The following hyperlink connects you to a very positive evaluation by faculty at Arizona State University of the NIPS residential weekend workshops attended by 2500 returning U.S. veterans from Iraq and Afghanistan.
The peer-reviewed version of the study is presented below. It uses the same data, but controlling for the influence of a number of variables. Significant positive outcomes were still observed. The citation is :
Ann MacEachron and Nora Gustavsson. Peer Support, Self-efficacy, and Combat-related Trauma Symptoms among Returning OIF/OEF Veterans. ADVANCES IN SOCIAL WORK, Fall 2012, 13(3) ,
Key Words: Veterans, peer support, PTSD, social support, self-help, self-efficacy, general self-efficacy
Peer support, self-efficacy, and combat-related trauma symptoms among returning OIF/OEF veterans
The incidence of PTSD and other combat-related trauma symptoms among veterans returning from the Iraq and Afghanistan wars suggests that many will experience psychological challenges in adjusting to civilian life. We evaluated a national program called, Vets4Vets, whose mission is to improve the psychological well-being of returning Iraq and Afghanistan veterans. The study included veterans (n = 216) attending one of 17 Vets4Vets peer support weekend retreats. Using hierarchical regression analysis of post-test change, we found that increased perceived peer support, self-efficacy and general self-efficacy reduced PTSD symptoms. Both situation-specific self-efficacy and general self-efficacy mediated the relationship between peer support and PTSD symptoms. Implications for social work are discussed.
Peer support, self-efficacy, and PTSD symptoms
among returning OIF/OEF veterans
After more than a decade of war in Iraq (OIF, Operation Iraqi Freedom) and Afghanistan (OEF, Operation Enduring Freedom) and with over 2.6 million troops deployed, a continuing challenge is taking care of veterans who have endured these wars. While it is known that veterans may experience multiple physical challenges, recognition is growing in regards to the psychological and social consequences of deployment, extended or multiple tours of duty, and combat (Burnam, Tanielian, & Jaycox, 2009; Eibner, 2008; Institute of Medicine, 2010). Reviews of the literature (Schell & Tanielian, 2011; Tanielian & Jaycox’s 2008) indicate that the prevalence of posttraumatic stress disorder (PTSD) ranges from about 5 to 15 percent for returning OIF/OEF veterans. Recurrent PTSD symptoms often interfere if not impair functioning in personal, social, and work realms. Another recently publicized risk is the increasing prevalence of suicide among both soldiers and veterans. The Center for New American Security (2011) recently estimated that a veteran dies from suicide about every 80 minutes.
Peer support is increasingly recognized as an important component of mental health services for improving psychological well-being among veterans because of its congruence with veterans’ common experience of military culture and its high value placed on camaraderie and unit cohesion (Barber, Rosenheck, Armstrong, & Resnick, 2008; Center for New American Security, 2011; Poole, 2010; Schell & Tanielian, 2011; Seligman, 2011; Tanielian & Jaycox, 2008). From a social cognitive perspective, the effectiveness of peer support is explained in terms of an individual’s improved self-efficacy due to peer learning about how to cope and manage a stressful environment (Benight & Bandura, 2004). The focus of our study is evaluating a national, grassroots peer support veterans program, called Vets4Vets. Founded in 2004, Vets4Vets is among the 50 outstanding nonprofits to receive an award through the 2006 Iraq-Afghanistan Deployment Impact Fund (NBC Nightly News Weekend Edition, 2009). The award was for using intensive peer support weekend retreats to help veterans “heal from the psychological injuries of war” (Vets4Vets, 2011). In this pretest-posttest study OIF/OEF veterans who participated in the Vets4Vets weekend peer support program, the research questions are: a) do PTSD symptoms lessen with increased peer support and self-efficacy, and b) does self-efficacy mediate or explain the possible relationship between peer support and PTSD symptoms?
Kurtz (1997) defined a self-help group as “a supportive, educational, usually change-oriented mutual-aid group that addresses a single life problem or condition shared by all members” (p. 4). The condition shared among peer support groups is often traumatic experiences. Mead, Hilton, & Curtis (2001) define peer support as “a system of giving and receiving help founded on key principles of respect, shared responsibility, and mutual agreement of what is helpful…It is about understanding another’s situation emphatically through the shared experience of emotional and psychological pain” (p. 135). Brown & Lucksted (2010) suggest that there are multiple, overlapping dimensions to peer support. It is not just a common experience but also a healing and empowering process.
