Promoting Successful Integration
E d i t o r i a l S t a f f

Edward A. Lindeke, Colonel (Retired), MSC, US Army 

Director, Borden Institute

Vivian Mason 

Senior Volume Editor, Borden Institute

Christine Gamboa-Onrubia, MBA 

Creative Director and Production Manager, Fineline Graphics, LLC

The opinions or assertions contained herein are the personal views of the authors and are not to 

be construed as doctrine of the Department of the Army or the Department of Defense.

CERTAIN PARTS OF THIS PUBLICATION PERTAIN TO COPYRIGHT RESTRICTIONS. ALL RIGHTS 

RESERVED. NO COPYRIGHTED PARTS OF THIS PUBLICATION MAY BE REPRODUCED OR 

TRANSMITTED IN ANY FORM OR BY ANY MEANS, ELECTRONIC OR MECHANICAL 

(INCLUDING PHOTOCOPY, RECORDING, OR ANY INFORMATION STORAGE AND RETRIEVAL 

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Published by the

Office of The Surgeon General | Falls Church, Virginia

Borden Institute | Fort Detrick, Maryland

US Army Medical Department Center and School 

Health Readiness Center of Excellence | Fort Sam Houston, Texas

2018

Library of Congress Cataloging-in-Publication Data

Names: Cooper, Rory A., editor. | Pasquina, Paul F., editor. | Etter, Douglas

 A., editor. | Borden Institute (U.S.), issuing body.

Title: Promoting successful integration / edited by Rory A. Cooper, 

Paul F. Pasquina, Douglas A. Etter.

Description: Fort Sam Houston, Texas : Borden Institute, US Army Medical

 Department Center and School, Health Readiness Center of Excellence ;

 Falls Church, Virginia : Office of The Surgeon General, United States

 Army, 2018. | Includes bibliographical references and index. |

Identifiers: LCCN 2018010383 (print) | LCCN 2018011369 (ebook) | 

ISBN 9780160939839 | ISBN 9780160939846 | ISBN 9780160939853 | 

ISBN 9780160944758

Subjects: | MESH: Veterans Health | Community Integration | Disabled Persons

Classification: LCC UB369 (ebook) | LCC UB369 (print) | NLM WA 360 | DDC

 362.1086/97--dc23

LC record available at Caution-https://lccn.loc.gov/2018010383

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Fax: (202) 512-2104 Mail: Stop IDCC, Washington, DC 20402-0001

ISBN No. 978-0-16-093983-9
Promoting Successful 

Integration

E d i t e d b y

H H H

RORY A. COOPER, PhD 

PAUL F. PASQUINA, MD, COLONEL (Retired), MC, US ARMY 

DOUGLAS A. ETTER, COLONEL (Chaplain), US ARMY

O f f i c e o f T h e S u r g e o n G e n e r a l

Falls Church, Virginia

B o r d e n I n s t i t u t e

Fort Sam Houston, Texas

U S A r m y M e d i c a l D e p a r t m e n t C e n t e r a n d S c h o o l

H e a l t h R e a d i n ess C e n t e r o f E x c e l l e n c e

Fort Sam Houston, Texas

This book is dedicated to the men and women

of the armed services, to their families, 

veterans, and the civilians who serve the

United States of America to provide

for freedom and democracy.

H H H

Authors’ Note: In honor of those who have served and sacrificed in defense of our Nation, this book uses 

the convention of capitalizing terms for those who served.

Contents

Soldier Profiles x

Contributors xi

Foreword xiii

Preface xv

Prologue xvii

Introduction xix

Chapter One

Framework for Reintegration and Resilience for 

Service Members and Veterans H 3

Rory A. Cooper, Paul F. Pasquina, and Douglas A. Etter

Chapter Two

Physical Medicine and Rehabilitation H 23

Adam J. Susmarski

Chapter Three

The Promise of the Future: Assistive Technology, 

Transportation, and Emerging Technologies H 41

Rosemarie Cooper, Cheng-Shiu (Joshua) Chung, 

John Coltellaro, Christina LaCroix, Amy Lane, Alissa Ling, 

Amanda Reinsfelder, Benjamin Salatin, and Goeran Fiedler

Chapter Four

Psychosocial Factors in Reintegration H 81

Michelle L. Sporner and Anne E. Barry
viii H Contents

Chapter Five

Spirituality and Reintegration: 

Building Strength, Fortitude, Optimism, and Connection H 109

Douglas A. Etter, Amy Mountain, and Audrey Schoomaker

Chapter Six

The Role of Friends and Family in Reintegration: Building Insights and 

Strategies That Promote Reintegration and Resiliency H 139

Christina Berchock Shook

Chapter Seven

Sexuality and Intimacy H 173

Stanley H. Ducharme, Rebecca P. Cameron, and Linda R. Mona

Chapter Eight

The Role of Sports and Recreation in 

Promoting Successful Reintegration H 199

Rory A. Cooper, Michael Mushett, and Thomas Williams

Chapter Nine

Virtual Reality and Telemedicine to Support Reintegration and 

Health Maintenance H 221

Deepan C. Kamaraj and Rory A. Cooper

Chapter Ten

Community/Peer Support and Services H 239

Al Condeluci, Rory A. Cooper, Melva Gooden-Ledbetter, and

D. Joshua Marino

Chapter Eleven

Financial Management H 263

Daniel J. Fisher, Joseph A. Wineman, and Randy Levander

Chapter Twelve

Education and Employment H 295

Mary R. Goldberg, Anne E. Barry, Maria Milleville, Michelle L. Sporner, 

Ron Drach, Allen Lewis, and Brian Bilski
Contents H ix

Chapter Thirteen

Accessible Homes, Communities, and Transportation H 325

Carol Peredo Lopez, Lavinia Fici Pasquina, Amanda McAlpine, 

Patrick Rakszawaski, Steve Bucha, and Paul F. Pasquina

Chapter Fourteen

Overview of Military and Veteran Resources H 357

Rory A. Cooper

Chapter Fifteen

The Role of Service Organizations and Volunteers H 375

S. Elaine Eitler and William M. Lake

Chapter Sixteen

Culture and Reintegration of Veterans H 395

Allen Lewis, Seth Messinger, Twylla Kirchen, 

Jeanne Wenos, and Shelly Brown

Chapter Seventeen

Summary H 419

Rory A. Cooper

Acknowledgments 429

Acronyms and Abbreviations 431

Suggested Reading List 435

Index 437
Soldier Profiles

At t h e e n d o f ea c h c h a p ter, a profile is given about Soldiers who 

have successfully adapted to their impairments and are leading remarkable 

lives as Soldiers or Army Veterans. These dedicated individuals have overcome numerous physical obstacles, focused on their abilities, committed 

themselves to optimal recovery, and made important contributions as role 

models. In order of appearance, they are as follows:

Steven E. Gventer, Lieutenant Colonel, US Army H 18

Michael Kacer, Staff Sergeant (Retired), US Army H 36

John J. Farley, III, Captain (Retired), US Army [and Judge (Retired), 

US Court of Appeals for Veterans Claims] H 76

Steve Domitrovich, Private First Class, US Army H 103

Miles Kamson, Sergeant, US Army H 135

Tim Maxwell, Lieutenant Colonel, US Marine Corps H 168

Baren Berg, Sergeant (Retired), US Marine Corps H 195

JoAnn Tresco, Sergeant Major (Retired), Army 

National Guard H 216

Amber Blanton, Staff Sergeant, Pennsylvania 

Army National Guard H 235

Greg Crouse, Private Second Class, US Army H 258

Sherman Gillums, Jr, Chief Warrant Officer 2, 

US Marine Corps H 291

D. Joshua Marino, Sergeant, US Army H 320

James M. Joseph, Gunnery Sergeant, US Marine Corps H 352

Mike Savicki, Ensign, US Navy H 369

Matthew Hannan, Gunnery Sergeant, US Marine Corps H 390

Al Kovach, Petty Officer 3rd Class, US Navy H 414

Matthew A. Staton, Staff Assistant to the Secretary of the Army, 

US Army Captain (Retired) H 425
Anne E. Barry, MS, CRC

Brian Bilski, BS, Colonel (Retired), 

US Marine Corps

Shelly Brown, MEd

Steve Bucha, AET

Rebecca P. Cameron, PhD

Cheng-Shiu (Joshua) Chung, PhD

John Coltellaro, ATP

Al Condeluci, MS, PhD

Rory A. Cooper, PhD

Rosemarie Cooper, MPT, ATP

Ron Drach, Sergeant (Retired), 

US Army 

Stanley H. Ducharme, PhD

S. Elaine Eitler, MEd, IAST

Douglas A. Etter, MDiv, MSS, 

Colonel (Chaplain), US Army

Goeran Fiedler, PhD

Daniel J. Fisher, MHA, Colonel 

(Retired), US Army 

Mary R. Goldberg, PhD

Melva Gooden-Ledbetter, MS

Deepan C. Kamaraj, MD, MS

Twylla Kirchen, PhD, OTR/L

Christina Lacroix, DO

William M. Lake, BS, Colonel 

(Retired), US Marine Corps 

Amy Lane, OTR/L, CDRS 

Randy Levander, SFC

Allen Lewis, PhD, CRC

Alissa Ling, MS

Carol Peredo Lopez, AIA

D. Joshua Marino, MS

Amanda McAlpine, NCIDQ, 

LEED AP 

Seth Messinger, PhD

Maria Milleville, MEd

Linda R. Mona, PhD

Amy Mountain, MS

Michael Mushett, MS 

Lavinia Fici Pasquina, MS

Paul F. Pasquina, MD, Colonel 

(Retired), MC, US Army 

Patrick Rakszawaski, RA

Amanda Reinsfelder, MS, ATP

Benjamin Salatin, MS

Audrey Schoomaker, RN, BSN, 

E-RYT

Christina Berchock Shook, PsyD, 

ABPP

Michelle L. Sporner, PhD, CRC

Adam J. Susmarski, DO, Lieutenant 

Commander, MC, US Navy 

Jeanne Wenos, Ped

Thomas Williams, PhD

Joseph A. Wineman, MHA, DMD, 

ABGD, Colonel (Retired), 

US Army 

Contributors

Foreword

Bu i l d i n g a n d m a i n ta i n i n g res i l ie n ce among our military and Veteran communities is an essential factor in maintaining the fighting force and 

in promoting successful reintegration into garrison communities or the civilian sector. Strong families, supportive friendships, and understanding communities are necessary to ensure that our Service Members and Veterans are safe, 

effective, and successful. Resilience is multifactorial and requires effort on the 

part of multiple parties; foremost among them is the Service Member and the 

command structure. 

Soldiers, Sailors, Airmen, Marines, and Coast Guardsmen are the military’s greatest asset. Their talent, commitment, and tenacity are unmatched 

by any force in the world. We ask our Service Members and their families to 

frequently make sacrifices that are difficult for those who have not served in 

the Armed Forces to understand. They endure repeated deployments, hazardous environments, and long hours away from friends and families. However, 

they are professionals and serve with honor and deserved pride.

It is the responsibility of the leadership of the Armed Forces and the 

civilian communities to provide Service Members with the tools and resources 

they need to succeed on the battlefield. This responsibility remains when they 

return home to lend their talents to building happy and healthy Families, and 

when their time of service is completed so that they have every opportunity to 

contribute to their chosen civilian communities. Whether a person serves for 2 

years or 40 years, we must value his or her contributions and patriotism. Less 

than 1% of Americans are serving in the Armed Forces today, and less than 

6% of living Americans have ever served in the military.

The face of the all-volunteer force is different than that of previous 

generations. The military works as a total force to include active, guard, and 

reserve components. In addition, the US Public Health Service, the Department of Homeland Security (US Coast Guard), the Department of Veteran 

Affairs, and first responders have worked with our military at unprecedented 

levels. Moreover, the US Army, Air Force, and Navy Health Services depart-
xiv H Foreword

ments are more integrated and communicate at unprecedented levels. This 

has facilitated impressive levels of success in the care and reintegration of 

wounded, injured, and ill Service Members. Survival rates on the battlefield 

are higher than in any previous conflict, and the accomplishments postdeployment and upon departing military service are impressive. This generation of Veterans has yielded several leaders in politics, government, business, 

and academia.

Promoting Successful Integration serves as a valuable resource for 

our Service Members, Military and Veteran leadership, Veterans, Family 

members, and civilian communities. This book contains extremely helpful 

information about resilience and reintegration. It also provides concise and 

practical information for being successful in developing important life skills. 

The authors have generously shared their knowledge and experience, many 

of whom have relevant military experience. The chapters include references 

for readers seeking more information, as well as an end-of-book suggested 

reading list. This is a book that should be widely read and kept as a reference.

Dr Cooper, Colonel (Retired) Pasquina, and Colonel Etter—all Soldiers 

—are to be commended for leading this important effort and for assembling 

this excellent resource. Each of them has been engaged in the care and successful reintegration of Service Members, Veterans, and Families for more 

than two decades. They are committed professionals who have helped countless individuals, Families, leaders, and communities. Promoting Successful 

Integration is only one of their many contributions. The positive impact that 

they have had is extraordinary and is reflected in the thousands of people 

who have benefited from their expertise. They embody the concepts of 

“Soldier for Life” and “Selfless Service.”

Lieutenant General Nadja Y. West, MD

The Surgeon General

Commanding General, U.S. Army Medical Command
Preface

T h e st re n g t h a n d susta i n a b i l i t y o f o u r m i l i ta ry is dependent 

on the resilience of our Service Members, their families, and our civilian 

employees. Additionally, the successful reintegration of Service Members 

back into their families, military garrisons, and civilian communities after 

each deployment is essential to the continued health of our military and our 

nation. To those Service Members who become wounded, injured, or ill in 

service to our nation, we have a nonnegotiable obligation to provide them 

with an array of tools to assist them in continuing to lead fulfilling lives, and 

to contribute to their communities and society as a whole. Inarguably, this is 

a grand undertaking that requires a concerted effort and diligence throughout 

the Department of Defense (DoD), across the federal government, and within 

our civilian communities. 

The DoD has made considerable strides in understanding and addressing 

the importance of focusing on resilience and successful reintegration. Each 

service has created programs that attempt to reach Service Members and their 

families wherever they may be in their deployment cycle, and in whatever 

circumstances they may find themselves. Effective programs and resources 

now exist to help Service Members and their families strengthen relationships, 

pursue careers, obtain educational opportunities, and manage finances—all 

aimed at building resilience and facilitating reintegration. Undoubtedly, we 

have learned much and advanced far in supporting our all-volunteer force 

and its families. Nevertheless, we must continue to press forward in enhancing and improving these programs—programs that must be adequately 

resourced and fully integrated throughout all stages of one’s service lifecycle in 

an effort to provide the absolute best resources to our nation’s heroes. 

This handbook intends to serve as one of those resources. Offering very 

practical guidance, the book adeptly pulls together a wide variety of tools 

available to Service Members and their families. Incorporating real-world case 

studies throughout, the authors have clearly demonstrated that supporting 

these Service Members and their families truly takes a team effort. Building 
xvi H Preface

resilience and a successful reintegration process, as this work proves, depends 

on the interconnectivity of Service Member, family, and community. The book 

itself exemplifies this collaborative effort within the DoD, the Department of 

Veterans Affairs, and numerous other agencies focused on this same mission. 

