From Homelessness to Employment: Perceptions of OEF and OIF Veterans With Posttraumatic Stress Disorder

Abstract

The purpose of this study was to document the first-person perspectives of 10 Operation Enduring Freedom/Operation Iraqi Freedom (OEF/OIF) veterans with posttraumatic stress disorder (PTSD) regarding their efforts to move from homelessness to employment. A qualitative, phenomenological study design was employed through the use of in-depth interviews. Five themes emerged, labeled as (a) fallout from PTSD, (b) motivation to change, (c) family support, (d) rehabilitation counseling, and (e) developing a new work identity. Findings suggest that veterans of this era with PTSD express the values and attitudes needed for work adjustment and successful reintegration into the workforce. It is anticipated that the results of this study will stimulate the rehabilitation counseling profession to continue advancements in training, research, and service provision to better meet the vocational rehabilitation needs of veterans with PTSD.

Keywords

veterans career development psychiatric rehabilitation psychological aspects of disabilities PTSD

Following the September 11, 2001, terrorist attacks, the U.S. military sent service members to warzones in Afghanistan for Operation Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF), propelling the United States into a new era of protracted conflicts in the Middle East. The human and financial costs of these conflicts are enormous. Since its inception on October 7, 2001, OEF operations have resulted in 2,355 deaths, with another 20,071 wounded in action. OIF operations began on March 19, 2003. Since then, 4,424 military personnel have been killed, with another 31,951 wounded in action (Fischer, 2015). In terms of financial costs, an estimated US$686 billion has been spent on OEF operations, with another US$815 billion on OIF. Also, from fiscal year (FY) 2001 through FY 2015 budget requests, the U.S. Department of Veterans Affairs (VA) medical costs for OEF were approximately US$6.9 billion for OEF and US$15.9 billion for OIF veterans (Belasco, 2014).

Among the many personal costs of these conflicts is posttraumatic stress disorder (PTSD). Along with traumatic brain injury (TBI), PTSD is considered to be a “signature wound” of these conflicts (Fairweather & Garcia, 2007). The National Center for PTSD (2015) estimated 10% to 18% of all OEF and OIF veterans experience PTSD. Because of the chronically high stress and hazardous environments of combat operations in Iraq and Afghanistan, PTSD is of particular risk, and often occurs alongside TBI and the multitude of other injuries caused by improvised explosive devices (IEDs). When an individual experiences TBI caused by an IED, PTSD can result from memory of the event, a reduced ability to respond to anxiety-related symptoms, and/or PTSD already occurring at the time of the TBI (Burke, Degeneffe, & Olney, 2009). While IEDs and other combat injuries can result in PTSD, it is also important to note PTSD can occur in the absence of combat-related events. One such cause is military sexual trauma (MST). Tamez and Hazler (2014) noted female veterans face increased risk of PTSD due to pervasiveness of MST. Their review included (as cited in Corbett, 2007) FY 2003 Veterans Health Administration data reporting women who incurred MST were approximately 3 times more likely to develop PTSD than male MST victims. Also, Tamez and Hazler (as cited by the National Center for PTSD, 2010) noted one in five female veterans reported an MST compared with one in 100 male veterans.

Grouped with trauma and stressor-related disorders in the Diagnostic and Statistical Manual of Mental Disorders (5th ed.; DSM-5; American Psychiatric Association [APA], 2013), PTSD is, by definition, “the development of characteristic symptoms following exposure to one or more traumatic events” that encompasses a range of emotional criteria (p. 274). PTSD is differentiated from anxiety disorders by the presence of symptoms of re-experiencing trauma, hyperarousal, avoidance behaviors, flashbacks, and intrusive memories. To be diagnosed, PTSD must include symptoms that to some degree impair normal functioning for at least 1 month (APA, 2013; Cigrang, Peterson, & Shobitz, 2005; Satel, 2010). Ruzek et al. (2004) found a nexus between chronic, combat-related PTSD and “high rates of job turnover and general difficulty in maintaining employment,” and noted, “these are often attributed by veterans themselves to anger and irritability, difficulties with authority, PTSD symptoms, and substance abuse” (p. 35). In their review of studies examining post-deployment adjustment challenges for OEF/OIF veterans, Bush, Bosmajian, Fairall, McCann, and Ciulla (2011) found a growing population of warzone returnees with behavioral health and psychological concerns. In addition to PTSD, OEF and OIF veterans can experience homelessness, anxiety, depression, substance abuse, and diminished quality of life. Gates et al. (2012) also noted OEF and OIF veterans with PTSD can encounter serious physical health problems, legal difficulties, marital and family problems, and job instability.

Calhoun et al. (2007) indicated that finding a job or returning to work can be prevented if PTSD symptoms are not effectively treated and managed (Carroll, Ruegar, Foy, & Donahoe, 1985; Chalsma, 1998). Tanielian and Jaycox (2008) indicated veterans sometimes experience negative outcomes such as divorce, substance abuse, homelessness, violence, suicide, and unemployment.

With respect to employment, Wald and Taylor (2009) placed PTSD in the top 10 physical and mental disorders associated with work loss days. They also found a direct correlation between PTSD and difficulties with time management, workload management, inability to concentrate, and difficulty maintaining interpersonal relationships. They noted that persons with PTSD have significant underemployment and job loss, lower production rates, often work below their skill and/or educational level, and sometimes attribute their symptoms to their current employability status.

