BACKGROUND/RATIONALE:
While the support of education goals for Veterans with disabilities has long been of interest to the VA, it is even more important following the passage of the Post 9/11 Veteran's Educational Assistance Act of 2009, which provides recently separated Veterans expanded benefits for post-secondary education tuition and fees. Returning Veterans from Iraq and Afghanistan with PTSD, however have special obstacles to successfully utilizing these benefits due to their impairments and disability adjustment. While there are successful models of supported education (SEd) for civilians with serious mental illness, there has been no previous exploration of the needs of today's returning Veterans to guide the design of a Veteran centric SEd service. Therefore, we proposed a needs assessment for a VA supported education service and the development of a VA treatment curriculum and related implementation guidelines.


OBJECTIVE(S):
1. Use a Participatory Action Research team that will be charged with informing all phases of the project;
2. Conduct a needs assessment for supported education using focus groups with OIF/OEF Veterans with PTSD;
3. Conduct an implementation assessment using key informant interviews with multiple stakeholder representatives; and,
4. Prepare a supported education practice curriculum and implementation guidelines based on data collected.

METHODS:
Data was collected through focus groups with OIF/OEF Veterans with self-reported symptoms of PTSD. Focus group topics concerned their perceived barriers and facilitators to accessing and advancing education. Additional data for the implementation assessment was collected via key informant interviews with local and national VA leaders and administrators in mental health and vocational rehabilitation services. These stakeholders were assessed for perspectives and recommendations regarding: 1) appropriate supported education models; and 2) how best to augment VA clinical services with supported education. In addition, a Participatory Action Research (PAR) approach was used. A PAR team was assembled consisting of project investigators and stakeholder group members including Veterans with psychiatric disabilities, educational professionals, and VA practitioners and administrators. The PAR team was tasked with reviewing all research activities.

FINDINGS/RESULTS:
Barriers to advancing education:
Developing an educational goal. Thinking about going to school and getting into school presented numerous challenges. Many did not know what kind of program to enroll in, or where. Many were worried about meeting the demands of the academic environment and both desired and were anxious about initial assessments for academic readiness.

GI Bill education benefits and VA benefits counseling. Veterans repeatedly described their difficulties in accessing and confusion about choosing the GI Bill and related benefits.

Education goals occur in a challenging context of re-integration into civilian life. The reintegration context for OIF/OEF Veterans with education goals can be fraught with challenges such as: unstable living conditions, financial pressures, disintegrating family support, urgent clinical needs such as addiction relapses, physical injury and disability, and an adjustment process to civilian life that was at times overwhelming. We heard that there was no "basic training" for getting back to civilian life.

Impact of PTSD on educational attainment. Veterans reported that PTSD symptoms posed additional
challenges e.g., felt overwhelming anxiety during class time, perceived impairments in memory and concentration, and found the flow of information overwhelming. Veterans voiced a need for accommodations such as: classes with fewer students, isolated settings for test taking, evening or on-line classes to reduce anxiety, audio-recording classes, or extensions of time for assignments.

Veteran recommendations for supported education and rehabilitation service.
The Veterans had numerous suggestions about the context and types of services that would be beneficial to them in reaching their educational goals. Some mirrored the needs previously described (i.e., provide benefits counseling). Other additional recommendations are described below. The first of these, "age appropriate outreach and services" pertained to the younger group of Veterans we talked with, while the remainder were common to both younger and older Veterans.

Age appropriate outreach and services. Younger Veterans found it hard to relate to clinical groups composed of Veterans who were old enough "to be their fathers". The younger Veterans preferred contact with Veterans of similar age or at least of similar OIF/OEF experience. Younger Veterans voiced a lot of interest in having access to technology to get information on school and benefits.

Peer Support. Veterans voiced the need to hear about and get counseling, information and help from other Veterans. There is an immediate extension of trust between Veterans who may not know each other but have who have both been in combat situations.

Veteran-driven intensity of services including one-to-one assistance. Veterans in the focus groups described different levels of service needs. Some Veterans desired autonomy, others were looking for more active and intensive assistance including follow-along supports.

SEd integration with clinical team and VA clinical programs. Many Veterans in the focus group indicated that they were interested in having the VA educational services connected with their clinical services, due to the complexity of their various needs such as therapy, case management, medical, and school related.