The important work of creating this book would not have been possible without the initiative and dedication of Rory A. Cooper, PhD, Colonel 

(Chaplain) Douglas A. Etter, and Colonel (Ret) Paul F. Pasquina, MD—all 

soldiers. I wish to extend my thanks to these gentlemen, all of the authors, 

the talented staff of the Borden Institute, and, most importantly, to the many 

Service Members who selflessly shared their personal stories of struggles and 

successes, as portrayed in the case studies throughout the book. All of these 

contributors assumed a noble mission, performed valiantly in offering their 

time and expertise, and have now provided a resource that has the potential 

to help countless Service Members throughout the coming years.

Honorable Jessica L. Wright

Major General (Retired)

Former Under Secretary of Defense for

 Personnel and Readiness, Department of Defense

Former Adjutant General, Pennsylvania, 

 Department of Military and Veterans Affairs
Prologue

At t h e c o re o f m i l i ta ry serv i ce i s i ts pe o p le. Despite the emphasis on technology and the impact that it can have on shaping military 

operations, it is people who must ultimately fight our Nation’s battles. The 

people who volunteer to serve in our military are our most valuable asset, and 

we must take great care to ensure that they are given all the tools and skills 

necessary to complete their mission. However, when their time in the military 

comes to an end, they need the resources and guidance to help them succeed 

as Veterans.

Families and friends are central to the success of our Service Members 

because they provide the needed stability and security in their lives that enable our Service Members to become more resilient and resourceful in their 

military duties. Thus, families and friends of our Service Members need to be 

educated about the challenges and burdens that they will be asked to face, as 

well as the importance of their service to this country.

This book strives to provide information and to serve as a resource 

to Service Members across all of the services and at all ranks. It is also an 

important guide for families and professionals outside of the military who 

interact with Service Members and Veterans. America has the strongest and 

best military force in the world, with Service Members who are intelligent, 

resourceful, talented, and respected. The military is one of the most revered 

institutions in America, but maintaining this reputation and success requires 

focused effort and steadfast commitment.

In America, where less than 1% of the citizenry is serving in the military 

and where less than 6% of living Americans ever served in the military, it is 

essential to support our Service Members and their families in meaningful 

and tangible ways. Moreover, it is important to keep our Veterans connected 

to the military and for them to understand that their service and sacrifice, 

whether for 2 years or 40 years, are valued and appreciated. 

The American public is largely disconnected from the military. Most 

people do not understand it and are not personally invested in its operation. 
xviii H Prologue

The dwindling number of Veterans exacerbates this problem and lessens our 

most supportive population.

Only 29% of today’s youth meet our high standards and are eligible for 

service. Educational, medical or physical limitations, mental health challenges, 

or criminal history often rule out the opportunity to serve in the military. 

Obesity accounts for approximately 31% of disqualifications. Of the 29% 

of youth who are eligible to serve in the military, less than one in four has a 

strong desire to serve. Most Americans, while supportive of the military, are 

not willing to engage even if there is a need for more troops.

The military is a challenging profession, but it is also a proud and distinguished profession that conveys many lifelong benefits to the people who 

have served, as well as their communities. When compared to their non-Veteran counterparts, Veterans are more likely to volunteer, give to charity, vote, 

help their neighbors, and participate in service or community organizations. 

Long after their military service ends, many Veterans choose to continue to 

help strengthen the Nation by serving as civic leaders in communities across 

the country. Because of their experience, training, and skills, Veterans are 

well-suited to provide solutions to some of our Nation’s toughest challenges.

Promoting Successful Integration provides an important resource to our 

military and adds to our knowledge of successful reintegration and resilience. 

I wish to convey my thanks to Rory A. Cooper, PhD, Colonel (Retired) Paul 

F. Pasquina, MD, and Colonel (Chaplain) Douglas A. Etter for volunteering 

their time and expertise to write this important work. They are models of 

long-term, dedicated, selfless service to a cause greater than themselves. All 

of the authors and contributors are to be commended for making this book 

possible because our military’s success is built on our Service Members, their 

families, our civilian employees, and countless volunteers.

Ronald L. Green

18th Sergeant Major of the Marine Corps

US Marine Corps
Introduction

Our Service Members and their families are incredibly strong, 

resilient, and dedicated. 

H H H

LTG Eric B. Schoomaker, MD, PhD

The Surgeon General/The Commanding General

US Army Medical Command

T h e g o a ls o f t h i s b o o k a re t o ed u c ate, em p o wer, and elevate 

the resilience of Service Members and their families and to help those people 

who are transitioning to successfully reintegrate into their chosen civilian 

community. It is intended to be useful to Service Members and their families 

of all levels and experiences. A theme of the book is that resilience and 

successful reintegration are intertwined. Successful reintegration for Service 

Members and their families requires resilience. This is due in part to Service 

Members, Veterans, and families having experiences that are unfamiliar 

to the general public. Over time, the percentage of Americans serving in 

uniform has dropped to below 1%, and the percentage of Veterans of who 

have served in the military is less than 6% of the American population. 

Thus, although most Americans support members of the Armed Forces, few 

are familiar with the experiences of Service Members, Veterans, and their 

families, which present challenges for reintegration.

There are many facets of building resilience and the promotion of 

successful reintegration. Resilience is a family affair, and it can be viewed like 

a muscle. It takes regular, targeted work to build and maintain resilience. 

Resilience has several components, including physical, mental, social, and 

moral components. If any one component is vulnerable, then the Service 

Member, Veteran, or family may be at risk. Readiness for transition is 

similar to military readiness; it requires knowledge, training, and resources. 
xx H Introduction

When resilient and well prepared, the likelihood of successful reintegration is 

maximized.

The information in this book is presented in the context of both current 

programs and the best knowledge available. We hope that this book serves 

as a valuable tool for learning about the resources and processes that may 

facilitate each Service Member and his or her family’s success. It is also 

intended to serve as a resource for leaders at all levels.

This book provides information about various transition programs, 

key federal agencies, Veteran and Military Service Organizations, and the 

programs and tools that are available to help Service Members and their 

families. Chapters are written to be broadly accessible, but they are also 

referenced for people who would like to obtain more in-depth information. 

Several vignettes are provided about Service Members and Veterans who have 

faced challenges and addressed them through their resilience. They help to put 

a human face on the concepts presented in this book.

As a handbook, our intent is to cover a variety of relevant topics, with 

sufficient depth to provide the reader with working knowledge; but, it is 

not intended to make people experts in building resilience and successful 

reintegration. It is expected that this handbook will augment programs 

and services. Service Members, Veterans, and their families should acquire 

additional tools or at least refresh their knowledge by reading this book.

Members of the American Armed Forces and their families are remarkably strong and resourceful. They have repeatedly proven that they can rise to 

every challenge presented to them. Anyone who has served or spent significant 

time with our members of the Armed Forces and their families understands 

their commitment to selfless service to something greater than themselves.

We are grateful for this opportunity to continue to serve and to 

contribute to improving the quality of life for members of the Armed Forces, 

Veterans, and their families. Each of us has been affected in a very personal 

way by service in the military, and remains committed to the welfare and 

success of Military and Veteran families. We are grateful for the support from 

our families, friends, and colleagues, and for members of the Armed Forces 

and Veterans with whom we have had the privilege to serve. We will consider 

ourselves successful if this book proves helpful to military leaders, members 

of the Armed Forces, Veterans, and their families. It has been an honor to 

volunteer to serve in the capacity as authors and editors.

Respectfully,

Rory A. Cooper, PhD

Colonel (Retired) Paul F. Pasquina, MD

Colonel (Chaplain) Douglas A. Etter
Promoting Successful Integration

The Performance Triad. 

It summarizes a simple truth about human performance 

and well-being: that all of us—no matter who we are, 

how old we are, or what we do—need a balance of 

three things to build and sustain health. 

The three are sleep, activity, and nutrition.

H H H

Lieutenant General (Retired) Patricia D. Horoho

US Army Surgeon General

Commanding General of the US Army Medical Command

September 27, 2012

C h a p ter On e

Framework for Reintegration 

and Resilience for Service 

Members and Veterans

RORY A. COOPER, PhD*; PAUL F. PASQUINA, MD†; and

DOUGLAS A. ETTER, MDIV, MSS‡

*

Director and Senior Career Scientist, Human Engineering Research Laboratories, 

Rehabilitation Research and Development Service, US Department of Veterans 

Affairs, 6425 Penn Avenue, Pittsburgh, Pennsylvania 15206, and Distinguished 

Professor and FISA Foundation–Paralyzed Veterans of America Chair, Department of 

Rehabilitation Science and Technology, University of Pittsburgh, 6425 Penn Avenue, 

Suite 400, Pittsburgh, Pennsylvania 15206

†

Colonel (Retired), Medical Corps, US Army; Chief, Department of Orthopaedics and 

Rehabilitation, Walter Reed National Military Medical Center, 4494 North Palmer 

Road, Bethesda, Maryland 20889 

‡

Colonel, US Army; Joint Headquarters Chaplain, Pennsylvania National Guard and 

Chief Communications Officer, Lebanon VA Medical Center, 1700 South Lincoln 

Avenue, Lebanon, Pennsylvania 17042 

INTRODUCTION 

Complete freedom from stress is death.

Hans Selye

Father of Stress Research
4 H Promoting Successful Integration

Military and Veteran communities represent a unique culture within 

the United States, while at the same time often living among and 

supporting the broader civilian communities. The exact number 

of Service Members and Veterans who have had their lives altered by serving during the last decade and beyond is yet unknown, and it will likely take 

years for the personal costs to be determined because conditions such as 

traumatic brain injury, posttraumatic stress, orthopedic injuries, and hearing 

loss are more precisely identified among Military and Veteran populations.1

More than 2 million US Service Members have been deployed to Iraq or 

Afghanistan, approximately 27% of whom have been deployed more than 

once.2 People serving within the US military represent <1% of the American 

population.3 Furthermore, living Military Veterans (individuals who have 

ever served in uniform as part of the Armed Forces) are only about 6% of 

the current population of the United States.4 Therefore, only a small portion of the population has first-hand experience of the challenges faced and 

sacrifices made by members of the Armed Forces. This prolonged period of 

war and the operational tempo for Service Members have placed strain on 

Military families and the Military community. The United States has asked a 

lot of its Military community. Among the persistent challenges are building 

and maintaining resilient Service Members, families, Veterans, and communities. The long-term health of Military and Veteran communities is also in part 

dependent on the successful reintegration of Service Members into the force, 

with their families, and into their communities.5 Thus, it is our hypothesis 

that resilience and successful reintegration are highly interrelated, and that 

one cannot be achieved without the other. 

PURPOSE

This handbook is intended to be a source of information for the broad 

Military community. In this case, the broad Military community includes 

uniformed Military personnel, family members, civilian personnel of federal 

agencies, Veterans, and all people who contribute to the success of wounded, 

injured, and ill Service Members. When Service Members return from a deployment with visible or hidden impairments or challenges, it is important for 

the entire community to provide support to ameliorate the long-term impact 

of wounds, injuries, and illnesses that can manifest into permanent disabilities. The information contained herein should help the reader to understand 

and implement the steps necessary for helping wounded, injured, or ill Service 

Members and their families to successfully continue their military careers or 
Framework for Reintegration H 5

to become successful as Veterans within civilian communities. A multifaceted 

approach will be presented, and there is no one single solution that will work 

for all Service Members. However, the information contained within this 

handbook should provide insight into the options available and the many 

pathways that lead to success.

Our definition of disability throughout this handbook is consistent with 

that of the World Health Organization (WHO) and its International Classification of Functioning, Disability, and Health (ICF). The WHO-ICF model 

defines an impairment as a loss of or a significant reduction of function as a 

result of biological development or change.6 For Service Members, impairment and changes in function are frequently the result of wounds, injuries, or 

illnesses. For example, damage to a limb from an improvised explosive device 

can require limb salvage or amputation, which leads to a reduction of function over the previous intact limb. Therefore, the person has an impairment. 

A disability is the result of the interaction of a person with an impairment 

with the environment, and the environment includes the following:

• physical environment (eg, how buildings and communities are designed 

and built),

• social environment (eg, how people respond and is inclusive of people 

with impairments), and 

• policy environment (eg, how laws and regulations affect people with 

impairments and their ability to participate in society). 

If the environment is accessible and inclusive, a person’s disabilities can 

be minimized and possibly to a great extent eliminated within that context. 

For example, if a Service Member has a spinal cord injury and uses a wheelchair, an environment in which everything is accessible from a wheelchair—

where colleagues respect him or her and where he or she is treated fairly by 

the employer—contributes to minimizing the disability.

Wounded, injured, and ill Service Members and their families are part of 

the tapestry of Military and Veteran communities. Even with impairments, 

limitations, and differences, they are deserving of respect, inclusion, and 

integration into our communities. A fundamental theme that readers should 

consider is that everyone has something to contribute to society and to their 

communities, including both the Military community of Service Members, 

their families, and civilian employees of the Armed Forces, as well as the civilian community where Service Members and Veterans live with their families. 

The concept of “social capital” is another theme within this handbook that 

will be described in greater detail in a later chapter. This concept emphasizes 
6 H Promoting Successful Integration

that communities are composed of groups of people with common beliefs, 

goals, or physical locations, and that everyone can make a contribution to the 

culture of the community and ultimately to its success.

GOALS

The overarching goal of this book is to provide the reader with the tools and 

knowledge to help wounded, injured, and ill Service Members live healthy, 

happy, and prosperous lives. Another goal is for the reader to gain an understanding of the key factors and current resources that may contribute to 

successful and fulfilling lives of wounded, injured, and ill Service Members 

and their families. Furthermore, the current state of knowledge, pathways, 

programs, and concepts that may help Service Members and their families to 

pursue and achieve their goals are presented.

One focus of this handbook is to provide practical guidance to Military 

personnel, families, and civilians on how to build resilience, especially among 

wounded, injured, and ill Service Members. Resilience and reintegration go 

hand-in-hand, although few have treated them as such.7 Ultimately, the goal 

of resilience is the successful reintegration of soldiers into the Armed Forces, 

with their families, and into their communities. Another focus of this book is 

that Service Members, Veterans, and families who are resilient will be more 

successful in reintegration. Therefore, this handbook is intended to serve 

as a practical guide based on science, clinical experience, and knowledge of 

programs for promoting successful reintegration.

STRUCTURE

Reintegration of Service Members with their families, communities, and the 

Military/Veteran communities is a substantial challenge facing the Department of Defense (DoD), the Department of Veterans Affairs, and the entire 

United States. This book ties together scientific evidence, clinical knowledge, 

and practical experience into a handbook accessible to professionals within 

military medicine and the military population at large, while serving as a 

resource for Veterans, Service Members, and their families. When Service 

Members and their families face severe challenges, they may often become 

overwhelmed. Clinicians, other service providers, and Service Members and 

their families should all benefit from this reference work.

Each chapter in this handbook is intended to stand alone, while also 

maintaining consistency with the other chapters. There are scientific and 
Framework for Reintegration H 7

clinical references for each chapter for readers who wish to delve deeper into 

original source material. However, the information contained within each 

chapter should be applicable as written.