Given the varied challenges, many OEF and OIF veterans with PTSD unfortunately do not receive adequate mental health services, both during and after their military service. While in the armed services, military culture works against the identification and treatment of PTSD. For example, the Army Mental Health Advisory Team’s (Willis, 2007) survey of active duty Army and Marine personnel found that 59% of those in the Army and 48% of Marines believed that seeking counseling for their psychological conditions would result in different treatment by command leadership. Consistent with this finding, Hall (2008) noted that military culture discourages divulging information about feelings and emotions. This code of silence creates an atmosphere where stigma leads to concealment by military members, making them less likely to request mental health services for emotional distress, or overtly acknowledge trauma during counseling. Following their military service, OEF and OIF veterans are often challenged by chronic delays and inefficiencies in receiving timely support from the VA. For example, as of April 16, 2016, the Veterans Benefits Administration (VBA; 2016) reported there are 349,601 pending claims for VBA benefits, with 79,067 of these claims in review for more than 125 days. In total, the VBA provides compensation and pension benefits to more than four million veterans, with 940,000 of this total added since 2012. In FY 2012, the VBA provided US$54 billion in benefits. Also, VBA claims based on PTSD may be rejected. From 2007 to 2008, 42.5% of VBA compensation claims based on PTSD were rejected, with another 2.9% given 0% ratings (Rosen, 2010).

Focus of the Present Study

It is likely most rehabilitation counselors possess limited understanding of the lived experiences and post-deployment challenges of OEF and OIF veterans with PTSD. Current Council on Rehabilitation Education (CORE, 2014) standards do not require specific curricula content on serious mental illness (including PTSD) nor are CORE program graduates required to learn about military organization, culture, and post-deployment challenges. Also, it is likely most rehabilitation counselors do not benefit from a lived military experience. It is estimated less than a half of 1% of the U.S. population are in the armed services, with 49% of all active duty military personnel congregated in California, Virginia, Texas, North Carolina, and Georgia (Zucchino & Cloud, 2015). The shortcoming in awareness among rehabilitation counselors is unfortunate given the likelihood they will work with veterans impacted by PTSD. A primary setting is through the VBA’s Vocational Rehabilitation and Employment service, where rehabilitation counselors provide veterans with qualifying service-connected disabilities with vocational rehabilitation services leading to employment. Also, it is likely the State/Federal Vocational Rehabilitation System will serve a greater number of OEF and OIF veterans in future years (Frain, Bishop, & Bethel, 2010).

As noted, OEF and OIF veterans with PTSD face a variety of negative employment outcomes. Although specific employment data among OEF and OIF veterans with PTSD are not available, employment data suggest OEF and OIF veterans with service-connected disabilities present employment concerns that should be of interest to rehabilitation counselors. According to the U.S. Bureau of Labor Statistics (2016), approximately 33% of all OEF and OIF veterans were rated by the VA as having service-connected disabilities, compared with 20% of all veterans. As of August 2015, 73.2% of OEF and OIF veterans with service-connected disabilities were in the labor force compared with 87.3% of OEF and OIF veterans without a service-connected disability rating. Many veterans counted as service-related disabled possess ratings high enough to present significant employment challenges. Among all veterans with service-connected disabilities in August 2015, 37% had ratings higher than 60%, with only 30.7% of this group in the labor force.

Currently, there is a lack of information about the employment status and needs among OEF and OIF veterans with service-connected disabilities. In making this point, Frain and associates (2010) argued,

For example, there is not yet reliable information available about the employment status of either retired active duty personnel, or the military reservists who, as a result of disability, are not able to return to their previous employment. Nor is there information about the specific vocational rehabilitation needs of such individuals, or how effectively these needs are being addressed. (p. 13)

Because of the nascent state of our understanding of OEF and OIF veterans with PTSD, the present study aimed to give these veterans a voice about their lived experiences from the continuum of homelessness to employment. To our knowledge, no previous research exists that documents these perspectives. The present study provides rehabilitation counselors an insider view of the challenges, perceived vocational competencies, and opinions about effective rehabilitation counseling supports, as reported by 10 OEF and OIF veterans with combat-related PTSD.

Method

Given the lack of previous research on employment participation and vocational rehabilitation among OEF and OIF veterans with PTSD, a qualitative approach was employed. Rather than conducting the study with predetermined assumptions and hypotheses, qualitative methodology allowed the data to speak for itself (Hagner & Helm, 1994). An aim with the use of a qualitative approach was to provide a foundation for future research, theory development, and clinical interventions. Specific to the aims of the present study (i.e., to give voice to the lived experiences of OEF and OIF veterans with PTSD), we determined a phenomenological approach was an appropriate choice.

Patten (2012) indicated that phenomenology is an approach to studying the subjective perceptions of events and the meaning that individuals make of the events. While many veterans who served in Iraq and Afghanistan now experience PTSD, their experiences should be viewed as unique when considered in the context of American society, where most citizens have not been in combat or even served in the military. Hence, the participants in our study possessed common “lived experiences of a concept or a phenomenon” (Creswell, 2007, p. 57), not accessible to most rehabilitation counselors or those in the general public. The descriptions that follow will explain how a phenomenological approach was used to address the focus of the present study.

