfully used virtual reality and computer game mediated cognitive behavioral interventions.

Cognitive behavior therapy usually includes education regarding the stress response and relaxation techniques in efforts to enable the individual to exercise control over the extreme physical reaction to PTSD triggers and engage completely in therapy, overcoming avoidance symptoms. Case management, psychosocial rehabilitation, pharmacotherapy, and psychotherapy are all viable components and options regarding treatment and care provision for individuals who have incurred PTSD and TBI (Kennedy et al., 2007).

The National Center for PTSD embraces the customary treatment strategy for TBI and PTSD as being symptomalogically based. As such, individuals diagnosed with depression and anxiety receives pharmacologic treatment, in addition to the use of cognitive behavior therapy to help individuals with cognitive deficits (Summerall, 2008).

Medication Management. Special attention should be paid to possible drug interactions in individuals diagnosed with TBI and co-occurring PTSD. These individuals may be taking medications for various symptoms such as pain, insomnia, and dizziness, in addition to surgery-associated anesthesia and antibiotics. Fluid changes resulting from procedural treatment of bums, amputations, wounds or internal organ injuries can dramatically effect the action and interaction of drugs. Moreover, individuals with TBI may be hypersensitive to medicinal effects and corresponding side effect. Medications have proved helpful to treat depression, seizures, and agitation among persons with TBI (Pema, Rouselle, & Brennan, 2003). However, antipsychotic medications should be used with caution given their potential to increase negative neurobehavioral symptoms (Rosenthal & Ricker, 2000). Impaired recall and attentiveness resulting from both PTSD and TBI can also complicate medication management, as an individual may have difficulty accurately following dosage recommendations (Kennedy et al., 2007).

New Treatment Modalities. In recognizing the need to meet the unique needs of military personnel with TBI and PTSD, the United States Government is exploring a variety of new treatment models. For example, the Office of Naval Research funded a $4 million project in 2005 to study the efficacy of virtual reality treatments for PTSD, which is being tested in universities and military installations across the United States (Bergfeld, 2006). This treatment involves the person experiencing virtual reality situations (i.e., guiding them through a military compound in Fallujah or going on patrol through homes of Iraq citizens). The therapist monitors the veteran's responses (e.g., breathing, sweating) and then teaches the veteran how to remain calm and composed through the use of meditation. The hope is that that the client can generalize this skill to prospective high stress situations in the real world (Bergfeld), ultimately leading to a reduction in the occurrence of PTSD symptoms.

National Polytrauma System of Care (NPSC)

To meet the unique needs of Iraq war veterans with TBI and PTSD, the VA has created the National Polytrauma System of Care (U.S. Department of Veterans Affairs, 2007a). This system consists of four Polytrauma Rehabilitation Centers, located in Richmond, VA, Tampa, FL, Minneapolis, MN, and Palo Alto, CA. Polytrauma Rehabilitation Centers maintain an inter-disciplinary team of rehabilitation professionals and consultants from various medical specialties that provide acute, inpatient treatment, and consultation for professionals at other facilities within the NPSC (U.S. Department of Veterans Affairs, 2007b).

The goals of the National Polytrauma System of Care focus on initial rehabilitation efforts, supplementary inpatient and outpatient rehabilitation services, proactive case management, telehealth, extensive individual follow-up, and care for individuals who require extensive, long-term inpatient services (Craine, 2008). The majority of patients admitted into the system of care facilities have been active duty service members, with the chief source of injury noted as combat acquired trauma (U.S. Department of Veterans Affairs, 2007c). Upon discharge from a Polytrauma Rehabilitation Center, service members receive follow-ups plans that include recommendations for continued medical and mental health rehabilitative care as well as referrals to community reintegration supports and resources (U.S. Department of Veterans Affairs).

Each of the National Polytrauma System Rehabilitation Centers also serves as a Polytrauma Network Site, in addition to 17 geographically diverse network sites located in Boston, MA, Syracuse, NY, Bronx, NY, Philadelphia, PA, Washington, DC, Augusta, GA, Lexington, KY, Cleveland, OH, Indianapolis, IN, Hines, IL, St. Louis, MO, Houston, TX, Dallas, TX, Tucson, AZ, Denver, CO, Seattle, WA, and West Los Angeles, CA (U.S. Department of Veterans Affairs, 2007b). Polytrauma network sites provide post-acute rehabilitation and engage in on-going consultation, often via electronic and telecommunications with Polytrauma Rehabilitation Centers. Professionals at network sites also provide case management services to identify and utilize local resources (U.S. Department of Veterans Affairs).