DEFINITION OF RESILIENCE

Resilience is a topic that has been studied by scientists and clinicians for 

several decades. Much of the scientific literature has been focused on children and other survivors of abuse.8

 Some of this work is of relevance to the 

Military population, and recently there has been more work directly related 

to the Military population.9 There are also several theories of resilience, as 

well as definitions of resilience. Thus, we present a definition and description 

of resilience in the context of this book to provide readers with a framework. 

The DoD has yet to adopt a unified definition of resilience. When a definition 

or description is adopted, it may not completely align with our approach. 

However, the fundamental concepts and components are likely to be similar. 

The Army’s Comprehensive Soldier & Family Fitness Program uses the following definition of resilience: “the ability to grow and thrive in the face of 

challenges and bounce back from adversity.”

 In this handbook, we consider resilience to be “the ability to recover 

from, ameliorate, or avoid the negative effects of risk or adversity.” Adversity 

may be due to 

• prolonged separation from friends and family, 

• major disasters,

• violence (whether in the home or elsewhere), 

• extreme poverty, 

• persistent fear of harm for oneself or another, 

• trauma (severe injury, illness, or cumulative negative life events), or

• war. 

Service Members deployed on hazardous or combat missions often face 

extreme risk and adversity that place stressors on them, the members of their 

units, their commanders, their civilian leaders, and their friends and families. 

Frameworks to build resilience among all potentially affected parties are 

important, and can help to reduce the negative effects of stress, risk, and adversity. Individuals, families, communities, and organizations that are resilient 

display positive adaptation despite experiences of significant adversity, risk, 

or trauma. There are clear examples of Service Members and families who experienced extreme risk and/or adversity to include loss of limb from combat 
8 H Promoting Successful Integration

operations, yet who remain strong and even go on to help others. Some such 

examples are illustrated in this handbook.

FRAMEWORK FOR BUILDING RESILIENCE

Service Members and their families have frequently been endangered by 

extreme and often complex adversities. This fact requires all of those concerned—including commanders, civilian leaders, healthcare providers, volunteers, Military and Veterans service organizations, and other professionals, 

as well as families and communities—to confront many challenging issues. 

Although there is a substantial body of research on resilience, the immediate 

threats to life or bodily harm, family security, community integrity, and the 

readiness of the Armed Forces cannot wait for research to provide complete 

answers before action is taken. Hence, there are multifaceted programs to 

help build resilience among Service Members, families, and Military communities. The overall framework for building resilience requires a multidimensional approach to building capacity for, processes to, and outcomes 

of successful adaptation and growth in the face of significant threats to the 

integrity of the person, family, organization, or community. Programs for 

resilience need to focus on promoting strength, stability, growth, healthy 

recovery, function, and adaptation (to include compensatory strategies). The 

definition of resilience used in the US Army’s Ready and Resilient program is 

as follows: “Resilience is the mental, physical, emotional, and behavioral ability to face and cope with adversity, adapt to change, recover, learn, and grow 

from setbacks.”

The components of resilience can be remembered using the acronym 

MEPS: Mental, Emotional, Physical, and Spiritual.10 Mental refers to the 

ability to build a coherent plan with goals and objectives. Emotional is the 

ability to trust in self and the ability to give to others. Physical is the ability to accomplish the plan or goal. Spiritual is the moral compass (doing the 

right things for the right reasons). Our framework for building resilience 

includes the interrelation of several essential components that include adversity, positive adaptation, factors promoting positive responses, and protective 

factors. There are some individuals who are naturally resilient, and others 

who require assistance to become more resilient. Moreover, the life course of 

individuals and families can influence resilience. Intervention strategies for 

resilience should include the following components: 

• minimizing or reducing risk exposure, 

• strengthening compensatory strategies, 
Framework for Reintegration H 9

• increasing factors promoting positive responses, 

• having a moderate impact of adversity, and 

• boosting protective mechanisms. 

People respond differently to the same or similar experiences. There are also 

some other factors of adversity that should be considered: general dose-effect 

(closer proximity, relation, or severity of adversity), cognitive awareness of 

the adversity, the behavior of other people, previous traumatic or adverse 

experiences, cultural and/or community beliefs/customs, and the context of 

the adversity (eg, education and sociodemographic factors).11

Programs to encourage building resilience should include the following 

components: 

• a program to help individuals, families, and communities frame 

positive goals; 

• emphasis on positive influences and outcomes; 

• collection of data on positive indicators of change; 

• inclusion of multifactorial approaches (to include tailoring the program 

to the individual, family, or community); and 

• encouragement of collaboration among all stakeholders. 

Some people, and even some communities, are able to embrace adversity and 

turn it into positive energy for change and to continuously improve. Using adversity as a tool for positive growth is often achieved through teamwork and 

goal setting. The military is very familiar with this concept and uses it quite 

effectively in training. This is accomplished through a variety of means, such 

as training in cold or hot weather, training in the rain, or performing a night 

parachute jump. The US Army Ranger School (Fort Benning, GA) or the US 

Army Reconnaissance and Surveillance Leaders Course (Fort Benning, GA) 

exemplifies using adversity to promote positive growth by placing people in 

extremely challenging circumstances for prolonged periods of time and then 

recognizing the accomplishments of those Service Members who complete the 

program. All branches of the military utilize similar models to use adversity 

as a tool. Entire communities may use similar techniques (eg, by rebuilding a 

school after a flood or organizing and participating in a run to raise funds for 

a member of the community in need). Many not-for-profit organizations use a 

similar model to encourage people to run a marathon or complete a triathlon 

as a means to support a cause. Even if a person cannot run anymore, that 

person can train for the Marine Corps Marathon using a handcycle. These 

approaches encourage people to embrace adversity and to help turn it into a 

positive force in their lives. 
10 H Promoting Successful Integration

One uplifting example is Terry Fox, who as a young man had to have his 

leg amputated because of cancer. He chose to face his change in physical ability and how he was perceived by others by running across Canada.12 Other 

people have taken on more personal challenges to force themselves to adjust 

to their “new normal.” Then there is Scott Rigsby, who struggled for years 

with a traumatic brain injury while having one leg amputated and the other 

with a difficult limb salvage.13 He had a hard time earning a college degree, 

maintaining relationships, and managing his finances. Eventually, he came to 

the conclusion that he should have the salvaged leg amputated and that he 

needed to change his life. To achieve this and to challenge himself, he set a 

goal of completing the Hawaiian Ironman Triathlon. Without any prior training or even the appropriate equipment, and after many trials and tribulations, 

he successfully completed his goal. Scott then wrote a book about his experiences and now works to motivate other people to make positive changes in 

their lives. 

Another uplifting example is Max Cleland. Max is a Vietnam Veteran 

who had both legs and most of an arm amputated because of wounds 

received in combat.14 Despite returning to an America that he found was 

not accessible physically or socially to someone with his type of injuries, he 

persevered and set for himself a goal to enter politics and become a US Senator. He ran grassroots campaigns and traveled across the state of Georgia to 

win a successful bid to the US Senate. He also served as Chief of the Veterans 

Administration during his career. He set high and seemingly unattainable 

goals for himself, and achieved them. Despite his successes, he faced many 

challenges, including requiring treatment for posttraumatic stress decades 

following his original wounds and after enduring a difficult and unsuccessful 

reelection campaign. Max used the joy of serving others and making a positive difference in the lives of America’s Military Veterans as a tool to make a 

positive change in his life, as well as in the lives of millions of other people. 

These individuals set goals to challenge themselves and then pursued them 

with passion.

Building resilience does not always require making large changes in 

one’s life; sometimes focusing on small things frequently, even daily, can help 

to increase resilience. A tool used in positive psychology is to use a diary to 

record three positive notes each day and then to review them once per week.15

The “good things” that happen in our lives every day often go unnoticed; but, 

when we write them down, they remind us of our accomplishments and positive experiences. Small things can make a big difference in our outlook toward 

life and other people. Another simple tool for building resilience is to do something for someone else. Writing a brief, handwritten thank you or congratula-
Framework for Reintegration H 11

tory note to a friend, family member, or even someone you do not know well 

can make a difference in both the outlook of the sender and the receiver.

FRAMEWORK FOR REINTEGRATION

Reintegration, for the purposes of this book, occurs when Service Members 

who have become wounded, injured, or ill are successful in becoming loving 

and valued members of their families and social networks, in continuing with 

active duty or active guard/reserve, or in assimilating successfully into civilian 

society as Veterans. For wounded, injured, and ill Service Members to reintegrate into a military unit, their family structure, and the community at large, 

they need opportunities, accessible goals and resources, and enlightened (and 

hopefully) welcoming attitudes from the people around them. According to a 

report produced by the RAND Corporation (Arlington, VA):

Since 2001, the National Guard and Reserve have been utilized at unprecedented levels to fill key roles in overseas operations, with more than 

800,000 reserve component members called to active duty since 9/11. As 

a result of these increased demands, guard personnel and reservists have 

experienced more overseas deployments—often in combat situations that 

extend for long periods or occur in rapid succession. In many cases, this 

shift in operational tempo places a strain on families, especially as citizen 

warriors reintegrate back into their civilian lives and return to their 

civilian jobs after deployment. A smooth reintegration is critical not only 

for family well-being but also for Military readiness.16(p1)

Our approach to successful reintegration is based on the concept of social 

capital. Although there is no uniform definition of social capital, in this handbook, we will use the following: Social capital is the strength of the human 

networks that people have, and how those networks contribute to the sharing 

or exchange of resources (support, information, influence, finances, etc).

Each journey begins with the first step, and it takes planning on the 

part of individuals and communities to attain successful reintegration. One 

such tool is to set specific, measurable, attainable, realistic, and time-bound

(SMART) goals.17 SMART goals help to break down larger aspirations into 

manageable and achievable tasks that prevent the goalsetter from becoming 

overwhelmed. SMART goals are concrete and can be precisely defined and 

therefore more easily targeted. “To become a better person,” for example, 

is not a SMART goal, because it is ill-defined. However, it can be rewritten 
12 H Promoting Successful Integration

to “spending more quality time with my family.” This goal can be measured 

in the time together with family and how that time was spent (eg, movies, 

sports, games, etc). A SMART goal must be something that is achievable 

from the current vantage point. A series of SMART goals can be chained 

together to create more ambitious goals. For example, if one of the goals is to 

take the family on vacation, then planning is required and resources must be 

committed. The type and location of the vacation will depend on the availability of resources (eg, funds, time, accommodations for any disabilities, 

and possibly passports). A SMART goal must be realistic; traveling overseas 

takes more planning and resources than taking a short camping trip to a local 

state park. Lastly, SMART goals need to be time-bound. The world is full of 

dreamers who someday are going to do something. SMART goals require setting a date and making a commitment to achieve it. Adjustments can be made 

for unforeseen events, but then a new date needs to be established. Nearly all 

great things are accomplished by completing each little step along the way.

The US Marine Corps uses a tool (that originated with the US Army and 

was originally called the “Leavenworth Order”) to help leaders achieve their 

goals, which can equally be applied to other areas of life for both individuals 

and organizations. The tool is called a SMEAC, an acronym for Situation, 

Mission, Execution, Administration, and Communication.18 These are the 

items needed to achieve a goal or mission. Situation is used to describe current 

circumstances and obstacles in the way of achieving the Mission; support 

mechanisms to overcome the obstacles are also noted. Execution describes the 

steps that will be taken to accomplish the Mission or to achieve the desired 

goal; these are essentially subgoals or steps toward the goal that must be 

acquired. Administration is the category in which all of the resources required 

to accomplish the Mission are listed, including people, gear/equipment, 

funding, transportation, time, etc. Communication consists of people and the 

methods of conveying information regularly to achieve the desired goal.

At the Semper Fi Odyssey program (Ligonier, PA) participants are taught 

the tool MA2R*INES3 to help prepare their plan for reintegration into their 

units or into their home communities.10 MA2R*INES3 provides a framework 

for moving forward with reintegration, and helps people and communities 

to prepare a roadmap to achieve their goals and become more accepting of 

others and themselves:

M Mission—What you are going to do and why.

A2 Accountability and Attitude—You must be in control of your attitude 

and hold yourself accountable.

R* Responsibility—You must be responsible for your actions. Are you going 

to be a giver or a taker?
Framework for Reintegration H 13

I Integrity—Completeness. Are you whole in your MEPS (Mental, Emotional, Physical, and Spiritual)?

N Nourish—Is your MEPS balanced enough that you will be able to give to 

yourself and others? Do you have people that you Value, Accept, Understand, Love, and Trust—VAULT)?

E Energy—It is either positive or negative. Negative energy travels faster 

than positive energy. Can you provide positive energy in your life?

S3 Synergy, Strive, and SMEAC. Strive to find ways to surround yourself 

with people and activities that make you and them better.

SOCIAL CAPITAL AS A MODEL FOR 

SUCCESSFUL REINTEGRATION

The energy I give is equal to the inspiration I provide, which results in

the impact I make, which leads to the legacy I leave.

Major General (Retired) T. S. Jones

US Marine Corps

The idea of social capital tells us that all people are interconnected and that, 

through our interactions with one another and the exchange or sharing of 

resources, communities can become stronger. For wounded, injured, and 

ill Service Members and their families, a basic premise is that everyone has 

something to contribute and can add value. This premise must permeate the 

Military, their families, circle of friends, and communities. An individual’s value to his or her community can present in many forms. It can be in terms of 

knowledge, influence, finances, strength, or relationships. These factors have 

value and in some cases can even be financially quantified. For example, if a 

friend purchases a new couch, that person can either pay to have the couch 

delivered to his or her home or call on friends and family members to help by 

drawing on his or her social capital. Similarly, when wounded, injured, or ill 

Service Members move to a new community, they typically wish to make new 

friends. Most friends are people with shared experiences and/or interests, but 

this is not enough. Being introduced into a community can be made easier 

when a trusted member of the community makes the introductions, and this 

person is using his or her social capital to endorse the new person to other 

members of the group. 

The ultimate goal is for wounded, injured, and ill Service Members to 

become valued, contributing, happy, healthy, and fulfilled members of their 

families, circle of friends, and communities. According to the RAND survey, 
14 H Promoting Successful Integration

families and Service Members who were most successful with reintegration 

had the following traits:

These families felt ready for deployment, had good communication with 

the Service Member and with the member’s unit during his or her time 

away from home, and tended to be comfortable financially. When the 

Service Member deployed with his or her own unit and returned home 

without a combat-related wound, other physical injury, or a psychological issue, readjustment tended to go more smoothly.16(p1)

The RAND report also noted that some of the families had problems 

with reintegration following deployment, and some of their challenges 

were “emotional or mental health, health care, civilian employment, the 

spouse/partner relationship, financial or legal matters, child well-being, and 

education.”16(p1) For successful reintegration to occur, it is essential to prepare 

Service Members, families, and friends for reintegration postdeployment, and 

to involve a wide array of resources from the federal government, not-forprofit organizations, and communities. Frequent communication between all 

stakeholders has been shown to improve reintegration.19

It is important to note that everyone in a community has something to 

contribute, and this adds to the tapestry that makes up communities. They 

are essential to successful reintegration. Communities must be transformed so 

that everyone has a sense of belonging, with Service Members and Veterans 

being of their communities and not simply part of them. Communities must 

strive to create measurable and obvious human gain. Therefore, this requires 

communities to ask themselves questions such as: 

• Can they effectively apply capital?