Participants

Study participants were served by a residential veteran-focused program in a large city in the southwest United States. The program receives funding from the VA, other federal agencies, and private donations. Participants met the following inclusion criteria: (a) OEF/OIF veterans with a warzone duty assignment, (b) separated from military service no less than 1 year prior to the interview date, (c) met the VA/Department of Defense (DOD, 2010) definition for PTSD (i.e., persistent re-experiencing, avoidance, and increased arousal symptoms of the traumatic event), and (d) met VA criteria for combat trauma exposure by experiencing clinically significant symptoms. All participants were still residing in the facility at the time of data collection. Table 1 describes the military service and PTSD ratings for all 10 participants. Assigned PTSD ratings from the VA reflect the degree of PTSD-related impairment as part of the participants’ overall military disability compensation.

Table 1.

Military Service and PTSD Ratings.

Participant	Military branch	Warzone	Assignment	PTSD rating (%)
1. Kim, female	Army	OEF	Combat support	10
2. Jenna, female	Navy	OEF/OIF	Combat service support	10
3. Richard, male	Navy	OIF	Combat service support	30
4. Todd, male	Navy	OIF	Combat	30
5. Danny, male	Marines	OIF	Combat/combat support	30
6. Scott, male	Navy	OEF/OIF	Combat service support	70
7. Martin, male	Army	OEF	Combat	70
8. Robert, male	Navy	OIF	Combat	100
9. Damon, male	Navy	OEF	Combat	70
10. Seth, male	Marines	OIF	Combat	70

Note. PTSD = posttraumatic stress disorder; OEF = Operation Enduring Freedom; OIF = Operation Iraqi Freedom.

The study included eight men and two women. Six of the participants were between 25 and 35 years of age. Six participants were White, five were separated or divorced, six were Navy veterans, and six had some college or professional school experience. Table 2 summarizes the demographic backgrounds of the participants.

Table 2.

Participant Demographics.

Item	n	%
1. Gender
Male	8	80
Female	2	20
2. Age
<25	1	10
25–35	6	60
36–40	1	10
40>	2	20
3. Ethnicity
White	6	60
Black	2	20
Latino/Hispanic	2	20
4. Marital status
Married	4	40
Single	1	10
Separated/divorced	5	50
5. Current education level
High school graduate/General Educational Development	4	40
Some college/professional school	6	60

Procedure

The study received approval from the authors’ university institutional review board. The first author recruited participants at the treatment center’s employment and training section, where the first author was employed during data collection. The employment and training section director limited participant recruitment to only those who specifically sought vocational and academic assistance, which limited the pool of prospective participants. The process of recruiting and selecting the study’s 10 participants took approximately 3 months to complete.

After prospective participants disclosed they experienced PTSD, they were provided with a letter of introduction about the study, their informed consent rights as research participants, and an overview of the purpose, methods, and expected outcomes of the study. To build rapport with prospective sample members, information on individual military assignments and background information were discussed between the first author (an Army combat veteran) and participants. Over approximately 3 months, 10 veterans initially expressed their interest in participating, with two later requesting removal from the study for personal reasons. These two individuals were then replaced by two additional participants. All participants completed consent forms. During the period when data collection took place, participants were not clients of the first author. After data collection ended, three participants later became clients of the first author. Participants were informed that their involvement in the study would not affect their services and they could decide to end their involvement at any time. Participants were not provided financial compensation.

The first author met with and interviewed the 10 participants. Each interview lasted between 35 and 75 min, depending on the wishes of the interviewee. Each interview was audio-recorded, and predetermined interview questions were used to elicit and preserve candid and insightful responses from each participant. Eight of the interviews were conducted in a private conference room in the treatment facility and two were conducted at a private office in the facility’s family center.

A semi-structured interview format was used to foster freedom and flexibility for the participants as they talked about their specific experiences. This allowed the opportunity to gather rich descriptions of veterans’ perceptions and experiences (Kolb, 2012; Smith & Osborn, 2003). Interview questions were grouped into three domains and were rooted in the Hershenson Model of Vocational Adjustment (Hershenson, 1996; Szymanski, Enright, Hershenson, & Ettinger, 2010). Hershenson believed people experience a sequential process of vocational development in response to their particular contexts and circumstances in three domains, including (a) the work personality (i.e., worker self-concept and motivation to work), (b) perceived work competencies (i.e., work habits; physical, mental, and interpersonal skills), and (c) development of realistic work goals.

In phenomenological research, participants are asked questions to coalesce around two major areas, (Creswell, 2007) including “What have you experienced in terms of the phenomenon?” and “What contexts or situations have typically influenced or affected your experiences of the phenomenon?” (p. 61). The Hershenson model was chosen given its utility in examining how individuals perceive themselves with regard to the process of moving from homelessness, substance abuse, and other negative indices to a place of hope for vocational success and adjustment. The present study’s interview protocol (see Table 3) included questions anchored in each Hershenson model domain. Each participant was prompted to respond to follow-up questions designed to provide an opportunity to clarify, modify, or to further explain any answer. Follow-up question examples included the following: (a) Can you tell me more about that? (b) What was that like for you? and (c) Is there anything else you would like to add?