Network sites create specialized support teams to meet the specialized needs of veterans with TBI and PTSD in addition to those with spinal cord injuries, amputations, soft tissue trauma, vision loss, vocational limitations, and pain management issues (Craine, 2008). Support teams are specifically trained to work with patients with multiple areas of trauma (i.e., polytrauma). Service delivery is conducted through coordination and communication with network specialists, and treatment efforts entail direct care, consultation and telehealth technologies (U.S. Department of Veterans Affairs, 2007a; 2007c).

The Polytrauma System of Care Rehabilitation Centers and Network Sites serve both veterans and active duty military personnel (U.S. Department of Veterans Affairs, 2007a). Admission requirements necessitate that an individual must not need one-to-one staffing for therapeutic or behavioral reasons or require a ventilator for respiratory functioning. The eligible service member must also have been impacted by numerous physical, cognitive and/or emotional injuries secondary to trauma and be assessed to potentially benefit from rehabilitative care or display a need for a thorough, preliminary rehabilitation evaluation and care plan (U.S. Department of Veterans Affairs, 2007a).

In addition to National Polytrauma System of Care, veterans with TBI and PTSD and their families can access several other resources associated with rehabilitative assistance. Active duty service members and their families are eligible to utilize health care services through Tricare, or Triwest depending on geographic region. Services are available on base from military providers, as well as through private care providers who require a co-payment. Also available to active duty members is Military Onesource, which provides a maximum of six free counseling sessions for service members and their families. Military OneSource has licensed counselors available 24 hours a day, seven days a week, and also serves as informational resources, addressing topics such as relocation and finances (Fairweather & Garcia, 2007).

A number of community organizations have been established to assist veterans and their families with adjustments to daily living brought about by combat incurred injuries such as TBI and PTSD. Swords to Plowshares, Veterans for America, and Veterans and Families exemplify groups that offer a wide range of information, resources and services (Fairweather & Garcia, 2007). Table 1 presents a comprehensive list of Internet-based health, family, employment and education, and benefit, advocacy, and general resources to meet the needs of veterans with TBI and PTSD and their families compiled from our research as well as from Fairweather and Garcia (2007) and Yeoman (2008).

Recommendations

The following research and practical recommendations are proposed to enhance rehabilitative support services for veterans with this new combination of disabilities.

1. Increase research concerning neurobiological, psychological and physical health implications. Research exploring the neurobiological implications of acquiring both TBI and PTSD is recommended. A better understanding of exactly how these two disabilities interact biologically, and potentially affect the manifestation of symptoms, will enhance a practitioner's knowledge of what individuals affected by both TBI and PTSD experience that is unique in comparison to mutually exclusive diagnoses. Continued research into co-occurring TBI and PTSD and its impact on the service member's physical and psychological health, as well as societal reintegration efforts, is further recommended. Rehabilitation supports could then be better crafted to serve individuals' specific needs.

2. Research on employment outcomes for veterans. Researchers in rehabilitation counseling and other disability-related areas need to explore which treatment and intervention modalities provide the most positive vocational outcomes. Such knowledge will aid the rehabilitation counselor in collaborating productively with the job seeker who has both TBI and PTSD.

3. Clinical considerations. Rehabilitation counseling professionals serving veterans with both TBI and PTSD may need to consider applying an extended period of evaluation, offering counseling/therapy, and assistive technology among other individualized services.

4. Bureaucratic/systematic improvements. Exceptional care and consideration in pursuit of optimal reintegration in their respective communities and families is of utmost importance. While the United States Department of Veterans Affairs, the Department of Defense, and the military service branches continue to address bureaucratic inefficiencies, we stress that further delays and obstacles be reduced and additional supports be implemented for veterans, particularly those impacted by the unique set of barriers that exists with the combination of TBI and PTSD.

