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Doing whatever it takes: treatment programs try to employ a full arsenal to meet the complex needs of veterans.

Any routine Internet search for behavioral health issues in military veterans turns up scores of discussions and initiatives taking place at the local, state and national levels. While some observers still argue that service coordination and integrated care for complex diagnoses remain elusive, the treatment community clearly is not lacking for enthusiasm in serving this population.

Helping returning veterans reintegrate into their communities no longer is seen as the military's problem. Whether because of benefit disputes, a reluctance to access services through the Department of Veterans Affairs (VA), or years of waiting before pursuing addiction and mental health treatment, more individuals with combat histories are walking through the doors of treatment centers at the community level.

"For some members of the military, they feel that the Department of Defense got them into this situation and it's hard for them to trust going back to the base for help," says Larry Harrison, a therapist and Army veteran who works at the community behavioral health organization Centerstone's Frank Luton Center in Nashville, Tenn.

Centerstone is part of a growing legion of treatment organizations that have recently established initiatives specifically tailored to the health concerns of veterans. It is partnering with Not Alone (, an organization supporting veterans dealing with posttraumatic stress disorder (PTSD) and related issues, to offer online support and other services.


As part of its overall effort, Centerstone is involved in establishing a network of service providers who identify with veterans' needs by virtue of their own military service or experience with it in their families.

"The highest levels of the VA want to work with their community partners," says Bob Williams, PhD, CEO of Centerstone of Indiana. "The generals want more networks of resources. There are still some barriers and territoriality at the 'boots on the ground' level," he says, where stigma associated with substance use or PTSD still can be prevalent.

Clearly this is an issue that is being watched at the highest levels of the military. The director of the Defense Department's leading center for PTSD and TBI recently resigned from the post amid ongoing criticism that the military remains inefficient in detecting conditions that are believed to affect as many as one-third of returning troops.

At the community treatment level, lingering frustrations are apparent as well. More than 90 percent of respondents to a June poll on the Addiction Professional Web site said their communities had not yet established enough programs to meet the needs of returning veterans, with some citing a lack of PTSD treatment and a shortage of residential services among the deficiencies.

Trauma programming

At Twelve Oaks Alcohol and Drug Treatment Center, a CRC Health Group residential treatment facility in Navarre, Fla., the staff has established a PTSD track that serves both members of the military and other individuals with a trauma history.

The ASPIRE (Addicted Survivors of PTSD Integrated Recovery Experience) track is designed to meet the needs of individuals who have battled substance abuse and traumatic experiences. The architect of the track, clinician B. Diane Vchulek, explains that it is based on the notion that treating co-occurring substance use problems and PTSD must occur in a comprehensive fashion in which both disorders are treated simultaneously.

Much of the work in the track takes place in psychodynamic groups where participants do more sharing than routine talking. "They support and confront one another," says Twelve Oaks executive director Bob Lehmann.

There also is a great deal of individual work in the program, including journaling. The program employs therapeutic strategies ranging from cognitive-behavioral therapy (CBT) to art therapy--essentially, anything that will get patients to open up.

Twelve Oaks uses a VA-sanctioned post-traumatic stress checklist to evaluate patients' functioning on a number of dimensions, and Lehmann says the program is seeing patients reduce their scores to non-dysfunctional levels in several of the measured areas.

Lehmann adds that one difference he is seeing in today's military is a higher level of concern among military leaders about their personnel's welfare over the long term. "The cooperation from the military has been incredible," he says.

Tackling TBI

Treatment programs' can-do spirit in meeting the needs of returning veterans gets challenged in cases where cognitive impairment due to a traumatic brain injury (TBI) is present in the client.

"A lot of places don't want a person with a cognitive disability," says Duane Reynolds, a director at Vinland National Center in Loretto, Minn., one of few treatment facilities in the country that specializes in the treatment of brain-injured patients. "People say, 'With a brain injury, how can you expect them to learn anything?' I say, 'Well, they learned to drink.'"

The typical veteran who might be seen in Vinland's program has a primary alcohol problem that likely started as self-medication. "They feel better when they're intoxicated," Reynolds says. Oftentimes the person has received medical care in the past, but substance use issues have not been addressed or have been underemphasized. "Then maybe 18 months later it rears its ugly head again," he says.

Many of these clients will be in treatment at Vinland for about 45 days, with their services covered either through state funding or veterans benefits. Clinical services for these individuals must employ a slower, more repetitive approach, but Reynolds says success is possible, and the veterans seem to fare better in settings where others have similar problems. In a more traditional treatment setting, a cognitively impaired person might be identified as somehow holding back the rest of the group, Reynolds says.

The program's spacious lakeside setting offers great potential for outdoor activities as part of the therapeutic process. The focus of the therapy is to get the client as many types of services as they're eligible for, Reynolds explains. Motivational Interviewing, mindfulness therapies and 12-Step therapies all can be part of the mix, depending on the client. "You don't know what's going to resonate with the client," he says.

Building resilience serves as an important theme of treatment, with the program emphasizing impulse control through a "stop, think, act" strategy, Reynolds says. Some individual therapy is critical for this cognitively impaired group, he believes. "In a group there is so much chatter that they can lose focus," he says.

Soldiers helping soldiers

At many of the facilities that have defined a specialization in treating veterans with complex diagnoses, there is a presence of high-level officials in the organization who have a direct military background. At Twelve Oaks, for example, the medical director is a Vietnam combat infantry veteran who received a Purple Heart and a Combat Infantry Badge.

A division of the Outreach Project treatment organization in the New York metropolitan area ( is trying to do its part toward developing a treatment workforce with a firsthand appreciation of what the soldier experiences. The Outreach Training Institute is offering veterans its 350-hour, 11-month course that makes them eligible for Credentialed Alcoholism and Substance Abuse Counselor (CASAC) training in the state. Honorably discharged veterans within the past nine years are eligible for full scholarships for the training.

"If we can train veterans who are not presently suffering, they would be the most appropriate people to treat other veterans," says David Greenberg, who is leading the Outreach Project's training program.

So far, nine veterans have been admitted into the training programs and two have already graduated. Greenberg says the organization plans to step up its marketing of the program's availability to veterans.

"We're trying to head off a problem that we know we're going to get," says Greenberg, referring to communities meeting the complex needs of returning veterans. "It is no mystery that as a country we will have to take care of these people."

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Author:Enos, Gary A.
Publication:Addiction Professional
Date:Jul 1, 2010
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