Table 3.

Hershenson’s (1996) Model Domains and Corresponding Questions.

Domain	Corresponding domain questions
1. Work personality	(7) What concerns do you have about working?
	(9) What are the advantages or disadvantages working will have on your disability?
	(12) Can you describe the sense of purpose you will derive from employment?
2. Work competencies	(2) What kind of employment are you actively seeking?
	(3) Can you describe what jobs you are prepared to accept?
	(5) What are the most important reasons why you want to work?
	(8) How will your disability affect your work competency?
	(11) How are you preparing for employment?
3. Work goals	(1) What are your career goals?
	(4) Can you describe or tell me how you have planned for a specific job?
	(6) Do you have a proposed timeline for starting work?
	(10) How much additional rehabilitation do you need to prepare for work?

Note. The order of each question is indicated in parentheses.

Data Analysis

Audio recordings were transcribed verbatim. Transcribed answers to the questions were modified only as needed to ensure privacy, and pseudonyms were used to provide anonymity.

Data gathered during this study resulted from the inductive method of phenomenology in which the researcher systematically collects qualitative data and analyzes them for connections and insights (Taylor & Bogdan, 1998). Transcriptions of the interviews generated 53 single-spaced pages. Transcripts were downloaded to Saturate, a web-based qualitative analysis application (Sillito, 2010).

In qualitative research, Creswell (2009) argued the researcher serves in the role of being a data collection instrument, which “necessitates the identification of personal values, assumptions, and biases at the outset of a study” (p. 196). As such, the first author viewed the findings from his perspectives as a former Army officer that served in combat in OIF and also through his work as a vocational rehabilitation professional at the veteran treatment setting where the participants resided. The first author’s analysis was further influenced by his participation in a CORE accredited master’s in rehabilitation counseling program during the time of data collection and analysis. The present study was conducted as a thesis, his culminating experience as he earned the master’s degree. These collective experiences provided the first author an insider perspective that allowed him to relate to and understand participant responses on a level deeper and more nuanced than if he lacked his military and educational background.

To maintain the credibility of the data, the first author relied on writing analytic memos following each interview and working with the second and third authors on the coding process, using open and axial coding strategies offered by Strauss and Corbin (1990). In accordance with the constant comparative method, the first author used open coding to assign initial codes, and shared interview transcripts and initial codes with the second and third authors throughout the interview process. As interviews were conducted and transcribed, the three authors met on a regular basis to discuss the assignment and refinement of codes. During these meetings, the first author shared his feelings about the interviews and assignment of codes, and was able to emotionally process what he was thinking and feeling in trying to make sense of the data.

Previously coded data were re-coded until all data had a logical home. Connections between codes resulted in refining some themes by combining related categories, thus accommodating original quotes and allowing for better coherence within the themes. The final set of codes that emerged in the present study resulted from the shared perspectives among the first three authors. The first three authors collectively determined data saturation was reached through the 10 participant interviews because no new themes had emerged.

Concerning generalizability of the study findings, as noted, participants were required to be OIF or OEF combat veterans, separated from military service for at least 1 year prior to the study, have a verifiable VA PTSD disability rating, and be willing to share their experiences with the first author. The population of the facility was overwhelming male. Therefore, more men visited the employment and training office than women, giving the first author more opportunity to approach and ask male residents whether they were interested in participating in the study. The first author strove to be unbiased in his recruiting and selection efforts. The two females who committed to the study expressed responses similar to the male participants. Military branch was not an influencing factor in the participant selection process because the first author had no prior information about which military branch they served in until the questions were asked during the interview.

To establish the confirmability of the data, a member check was conducted with participant Danny. He was asked to examine the data and comment on whether or not the codes accurately reflected the themes of the interview findings. Danny largely confirmed the accuracy of the analysis and the positive impact of participating by stating in part,

Often times, I don’t get the opportunity to share on these topics, am encouraged not to by others, and often avoid it entirely due to aggravation from others in my past. However, this experience was the opposite, and overall I think that this study did me some good on a therapeutic level, I was speaking to a professional, patient, and understanding fellow veteran who really wanted to just hear what I had to say. I hope that this study helps veterans reconnect with themselves and find better ways to embrace their military service even if it wasn’t so easy and get back into the workforce. (Semper Fidelis)

Results

Five overlapping themes emerged from the interviews. These are arrayed in order of apparent importance to the participants, based on the salience of the topics to them: (a) fallout from PTSD, (b) motivation to change, (c) family support, (d) rehabilitation counseling, and (e) developing a new work identity. Subthemes undergirding major themes are provided. Throughout the “Results” section, participants’ quotes are used to both illustrate and substantiate findings.

Theme 1: Fallout From PTSD

Participants reported specific symptoms and experiences associated with their PTSD such as mood issues, run-ins with the law, physical disability, family issues, legal problems, homelessness, and substance abuse. They noted that their anger, depression, and anxiety, due to symptoms of PTSD, had disrupted family relationships and resulted in confrontations with law enforcement. While participants were dealing with the fallout from their PTSD, their careers were temporarily derailed, creating a need to start again with new career development.