5. Examination o[impact on the family. Familial supports and needs of individuals who incur these co-occurring disabilities need to be further examined and addressed. This includes the impact of caring for veterans with combined TBI and PTSD on aging parents and spouses, domestic violence, marital/relationship and sexual difficulties, and child rearing issues.

6. Advocacy within criminal justice system. Advocacy efforts should increase in reference to criminal justice issues for veterans who have legal problems. Criminal justice procedures and protocols that further prevent veterans from receiving care and treatment for service related injuries such as TBI and PTSD need to be examined and alternatives implemented that allow veterans to receive the care and support they need to effectively rehabilitate.

7. Screening improvements. Screening improvements that facilitate earlier detection and treatment of co-occurring TBI and PTSD are needed. Early detection and diagnosis would likely expedite the specialized care and support services that are needed by the veterans.

8. Expanded treatment options. Based on our understanding of promising practices to improve the quality of life for individuals with PTSD as well as those developed for those with TBI, a number of possible interventions involving computer technology, cognitive restructuring and other approaches could be developed for those with co-occurring TBI and PTSD.

9. Networking among service providers. Increase resource sharing and partnership formation among government and community based services and organizations working to aid veterans would maximize rehabilitation efforts for veterans with co-occurring TBI and PTSD.

10. Increased community outreach. Increasing community awareness of this new disability and the resulting barriers to transition is encouraged to accentuate the need for additional resources, services and research.

11. Ongoing learning. Professionals providing rehabilitative services to veterans will need to stay informed about the on-going research and developments relating to co-occurring TBI and PTSD.

Conclusion

Veterans impacted by TBI and PTSD face cumulative rehabilitation challenges that are evolving daily. Numerous physiological, psychological, cognitive and systematic barriers to recovery and community reintegration are experienced by veterans with this new combination of disabilities. It is our hope that rehabilitation counselors will be able to better serve and meet the needs of veterans impacted by TBI and PTSD through knowledge and understanding of the unique experience and barriers to which this new population is exposed.
Appendix 1
Internet Resources for Veterans with TBI/PTSD and Their Families

Resource                     Description and Web.site address

Health Resources

National Center for          http://www.ncptsd.va.gov/ncmain/index.jsp
Post-Traumatic               Information regarding PTSD for families,
Stress Disorder              service providers, and military service
                             members

Defense and Veterans         http://www.dvbic.org/index.html
Brain Injury Center          Provides information pertaining to
                             traumatic brain injury including patient
                             care, research, education, and links to
                             related sites

Tricare (Military            http://www.tricare.mil/
Health Insurance)            Contains information on the military
                             health system, eligible provider
                             information, and other information for
                             military personnel and their family

Tri West                     http://www.tricare.mil/west/
                             Military health insurance information
                             for individuals living west of the
                             Mississippi

Substance Abuse and          http://www.samhsa.gov/vets/index.aspx
Mental Health Services       Substance abuse and mental health
Administration: US           information and resources including
Department of Health         webcasts, conferences, and resources for
and Human Services           families coping with trauma

My Health Vet                http://www.myhealth.va.gov/
                             Veterans Affairs related health and
                             benefits information

My Hoorah for Health         httr://www.hooah4health.com/deployment/
                             familymatters/
                             Health information and resources for
                             Army personnel and their families

Family Resources

Deployment Health and        http://deploymenthealthlibrary.fhp.osd.mil/
Family Readiness Library     home.jsp
                             Deployment information for service
                             members and families, as well as service
                             providers

Military Family              http://www.cfs.purdue.edu/mfri/
Resource Institute           Provides research and information
                             relating to military families

Veterans and                 http://www.veteransandfamilies.org
Families                     Information and resources specific to
                             veterans and families, including topics
                             regarding mental health, transition
                             assistance and service provision

Air Force                    http://www.afcrossroads.com/
Crossroads                   Information/resources designated for Air
                             Force personnel and their
                             familiesResource

Marine Corps                 http://www.usmc-mccs.ore/
Community                    Information about the military
Services                     lifestyle, retirement information, and
                             services offered to Marine s Corp
                             service members and their families

The Coming Home              http://www.cominghomeproject.net
Project                      Workshops and retreats for Iraq-era
                             veterans and their families.