Recommendations for Colleges and for College/VA integration.
Veterans also mentioned the need for the colleges and universities to be better connected to the VA. This could involve scheduled visits on campus by Veteran groups, or having Colleges come to VA hospitals. In the absence of these supports, several Veterans spoke highly about the use of an individualized advocate who could provide the one to one support to walk them through the admissions, financial aid, and enrollment process and could run interference with professors. Other needs related to educational attainment.

Loss of social networks. Having gone through a life changing experience of combat and trauma, Veterans, especially younger Veterans, had trouble "fitting in" with prior social networks. Several noted the loss of family support including divorce. The military has become their new family.

Adjusting from military to civilian culture. Some of the Veterans we spoke to indicated that military life fostered a kind of dependency where you were not encouraged to ask questions and you could rely on commanding officers to be told what to do. Civilian life in contrast was less structured, and relied more on personal persistence to get information and make decisions. Veterans, especially younger ones, described a difficult adjustment to the myriad of choices facing civilians and frustration at not having simple and clear information on which to base decisions.

Need for outreach and support to access and use clinical services, though once accessed VA clinical services were valued. Despite significant clinical challenges we heard repeatedly that Veterans were simply unaware of the clinical supports that were available to them, that they didn't know where to go for help, or that when such information was given they were not ready or able to hear it. Many spoke of "finding the VA" after crises and homelessness. Outreach needs to persist over many years while Veterans cycle through periods of recognizing needing help and of trying to "tough it out" on their own.

The implementation assessment resulted in the following findings:

1. Peers should be the primary deliverer of supported education service, the existing peer specialist positions can serve as a model.
2. Supported education should be housed in VA CWT although other VHA components are possible.
3. Services should be delivered within the community and school setting as much as possible.
4. A strengthened relationship with VBA services is needed to address needs for benefit counseling.

Many of the needs identified suggest that initial supported education services are best met with a "regional education resource center". This center could provide information and referral to VA and community services, including mental health clinical services, benefits counseling, internet access to schools and programs, individualized education goal planning and assistance with admissions
processes, educational testing, as well as group activities on important skills such as time management and study skills. The center can provide this variety of services and meet the needs of a much larger population of OIF/OEF Veterans with PTSD rather than solely providing individualized peer services that can only meet the needs of a few.

IMPACT:
This project's findings are highly important to developing services that promote the successful reintegration and education of returning Veterans with PTSD. The findings also contribute to understanding how education support can prevent homelessness. Project investigators also contributed to a national VHA workgroup on supported education and their resulting recommendations. Findings have been submitted for peer review publications and a draft manual and implementation guideline is developed. This project also contributes directly to a newly funded HSR&D pilot of a supported education practice that will test feasibility and outcome. Long term goals are to conduct a definitive comparative trial of this intervention and assess implementation strategies and establish a best practice for national implementation. The impact on Veterans will be improved educational access, completion, and ultimate attainment,. This in turn is expected to contribute to long term outcomes of employment and housing stability.

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External Links for this Project

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PUBLICATIONS:

Journal Articles

1. Ellison ML, Belanger LK, Niles BL, Evans LC, Bauer MS. Explication and Definition of Mental Health Recovery: A Systematic Review. Administration and policy in mental health. 2018 Jan 1; 45(1):91-102. [view]

Conference Presentations

1. Ellison ML. Adult system responses to detecting and treating veterans and young adults with mental illness. Paper presented at: University of South Florida Department of Child and Family Studies Annual Children’s Mental Health Research and Policy Conference; 2011 Mar 21; Tampa, FL. [view]
2. Ellison ML, Mueller L. Needs for supported education among young adult veterans with PTSD. Paper presented at: U.S. Psychiatric Rehabilitation Association Annual Conference; 2011 Jun 13; Boston, MA. [view]
3. Ellison ML. Supporting the education goals and community participation of OIF/OEF/OND Veterans with PTSD: Results of a Needs Assessment. Presented at: Temple University Collaborative on Community Inclusion of Individuals with Psychiatric Disabilities International Conference; 2011 Sep 19; Philadelphia, PA. [view]

DRA: Military and Environmental Exposures
DRE: none
Keywords: Disability, Operation Enduring Freedom, Operation Iraqi Freedom
MeSH Terms: none