Generally speaking, the peer group process offers the opportunity to learn from the coping competency of others. Peers “model coping attitudes and skills, provide incentives for engagement in beneficial activities, and motivate others by showing that difficulties are surmountable by perseverant effort” (Benight & Bandura, 2004, p. 1134). Peers not only model and demonstrate coping and adaptive skills but also offer contextual wisdom through personal stories of recovery or adaptive coping (Solomon, 2004). The experiential principle is key to peer support because it creates a relationship based on a shared life experience to foster understanding, trustworthiness and safety in helping relationships (Hegelson & Gottlieb, 2000; Mead , Hilton, & Curtis, 2001; Solomon, 2004).
Overall, peer support is a well-established pathway to reduce vulnerability to stress and depression by emphasizing strengths and coping resilience to overcome trauma and rebuild one’s life (Bandura, 1997;Calhoun & Tedeschi, 2006; Saleeby, 2006; Schwarzer, 2001; Seligman, 2011). A meta-analysis of PTSD predictors by Ozer, Best, Lipsey, & Weiss (2008) revealed a significant inverse relationship between social support and PTSD symptoms that was strongest in studies of combat trauma among American veterans of the Vietnam War and the Persian Gulf War. In this pretest-posttest study of OIF/OEF veterans, our first hypothesis is that increased peer support experienced in theVets4Vets weekend peer support program reduces perceived PTSD symptoms.
Self-efficacy has been conceptualized in two distinct ways by Bandura (1997) and by Schwarzer & Jerusalem (1995). From Bandura’s perspective, perceived self-efficacy in coping is the “core belief that one has the power to produce desired effects by one’s actions” and “plays a key role in stress reactions and quality of coping in threatening situations” (Benight & Bandura, 2004, p. 1131). Self-efficacy reduces the effect of a stressor by enabling individuals to use proactive coping strategies. Individuals with high self-efficacy see challenges as mastery tasks, focus on strengths, and recover more quickly from setbacks. Individuals with low self-efficacy see challenges as areas of personal failure, focus on their failings, and have low confidence in themselves. Self-efficacy is thus a key component of resilience to trauma (Bandura, 1994). Combat traumatization, as discussed by Benight & Bandura (2004), has received limited attention in the research literature. Among the very few available studies reviewed by Benight & Bandura (2004), findings indicate that the lower the perceived self-efficacy of soldiers, the more trauma symptoms experienced. Our second hypothesis is that increased situation-specific self-efficacy reduces perceived PTSD symptoms.
Self-efficacy as defined by Bandura (1997) is situation-specific, that is, depends on the particular context and activity. It focuses on an adaptive functioning relative to the surrounding circumstances, context and goals. An alternative conceptualization is that of an omnibus or general self-efficacy. General self-efficacy is an optimistic “self-belief that one can perform … difficult tasks or cope with adversity – in various domains of human functioning” (Schwarzer & Jerusalem, 1995, p. 1). It is a stable adaptive strategy if not trait based on an optimism regarding one’s coping ability (Schwarzer, 1994). Vernon, Dillon, & Steiner (2009), found general self-efficacy to be one of several proactive coping factors in reducing PTSD symptoms among undergraduate women with trauma backgrounds. This conceptualization suggests that people higher in general self-efficacy are more likely to have less intense trauma symptoms, set higher goals, persist towards their goals despite obstacles, and create opportunities for personal growth. Our third hypothesis is that increased general self-efficacy reduces perceived PTSD symptoms.