Significance of the problem

Ironically, participants’ abuse of substances to help them deal with PTSD actually seemed to interfere with their ability to successfully cope with PTSD. Several participants shared how alcohol abuse impaired decision making, although it was used to cope with the pain and confusion of depression, anxiety, or panic attacks. Scott, for example, experienced a very disturbing shipboard tragedy that left him severely traumatized. He sought consolation in alcohol:

My disease is drinking alcohol, and sitting around the house everyday, there is a possibility that I could fall back into the drinking trap. I do have some anger issues that I have worked on. It’s a risk right now because of medications, but it’s good because if I stop taking my medications I could spin out of control, which I have done before on several occasions. It’s a hard world. I find it difficult to deal with all the noise because I’m on medication and my anger is under control, but at times it really does annoy me and bothers me.

Apprehension

Some participants voiced apprehension about living with PTSD and comorbid health conditions. Danny struggled with TBI, significant bi-lateral hearing loss, and injury to his lower back. After significant alcohol abuse in an attempt to reduce his symptoms, he sought counseling through the VA:

I had a PTSD flyer just after I got divorced and out of the military a couple years after I came back from Iraq and I saw a therapist about two, three times a week. I was medicated. They kept me on Prozac for my depression and anxiety and I’ve done a lot for my own mental health to keep it right. I took a break and needed to focus on me and get myself straight. I’m still doing a lot of healing on my own from everything that has happened in my military life and coming to terms with it.

Legal difficulties were common among participants. Richard, for example, was repeatedly jailed for a variety of petty offenses and sensed his family, none of whom attempted contact or communication during his multiple incarcerations, had abandoned him. Richard explained,

Every time I went to jail my family didn’t call me, they didn’t visit me. They probably didn’t understand how deep the situation was or maybe they were just scared so maybe they just wanted to leave me alone.

Because his condition caused turmoil within his extended family, Richard feared others would judge him harshly on past behaviors. Concerning PTSD symptoms, he further revealed,

I am worried that they’re going to be scared because they don’t really understand it. Maybe they heard about somebody that had it or maybe they watched a movie and somebody flipped out. I’m just scared about them finding out about that or my past, anything that I have done bad catching up to me. I’m scared that I won’t be accepted because some people don’t like people that are in the military. I just don’t want any of the symptoms to come out if someone tries to control and keep me down, like my not being in the moment.

Whether it was dealing with disability, managing perceptions within family relationships, dealing with the law, or battling substance abuse, the participants saw the fallout from PTSD to be central to their daily experience.

Theme 2: Motivation to Change

Gaining awareness of personal values allowed many participants to achieve fulfillment and feel useful, independent, and self-sufficient. Personal development often presented a range of emotions that required an ability to overcome fear, confusion, and reluctance to accept new commitments. Foremost in the area of motivation to change was the ability of participants to adapt to new environments and accept new expected behaviors. Participants worked toward accomplishing this development through such approaches as behavior modification and the 12-step addiction treatment model. Adherence to these processes allowed participants the opportunity to achieve acknowledgment of counterproductive or negative behaviors.

Need to change

Prior to their treatment facility admissions, six participants had been homeless, whereas the other four were at risk of homelessness due to a wide array of challenges such as chemical dependency, family disruptions, physical disabilities, mental health challenges, multiple incarcerations, and exclusion from the labor force. Kim stated she experienced chronic homelessness and alcohol abuse since separation from military service until she discovered the recovery facility offered a substance abuse treatment program. She is a single parent with two children who sought to enroll in a program that provided needed rehabilitation for alcohol dependency and psychosocial difficulties and was motivated by the desire to give her children a better life. She related,

I have two children at home. Ever since I got out of the military, I have been homeless, bouncing from place to place. The longest I’ve been at a place is at a shelter for eight months. I’ve been kind of depressed because I don’t have a job and I’m not providing for my children. We lived in my car, we lived out on the streets, we lived in a shelter, and now transitional housing in the family program. I don’t want my children to go back there or wind up in this position again. My number one concern is to get a job and give them the life they deserve rather than what they have had during the last year since I’ve been out.

Desire to change

Damon was motivated by a strong desire for independence and aspired to reside in an apartment or condominium surrounded by nice things. He talked about wanting his residence perfectly clean with nice furniture, a big screen TV, and a place where buddies can come over on weekends:

That’s what motivates me to get full-time employment and work and work hard, because I’m a very hard worker. To be in the military you have to work hard and be driven. That’s how I was before a lot of things happened. That’s the most motivating factor–just to be independent. It really scares me because I’m fearful of failing, of not being able to do the job like I used to be able to do my military job. That’s a huge fear because I was very good at what I did and now going out into the real world and getting something that’s maybe completely different, or if it’s the same thing in a civilian environment, it’s working with all different types. Fear of failure is something that’s been on my mind.

Participants looked forward to the rewards a job could bring them, such as a place for their children to grow up in safety and a home that is comfortable and well appointed. Because they had been homeless, perhaps these rewards were more salient to the participants than they would be to someone who takes these advantages for granted.