• Do they have a big enough vision?

• Do they have the capacity to achieve their goals?

Communities need to understand and engage their human capital, intellectual capital, social or network capital, and financial capital to effectively 

apply social capital to be inclusive of Service Members, Veterans, and their 

families. 
Framework for Reintegration H 15

COMMENTS

For wounded, injured, and ill Service Members and their families, resilience, 

social capital, and reintegration are all inextricably intertwined. It is essential 

that Service Members and their families be provided the counseling, education, and resources needed to help build their social capital so that they can 

become and remain resilient, and can successfully reintegrate into their families and circles of friends, into the Military community as desired and 

appropriate, or into civilian communities either as Veterans or continuing 

their Military service.

In today’s world, it seems that there are more demands placed on everyone’s time and that people are available to their families, friends, coworkers, 

and bosses nearly 24 hours per day. This places demands on our minds and 

bodies that we are not built to withstand for long periods of time. Good 

health is built on three pillars: (1) nutrition, (2) activity, and (3) sleep.20 Too 

many people eat improperly and do not watch the nutritional content of what 

they eat; they ingest entirely too much sugar and caffeine. People today, even 

some Service Members, are at risk for sitting too long daily and not getting 

enough activity. More is needed than a simple 30-minute workout each morning or afternoon; even simply adding parking further away from the building 

or taking the stairs can make a big difference in the long run. Sleep is also 

critical to health and to being effective as a spouse, parent, colleague, and 

member of the community. At least seven hours of uninterrupted sleep each 

night is essential to long-term health.21 This means removing the electronics 

from the bedroom, taking away the blinking lights, and reducing any noise. 

Getting a solid night’s sleep helps us to stay healthy, remain alert, and make 

good decisions. Being healthy, fit, and able to make good decisions helps to 

reinforce key attributes of Military leadership: character, commitment, and 

competence.

22

Bringing self-awareness, self-care, and mutual support to the center of 

all activities is key for both resilience and reintegration. For example, science 

shows that two of the most effective approaches to treating depression are 

(1) talking to a sympathetic, compassionate, and experienced listener, and 

(2) doing physical exercise.23–25 Self-awareness, self-care, and mutual support 

are tools that can help everyone and should be fully integrated into the community. Community activities in which people with similar experiences and 

interests can get together and talk can help to remove barriers of isolation and 

feelings of loneliness. 
16 H Promoting Successful Integration

Refere n ces

1. U.S. vet’s disability filings reach historic rate. USA Today Web site. http://

usatoday30.usatoday.com/news/health/story/2012-05-28/Veteran-disability/55250092/1. Accessed July 13, 2014.

2. U.S. veterans: by the numbers. ABC News Web site. http://abcnews.go.com/

Politics/us-Veterans-numbers/story?id=14928136. Accessed July 13, 2014.

3. Americans and their military, drifting apart. New York Times Web site. http://

www.nytimes.com/2013/05/27/opinion/americans-and-their-Military-driftingapart.html?pagewanted=all&_r=0. Accessed July 13, 2014.

4. Gallup.com. In U.S., 24% of men, 2% of women are veterans. http://www.

gallup.com/poll/158729/men-women-Veterans.aspx. Gallup Web site. Accessed 

July 13, 2014.

5. Doyle ME, Peterson KA. Re-entry and reintegration: returning home after combat. Psychiatr Q. 2005;76:361–370.

6. World Health Organization. How to Use ICF: A Practical Manual for Using the 

International Classification of Functioning, Disability and Health (ICF). Geneva, 

Switzerland: WHO; 2013.

7. Bowles SV, Bates MJ. Military organizations and programs contributing to 

resilience building. Mil Med. 2010;175:382–385.

8. Richardson GE. The metatheory of resilience and resiliency. J Clin Psychol.

2002;58:307–321.

9. Finkel D. Thank You for Your Service. Toronto, Ontario, Canada: Bond Street 

Books; 2013.

10. The Semper Fi Odyssey. Semper Fi Odyssey Handbook. Outdoor Odyssey Leadership Academy Web site. http://www.outdoorodyssey.org/leadership-programming/Veteran-programming/semper-fi-odyssey/2013. Accessed July 13, 2014.

11. Aiken AB, Bélanger SAH. Beyond the Line. Montreal, Quebec, Canada: 

McGill-Queen’s University Press; 2013.

12. Scrivener L. Terry Fox: His Story. Toronto, Ontario, Canada: McClelland & 

Stewart Ltd; 2000.

13. Rigsby S, Glatzer J. Unthinkable: The True Story About the First Double Amputee to Complete the World-Famous Hawaiian Ironman Triathlon. Carol Stream, 

IL: Tyndale House Foundation; 2009.

14. Cleland M, Raines B. Heart of a Patriot: How I Found the Courage to Survive 

Vietnam, Walter Reed and Karl Rove. New York, NY: Simon and Schuster; 

2009.

15. Cohn MA, Fredrickson BL, Brown Sl, Mikels JA, Conway AM. Happiness 

unpacked: positive emotions increase life satisfaction by building resilience. 

Emotion. 2009;9:361.
Framework for Reintegration H 17

16. RAND Corporation. Reintegration after deployment. RAND Corporation Web 

site. http://www.rand.org/pubs/research_briefs/RB9730/index1.html. Accessed 

July 13, 2014.

17. Bovend’Eerdt TJ, Thamar JH, Rachel E. Botell, Derick T. Wade. Writing SMART 

rehabilitation goals and achieving goal attainment scaling: a practical guide. 

Clin Rehabil. 2009;23:352–361.

18. Wiechmann JR. Marine Corps Leadership Lessons for the Workplace A Case 

Study [dissertation]. Lawrence, KS: The University of Kansas; 2011.

19. Downs DA, Murtazashvili I. Arms and the University: Military Presence and the 

Civic Education of Non-Military Students. New York, NY: Cambridge University 

Press; 2012.

20. Resnick HE, Carter EA, Albia M, Phillips B. Cross-sectional relationship of 

reported fatigue to obesity, diet, and physical activity: results from the Third 

National Health and Nutrition Examination Survey. J Clin Sleep Med. 

2006;2:163–169.

21. Gehrman P, Seelig AD, Jacobson IF, et al. Predeployment sleep duration and insomnia symptoms as risk factors for new-onset mental health disorders following 

military deployment. Sleep. 2013;36:1009–1018.

22. Venturella P. Character, Competence, and Commitment . . . The Measure of a 

Leader—Leadership Philosophies, Principles and Observations of a Career Air 

Force Combat Controller. Bloomington, IN: AuthorHouse; 2007.

23. Association of the United States Army. Vice chief calls on NCOs to promote 

Ready and Resilient Campaign. Association of the United States Army Web site. 

http://www.ausa.org/meetings/2013/AnnualMeeting/Pages/story13.aspx. Accessed July 13, 2014.

24. Segal ZV, Williams MG, Teasdale JD. Mindfulness-based Cognitive Therapy for 

Depression. New York, NY: Guilford Press; 2012.

25. O’Neal HA, Dunn AL, Martinsen EW. Depression and exercise. Int J Sport 

Psychol. 2000;31:110–135.
18 H Promoting Successful Integration

Lieu te n a n t C o l o n el (LTC) Steve n E. Gve n ter is currently serving as Commander of the 2nd Squadron, 2nd Cavalry Regiment’s Cougar 

Squadron, in Vilseck, Germany. He assumed command of Cougar 6 on September 1, 2015. Prior to this command, he served at NATO (North Atlantic 

Treaty Organization) Joint Forces Command in Naples, Italy, and is honored 

to have been chosen to command a Stryker Cavalry Squadron in Germany in 

2016. Gventer was wounded twice leading his Troopers through the volatile 

streets of Sadr City in Baghdad, Iraq, in 2004–2005 as a Company Commander with Cobra Company, 2-8 Cavalry. In 2004, Gventer (then a Captain) was 

first shot through the leg while on patrol. A few weeks later, he was wounded 

by a rocket-propelled grenade while dismounted with his Soldiers. After overcoming these wounds and the surgeries required to repair his right arm and to 

remove fragments from his shoulder, back, and leg, he again deployed less than 

a year later as the Aide-de-Camp to the Corps Commander in Iraq. 

Gventer was then handpicked to report to Walter Reed Army Medical Center 

(Washington, DC) in early 2007, and was the first soldier assigned to the new 

brigade overseeing the care of the Army’s Wounded Warriors and their families. He stood up the Army’s first Warrior Transition Unit on April 27, 2007, 

establishing a new set of standards adopted by the Army under the principle of 
Framework for Reintegration H 19

the Warrior Ethos: I will never leave a fallen comrade. Upon completion of this 

command, he assumed responsibilities as the Executive Officer and Advisor to 

the Commanding General of the Warrior Transition Command that oversaw 

36 Warrior Transition Units and 9 Community-Based Warrior Transition 

Units all over the world, and supported more than 10,000 wounded, ill, or 

injured soldiers, and 2,500 cadre.

While serving in the USAMEDCOM (US Army Medical Command), LTC 

Gventer overcame severe complications and a major illness exacerbated by 

infections from his old wounds. He became a patient in the very system that he 

helped to improve. After 13 months and several surgeries, LTC Gventer healed 

and was selected to attend the Australian Command and General Staff College in Canberra, Australia. He was ordered to depart General Staff College 1 

month early to deploy with the 3rd Brigade, 1st Cavalry Division, for his third 

Iraq tour. He served as the S3 for the 3-8 Cavalry at Camp Garry Owen, Iraq. 

There, the lone battalion conducted operations along the Iranian border in the 

Maysan Province, closed Camp Garry Owen, and redeployed as part of the 

last brigade out of Iraq in late 2011.

Upon redeployment to 

Fort Hood, Texas, Steve 

was selected to become 

the 3rd Brigade Operations Officer for the 

“Greywolf” Armored 

Brigade Combat Team. 

During his 15 months 

as Greywolf 3, LTC 

Gventer executed the 

reintegration of the Brigade Combat Team, and 

planned, resourced, and 

successfully executed 

the Armored Brigade 

Combat Team’s full train-up for a Decisive Action Rotation to the National 

Training Center for Rotation 13-03.
20 H Promoting Successful Integration

Gventer joined the Army (“the family business”) after working for a few years 

as a high school teacher and coach. His father retired as a Lieutenant Colonel, and both his sister and brother served as Army officers. In 1998, Gventer 

enlisted and attended basic training at Fort Jackson, South Carolina, and then 

Officer Candidate School at Fort Benning, Georgia.

LTC Gventer’s awards include the Bronze Star with V-“Valor” Device, the 

Bronze Star with 2 Oak Leaf Clusters, the Purple Heart with 1 Oak Leaf 

Cluster, the Defense Meritorious Service Medal, the Meritorious Service Medal 

with 3 Oak Leaf Clusters, the Army Commendation Medal with 2 Oak Leaf 

Clusters, the Army Achievement Medal, the National Defense Service Medal, 

the Iraqi Campaign Medal with 4 stars, the Global War on Terrorism Expeditionary Medal, the Global War on Terrorism Service Medal, the Korea Defense 

Service Medal, the Army Service Ribbon and the Overseas Service Ribbon 

with Numeral 5, the Valorous Unit Award, the Meritorious Unit Citation, and 

the Army Staff Identifier Badge. He has also been awarded the Combat Action 

Badge. Steve Gventer is also an Eagle Scout.
One of the things that, maybe, the American people are 

not as familiar with as we are, . . . is . . . [that]

our work on prosthetics, traumatic brain injury, 

medical evacuation has actually had a beneficial

 effect, not just for our Servicemen and women, and

 their families, but also for the American people at large.

H H H

General Martin E. Dempsey

Warrior Games

US Air Force Academy

Colorado Springs, Colorado

October 5, 2014

C h a p ter Tw o

Physical Medicine and 

Rehabilitation

ADAM J. SUSMARSKI, DO*

*

Lieutenant Commander, Medical Corps, US Navy; Department of Physical 

Medicine and Rehabilitation, University of Pittsburgh Medical Center, 1400 Locust 

Street, Pittsburgh, Pennsylvania 15219

INTRODUCTION

Author Margaret Carty stated, “. . . the nice thing about teamwork 

is that you always have others on your side.”1(piii) Throughout its 

history, the US Military has been, continues to be, and always will be 

one of the greatest fraternities of men and women (literally and figuratively) 

fighting side by side with one another to achieve some of the greatest accomplishments our country has ever seen. 

Just as the US Military sets the standard for teamwork and camaraderie, 

the field of Physical Medicine and Rehabilitation has been leading the way 

in the successful team approach to patient care through the interdisciplinary work of a number of individuals. Each member of this multidisciplinary 

team works together with the individual Service Member (as well as with one 

another) to not only formulate the best medical care plan for that member, 

but also to act as a teammate in the fight for successful rehabilitation and 

reintegration into the community.

This chapter will explore the expertise of each team member, provide an 

overview of how the team formulates and carries out a care plan, discuss the 

benefits of rehabilitation, and note the role of education for Service Members 

and their families. 
24 H Promoting Successful Integration

THE MULTIDISCIPLINARY REHABILITATION TEAM

The Multidisciplinary Rehabilitation Team consists of the following 

specialists:

• physiatrists,

• physical therapists,

• occupational therapists,

• speech and language pathologists/therapists,

• recreational therapists,

• rehabilitation nurses,

• social workers,

• mental health workers,

• orthotists and prosthetists,

• exercise physiologists,

• athletic trainers, and

• rehabilitation engineers.

P h ys i at r i sts

Although the physiatrist is often viewed as the director of the Multidisciplinary Rehabilitation Team, the true director of that team is the Service 

Member. Recovering and reintegrating Service Members are the focal points 

of every rehabilitation team. By establishing their goals and subsequent 

feedback, the rehabilitation teams adapt and personalize rehabilitation plans 

(Figure 2-1).

Physiatrists are medical doctors practicing in the field of Physical Medicine and Rehabilitation. The field dates back to the founding of the American 

Board of Physical Medicine and Rehabilitation in 1947 and the establishment 

of Physical Medicine and Rehabilitation as an official field of medicine within 

the American Medical Association.2

However, prior to the official founding of the American Board of Physical Medicine and Rehabilitation, the field can be traced back to World War I. 

In response to a growing number of wounded soldiers returning home from 

World War I and an already successful rehabilitation program flourishing in 

European countries, The Surgeon General in 1917 established the Division 

of Special Hospitals and Physical Reconstruction based on a similar program 

conducted at British Army hospitals.3 Physical reconstruction, which at this 

time was defined as maximum mental and physical restoration of the individual, flourished. By 1919, there were 45 hospitals throughout the country, and 

nearly 50,000 returning Veterans had been treated at these facilities.4
Phys ical Medicine and Rehabilitation H 25

Before World War I, there were very few physicians actively practicing 

physical therapy in the United States. However, after the wars, the civilian 

sector saw an influx of well-trained personnel in the field.5

Two subsequent sentinel events occurred in the 1930–1940s with the 

advent of World War II, as well as the poliomyelitis epidemic and the associated need for rehabilitation services in these growing populations. Dr Howard Rusk,6 a lieutenant colonel in the Army Air Corps, is often credited with 

bringing rehabilitation medicine to the forefront during and after World War 

II through the reintroduction of active rehabilitation and the resulting success 

with treating wounded soldiers through early ambulation and exercise following surgery and the treatment of men, not diseases. 