From a social cognitive perspective, individuals are proactive both in adapting to the multi-causality inherent to environmental challenges and risks and in developing competencies and regulating their actions (Bandura, 1997). Resilience to adversity is viewed as relying “more on personal enablement than on environmental protectiveness” or on proactivity rather than reactivity (Benight & Bandura, 2004, p. 1133). To the extent that peer support enables learning of adaptive knowledge and coping skills within a multi-causal context, it fosters what Bandura calls self-efficacy. Peer supporters provide a social learning context in which they model a variety of coping skills across multiple situations as well as encourage perseverance in achieving mastery over trauma-related symptoms or other goals. The explanatory link between support and reduced trauma-related symptoms is self-efficacy. Self-efficacy requires a proactive approach to find, maintain and learn from peers. Benight & Bandura’s 2004 review of the literature discussed the important mediating role played by self-efficacy: “social support produces beneficial outcomes only to the extent that it raises perceived self-efficacy to manage environmental demands” (p. 1134).
As Benight & Bandura noted, much more research is needed to evaluate self-efficacy as a mediator especially in regards to explaining the relationship between social support and combat-related trauma. Our fourth hypothesis is that Bandura’s situation-specific self-efficacy will play a mediator role in explaining the relationship between peer support and perceived PTSD symptoms at posttest. Our fifth hypothesis, in parallel fashion, is that Schwarzer’s concept of general self-efficacy will also play a mediator role in explaining the relationship between peer support and perceived PTSD symptoms at posttest.
Since World War II, peer support and peer services have grown exponentially (Brown & Lucksted, 2010; Campbell, 2005; Clay, 2005; Davidson et al., 1999). This growth is especially evident in the mental health and addictions field with many Anonymous programs for alcohol, drugs, gambling and other issues (Solomon, 2004). Since the 1970s, peer support has been a component of the Community Support System in mental health as well as other mental health services (Goldstrom et al., 2006; Solomon, 2004). Peer support in mental health services is also expanding in the Veteran’s Administration (Barber et al., 2008; Resnick & Rosenheck, 2008). There is substantial variation in the purpose, format and setting for peer support, for example, one-on-one sessions, small to larger groups, face-to-face versus online, therapeutic or personal growth, and short-term intensive retreats versus ongoing sessions (Hirschhorn & Gilmore, 2004; Liteman et al., 2006; Martone, 2010; Orloff, Armstrong, & Remke, 2009; Rains & Young, 2009).
The Vets4Vets is a national grassroots organization that works with OIF/OEF veterans to develop local peer support groups and to coordinate these groups to become a national network. One part of their peer support program is to hold regional intensive weekend retreats. The residential retreats start on Friday afternoon and end on Sunday noon. The schedule and content of each hour is manualized for leaders. The leaders themselves are OIF/OEF veterans who have been trained through co-leading at previous retreats. Each retreat emphasizes peer support through engagement in multiple group sessions throughout the weekend. The groups encourage members to talk openly about and re-evaluate their military experiences, to use active listening skills, to re-experience camaraderie or social connectedness of peers, discuss challenges to reentry to civilian life, and recognize common issues for advocacy within their veteran communities.
A total of 325 of 466 OIF/OEF (70%) veterans completed either a pretest or posttest while attending one of 17 Vets4Vets weekend retreats between January 2010 and January 2011. Given veteran reluctance to share information about combat-related trauma (e.g., Schell & Tanielian, 2011), anonymous identifiers were chosen by participants to self-identify each test. Using these identifiers, a total of 216 participants (46% response rate) completed both the pretest and posttest.
To maintain the anonymity of participants, the only background information collected was for age, gender, and race/ethnicity. Participants were 37 years old on average (sd = 11). About 40% of participants were married and 60% were single. The majority were males (70%). Most participants were white (58%), and then Hispanic American (14%), African American (13%), Native American (3%), Asian American (less than 1%), or others who did not define their race or ethnicity (9%). There was no significant difference on background characteristics for participants who either completed both tests or just one test.
Vets4Vets followed a pretest-post one group design (Rubin & Babbie, 2010). A pretest was given to participants during the first evening (Friday) of the weekend retreat and a posttest the following Sunday at the end of the retreat. Vets4Vets staff designed the survey and collected the pretest-posttest data, but the authors coded the data. The university IRB reviewed and approved use of this secondary data for this study.