Theme 3: Family Support

Whereas some people talked about being estranged from their families of origin, several participants became very passionate when talking about close family bonds. They appeared to benefit from positive, caring family relationships. Participants reported that family support facilitated their psychological health. However, it seemed that both participants and members of their nuclear families sometimes undervalued family support efforts. Danny benefited from a geographically close extended family:

My family helps me in every way possible. They helped very much in my childhood and young adult life but for some reason I chose to do things my own way. I don’t know if that’s a sense of pride or just a needed separation from having such a close family, but I’ve chosen to do things my way and it’s not always been the best decision. They have given me tremendous support in everything. My dad gifted my vehicle back for nothing. It was such a huge gesture, giving me that freedom and ability to travel to a job.

Participant Damon related thoughts and feelings he shares with his family about his stay at the treatment center. He had diligently participated in his individual treatment program and made great strides due to the level of support from his entire family. He articulated,

Once I got out of my own shell and actually stepped back and looked at the love, the support, and the pain that they have for me because I’m their son, their brother, their nephew, or their grandchild, it’s incredible. My family is very supportive of what I’m doing right now. I’m just seeing that now because I’m coming out of this cloud of selfishness and everything else, and support is unbelievable. If I didn’t have that I would be hurting in here. They support my vocational goals and they support me having a good life. Everybody loves me out there. I have a great family and I’m lucky to have that. So many veterans don’t have that.

For several participants, family involvement and support, both tangible and emotional, motivated them to work toward continued recovery. Having strong family bonds seemed to be protective for the people who had them.

Theme 4: Rehabilitation Counseling

This theme addresses the preparation of participants to enter civilian life. As part of their recovery program, all participants received rehabilitation counseling services to find employment, make career decisions, prepare for work, and eventually leave the facility. Many chose to receive vocational counseling services to discuss career readiness or identify an educational goal. Participants conveyed the skills and new awareness attained through their involvement in rehabilitation counseling support.

New career plans

Several participants needed to retool their career plans. Martin, who formerly tended to emergency room hospital patients and provided hospice care, found a position that did not require close contact with people now suited him better:

I was a medic. That was my set path and that’s what I was determined to pursue. It was in the military that I discovered the satisfaction that I had in health care, but now apparently health care subconsciously has been a trigger to PTSD keeping me in that frame of mind. I switched from health care, which I was pursing in nursing school since I separated from the Army, to environmental science. I literally felt loss of identity and could not enjoy the things that I’d always loved. It caused a lot of anger in me because I felt like this anxiety, this demon that had taken me over had literally robbed me of my soul, of a lot that I loved, of my goals, my passions, of the lifestyle that I’d always enjoyed. I now have the basic goal of helping people but in this case I’m taking care of people on more of a global level or a mental level rather than such a personal level.

This transition appeared extremely difficult for Martin, who felt that his career had been taken from him, as Martin redirected his passion for health studies into a career goal of employment in water quality control.

Getting to the next level

Preparation to begin work is an important aspect of career development. Jenna was searching for a better quality of life by seeking a career that would move her forward, provide potential growth, and equip her with skills to find sound employment:

I have moved through my recovery program for about seven months so I can start work as soon as possible to support my family. I prepared for work by attending Job Club at (the treatment center) and learned job-seeking skills such as interviewing skills and how to keep an interview short and simple. I also learned about web sites for job research and how to prepare a professional looking resume. I use that resume now to submit to prospective employers.

Entering a new career or preparing for a career was important to participants. These activities took place within the context of rehabilitation counseling, although participants did not specifically identify the counselors.

Theme 5: Developing a New Identity

Incurring a disability was life changing for all participants. Similarly, becoming employed as a civilian contributed to a positive sense of self in most cases. Movement toward developing a new identity involved going past the stigma of receiving help and finding a new basis for identity beyond their military service and into civilian employment.

Identity issues

Danny stated that he felt being a Marine had been the most important aspect of his life. After discharge, he attempted self-healing and coming to terms with everything that happened during his military experience. He explained,

It was very disheartening for me to acknowledge my new civilian role. I was so thoroughly identified by my third generation active military status. I am trying to moderate thoughts of my military experience but they will always be present. With additional therapy I can free myself from the resentment I hold toward my physical and mental conditions.

Employment as recovery

Participant Todd was aware of personal health, well-being, development, and additional factors that contributed to his new identity as a person with a disability. In Todd’s opinion, health and well-being were important to his daily function, and at times he struggled to pursue functioning at a peak level. He stated,

Disability has a part in depression and being depressed is partly because I feel like I’m useless or feel like I’ve been useless for a long time. I feel like I have the same capability as I once had as a result so that kind of puts you in a depressing state of mind, not being able to do the things you used to be able to do, or being limited, or being not able to do what you want to do. And it’s been hard. I think for one, [I] could not survive on the monthly disability payment I am getting. I wouldn’t make it. Two, I have a child coming. And for three, I don’t know what my life would look like if I didn’t have a job to go to every day.

Identity and stigma

Participants were sensitive to being identified as a person with a disability in the workplace. An employment criterion for hiring by a federal contractor is a VA disability rating of the degree of disability, which Robert considered stigmatizing if shared with a potential employer. Robert, a former mortgage broker, lost a promising career within a short time as a result of PTSD triggers and depression. He concluded,

I will need quite a bit more therapy. Combat therapy scratched the surface but obviously I need rehabilitation to just carry out a normal job. It’s kind of like needing a lot of basic things to be rehabilitated like some things I can’t do anymore. I wouldn’t be there if I didn’t have these issues and I wouldn’t have this job without a disability. If you want to look at it as some kind of spiritual quest, learn to overcome things, character building, I don’t know.