Physiatrists specialize in a wide variety of disciplines that are of great 

importance and applicability to 21st century Service Members and Veterans, 

including 

• traumatic brain injury, 

• spinal cord injury, 

• musculoskeletal sports medicine, 

• polytrauma, 

• burns, 

• amputation, 

• arthritis, 

• neurological disorders, 

• pain management, and 

• stroke.

Fi g u re 2-1. Rehabilitation Interdisciplinary Team. 

OT: occupational therapist; PT: physical therapist; RT: recreational therapist; 

SLP: speech and language therapist.

Psychiatrist

(medical doctor)

SERVICE MEMBER

Social Worker

Orthotist, 

Prosthetist, Rehab 

Engineer

Exercise 

Physiologist, 

Athletic Trainer

Nurse

Therapists

(OT, PT, SLP, RT)

Mental Health,

Rehab Counselor
26 H Promoting Successful Integration

In conjunction with 

treatment of the aforementioned diagnoses, 

physiatrists also have 

unique training in the 

assessment and prescription of assistive technology from prosthesis to 

braces to wheelchairs and 

everything in between 

that helps maximize an 

individual’s functional 

independence.

The physiatrist can 

also take on the role of 

primary care manager 

during the inpatient hospital stay of the Service 

Member/Veteran, as well 

as assume roles in a variety of situations during 

outpatient (eg, clinic or 

deployment setting) care.

P h ys i c a l T h er a p i sts

Physical therapists (PTs) 

are specialists in evaluating and treating disorders of the human body 

primarily by physical 

means. Whether the 

condition results from 

injury, disease, or other 

causes (eg, trauma), they 

focus primarily on those 

individuals who have 

disturbed function or impairment related to the musculoskeletal, neurological, 

cardiopulmonary, and integumentary (skin) systems. PTs evaluate the functioning of these systems and apply the appropriate treatment to alleviate pain 

and improve physical function.7

Fi g u re 2-2. Taping a patient’s knee. 

PHOTOGRAPH: COURTESY OF DALE WILLIAMS.
Phys ical Medicine and Rehabilitation H 27

PTs utilize their specialized training to improve an individual’s physical 

function through optimizing one’s ability for mobility; transferring to and 

from a variety of surfaces; and increasing gross motor strength, range of motion, and endurance (Figure 2-2). 

Oc c u pat i o n a l T h er a p i sts

Occupational therapists help Service Members participate in the things 

they want and need to do through the therapeutic use of everyday activities (eg, eating, getting dressed, cooking, etc). Therapy services may include 

comprehensive evaluations of the client’s home and other environments (eg, 

workplace, school), recommendations for adaptive equipment and associated training in its use, and guidance and education for family members and 

caregivers.8

In Figure 2-3, PerMMA, a robotic wheelchair and arm with mobile wrist 

and fingers, is designed to aid those with physical impairments complete the 

activities of daily living. 

Fi g u re 2-3. PerMMA is a robotic wheelchair and arm with mobile wrist and 

fingers. It is designed to aid those with physical impairments complete the activities 

of daily living. PHOTOGRAPH: COURTESY OF MICHAEL LAIN.
28 H Promoting Successful Integration

S peec h a n d La n g u a ge Pat h o l o g i sts /T h er a p i sts

Speech and language pathologists assess, diagnose, treat, and help to prevent 

disorders related to speech, language, cognitive communication, and swallowing. These therapists work with Service Members who cannot produce speech 

sounds or who cannot produce them clearly, those with speech rhythm and 

fluency problems and swallowing difficulties, those with problems understanding and producing language, and those with cognitive communication 

impairments (eg, attention, memory, and problem-solving disorders).9

Rec reat i o n a l T h er a p i sts

Recreational therapists promote play, recreation, and leisure as a means to 

psychological and physical recovery. These therapists design interventions 

that include a wide range of modalities and facilitation techniques, including aquatics therapy, wheelchair sports, exercise programs, animal-assisted 

therapy, and yoga (Figure 2-4).10 

Re h a b i l i tat i o n Nu rses

The goal of rehabilitation nursing is to assist individuals with a disability and/

or chronic illness to attain and maintain maximum function. Rehabilitation 

nurses, in addition to their traditional job requirements, play a unique role 

in assisting patients in adapting to an altered lifestyle (eg, teaching a patient 

Fi g u re 2-4. Hand cyclists and a visually impaired runner at the start of the 

Pittsburgh Marathon. PHOTOGRAPH: COURTESY OF RONALD ROTH.
Phys ical Medicine and Rehabilitation H 29

with a spinal cord injury to properly self-catheterize his/her bladder, teaching 

a newly diagnosed diabetic patient to administer his/her own insulin prior to 

returning home, etc). 

S o c i a l Wo r kers

US Military social workers are officers who enhance unit readiness and the 

emotional well-being of military personnel, their family members, and other 

eligible beneficiaries. They provide a wide array of support through clinical 

counseling, crisis intervention, disaster relief, critical event debriefing, as well 

as teaching and training in various military settings.11

Me n ta l Hea lt h Wo r kers

The Mental Health Rehabilitation 

Team can be made up of any single, 

individual, or combination of multiple different aspects of mental health 

care. Some of the most common 

members of the rehabilitation team 

are psychiatrists, psychologists, neuropsychologists, and rehabilitation 

counselors. These practitioners specialize in a wide variety of diagnostic 

and treatment methods in numerous 

diagnoses, including traumatic brain 

injury, posttraumatic stress disorder, 

anxiety, depression, anger, as well as 

relationship and marriage counseling. 

Further information regarding their 

integral role in successful integration 

is addressed in Chapter 4, Psychosocial Factors in Reintegration. 

Ort h o t i sts a n d Pr o st h et i sts

Orthotists and prosthetists use stateof-the-art advanced orthotic and 

prosthetic limb technology for the 

design and production of orthotic 

and prosthetic devices. Prosthetic and 

orthotic devices can be custom manufactured and adjusted by a prosthetist 

or orthotist who works closely with the rehabilitation team to ensure the best 

possible fit and utilization (Figure 2-5).12 

Fi g u re 2-5. Mike Anderson, a Gulf 

War Veteran and knee disarticulation amputee, is an active participant in a variety 

of athletic endeavors, including running, 

CrossFit, obstacle races, and golf. 
30 H Promoting Successful Integration

Exer c i se P h ys i o l o g i sts

Exercise physiologists are often divided into two categories: (1) clinical and 

(2) applied. Applied exercise physiologists manage programs to assess, design, 

and implement individual and group exercise and fitness programs. Clinical 

exercise physiologists work under the direction of a physician in the application of physical activity and behavioral interventions in clinical situations 

where they have been scientifically proven to provide therapeutic or functional benefit (Figure 2-6).13 

At h let i c Tr a i n ers

Athletic trainers are healthcare professionals who collaborate with physicians 

to provide preventative services, emergency care, clinical diagnosis, therapeutic intervention, and rehabilitation of injuries and medical conditions.14 

Athletic trainers are not just beneficial for professional and amateur athletic 

teams. US Service Members can reap the same benefits from input and collaboration with athletic trainers; the physical and mental rigors placed on the 

Service Member are not all that dissimilar to their civilian counterparts. A 

Service Member or military athlete relies on the health and fitness of his/her 

mind and body to make a living and complete the mission (Figure 2-7). 

Re h a b i l i tat i o n E n g i n eers

Rehabilitation engineering involves the use of engineering science and principles to develop technological solutions and devices to assist individuals with 

disabilities. It also aids in the recovery of physical and cognitive functions lost 

because of disease or injury. Rehabilitation engineers design and build devices 

Fi g u re 2-6.

Evaluating aerobic 

capacity through 

VO2max testing at 

the Neuromuscular Research 

Laboratory 

(Pittsburgh, PA).

PHOTOGRAPH: 

COURTESY OF 

CHRIS CONNABOY.
Phys ical Medicine and Rehabilitation H 31

Fi g u re 2-7. US Army soldier getting his ankle taped by an athletic trainer prior to a 

training exercise. PHOTOGRAPH: COURTESY OF DALE WILLIAMS.

Fi g u re 2-8. Human Engineering Research Laboratories at the University of 

Pittsburgh and US Department of Veterans Affairs (Pittsburgh, PA). The motto is to 

“continuously improve the mobility and function of people with disabilities through 

advanced engineering in clinical research and medical rehabilitation.” Pictured is 

HERL’s (Human Engineering Research Laboratories’) CAREN (Computer Assisted 

Rehabilitation Environment) system, used to create a virtual reality environment (see 

Chapter 9). In the foreground is a collection of wheelchairs, including a selection of 

hand cycling chairs, a rugby chair, and other older and modern manual wheelchairs. 

PHOTOGRAPH: COURTESY OF MICHAEL LAIN.
32 H Promoting Successful Integration

and systems to meet a wide range of needs that can assist individuals with 

mobility, communication, hearing, vision, and cognition. These tools help 

people with day-to-day activities and tasks related to employment, independent living, and education (Figure 2-8).15 

VOCATIONAL REHABILITATION

Vocational rehabilitation provides services to help persons with disabilities 

prepare for, obtain, or maintain employment.16 Return to work can be a key 

component in the rehabilitation process because it can be integral to helping an individual integrate into the community, as well as achieve financial 

independence. Through vocational rehabilitation, a counselor will meet with 

the individual and develop an individualized plan to identify the service and 

needs of the individual to aid in the attainment of returning to the work force. 

Services can include help in accessing medical care and therapies, job-specific 

counseling and training, job placement programs, access to additional education, home and job modifications, and even transportation. 

THE IMPORTANCE OF SERVICE MEMBER AND 

FAMILY EDUCATION

The ultimate leader of the Medical Rehabilitation Team is the Service Member (see Figure 2-1). For the team to function at an optimal level and achieve 

the best outcomes, the leader of the team, in association with his or her 

family, must take an active role in the planning and continuous adjustment 

of the rehabilitation care plan. Just like any other aspect of one’s personal or 

professional life, the more educated a person becomes about a particular area 

or topic, the more effective that person can become at doing his/her job or 

completing a task. The key here again lies in the team approach of medical 

rehabilitation. The Service Member and family are not left alone to navigate, investigate, and interpret the wide breadth of rehabilitation medicine. 

Each member of the rehabilitation team is available to help direct the Service 

Member in the right direction to find the best and most accurate information 

available. 
Phys ical Medicine and Rehabilitation H 33

REHABILITATION CARE PLAN

The rehabilitation care plan can take place in a variety of settings and roles 

to aid in the recuperation of the Service Member from the inpatient hospital 

setting to the outpatient community office setting. 

When initially integrated into the Medical Rehabilitation Team in the 

inpatient hospital setting, each of the previously described members of the 

team will meet with the Service Member for an initial evaluation. At that 

time, the rehabilitation team members will meet with the Service Member and 

family members to evaluate previous function and current function, as well as 

to discuss functional goals for the future. Once each member of the team has 

had an opportunity to complete an initial evaluation with the Service Member, they will meet all together as a Medical Rehabilitation Team and again at 

regular intervals. These meetings allow team members to share their individual knowledge and expertise to formulate recommendations for the best way 

forward to achieve the Service Member’s goals. 

Throughout this process, team members will also routinely meet on 

numerous occasions—in between more formal group meetings—to discuss 

thoughts and insight on how to progress forward toward success. All the 

while, the individual Service Member is adding the key ingredient to the team: 

insight into what is or perhaps what is not working and how to progress forward to achieve the goals that have been set. Keep in mind that the rehabilitation care plan is one of great fluidity and flexibility (perhaps better known in 

the Marines and Navy as “Semper Gumby”) and can be molded and manipulated to fit the individual as he/she progresses. Thus, it is not a rigid and 

unchangeable format that cannot be adjusted after its initial establishment.

The rehabilitation care plan can also be applied in the outpatient community setting either as continuity of care after discharge from the hospital 

or independently through consultation. After discharge from the hospital, the 

physiatrist will continue to work with the rehabilitation team through a variety 

of formats to ensure continued success. A physiatrist also plays a role in the 

Service Member’s reintegration by working in conjunction with other medical 

providers to contribute a unique perspective through a variety of formats, including a comprehensive neuromusculoskeletal physical evaluation, assessment 

and prescriptions of assistive technologies, and electrodiagnostic studies. 

Electrodiagnostic studies include a two-part examination with a series 

of small electrical shocks to test the function of nerves and a needle portion 

in which a small, thin needle is placed into muscles to evaluate for proper 

functioning. The physiatrist can then interpret and evaluate this information 
34 H Promoting Successful Integration

to identify potential nerve and muscle diagnoses like carpal tunnel syndrome, 

as well as monitor health and recovery after injury during the rehabilitation 

process. 

SUMMARY

“From the hottest forge comes the hardest steel.”

Unknown

The 21st century American Service Member has faced great adversity and has 

not just survived, but has thrived in this setting. Oftentimes, when a Service 

Member first reports to rehabilitation, he/she is at, near, or beginning the 

recovery from a low point, a valley, and potentially one of the darkest and 

most trying moments. It is through these most difficult and challenging of 

times that one is forged and molded into the most resilient and strongest of 

individuals. Those who go through this transition will become a pillar of the 

strongest US steel and should know that there will be an entire team—the 

rehabilitation team—right beside them, working and cheering for each and 

every individual Soldier, Sailor, Airman, and Marine to succeed!

Refere n ces

1. Parcon P. Develop Your Team Building Skills. New Delhi, India: Lotus Press; 

2007.

2. Opitz JL, Folz TJ, Gelfman R, Peters DJ. The history of physical medicine and 

rehabilitation as recorded in the diary of Dr. Frank Krusen: part 1. Gathering 

momentum (the years before 1942). Arch Phys Med Rehabil. 1997;78:442–445.

3. Heaton L. Army Medical Specialist Corps. Washington, DC: U.S. Army Surgeon 

General’s Office; 1968.

4. Lynch C, Weed FW, McAfee L. The Medical Department of the United States 

Army in the World War. Washington, DC: U.S. Army Surgeon General’s Office; 

1923–1929.

5. Kovács R. Electrotherapy and Light Therapy With the Essentials of Hydrotherapy and Mechanotherapy. 4th ed. Philadelphia, PA: Lea & Febiger; 1942.

6. Rusk HA. The growth and development of rehabilitation medicine. Arch Phys 

Med Rehabil. 1969;50:463–466.
Phys ical Medicine and Rehabilitation H 35

7. University of Kansas Medical School Physical Therapy and Rehabilitation Science 

Web site. http://www.kumc.edu/school-of-health-professions/physical-therapyand-rehabilitation-science.html. Accessed August 31, 2014.

8. American Occupational Therapy Association, Inc. AOTA Web site. www.aota.

org. Accessed September 1, 2014.

9. University of Redlands Web site. http://www.redlands.edu/. Accessed September 

1, 2014. 

10. Temple University College of Health Professions and Social Work. Department 

of Rehabilitation Sciences Web site. http://chpsw.temple.edu/rs/home. Accessed 

September 1, 2014. 

11. US Army. US Army Careers and Jobs: Social Worker (73A). Go Army Web site. 

http://www.goarmy.com/careers-and-jobs/amedd-categories/medical-servicecorps-jobs/social-worker.html. Accessed September 10, 2014.