Operation First              http://wwwoperationfirstresponse.org
Response                     Provides clothing, toiletries, housing
                             cost and transportation assistance and
                             phone cards for injured veterans

My Army Life, Too            http://www.myarmylifetoo.com/
                             Information specific to service members
                             in the Army, including deployment,
                             benefit, and financial resources

Lifelines Services Network   http://www.lifelines.navy.mil/lifelines/
                             index.htm
                             Information for Navy personnel and their
                             families

Benefit, Advocacy, and General Resources
Veterans Affairs: Benefits   http://wwwl.va.gov/opa/vadocs/fedben.pdf
for Veterans and             Information relating to benefits and
Dependants                   programs for veterans and their families

Veterans Affairs:            http://www.1.va.gov/vso/index.cfm
Directory of Veteran         List of veteran service organizations
Service Organizations

Veterans of America:         http://www.veteransforamerica.org/files/
Veterans Self-Help Guide     vcs/VAClaims.pdf
to VA Claims                 Information to aid in making a
                             disability claim with the Veterans
                             Benefits Administration

Employment and Education Resources
Veterans Employment Center   http://jobsearch.usajobs.olvm.gov/
                             veteranscenter
                             Federal job listings, veteran's
                             employment preference, and training
                             assistance

Employer Support of the      http://esgr.org/
Guard and Reserve            Targets civilian employers and Guard and
                             Reservist members

Vet Jobs                     http://www.vetjobs.com/
                             Job listings and transition assistance
                             for veterans

Military Spouse              http://www.military..com/spouse
Career Center                Targets military spouses, providing job
                             search tools and career advice and
                             information

Vet Success                  http://vetsuccess.gov/
                             Information about employment services
                             that the Vocational Rehabilitation and
                             Employment (VR&E) program provides to
                             veterans with service-connected
                             disabilities, as well as job search
                             links

Veteran Employment           http://www.veteranemployment.com/
-Monster.com                 A website created with Monster.com to
                             provide job listings for veterans

The Key to Career            http://www.careeronestoly.ort/
Success                      militarytransition/
                             Connects veterans and transitioning
                             service members with high quality career
                             planning, training, and job search
                             resources available at local One Stop
                             centers. Provides individualized state
                             resources for veterans, including job
                             search, educational, national
                             Guard/Reserve, and homeless veteran
                             resources

Milspouse                    http://www.milspouse.org/
                             Resources and information related to
                             education, training, and employment for
                             military spouses

Montgomery G.I. Bill         http://www.gibill.va.gov/GI_Bill_Info/
                             benefits.htm
                             Provides information concerning
                             Montgomery G.I. bill education benefits

Coalition to Salute          http://www.saluteheroes.org
America -- Heroes            Provides financial aid, career
                             assistance and accessible housing for
                             wunded veterans and their families.

Wounded Warrior Project      http://www.woundedwarriorproject.org
                             Provides career and benefit counseling
                             in addition to sports opportunities


References

Army News Service. (2007, July 18). Army launches chain teaching program for PTSD, TBI education. Retrieved April 1, 2008 from http://www.military.com/features/0,15240, 142778,00.html

Bergfeld, C. (2006, July 6). A dose of virtual reality: Doctors are drawing on video-game technology to treat post-traumatic stress disorder among Iraq war veterans. Business Week. Retrieved October 18, 2008 from http://www.busi nessweek.com/technology/content/jul2006/tc20060725 012342.htm.

Bilmes, L. J., & Stiglitz, J. E. (2008, March 9). The Iraq war will cost us $3 trillion, and much more. Washington Post. Retrieved October 17, 2008 from http://www.washing tonpost.com

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Hillary S. Burke

San Diego State University

Charles E. Degeneffe

San Diego State University

Marjorie F. Olney

San Diego State University

Charles Degeneffe, Ph.D., Assistant Professor, San Diego State University, 5500 Campanile Drive, San Diego, CA 92182. E-mail: cdegenef@mail.sdsu.edu
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Author:Burke, Hillary S.; Degeneffe, Charles E.; Olney, Marjorie F.
Publication:The Journal of Rehabilitation
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Date:Jul 1, 2009
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