From managing the fallout of PTSD, to developing motivation to change and finding the family support to help, to developing a rehabilitation plan and ultimately getting a job, participants worked toward careers that would sustain them monetarily and psychologically.

Discussion

Through a phenomenological method, the present study provides insight into how 10 formerly homeless and unemployed OEF and OIF veterans transitioned into seeking employment and recovery. Completing the treatment and vocational rehabilitation process allowed participants to achieve independence or continue to be directed toward that goal. The results shown in Table 4 indicated that six of the 10 participants became employed in full-time positions whereas four participants did not find employment. Two were not able to work because of disability-related reasons, one withdrew from the program and another participant remained in treatment to complete her 12-step program while completing information technology employment preparation courses.

Table 4.

Participant Employment Outcomes.

Participant	Employment outcome
1. Kim	Continuing in treatment, enrolled in online IT courses
2. Jenna	Withdrew from treatment, part-time student
3. Richard	Full-time IT associate, part-time IT student
4. Todd	Full-time chauffer
5. Danny	Full-time veteran outreach coordinator
6. Scott	Physical disabilities prevent employment
7. Martin	Full-time caregiver, part-time water treatment student
8. Robert	Psychosocial barriers prevented employment
9. Damon	Full-time military materiel consultant
10. Seth	Full-time construction demolition specialist

Note. IT = information technology.

Implications for Rehabilitation Counseling

Many of the participants in the present study pursued (with great self-awareness and determination) their individual vocational goals. They encountered many challenges along their paths to recovery and adjustment knowing that the day would arrive when they accomplished job readiness. During their journeys through the recovery and employment-seeking process, they learned about themselves, their values, and their desires to live independently. Many self-starters emerged from the treatment center with action plans to obtain jobs in several diverse occupational domains. They participated in counseling and were diligent in learning about the occupational roles that would draw from their military skills and experience. Engaging in supportive collaborative relationships proved successful when encouraging and developing and accepting new perspectives on their post-military work role involvement.

Our findings speak to the need for rehabilitation counselors to assist veterans with PTSD in the process of returning to family relationships, employment, and community participation. Rehabilitation counselors need to recognize that to make a difference in the quality of life for a veteran with PTSD, the commitment requires (a) time for these veterans to equip themselves with tools to surmount certain job-related challenges, (b) special emphasis on counseling in job-related and academic skills, and (c) preparation to enter the competitive workforce. Our findings present a number of important considerations for rehabilitation counseling practice, advocacy, and future research.

As our findings suggest, preparing rehabilitation counselors with knowledge of effective PTSD treatment, vocational rehabilitation approaches, work adjustment, and other specialties is essential to the overall success of OEF/OIF veterans with PTSD. We provide recommendations for pre-service and continuing education. Pre-service rehabilitation counseling education should include (a) specialized training certificates that address PTSD among veterans; (b) assurance that all students are exposed to training in PTSD through readings and classroom-based learning in the existing curriculum; and (c) understanding how veterans adapt to their post-deployment needs for mental health treatment, relationship support, substance abuse treatment, and reintegration into civilian life. Rehabilitation counselors should receive specific training on how to recognize veterans in distress and when, where, and how to respond to PTSD reactions requiring referral to psychologists, psychiatrists, and other mental health professionals with specific training on treating veterans with PTSD. Rehabilitation counseling education programs that offer specific mental health counseling curriculum leading to licensure might be well suited to prepare students for future work with OEF and OIF veterans with PTSD.

After their formative training, rehabilitation counselors need ongoing continuing education through attending conferences, taking classes, participating in webinars, and reading journal articles and books. Content areas could include such topics as military culture, PTSD-specific counseling approaches, VA and DOD funding systems, and screening for PTSD and TBI (Burke et al., 2009; Frain et al., 2010). With VA funding systems, for example, rehabilitation counselors can assist veterans with PTSD with less than honorable military discharge ratings with reversing these ratings. A less than honorable discharge rating presents a significant barrier, given such a rating can limit many services the veteran may need in response to PTSD. The DOD and individual military services maintain processes for review and possible reversal of prior discharge ratings (VA, 2015).

In addition to these content areas, rehabilitation counselors should receive specific training on the VA’s Polytrauma Network System (PNS; Burke et al., 2009; VA, 2015). The PNS features an integrated and multidisciplinary system of support for veterans with PTSD and polytrauma injuries from acute-care to long-term community support in the veteran’s home community. After acute-care treatment at a Polytrauma Rehabilitation Center (located in Richmond, Virginia; Tampa, Florida; Minneapolis, Minnesota; Palo Alto, California; and San Antonio, Texas), veterans can receive continued inpatient or outpatient care at one of 23 different PNS network sites located in geographically diverse parts of the United States. Veterans can then receive outpatient care even closer to the home communities through one of 87 polytrauma support clinic teams.