Peer Support. A key theme of peer support is the feeling of social connectedness, a theme that we measured in this study by the Social Connectedness Scale (SC). SC is based on Kohut’s (1984) concept of belongingness or closeness with others in contrast to social isolation or “emotional distance between self and others” (Lee & Robbins, 1995, p. 236). The SC scale is the average of 8 items such as, “I have little sense of togetherness with my peers.” Each item is assessed by reverse scoring of a 6-point scale ranging from 1= “Strongly Agree” to 6 = “Strongly Disagree.” A higher score represents higher perceived social connectedness. Cronbach’s alpha of reliability is .96 in the pretest and .95 in the posttest. These reliabilities are consistent with the high reliabilities of .91 reported in Lee & Robbins (1995) and .94 reported in Lee, Draper & Lee (2001).
General self-efficacy. The General Efficacy Scale (GSE) measures an individual’s general sense of self-efficacy in coping with daily hassles and adapting to stress across domains of human functioning (Schwarzer & Jerusalem, 1995; Schwarzer & Fuchs, 1996). The GSE is the average of ten items such as “I can always manage to solve difficult problems if I try hard enough.” Each item is rated on a 4-point scale ranging from 1= “Not at all true” to 4 = “Exactly true.” A higher score represents a higher perceived general self-efficacy. Cronbach’s alpha of reliability is .92 for both the pretest and posttest and is thus consistent with previously reported reliabilities in the high .80s (Schwarzer & Jerusalem, 1995, 1996).
Situation-specific self-efficacy. The situation-specific self-efficacy (SE) measure is the average of four items developed by the Vets4Vets staff to tap coping with combat-related trauma. An example is: “I feel confident that I can manage any PTSD and related symptoms, or any effects of military service – such as sometimes feeling bad or guilty about my military service, getting angry easily, feeling isolated.” Each item is measured on a 6-point scale ranging from 1 = “Strongly disagree” to 6 = “Strongly agree.” A higher score represents higher perceived situation-specific self-efficacy. The Cronbach’s alpha is .82 for the pretest and .84 for the posttest.
PTSD. Perceived PTSD is measured by the global screening instrument called SPRINT (Davidson & Colket, 1997; Connor & Davidson, 2001). SPRINT contains 8 items such as, “How much have you been bothered by unwanted memories, nightmares, or reminders of the event.” Each item is measured on a 4-point scale ranging from 1 = ”Not at all” to 4 = “Quite a bit.” A higher average score represents a higher perceived risk of experiencing PTSD symptoms. The SPRINT has been reported as responsive to change over time and has high diagnostic accuracy and internal consistency. In this study, the Cronbach’s alpha of reliability is .93 for the pretest and .94 for the posttest.
Control variables. Previous research has found that age, gender, and marital status may influence perceived PTSD symptoms (e.g., Carter-Visscher, Pulusny, Murdoch, Thruas, Erbes, & Kehle, 2010; Worthen, 2011), self-efficacy (e.g., Bandura, 1997), and/or social support from peers (e.g., Brown & Lucksted, 2010). Thus, our analyses control for gender (0 = male, 1 = female), age, and marital status (0 = not married, 1 = married).
The measurement of change requires adjusting posttest scores for pretest differences. Dimitrov & Rumrill (2003) recommend using ANCOVA with a pretest-posttest design that regresses each posttest on its pretest covariate. Thus, in addition to the control variables of gender, age and marital status, we entered pretests scores as covariates in regression analyses before evaluating posttest change for peer support, GSE, SE, and PTSD symptoms.
PASW Statistics 20 was used for all statistical analyses. For descriptive purposes, Pearson correlations evaluated the strength and significance of bivariate relationships between all measures, while paired t-tests evaluated pretest-posttest mean differences of each independent and dependent variable.
We used hierarchical regression to test our hypotheses. Model 1 of each hierarchical regression analysis is the dependent variable posttest regressed on the control variables (e.g., age, gender, marital status, and the covariate pretests for the dependent and independent variables). Model 2 is the posttest dependent variable regressed on the posttest independent variable. R2 for each regression equation is the amount of variance explained in the adjusted posttest dependent variable. Change in R2 (DR2) between Model 1 and Model 2 is our measure of effect size, or the strength of association between the posttest independent and dependent variables when holding control and covariate variables constant.