12. Walter Reed National Military Medical Center. WRNMMC: Prosthetic Orthotic 

Service Web site. http://www.wrnmmc.capmed.mil/. Accessed September 14, 

2014.

13. Commission on Accreditation of Allied Health Education Programs. CAAHEP 

Web site. http://www.caahep.org/. Accessed September 11, 2014. 

14. National Athletic Training Association. NATA Web site. http://www.nata.org/

athletic-Training. Accessed September 8, 2014.

15. National Institute of Biomedical Imaging and Bioengineering. NIBIB Web site. 

http://www.nibib.nih.gov/. Accessed September 9, 2014.

16. Commonwealth of Pennsylvania. Pennsylvania Department of Labor & Industry 

Web site. http://www.dli.state.pa.us/portal/server.pt/community/vocational_

rehabilitation/. Accessed December 15, 2014.
36 H Promoting Successful Integration

Ret i red Sta f f Ser gea n t

Mi c h ael Ka cer grew up in the 

small town of Waymart, Pennsylvania. 

Just as he was about to graduate 

from high school, he decided to join 

the Pennsylvania Army National 

Guard for discipline and direction. 

Shortly after graduating from Fort 

Benning Infantry Basic and Advanced 

Individual Training, he returned home 

to start his citizen soldier life in the 

National Guard. After three long years 

trying to figure out if the military was 

the right life choice for him, September 

11, 2001 occurred and decided it for 

him. He was a lost soul who now 

found direction. However, after his 

first deployment, Kacer succumbed to depression. Bouncing from job to 

job, fighting alcoholism, and never starting college, Kacer felt helpless until 

another opportunity to deploy occurred. Lost and aware that he needed a 

restart in his life, he took the deployment.

What was supposed to be a 12- to 18-month deployment became nearly a 

23-month deployment. Shortly after bouncing around from camp to camp, 

his unit (the 2/103 Armor of the 55th Brigade, 28th Infantry Division (M)) 

fought and worked alongside the 2nd Battalion, 5th Marines Regiment, 1st 

Marine Division in Fallujah, Iraq, providing support on route patrols, outer 

cordon security, explosive ordnance disposal, and check points for people 

and vehicles entering and leaving the city. His unit also became the first unit 

in Operation Iraqi Freedom/Operation Enduring Freedom to receive a crossservice combat patch. 

In 2007, after finally starting to settle down, Kacer volunteered for his 

last deployment. Little did he know that his life was about to change. At 

the beginning of his deployment, he was promoted to Staff Sergeant. In a 

Staff Sergeant-heavy platoon, he was a team leader working alongside the 
Phys ical Medicine and Rehabilitation H 37

Navy Providential Reconstruction Team. On June 18, 2008, Kacer and his 

fellow soldiers were playing spades in a building on a combat outpost when 

insurgents began firing 110-mm Chinese rockets into the combat operations 

post. Kacer was unable to react when one of the rockets came in through a 

window and hit the wall next to him, resulting in a 6-inch fracture across the 

back of his head, three broken ribs, two collapsed lungs, severed intestines, 

and his left arm amputated above the elbow. Following his injury, Kacer again 

fell into a “lost state of mind.” The hardest thing for him to deal with were 

not only his injuries or upcoming divorce, but also the loss of his medic and 

mechanic, and the subsequent survivor’s guilt that resulted from these losses. 

Recuperating at 

Walter Reed National 

Military Medical 

Center (Bethesda, 

MD), help arrived for 

Kacer in the form of 

sports therapy. “The 

folks at Walter Reed 

pushed me to compete, 

due to my competitive 

nature,” said Kacer. 

“For me, competition 

and training are not 

just about recovery 

or physical fitness, it’s 

more about being in 

control of myself.”

Staff Sergeant Kacer is 

part of a small group 

of wounded soldiers 

who have not only 

spent long hours of 

rehabilitation to regain 

a sense of normalcy, but 
38 H Promoting Successful Integration

have also taken their recovery to new levels. Since his injury, Michael has been 

an active member of the Achilles Freedom Team, Hope for Warriors, and 

Disabled Sports USA. He has made Paralympic Track and Field Nationals 

every year since 2011 (just barely missing Worlds in 2013). He completed 

two New York City Marathons, 3 Army Ten Milers, the Boston Marathon, 

3 Bataan Death Marches, 3 Warrior Games (medaling in 10 of 15 individual 

events), 5 Hope & Possibilities Five Milers, the Chicago Marathon, the 

Detroit Half Marathon, the Disney Half Marathon, and 9 Tough Mudders, 

just to name a few of his outstanding athletic accomplishments. Currently, 

however, he has put all other races on hold as he trains at West Point for the 

2016 Paralympics in Rio de Janeiro, Brazil.

Kacer says that, “Each injury has left its scars both physical, emotional, and/

or mental. However, when I get in the pool, or on the track, the only thing 

that can be seen is my competitiveness and the desire to win. I hope I will be 

able to show my ability and also that just because people are injured doesn’t 

mean they are limited.”
There are those who speak about you who say, 

‘he lost an arm, he lost a leg, she lost her sight . . . ,’ 

I object. You gave your arm. You gave your leg. 

You gave your sight. 

As gifts to your Nation. That we might live in freedom. 

Thank you. And to your families. 

Families of the fallen and families of the wounded. 

You sacrificed in ways that those of us who 

have not walked in your shoes can only imagine.

H H H 

General Peter Pace

Center for the Intrepid

San Antonio, Texas

C h a p ter T h ree

The Promise of the Future: 

Assistive Technology, 

Transportation, and Emerging 

Technologies

ROSEMARIE COOPER, MPT, ATP*; CHENG-SHIU 

(JOSHUA) CHUNG, PhD†; JOHN COLTELLARO, ATP‡; CHRISTINA 

LACROIX, DO§; AMY LANE, OTR/L, CDRS¥; ALISSA LING, MS¶; 

AMANDA REINSFELDER, MS, ATP#; BENJAMIN SALATIN, MS**; AND 

GOERAN FIEDLER, PhD††

*

Assistant Professor, Department of Rehabilitation Science and Technology, University of Pittsburgh, and Director, Center for Assistive Technology, Forbes Tower, Suite 

3010, 5600 Forbes Avenue, Pittsburgh, Pennsylvania 15213 

†

Postdoctoral Researcher, Department of Rehabilitation Science and Technology, 

University of Pittsburgh, Human Engineering Research Laboratories, VA Pittsburgh 

Healthcare System, 6425 Penn Avenue, Suite 400, Pittsburgh, Pennsylvania 15206

‡

Rehabilitation Engineer, Center for Assistive Technology, Forbes Tower, Suite 3010, 

Pittsburgh, Pennsylvania 15213

§

Acting Assistant Service Chief, Director of Outpatient Services, Director of Mobility 

Clinic, and Staff, Physical Medicine and Rehabilitation, Walter Reed National Military 

Medical Center, 8901 Rockville Pike, Bethesda, Maryland 20889

¥

Instructor, Department of Rehabilitation Science and Technology, University of 

Pittsburgh, Suite 3010 Forbes Tower, 3600 Forbes Avenue at Atwood, Pittsburgh, 

Pennsylvania 15213
42 H Pr o m o t i n g Su c cess f u l I n teg r at i o n

¶

Student, Department of Physical Medicine and Rehabilitation, Uniformed Services 

University of the Health Sciences, 4301 Jones Bridge Road, Bethesda, Maryland 20814

#

Assistive Technology Specialist, Walter Reed National Military Medical Center, Building 19, 1st Floor, Room 1313, 4954 North Palmer Road, Bethesda, Maryland 20889

**Rehabilitation Engineer, Department of Physical Medicine and Rehabilitation, 

Virginia Commonwealth University, 1223 East Marshall Street, Richmond, Virginia 

23298 and Hunter Holmes McGuire VA Medical Center, 1201 Broad Rock Boulevard, Richmond, Virginia 23224

††Assistant Professor, Department of Rehabilitation Science and Technology, University of Pittsburgh, 6425 Penn Avenue, Suite 403, Pittsburgh, Pennsylvania 15206

INTRODUCTION

Disability sustained during military service presents a major challenge facing Service Members and Veterans, as well as their families. Physical and/or cognitive injuries are life-changing and may have 

emotionally devastating effects on both the person who has sustained injury 

and the family of the injured person. To successfully reintegrate into the 

community, injured Service Members or Veterans must discover their “new 

normal,” however they choose to define it.

Assistive technology (AT) can be a critical part of finding this new normal. Physical or cognitive impairments that at first may be perceived as highly 

limiting at best and insurmountable at worst can actually be compensated for. 

With the appropriate AT and guidance of qualified AT professionals, Service 

Members and Veterans are able to successfully rejoin the community, participate fully in family life, and partake in activities they have always enjoyed. 

Some Service Members are even able to return to active duty.

This chapter will provide a practical insight into the range of AT applications for individuals who have experienced physical, sensory, and cognitive 

impairments as a result of traumatic and nontraumatic injuries and disease. 

An important step to ensure appropriate selection of AT is to start with an 

AT team that consists of qualified AT professionals who have a keen interest 

in including and encouraging active participation of the end user in the AT 

evaluation and selection process. Sections covered in this chapter include clinical case examples of
The Promi se of the Future H 43

• AT interventions in wheelchair seating and mobility, 

• adaptive driving, 

• computer access, 

• cognitive technologies, 

• orthotics and prosthetics, and 

• emerging technologies (as they apply to independent community living and enhancement of performance for recreational, educational, and 

professional activities). 

Actual clients were the basis for the case examples. In certain instances, additional details were added to help clarify the effect of the technology.

SEATING AND MOBILITY

Service Members and Veterans with severe mobility impairments, such as 

lower extremity amputation or spinal cord injury, can achieve independence 

in daily life with the help of AT devices (eg, wheelchairs, assistive driving 

controls, and specialized computer applications). The process begins with a 

thorough assessment by a team of AT professionals, by trial and error, and 

with a series of more precise adjustments. The prescribed mobility solutions 

will lead to the fullest possible autonomy for the AT user. 

As the following examples illustrate (eg, ultralight manual wheelchairs, 

power wheelchairs, super lightweight manual wheelchairs, adaptive driving, 

and computer access), better mobility solutions result in more complete reintegration into the community. 

Ult r a l i g h t Ma n u a l Wh eel c h a i rs

Case Example: Katie

An active 23-year-old undergraduate student with tetraplegia following a 

C5–C7 spinal cord injury first arrived at the Center for Assistive Technology (Pittsburgh, PA) for modifications to her 16-inch width x 16-inch depth 

(16 ̋w x 16 ̋d) ultralight manual wheelchair that was equipped with push 

rim-activated power assist wheels for mobility. Since arriving at the university, 

she experienced difficulties in maneuvering this chair around her apartment 

and through the narrow doors and hallways on campus. Because her chair 

was only 2 years old, she assumed that she would not qualify for a new chair. 

However, because she had multiple inches of extra space between the frame 

and her hips, she wanted to see if her current chair could at least be modi-
44 H Pr o m o t i n g Su c cess f u l I n teg r at i o n

fied to allow her to get around and maneuver better at home and in school. 

The physical therapist, together with the rehabilitation technology supplier, 

discussed options with Katie and decided that a smaller-sized (14 ̋w x 16 ̋d) 

wheelchair frame would meet her needs. 

When Katie transferred to a 14 ̋w x 16 ̋d ultralight manual wheelchair, 

she immediately reported increased comfort because of the better fit and 

significant ease with self-propulsion due to the axle position. The smaller 

space between the wheels then aligned with her shoulders. A letter of medical 

necessity was submitted to Katie’s insurance company. One month later, she 

was seen for a final fitting and delivery of her new retrofitted 14 ̋w x 16 ̋d 

ultralight manual wheelchair equipped with power assist wheels. The power 

assist was necessary for her to be able to traverse the hilly university terrain. 

It allowed her to push for long distances up and down slopes, and over semiuneven terrain with less effort. The overall lighter wheelchair frame allowed 

her to continue with active self-propulsion of a manual wheelchair and to 

incorporate the benefits of an ultralight manual wheelchair into her active and 

independent lifestyle.

Case Example: John

A 35-year-old, full-time employed civil engineer, husband, and father—with 

amputations of both legs above the knees—came to the Center for Assistive 

Technology to inquire about assistive devices to supplement his prosthetic 

legs, which he felt were limiting his functional mobility. John needed to be 

able to maneuver a chair over uneven recreational outdoor terrain (eg, playgrounds, sports fields, family theme parks) and rougher terrain at construction sites. He was not interested in a power wheelchair because he preferred 

active self-propulsion of a manual wheelchair, and a power wheelchair would 

also limit the flexible transportation and vehicle options he needed for work. 

John tested one of the demo ultralight manual wheelchairs equipped with 

durable lightweight carbon-fiber wheels and quick-release options. Because 

he would have to transfer in and out of his car multiple times, the lighter the 

components John would have to manipulate, the less strain on his upper extremities. The wheels were equipped with ergonomically designed hand rims 

to reduce the risk of repetitive strain injury to wrist joints, and to protect the 

hand from injuries and lacerations. 

Once positioned in the demo chair, he reported increased comfort and 

experienced significant ease with self-propulsion. John was provided with 

the opportunity to use this demo chair for a 1-week, in-home trial to allow 

him to incorporate and evaluate its features during his daily mobility-related 

activities at home and at work. He spent significant time learning the center 
The Promi se of the Future H 45

of gravity adjustment and its effect on the responsiveness and “tippiness” of 

the chair. This was important because his center of gravity would be different 

when using the chair with and without his prosthetic legs. Based on John’s 

positive feedback of the in-home trial, a letter of medical necessity was submitted to his insurance company.

One month later, he was seen for a final fitting and training with his new 

ultralight manual wheelchair. John was instructed in appropriate semicircular 

propulsion, and he received “wheelie” training. He was able to hold and 

control the wheelie after 10 minutes of supported practice. He now has the 

ideal supplemental mobility device option to let him accomplish the highenergy–consuming activities for raising his young son and for doing field 

work at construction sites.

P o wer Wh eel c h a i rs

Case Example (continued): Katie

Katie also owned a 3-year-old power wheelchair equipped with power seat 

functions, including power tilt/recline/elevating leg rests and seat elevator, that 

she received on discharge from rehabilitation. This chair was appropriate at 

a time when her C5–C7 spinal cord injury was still very recent, and she was 

still adjusting to her new physical limitations. Being able to spend more time 

in her chair was important for Katie because she liked controlling her own 

schedule and joining activities with her friends and family. Thus, the power 

seat functions were important to her. 

She frequently used the power tilt after her therapist had explained to 

her the benefits of gravity-assisted positioning that increases stability and 

decreases fatigue. Also, the seat elevator allowed Katie to independently 

change her seat height levels at tables, restaurant counters, desks, and work 

surfaces. Reaching counters and cabinets were essential for her to participate 

in food preparation and to access storage cabinets and freezer contents. With 

the adjustable seating, she could reach into a washer and dryer, reach across 

a stove safely, push elevator buttons, and use ATMs. It also helped to manage 

the pain in her neck/back so that she could raise herself for eye-to-eye contact 

during social interactions without having to look up all the time.