Rehabilitation counselors should also become aware of the many local organizations and resources available to meet the needs of OEF and OIF veterans with PTSD. Legal jurisdictions across the United States offer “veterans treatment courts” (Justice for Vets, 2016), which provide a separate legal process for veterans to progress through the criminal justice system for those with PTSD or other challenges linked to military service. Veterans’ treatment courts focus on making linkages to needed funding and resources, and involve court personnel with specific military awareness and experience. Rehabilitation counselors are also encouraged to participate in “stand down” events. Stand down events (Military Connection, 2016) are directed toward homeless veterans and are held in one location for 1 to 3 days. Staff members from the VA and a variety of other veteran and community agencies are present to explain their services and provide access to their programs.

Research Implications

Findings of the present study with regard to (a) warzone traumatic stressors, (b) post-deployment behavioral adjustment, (c) social and interpersonal functioning, and (d) positive outcomes from employment are consistent with prior research (Bush et al., 2011; Carroll et al., 1985; Chalsma, 1998; Gates et al., 2012; Hoge, Terhakopian, Castro, Messer, & Engel, 2007; Sayers, Farrow, Ross, & Oslin, 2009; Schnurr, Lunney, Bovin, & Marx, 2009). For example, in their review of studies examining post-deployment adjustment challenges for OEF and OIF veterans, Bush and associates (2011) found a growing population of warzone returnees with behavioral health and psychological concerns. In the present study, participants described how PTSD was linked to instability and uncertainty in their lives as well as in the lives of their family members. Participants revealed that years of coping inability led to (a) problems with transitioning to life after leaving the military, (b) vocational stagnation, (c) substance abuse, and (d) homelessness, stress, and anger-laden situations.

Participants in the present study documented the value of PTSD treatment and engagement in vocational rehabilitation. Consistent with our findings, Geuze, Vermetten, de Kloet, Hijman, and Westenberg (2009) and Lunney and Schnurr (2007) concluded quality of life can improve following PTSD treatment. Findings from the present study support the role of vocational planning and employment as key elements in PTSD treatment. Our findings also document the value of treatment and employment for improving family relationships. There were several instances where families of participants made a positive contribution to well-being and recovery. For some participants, this sometimes required repairing strained or broken relationships with family members, often resulting from the struggles of living with PTSD. Positive family support resulted in better functioning, a more tolerable adjustment and reintegration process with family, and an overall higher level of functioning. In their review of the relationship of social connections and PTSD, Charuvastra and Cloitre (2008) determined positive family environments help reduce PTSD symptoms during treatment, while PTSD can conversely disrupt a person’s ability to benefit from PTSD treatment if it further strains family relationships. The present study findings reinforce the importance of involving positive support from family during a veterans’ path toward such goals as substance abuse recovery, education and training, and employment.

With regard to future research, our study will hopefully motivate rehabilitation counselors to further document the experiences of OEF and OIF veterans with PTSD with regard to substance abuse, PTSD treatment, family relationships, and vocational rehabilitation through research. To date, this research is limited or non-existent. Furthermore, we encourage rehabilitation counselors to develop specific interventions and programs targeted to the specific employment and career development needs of this population. A beginning step toward this goal is an overall increase in rehabilitation counseling research that addresses the needs of veterans. To this point, Frain and associates (2010) argued,

In order for rehabilitation to continue to provide appropriate interventions, researchers need to look towards future needs for this group. By supporting researchers in this line of interest through grants, journal space, and other outlets, the rehabilitation field will show that it is invested in continuing to provide effective services to veterans with disabilities. (p. 19)

Limitations

This study has several limitations. It focuses on OEF/OIF veterans who (a) functioned in a combat, combat support, or combat service support role in Afghanistan or Iraq; (b) separated from military service a minimum of 1 year prior to the study; and (c) sustained PTSD as the result of warzone trauma stressors. Therefore, findings do not necessarily provide insights into the vocational adjustment experiences of veterans who experienced PTSD linked to other conflicts, or non-combat and/or non-deployment events. In addition, the study is small and exploratory in nature. Additional qualitative and quantitative data would likely enrich the current findings.

Conclusion

An increasing number of veterans with PTSD symptoms are separating from military service and pursuing community integration. Many will elect to enroll in vocational and educational training through a variety of federal, state, and local social services providers. The unintended consequences of military downsizing will place an inordinate financial and personal burden on health care professionals, supportive service providers, community resources, families, and employers. Future research is needed to advance an understanding of funding streams, training, and educational options needed to enhance and facilitate work adjustment supports for veterans with PTSD. Findings from the present study as well as future research can serve as a guide for veterans with PTSD to navigate both the veteran and civilian social service systems, and to develop an understanding of complex skills and training. It also highlights the importance of family involvement in gaining a greater understanding of PTSD symptoms, stressors, and coping behaviors.

Our findings reinforce the idea that with effective intervention, veterans with PTSD are also capable of obtaining, maintaining, and retaining employment and successful reintegration. The topic of veterans with psychiatric disabilities and their capacity to return to work has not received sufficient attention in the rehabilitation counseling literature. It is anticipated that as more OEF/OIF veterans with PTSD reintegrate into civilian life, it will stimulate advancements in training, research, and service provision for this population.

Footnotes

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

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