Post-9/11 Veterans who served in OEF/OIF face many challenges as they re-enter civilian
life after structured military careers. Yet, underutilization and resistance to mental
health treatment remains a significant problem. Recent investigations of community
reintegration problems among returning Veterans found that half of combat Veterans who
use Veterans Administration (VA) services reported difficulty in readjusting to civilian
life, including difficulty in social functioning, productivity in work and school
settings, community involvement, and self-care domains. High rates of marital, family,
and cohabitation discord were reported, with 75% reporting a family conflict in the last
week. At least one-third reported divorce, dangerous driving and risky behaviors,
increased substance use, and impulsivity and anger control problems since deployment.
Almost all Veterans expressed interest in receiving services to help readjust to civilian
life, and receiving reintegration services at a VA facility was reported as the preferred
way to receive help. Mental health and anger problems are often cited as driving
Veterans' difficulties readjusting to civilian life. Anger is becoming more widely
recognized for its involvement in the psychological adjustment problems of post-9/11
Veterans. Research has shown that anger directly influences treatment outcome. In fact,
history of untreated PTSD and aggression have been demonstrated to be pervasive among
post-9/11 Veterans who die by suicide in the months before death. Veterans with probable
PTSD report more reintegration and anger problems, and greater interest in services than
Veterans without. Reintegration and anger problems continue for years post-combat and may
not resolve without intervention.
Research on TBI in post-9/11 Veterans underscores the need for programs that utilize an
interdisciplinary approach to reintegration. Programs designed to address challenges of
Veterans as they reintegrate in vocational environments, particularly integrative
approaches, are greatly needed. The STEP-Home intervention provides such a program.
STEP-Home includes focused cognitive and emotional regulation skills training and is
informed by the most recent research with returning Veterans and available programs
focused on reintegration in VA and military settings (e.g., Battlemind training).
Phase 1: Years 1 and 2 The investigators will initiate the study at the Boston VAMC and
develop Standard Operating Procedures for the addition of site 2 in Phase 2.
Phase 2: Years 3 and 4 The investigators will initiate the study at the second site, the
Houston VAMC, in Year 3. The investigators will apply in Year 2 for IRB approval to
initiate site 2.
Hypotheses & Aims
Primary Aim 1. Examine treatment effects of STEP-Home on primary outcomes relative to
Present Centered Group Therapy (PCGT):
Hypothesis 1A. Participants randomized into the STEP-Home intervention will show
improvement on reintegration, readjustment, and anger post-intervention (expressed by
lower scores; less difficulty).
Military to Civilian Questionnaire (M2CQ), Post-Deployment Readjustment Inventory (PDRI),
and State-Trait Anger Expression Inventory (STAXI-2) scores post-intervention (T4) <
baseline (T1)
Hypothesis 1B. Participants randomized into STEP-Home will show greater improvement in
primary outcomes as compared to PCGT.
Change scores baseline (T1) to post-intervention (T4) STEP-Home > PCGT change scores
Post-intervention (T4) primary outcome scores STEP-Home < PCGT primary outcome scores
(T4)
Primary Aim 2. Examine maintenance of treatment effects on primary outcomes:
Hypothesis 2: Treatment effects will be maintained at follow up in both groups.
Differential treatment effect of STEP-Home over PCGT post-intervention (T4) will be
maintained at follow up (T5).
Exploratory Aim 1. Explore treatment effects of STEP-Home on measures of mental health,
functional and vocational status and cognitive secondary outcomes targeted indirectly in
the workshop.
Exploratory Hypothesis 1. Acquisition of core skills (problem solving, emotional
regulation, attention training) will mediate the effect of treatment on primary outcomes
post-intervention and at follow up.
The successful completion of the aims proposed has the potential to significantly improve
skills to foster civilian reintegration in post-9/11Veterans. Furthermore, the STEP-Home
SPiRE feasibility study demonstrated that the workshop also serves as a gateway for
Veterans who are hesitant to participate in traditional mental health treatments to
promote openness and engagement in additional, critically needed, VA services. Given the
high rate of treatment resistance in this cohort, developing acceptable interventions
that promote treatment engagement and retention, and open the door to future VA care, is
necessary to improve functional status and to reduce long-term healthcare costs of
untreated mental health illnesses.