There are multiple criteria to test for mediation of the relationship between an independent variable (peer support) and dependent variable (perceived PTSD symptoms) by mediator variables (SE and GSE) (Kenny, Kashy, & Bolger, 1998). To demonstrate partial mediation, a) the independent variable and dependent variable must be significantly related, b) the mediator variable and dependent variable must be significantly related, and c) the independent variable and mediator variable must be significantly related. To demonstrate complete mediation, an additional criterion is that after controlling for the mediator, the independent variable has no significant effect on the dependent variable.
The means, standard deviations, and sample size for each measure and their bivariate inter-correlations are reported in Table 1. Descriptive bivariate statistics show that there are significant (p < .001) and strong, positive pretest-posttest correlations for peer support (r = .73), GSE (r = .65), SE (r = .60), and perceived PTSD symptoms (r = .87). The paired t-tests for each
pretest-posttest mean difference are significant (p < .001) for peer support (t = 5.15), GSE (t = 5.31), SE (t = 7.18), and perceived PTSD symptoms (t = -5.19). Higher pretest scores for peer support, general self-efficacy, and situation-specific self-efficacy predict higher scores on their respective posttests, whereas for perceived PTSD symptoms, a higher pretest score predicts a
Table 1: Means, standard deviations, sample sizes, and Pearson inter-correlations
Variable Mean SD N 1 2 3 4 5 6 7 8 9 10
- Support-1 3.6 1.4 211 —
- GES-1 3.1 .6 211 .51** —
- SE-1 4.1 1.2 208 .55** .52** —
- PTSD-1 3.0 .8 182 – .60** – .53** – .68** —
- Support-2 4.0 1.3 212 .73** .34** .41** – .48** —
- GES-2 3.2 .5 211 .42** .65** .40** – .37** .51** —
- SE-2 4.7 1.0 185 .45** .54** .60** – .52** .56** .59** —
- PTSD-2 2.7 .8 185 – .55** – .44** – .64** .87** – .51** – .38** – .56** —
- Age 36.9 11.2 212 .08 .01 .11 .00 .04 – .03 .06 .02 —
- Gender .3 .5 212 .04 – .03 – .04 .03 .11* .06 .08 – .02 – .12* —
- Married .4 .5 208 .21* .12* .21** – .12* .16* .11 .19** – .14 .27** – .25**
* p < .05; *** p < .01
lower posttest score. These findings offer support that change occurred in these measures over the course of weekend retreats.
Table 2 shows the hierarchical regression analyses for evaluating the influence of peer support on perceived PTSD symptoms, GSE, and SE. Tables 3 and 4 show the hierarchical regression analyses for evaluating the influence of SE and GSE on PTSD symptoms. In Tables 2 through 4, Model 1 for each analysis regresses the dependent variable only on the control and covariate variables. Note that, unlike previous studies, the control variables of age, gender, and marital status are consistently insignificant in predicting PTSD symptoms, GSE, or SE. Model 2 for each analysis regresses the dependent variable on the independent variable in addition to the control and covariate variables.
Hypothesis 1 is that increased peer support reduces perceived PTSD symptoms. As shown in Table 2 – Part A, the amount of change in variance explained is very small but significant (DR2 = .01, p < .05) in comparing Model 1 (R12 = .79) and Model 2 (R22 = .80) where posttest peer support is added to the regression equation with the control and covariate variables. The standardized coefficient (Beta = -.15, p < .001) shows that one standard deviation increase in posttest peer support is necessary to reduce posttest PTSD symptoms by only .15 standard deviations when holding control and covariate variables constant. These finding supports the hypothesis.