Su per Li g h t wei g h t Ma n u a l Wh eel c h a i rs

Case Example (continued): Katie

Katie returned to the Center for Assistive Technology in December 2013 to 

find out if there was a super lightweight manual wheelchair on the market 
46 H Pr o m o t i n g Su c cess f u l I n teg r at i o n

that she could possibly lift into a sedan-type vehicle. Although Katie was 

independent in driving her minivan, she was considering obtaining a smaller 

vehicle to use on campus and during local outings with her friends. With her 

goal in mind, we introduced her to a super lightweight carbon-fiber manual 

wheelchair (8 lbs total weight with wheels). By significantly reducing the 

weight of the wheelchair, Katie had enough strength to 

• self-propel the chair, 

• transfer into a smaller vehicle, and

• load and stow the super lightweight chair into a vehicle cabin. 

This chair will help her to achieve her goal of simplifying her reliance on 

autoadaptive equipment and vehicle modifications, and potentially reduce the 

need for purchasing costly vehicle technology. 

Ad a p t i ve Dr i v i n g

Case Example (continued): Katie

Katie had expressed an interest in exploring independent transportation 

options and was referred to the driver rehabilitation evaluation program to 

determine her transportation needs. During the course of the evaluation, she 

determined that she preferred using push-right, angle-style hand controls to 

operate the gas and brake pedals. She also determined that she would need a 

trip-in steering device because of her hand function. 

During Katie’s vehicle selection process, various vehicle options were 

reviewed. A significant consideration was Katie’s active lifestyle—her interchanging use of two wheelchairs and multiple recreational devices that would 

need to be transported. A lowered floor minivan with an entrance ramp allowed her greater options to

• use either of her wheelchairs, 

• transport equipment, 

• travel comfortably to her long-distance destinations, and 

• supply traveling space for family and friends. 

With the support of her family and funding sources, she was able to purchase 

a used, lowered floor ramp minivan. When using her new power assist wheels, 

she was able to independently propel herself up the ramp of the minivan, 

secure her wheelchair using a crash-tested securement system, transfer into a 

driver’s power base seat, and then drive using her adaptive driving equipment. 
The Promi se of the Future H 47

Case Example (continued): John

John also participated in a driver rehabilitation evaluation program to determine his transportation needs and goals. He was shown push-rock hand 

controls to operate the gas and brake pedals, as well as a spinner knob to 

steer. He questioned the possibility of using his prosthetic legs in lieu of the 

adaptive equipment to operate the gas, brake, and clutch in his work truck. 

John was advised that it was not generally recommended to use his prosthesis 

to access the vehicle’s pedals because of the loss of sensory awareness, limited 

control of knee and ankle mobility, and potential misstrike on the pedals. 

He was satisfied with the rationale for using adaptive driving equipment and 

quickly adjusted to driving with the controls.

At the time of the on-road evaluation, John was not using his prosthetic 

legs, but he had to transfer from his manual wheelchair to the driver’s seat. 

Both John and his seating team remembered that he needed to independently 

break down and secure his wheelchair during periods of time when he would 

not be ambulatory. John realized the options and expenses in modifying 

his manual transmission vehicle, and admitted that his truck was quite old 

and that he would prefer to obtain a new vehicle. He was able to identify a 

four-wheel-drive SUV (sports utility vehicle) that he could easily transfer into 

if he was walking, yet had ample space to store his new ultra lightweight 

wheelchair as needed. John was able to progress quickly through the driving training program, become licensed to drive with the devices, and had the 

vehicle modifications completed in his new SUV. He was quite satisfied with 

the ability to use the vehicle with or without his wheelchair, for both work 

and personal use.

C o m p u ter Ac cess

Case Example (continued): Katie

Katie was also introduced to various ATs that could benefit her that had 

computer access and could assist her in completing her college assignments. 

Although Katie could use a laptop computer keyboard, her typing speed was 

significantly slower because of her injury. Therefore, Katie was introduced to 

voice recognition software. Katie demonstrated the voice and breathing skills, 

as well as the cognitive abilities, required to become a very efficient user of 

voice recognition technology. Katie was also introduced to the Smartpen 

(Livescribe, Inc, Oakland, CA) to help compensate for her slower handwriting 

speed. The Smartpen is a unique device that records the audio from a lecture 

or meeting and matches the audio file to what was written at that moment. 

Katie felt this technology would really help with classroom note-taking.
48 H Pr o m o t i n g Su c cess f u l I n teg r at i o n

COGNITIVE ASSISTIVE TECHNOLOGIES

AT is comprised of two main parts: (1) the actual tangible tool (including specific software/applications where applicable) and (2) the services provided to 

teach a person how to use that tool. Generally speaking, AT is considered to 

be any tool that can increase the independence of an individual to accomplish 

a desired goal.1

Cognitive ATs are tools that help a person who has trouble with managing everyday cognitive activities (eg, maintaining a calendar/schedule or a 

current task list, finding one’s destination when traveling, remembering where 

the car was parked, etc). Some people may have difficulty physically speaking 

a particular word or cannot think of the word at all. Still other people may 

have decreased dexterity, which means that they may not physically be able to 

complete tasks as they were completed preinjury. A variety of cognitive ATs 

could be used to accomplish each of these tasks.2

Case Example: Jim

For Jim, checking his smartphone is a vital part of his daily routine because 

the alerts help him get through his day. He is able to remember to enter down 

when he has to complete tasks and when his appointments occur. However, 

he is unable to remember to check his schedule; thus, his phone becomes AT 

when it reminds him to look at his calendar, which he would not be able to 

do without the alarms that sound at the appropriate times. If Jim works in a 

secure facility and is unable to take his phone with him into work, the environment changes the effectiveness of his strategy to manage his appointments 

and task list. A solution might be to use the calendar on his computer at 

work, or he could print out the current copy of his electronic calendar on his 

phone and carry the paper copy with him. If Jim has to schedule an appointment that affects his home life, he could email himself the details to add to his 

calendar at home. Therefore, any AT solution must also consider the environment in which the person is planning to accomplish a task. 

Rehabilitation after an injury, especially a brain injury, requires a team 

approach.3 The team is centered on the individual, who can offer valuable 

insights from his or her perspective to expedite recovery from the brain injury. 

As noted in Chapter 2 (Physical Medicine and Rehabilitation), the multidisciplinary team will most likely include a mixture of the following specialists: 

• a physiatrist (or a doctor specializing in working with trauma to 

the body), 
The Promi se of the Future H 49

• an occupational therapist, 

• a physical therapist, 

• a speech language pathologist, 

• a recreation therapist, 

• nurse case managers, 

• vocational rehabilitation counselors, 

• personal care assistants, and

• a rehabilitation engineer/technologist or certified AT professional. 

Additional related discipline specialists may also participate on the team as 

appropriate. Communication among members of the team is vital for the 

patient to receive high-quality care. As a part of this multidisciplinary team, 

patients and their families should be confident in advocating for clear explanations or any unaddressed concerns. Some individuals with traumatic brain 

injuries may not realize the extent of their new inabilities and challenges until 

they return to a routine similar to the preinjury routine.4 With the Warrior 

Transition Command system implemented by the Army in 2009,3 and in 

collaboration with the vocational rehabilitation counselor and the appropriate therapists, patients are able to apply the skills and tools learned from the 

rehabilitation team in supervised work settings. Any challenges that surface 

can be addressed by the team to help the individual understand the situation 

and discuss options for the future. 

Case Example (Team Approach): Mark

Mark is an inpatient who has a delay in understanding speech. In addition, 

it is very difficult for him to move any of his body parts, and he is unable to 

speak. The physical therapist works with Mark to strengthen the muscles he 

does have control over. The speech language pathologist helps determine how 

much Mark is actually able to comprehend and the accuracy of his answers. 

The speech language pathologist is also able to determine that he can accurately answer yes and no, and can decipher whether he has a method to 

express yes and no. The AT specialist works with the physical therapist, the 

speech language pathologist, and the occupational therapist to determine 

that he is able to independently control his left thumb and his right foot. The 

AT specialist found a lever switch that he can activate with his foot and an 

infrared switch that can be activated when he raises his thumb. The switches 

are connected to a communication device that plays a recorded message 

of yes and no when he moves his thumb or foot. Adjustments are made as 

necessary throughout the process (eg, switch placement or switch type). The 

occupational therapist practices with Mark to work the muscles and answer 
50 H Pr o m o t i n g Su c cess f u l I n teg r at i o n

questions with yes and no. The entire team works together to help Mark 

strengthen his skills to independently answer questions. Once he has mastered 

responding yes and no, he will be set up to control his environment, which 

could include changing channels on the television. 

Healing occurs when multiple facets of the brain are engaged, such as 

requiring the person to complete physical tasks in addition to cognitive tasks.5

Therapists and members of the rehabilitation team can use electronics with 

touch interfaces and interactive video technology (computers) to customize an 

individual’s care plan.5,6 Virtual environments can be customized to target the 

needs of a particular patient by focusing on the specific goals of that patient 

and the rehabilitation team. Computer programs used in therapy can provide 

feedback to users as necessary, measure where users are looking to complete 

a task, or require patients to complete a task by focusing on a side they might 

tend to neglect (ie, left or right).5,6 Computer programs can also be used, in 

collaboration with the rehabilitation team, to strengthen cognitive skills by 

adjusting difficulty levels that are appropriate to the individual user.4

Because every person is unique, different tools need to be used to provide 

independence.7 Feature matching, a system that matches the needs of the 

patient with the specific abilities of available tools, is used to determine which 

tool will be the appropriate fit for an individual’s characteristics.8 People have 

different strengths and weaknesses, and devices have different features and 

specifications. Although the most advanced technology may be appropriate 

for some, it is important to understand that simple tools can also have a significant impact (eg, a notebook or a voice recorder to help a person remember 

important facts).8

Case Example: Feature Matching

Jim has difficulty remembering his appointments and uses an electronic 

tablet to manage his medical appointments. However, the best solution for 

Jane might be to use a paper planner with color-coded pens to help her stay 

organized. 

Automated reminders can be set to alert users for important events or 

tasks that need to be completed. For people who frequently lose their keys, 

a retracting keychain that can be tethered to a backpack, belt loop, or purse 

would help them meet the goal of not misplacing keys. An electronic wireless 

leash that sounds an alarm when a cell phone has been left behind would help 

someone remember a cell phone. As an alternate solution to not misplacing 

an important item (eg, a cell phone), a retracting keychain could be fastened 
The Promi se of the Future H 51

to the cell phone with Velcro. Options exist for each challenge a person faces, 

and it is important to remember that solutions range from simple to more 

advanced. 

With smartphones more easily available for end users, applications can 

serve as AT or alternate tools to accomplish a specific task.9 If an individual 

is going to the grocery store, he or she could carry a notepad. However, if the 

person frequently leaves the notepad but not his or her cell phone behind, 

grocery items could be stored in an application designed for tracking shopping lists. Some people note that applications can be synced to a cloud system, which could be monitored/edited by a family member in real-time from 

another location. Calendars and task lists can also be managed electronically 

from a smartphone. 

A person who has difficulty with auditory processing might be able to 

understand a conversation with visual captions.10 Captions are available for 

telephone conversations, large meetings, or presentations through captioned 

telephone services or CART (Communication Access Realtime Translation).11

Individuals who have difficulty typing can use mainstream speech recognition technology to speak into a phone or computer, as noted in the previous 

case example with Katie. If dictation is a problem because of difficulties with 

vocabulary, specialized predictive software programs are available. Specialized 

software is programmed to prompt users with a menu of options that change 

with every word entered. If the user is unsure of the words on the list, words 

can be “hovered” over in order to hear and see them used in a sample phrase.

Technology constantly changes at a rapid pace, and the way it is applied 

in a rehabilitation setting is evolving.12–15 A primary resource for all individuals is an AT professional, a therapist, or a medical provider (see the Rehabilitation Engineering and Assistive Technology Society of North America 

[RESNA]; www.resna.org). For individuals who are active duty Service 

Members, medical treatment facilities may have an AT professional ready to 

answer any questions. Veterans with a service-connected injury could access 

a Veterans Affairs facility for assistance. All individuals (including the general 

public) are able to access their local state AT resource center for free information regarding any AT questions. Current information for local resource 

centers can be found by state at the Association of Assistive Technology Act 

Programs (www.ataporg.org/states.html). 

Learning about AT is a team effort. There is no instant answer, and feedback is important. As noted in the beginning of this section, AT includes the 

services that support the actual tool. Sharing where an individual is having 

difficulty will help the AT professional pinpoint the barriers that need to be 

addressed. Once the barriers are identified, specific solutions can be imple-
52 H Pr o m o t i n g Su c cess f u l I n teg r at i o n

mented. If the suggested solutions are not working, the AT professional will 

continue to explore additional options until a successful solution has been 

identified.16 Some software programs, such as speech recognition software 

that types what is spoken, might be frustrating without proper instruction. An 

AT specialist will work with patients to help them learn the proper techniques 

for using the recommended software or tools. To find a certified AT professional registered through RESNA, visit the RESNA Web site. 

ORTHOTICS AND PROSTHETICS

Orthotic devices are attached or applied to the external surface of the body. 

They are used to improve function, restrict or enforce motion, or support a 

body segment. This is done by supporting, immobilizing, or treating muscles, 

joints, or skeletal parts that are weak, ineffective, deformed, or injured. A 

prosthetic device is an artificial device used to replace a missing body part. 

Both of these categories of AT devices are important tools in the reintegration of injured Veterans and Service Members into community life. These 

tools make it possible to perform activities of daily living (ADLs) essential to 

the emotional and physical well-being of the injured person, thus leading to 

greater independence and self-esteem. 

Ort h o t i cs

Orthotic devices are commonly divided into upper limb orthotic devices, 

lower limb orthotic devices, and spinal orthoses. 

• Upper limb orthotic devices include devices for the entire upper extremity 

and are used for many other conditions, including sports injuries, neurological conditions (eg, stroke and spinal cord injuries), and even burns. 

They are often known as splints or braces.

• Lower limb orthotic devices attach to the lower extremities to assist ambulation, transfers, and mobility. They range from simple arch supports 

bought from a local pharmacy to more complicated devices. 

• Spinal orthoses are used to stabilize and support the spine. A simple spinal orthotic is a soft collar given to patients after a whiplash injury. These 

devices are used for patient comfort, but sturdier examples are made to 

support a patient’s spine after injury or surgery. 

The rehabilitation team involved in the patient’s care—including the 

doctor, physical therapist (PT), and occupational therapist (OT)—decides if 
The Promi se of the Future H 53

a patient needs an orthotic device. More complicated devices usually require 

a prescription from the patient’s doctor. Often, a patient’s PT or OT can construct and fit these devices, particularly if they are made of softer materials. 

More complicated devices are usually constructed by orthotists. A certified orthotist has extensive training in the proper fit and fabrication of these devices, 

has undergone additional residency training, and has taken a national examination for certification supplied by the American Board for Certification in 

Orthotics, Prosthetics, & Pedorthics (Alexandria, VA; www.abcop.org).

In more recent years, prefabricated orthotic devices have become more 

common. These devices, made in various sizes, can be fitted to patients often 

with little or no adjustment. However, these are usually more appropriate for 

simpler issues and a more standard body size because custom orthotics are 

considered to have better fit and control.

Use of prefabricated components has also been beneficial to the development of next-generation orthotic devices on the other end of the spectrum. 