Hypothesis 2 is that increased situation-specific self-efficacy reduces perceived PTSD. As shown in Table 3, the amount of change in variance explained is very small but significant (DR2 = .01, p < .01) in comparing Model 1 (R12 = .80) with Model 2 (R22 = .81) where SE is added to the regression equation with the control and covariate variables. The significant standardized coefficient (Beta = -.14, p < .01) indicates that a one standard deviation increase in
Table 2: Hierarchical regressions with posttest peer support as the independent variable
Betas _____ __ R2 for Model 1 and Model 2 with
Pretest Pretest Posttest change in R2 from Model 1 to 2
Dependent Variable (DV) DV Support Age Gender Married Support R12 R22 DR2 DF
- Posttest PTSD
Model 1: Controls .86*** – .03 .01 – .02 – .07 .79*** 125.26
Model 2: Add posttest support .85** .08 .01 .00 – .05 – .15** .80*** .01* 7.31
- Posttest general self-efficacy
Model 1: Controls .59*** .12 – .07 .05 .06 .45*** 32.36
Model 2: Add posttest support .61*** – .23** – .05 .00 .04 .48*** .55*** .10*** 43.70
- Posttest self-efficacy
Model 1: Controls .50*** .14 – .03 .11 .03 .38*** 19.19
Model 2: Add posttest support .51*** – .20* – .03 .04 .01 .47*** .48*** .10*** 31.94
* p < .05; ** p < .01; *** p < .001
Table 3: Hierarchical regressions with posttest “situation-specific” self-efficacy as the independent variable
Betas _______ R2 for Model 1 and Model 2 wit
Pretest Pretest Posttest change in R2 from Model 1 to 2
Dependent Variable (DV) PTSD SE Age Gender Married SE R12 R22 DR2 DF
Model 1: Controls .73*** – .20*** .04 – .03 – .04 .80*** 109.46
Model 2: Add posttest self-efficacy .72*** – .12* .04 – .01 – .03 – .14** .81*** .01** 7.45
* p < .05; ** p < .01; *** p < .001
Table 4: Hierarchical regressions with posttest general self-efficacy (GES) as the independent variable (IV)
Betas _______ R2 for Model 1 and Model 2 wit
Pretest Pretest Posttest change in R2 from Model 1 to 2
Dependent Variable (DV) DV GSE Age Gender Married GSE R12 R22 DR2 DF
Model 1: Controls .86*** – .03 .01 – .02 – .07 .78*** 125.18
Model 2: Add posttest GES .86*** .05 .01 – .02 – .06 – .12** .79*** .01** 5.56
* p < .05; ** p < .01; *** p < .001
(Apologies: The data table is too wide for this format. We are trying to correct it. Please contact us at JimDriscoll@NIPSPeerSupport.org directly and not the author for a more readable format.)
posttest GSE reduces perceived posttest PTSD symptoms by only .14 standard deviations when holding other control and covariate variables constant. These findings support the hypothesis.
Hypothesis 3 is that increased general self-efficacy reduces perceived PTSD symptoms. As shown in Table 4, the amount of change in variance explained is very small but significant (DR2 = .01, p < .01) in comparing Model 1 (R12 = .78) with Model 2 (R22 = .79) where GSE is added to the regression equation with the control and covariate variables. The significant standardized coefficient (Beta = -.12, p < .01) indicates that a one standard deviation increase in posttest GSE reduces perceived posttest PTSD symptoms by only .12 standard deviations when holding other control and covariate variables constant. These findings support the hypothesis.
The last two hypotheses are that situation-specific self-efficacy (Hypothesis 4) and general self-efficacy (Hypothesis 5) will play a mediator role in explaining the relationship between peer support and perceived PTSD symptoms. Kenny, Kasher, & Bolger (1998) defined the criteria for demonstrating mediation. The first criterion is the same as the supported Hypothesis 1, namely that the independent variable of posttest peer support reduces perceived PTDS symptoms. The second criterion is the same as the supported Hypothesis 2 and Hypothesis 3, namely that the mediator variable of SE and GSE respectively reduces perceived PTSD symptoms. The third criterion is that the relationship is significant between the independent variable of posttest peer support and the mediator variables of SE and GSE respectively. As shown in Table 2-Part B and Part C, this criterion is supported by the strong significant relationship of peer support to both SE (Beta = .47, p < .001) and GSE (Beta = .48, p < .001). A one standard deviation increase in posttest peer support increases SE or GSE respectively by .47 or .48 standard deviations when holding other control and covariate variables constant. A fourth criterion is necessary to demonstrate full mediation, namely that the relationship between posttest peer support and perceived PTSD symptoms must be reduced to insignificance when controlling for posttest SE or GSE respectively. This criterion is satisfied when controlling for the control variables for posttest SE (Beta = -.07, p > .05) and posttest GSE (Beta = -.12, p > .05) respectively. The findings for all four criteria together support Hypotheses 4 and 5.
This study contributes to empirical knowledge about the effectiveness of peer support for veterans who have returned to civilian life, especially in regards to OIF/OEF veterans (Ozer et al., 2008). Perceived increases in peer support foster a significant but small reduction of perceived PTSD symptoms, as do increases in situation-specific self-efficacy and general self-efficacy. As Benight & Bandura (2004) report, little is known about the role of self-efficacy as a mediator variable between combat-related trauma and peer support. The strong, significant relationship between peer support and self-efficacy here suggests that peer support as change-oriented process provides an enabling environment that promotes self-efficacy beliefs regarding proactive, adaptive coping with PTSD symptoms. This mediator role was played by both situation-specific self-efficacy and the more future-oriented, optimistic concept of general self-efficacy.
These findings must be balanced with a number of study limitations. Although all hypotheses are supported, the strength of relationship is small between reduced PTSD symptoms, peer support, and self-efficacy. This change in PTSD symptoms may have resulted for reasons other than increased peer support or self-efficacy. For example, it may be that an intense weekend retreat created a positive ‘bounce’ effect in self-evaluation that will shortly diminish. The literature does suggest, however, that the effect of peer support for veterans is cumulative over time (Ozer, et al., 2008). Longitudinal, follow-up studies are needed to compare the initial and cumulative effects of different peer support formats. Another study limitation, perhaps best corrected by randomization to different groups when possible, is selection bias of participants in terms of attending a weekend retreat. Measurement could be improved by, for example, a) additional peer support measures to enhance understanding of the emotional, cognitive and social meanings of peer support, and b) increasing the range of outcomes to include more about the management of combat-related trauma and pain, social relationships, and instrumental needs such as use of veteran benefits, education, and employment to indicate how peer support is most helpful.
Implications for social work
Recognizing the behavioral health needs of veterans is an essential first step in the design of services. The recognition needs to be followed with referral for appropriate services. Social workers need to advocate on behalf of veterans to ensure they receive the benefits they and their families are entitled to. This requires assessing support systems and resources. Encouraging agencies to develop peer support programs that are sensitive to the needs of veterans can be a proactive strategy. Peer support plays a role in well-being and is consistent with the bio-psycho-social model and client-centered practice. This model assumes the client possesses strengths such as self-efficacy and resources that can be used to ameliorate current challenges in the fit between person and environment. Veterans face serious challenges as they integrate into civilian life after exposure to the multiple traumas associated with combat. Reliance on peer support, a core component of military culture and camaraderie, can play a critical role in re-integration. Using the resources they had in civilian life as well as the acquired coping skills such as self-efficacy that they developed during their military service, they can now go about the seemingly daunting task of returning to civilian life. The behavioral health needs of the increasing number of returning veterans may strain services at the community level. Engagement in the political process can ensure that the funding for these services is available. Augmenting professional services by using such cost effective strategies as peer support groups that rely on the strengths of the veterans should be pursued.
More broadly speaking, social workers are likely to meet veterans and their families in a variety of settings. A family focus, therefore, can facilitate recognizing the potential impact of untreated behavioral health problems of veterans on all family members. For example, school social workers may see students with a parent trying to deal with the hyper-vigilance that can characterize PTSD. This symptom can be confusing to children who do not see threats in their environments. Or, a child welfare worker may interview families in which one parent is experiencing the emotional numbness that can result from exposure to violence. This behavior can be upsetting to family members who view the veteran as rejecting or uncaring. Families may not be aware that these are symptoms of trauma and that treatment is available. By using the broader context of the family perspective, the social worker can both educate family members about veteran benefits and make appropriate referrals to supportive veterans’ services such as peer support groups.
Lastly, the weekend retreat potentially has much to offer the social service community. As time pressures of family, work and other responsibilities increase, the weekend can be the time most easily available for intervention. This may be especially true if spouses and partners are included in the intervention. From an agency perspective, use of weekend retreats may be a way to efficiently extend services to a wider clientele such as veterans. From the perspective of peer support and veteran camaraderie in this study, use of weekend retreats would seem to be a conceptually congruent method since retreats allow for spending an extensive amount of bonding time.
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