Dynamic exoskeletal orthoses serve the purpose of replacing lost muscle 

function. Their sophisticated actuator and control mechanisms exceed the capabilities of conventional passive devices, as the provided joint torques can be 

tailored exactly to the requirements in any given gait cycle phase. One prime 

example is the Intrepid Dynamic Exoskeleton Orthotic (IDEO), an energystoring ankle-foot orthosis that was developed at the Center for the Intrepid 

(CFI; San Antonio, TX), and has since been demonstrated to significantly 

improve rehabilitation outcomes in patients with high-energy lower extremity trauma.17 Powered exoskeleton technology continues to make advances as 

well, driven in large part by military research efforts. The main applications of 

this technology include the enhancement of physical performance of soldiers 

in the battlefield and the rehabilitation of patients after severe neuromuscular 

injuries. As we see breakthroughs in one area, the other area benefits as well.

Although the doctors, therapists, and other members of the rehabilitation 

team can answer any questions that patients may have about their orthotic 

devices, more information can be found at the American Board for Certification in Orthotics, Prosthetics, & Pedorthics and at the Orthotic and Prosthetic Activities Foundation (Charlotte, NC; www.opafonline.org).

Pr o st h et i cs

Because prosthetic devices can replace any missing body part, technically 

artificial eyes, implanted teeth, and even replacement heart valves can be 

considered prosthetic devices. However, for the purposes of this chapter, we 

will restrict our discussion to devices that replace missing limbs. With these 

exclusions, upper extremity prosthetic devices perform the functions of a 
54 H Pr o m o t i n g Su c cess f u l I n teg r at i o n

missing finger, hand, or arm. Lower extremity prosthetic devices perform the 

functions of a missing toe, foot, or leg.

The rehabilitation team involved in the patient’s care—including the 

doctor, PT, and OT—decides if a patient needs a prosthetic device. Prosthetic 

devices require a prescription from the patient’s doctor and are constructed by 

prosthetists. A prosthetist has extensive training in patient evaluation, prosthesis design, fabrication, fitting, and modification to treat limb loss for purposes of restoring physiological function and/or cosmetics. This professional 

has usually undergone additional residency training and has taken a national 

examination for certification given by the American Board for Certification in 

Orthotics, Prosthetics, & Pedorthics.

There are four major categories of upper extremity prosthetic devices: 

1. A passive upper limb prosthetic device is primarily cosmetic, but also 

functions as a brace for the task of the upper limb. It is sometimes used 

when the patient does not have enough strength to operate a device.

2. A body-powered prosthetic device uses the strength and range of motion 

of the remainder of the patient’s limb to control the prosthetic device. 

Body-powered systems are usually more durable and are usually able to 

bear more weight.

3. An externally powered system uses an outside power source (usually a 

battery) to move and control the prosthetic device. The patient controls 

the function through muscle contractions, thus inducing myoelectric 

signals that are registered by skin contact electrodes implemented in the 

socket. These devices are usually heavier and require more maintenance. 

4. A hybrid system is what its name implies; it uses both an outside power 

source and the patient’s own strength to operate the device. This is 

sometimes chosen to reduce the weight of the device. An example of this 

would be a body-powered shoulder accompanied with an externally 

powered elbow.

Common levels of upper extremity amputation include the following:

• partial hand (through the bones of the hand), 

• wrist disarticulation (through the wrist joint), 

• transradial (through the bones of the forearm), 

• elbow disarticulation (through the elbow joint), 

• transhumeral (through the bone of the upper arm), 

• shoulder disarticulation (through the shoulder joint), and 

• forequarter amputation (through the entire shoulder, including shoulder 

blade and collarbone). 
The Promi se of the Future H 55

With either extreme of amputation—partial hand amputation and forequarter amputation—prosthetic devices are rarely used. In the case of partial 

hand amputation, this is most often due to the patient’s ability to compensate 

for the missing part, as well as current limitations of the device (eg, lack of sensation). In the case of forequarter amputation, the device required is often too 

heavy, and there are limited options available for controlling it. In both cases, 

many patients are fitted with light, primarily cosmetic, prosthetic devices. 

Wrist disarticulation prosthetic devices are usually well tolerated by 

patients. They are fitted over the patient’s remaining forearm bones (radius 

and ulna) and are fairly functional because this level still permits full rotation 

(pronation and supination) of the wrist. At this amputation level, however, it 

is difficult to make the prosthetic limb the same length as the remaining limb 

on the opposite side (which patients often desire because of concerns about 

appearance). Thus, there is usually not a separate wrist joint provided in the 

prosthetic device. If there is a wrist joint, it is not externally powered because 

there is no extra room for a power supply. (Externally powered wrist joints 

are usually considered in the case of bilateral upper extremity amputees.) 

These wrist joints are usually manually manipulated by the patient with the 

opposing limb and are held in the desired place either by friction with a friction device wrist or by locking it into place with a locking device wrist. 

In terms of transradial amputation prosthetic devices, there are several 

common options for levels of amputation in the radius or forearm bone. In 

terms of functionality and the prosthetic device chosen, the “long” transradial 

amputations (distal third of the radius) are similar to wrist disarticulations, 

and the “short” transradial amputations (proximal third of the radius) are 

similar to elbow disarticulations. However, in most typical cases, the prosthetic device can be fitted over the radius and ulna and is therefore selfsuspending (not needing an outside harness or other device to keep the 

prosthetic device affixed, although there is usually a harness to control the 

terminal device). Common types of these self-suspending sockets are the 

Muenster socket and the split socket. These devices are usually well-tolerated 

by patients and are extremely functional. 

Elbow disarticulation prosthetic devices usually have excellent weightbearing capability and stability due to their support from the socket. 

Although the functionality of this level is excellent, cosmetic appearance is 

usually a problem because the artificial elbow is usually asymmetric to the 

other side. An artificial elbow joint, when present, is usually an externally 

locking elbow (which locks from the outside) because there is not enough 

space for an internally locking elbow.

Humeral amputation, in the same way as a transradial amputation, 

varies in functionality and in prosthetic choices depending on length. Very 
56 H Pr o m o t i n g Su c cess f u l I n teg r at i o n

long humeral amputations have many of the same benefits and disadvantages 

as elbow disarticulations. With amputation at this level, suspension is more 

challenging because the end of the humerus has been lost. Very short humeral 

amputations are challenging (although not impossible) to fit and control the 

device because of loss of strength and leverage. Often, a harness system must 

be implemented. Either externally locking or internally locking (locking from 

the inside) elbows can be used at this level.

Shoulder disarticulations have the most prosthetic device components of 

any commonly fitted amputation levels to replace all the joints below. Often a 

complete-enclosure socket, which encloses the limb to the chest, is used. Unfortunately, it is difficult to fit, and there may be issues with heat dissipation. 

Another option is a rigid X-frame shoulder socket that stays closely applied to 

the torso. It is usually lighter and cooler for the patient. 

Case Example: Leroy

The otherwise healthy patient lost his right hand due to a war injury in 

Afghanistan at age 28. As an accomplished and decorated soldier, his rehabilitation goal is to rejoin the military. Initial recovery at a US Army hospital in 

Germany included surgery and hospitalization for additional bullet wounds 

and fragment injuries suffered during combat. Early prosthesis fitting is further delayed by reamputation surgery to remove part of the wrist to allow the 

use of a prosthetic hand with wrist joint, a decision jointly made by the patient, his surgeon at Carl R. Darnall Army Medical Center (Fort Hood, TX), 

and his prosthetist. Leroy’s good overall physical constitution and determined 

mindset of an active soldier supports an ambitious approach to prosthetic 

rehabilitation. In addition to receiving a conventional body-powered hook 

prosthesis, the patient is deemed a candidate for an advanced myoelectric 

hand. Features of such devices now include individually movable fingers that 

conform to the shape of a grasped object; controllable speed and force of 

hand motion that allows proper grasping of objects of different weight and 

fragility; and performance of quick motions (eg, catching a ball in midair) and 

programmable moving and gripping patterns that mimic the human hand and 

that can be selected via the smartphone app. Leroy needs to learn and practice 

the control mechanism for a multitude of functions, which entails purposeful 

contractions of the remaining muscles in his arm to generate the signals that 

the hand’s microprocessor and electromotors translate into motion. Some 

of the control algorithms are intended to be intuitively accessible, for instance, by providing proportional response to the magnitude of contractions 

detected. Others require a retraining of the physiological muscle activation 

patterns; the signal for wrist rotation, for instance, may be a co-contraction 
The Promi se of the Future H 57

of hand flexors and extensors, something that most resembles the pattern for 

opening a fist. With diligent training, Leroy soon masters the operation of his 

new prosthetic hand and concludes his long road to rehabilitation about 10 

months after his initial injury. He reenlists and continues his Army career as a 

liaison officer, assisting injured Service Members and their families. 

As is the case in upper limb loss, the difficulty of prosthetic rehabilitation 

increases steeply with the level of amputation of the lower limb. The further 

proximal an amputation is performed, the greater the loss of functional joints 

and muscles, and the smaller the residual limb structure needed for suspension and control of the prosthetic device. Although limb prostheses may be 

abandoned because patients consider them either unnecessary or impractical, 

such occurrences are much less common in lower limb prosthetics than upper 

limb prosthetics. In most cases, the decision not to use a prosthesis requires a 

person with lower limb loss to resort to bilateral crutches or wheeled mobility 

for ambulation, both of which are often more debilitating than even a poorly 

functioning artificial leg.

There are several different types of artificial foot/ankle systems:

• A solid-ankle, cushion-heel (SACH) foot is a solid foot without articulations. The cushion in the heel of this artificial foot, when loaded by a 

patient’s weight, imitates the normal plantarflexion (movement of the 

foot that flexes the foot or toes downward toward the sole) of the human 

foot, but does not allow any motion in any other direction. 

• A single-axis foot is an artificial foot with an axis that allows for both 

plantarflexion and dorsiflexion (movement of the foot that extends the 

foot upward), but no motion in any other direction. 

• A multiaxis foot has motion in several planes, like a normal human foot. 

• A dynamic response foot acts similarly to a spring, as weight-bearing 

loads it to return energy back to the user.

• A hydraulic ankle provides adjustable resistance to dorsi- and plantarflexion, allowing seamless adaptation to sloped walking surfaces.

• A microprocessor-controlled ankle offers similar functionality as modern 

hydraulic ankles in addition to active regulation of the ankle angle that 

increases ground clearance in the swing phase and helps with activities 

such as stair climbing.

• A powered ankle replaces the lost function of the foot plantar flexors. 

Unlike any of the aforementioned systems, such a device provides active 

push-off force at every step and thus helps reduce asymmetry and metabolic cost of prosthesis gait.
58 H Pr o m o t i n g Su c cess f u l I n teg r at i o n

• Sprint feet and other sport-specific designs are dedicated to facilitating 

athletic activity. They are generally not very versatile, but can help 

approximate able-bodied performance in narrowly defined athletic 

disciplines.

Likewise, there are also several types of prosthetic knees in lower 

extremity devices:

• An outside (single-pivot) hinge is an artificial knee joint with one direction of motion applied to the outside of the prosthetic device. 

• A single-axis artificial knee joint has only one direction of motion 

(motion type), and is controlled by alignment and voluntary control. 

• A polycentric joint has more than one axis of rotation. This has the 

advantage that the instantaneous center of rotation can be outside the 

geometry of the device, which helps increase buckling resistance and/or 

proper knee axis alignment in long residuals.

• A weight-activated stance has a friction braking system, preventing 

further knee-bending when weight is applied. A manual-locking joint 

has a manual switch release for flexion. 

• A hydraulic knee unit allows the accurate adjustment of flexion and 

extension resistances over a wide spectrum, thus providing efficient swing 

phase control for walking at higher speeds, as well as dynamic stance 

phase control that enables controlled knee flexion under weight to prevent or mitigate accidental falls.

• A microprocessor knee has a microprocessor that adjusts friction in the 

artificial joint in response to the speed of walking. In combination with 

a hydraulic unit, the processor substantially increases fall safety by 

employing sophisticated stance phase activation roles.

• A powered knee is equipped with a large battery and actuator to replace 

the quadriceps muscle in providing active knee extension. Because prosthesis knee extension during gait is generally achievable by hip motion 

and gravity, powered knees are usually indicated for moderate activity 

patients who cannot generate a hip movement.

There are many common types of lower extremity amputation, each with its 

own considerations for appropriate prosthetics: 

• A partial foot can be an amputation removing as little as a toe. Solutions 

for the missing part of the foot can be as simple as a custom foot orthotic 

device with toe filler. For higher foot amputation levels, an orthopedic 
The Promi se of the Future H 59

shoe with a wide toe box is required. Sometimes a steel shank is built 

into such shoes for further support or a rocker-bottom sole (a sole with a 

rounded bottom) is added to unload the residual foot. Additionally, with 

some amputations, an ankle-foot orthosis is needed to help with functional length. 

• A Symes amputation level is an ankle disarticulation with the fat pad 

of the heel attached. Usually, this level of amputation allows for some 

weight-bearing on a long residual limb without a prosthetic device. 

Challenges arise from prosthetic fitting, primarily with encompassing the 

wide bulbous shape of the residual limb and making the prosthetic device 

equal in length to the opposite foot (usually a SACH foot is chosen for 

these patients). 

• Transtibial amputation is through the lower leg below the knee, and very 

often has a successful fitting and functional outcome. There is no need for 

knee joint components, and patients have many choices for componentry, 

unlike Symes or knee disarticulation levels. 

• A knee disarticulation creates an excellent weight-bearing surface on the 

end of the femur (upper leg bone). A prosthetic device may cause the two 

knees to be unequal, which often causes issues when the patient attempts 

to kneel or sit in close contact. This also causes some limitation in artificial knee choices. 

• A transfemoral amputation often has excellent results, despite the fact 

that there are additional components at this higher amputation level. 

Very long transfemoral amputations are fitted similarly to knee disarticulations, and very short transfemoral amputations are more challenging 

because they are more similar to hip disarticulations in functionality. 

• Hip disarticulation removes the entire femur, but leaves the pelvis intact 

and is often difficult to fit. Many components in the prosthetic device 

increase the weight of the device. Socket design often requires that the 

socket wraps entirely around the pelvis so that the belt system is commonly used for suspension. Often, the prosthetic device must be shorter 

than the remaining limb to assist with clearance, and to prevent knee 

buckling and falling. 

• A hemipelvectomy is a resection of the lower half of the pelvis. Results 

vary, depending on how much bone is removed postamputation, which 

can range from limited removal to removal of most of the hip bone. If 

much of the pelvis is intact, the fitting principles are similar to that of 

hip disarticulation. If very little pelvic bone remains, socket design will 

depend on the patient’s individual anatomical limitations. 
60 H Pr o m o t i n g Su c cess f u l I n teg r at i o n

• A hemicorporectomy is the amputation of both lower limbs and pelvis 

below the L4 and L5 levels. These patients usually do not use ambulation 

as a primary form of mobility; however, they may be fitted with a socket 

to assist in wheelchair sitting and prevent development of skin ulceration. 

Some individuals may also be able to ambulate short distances with a 

walker. These patients may be fitted with devices with manual-locking 

knees for maximum stability.

A key element of any limb prosthesis is the socket that encapsulates the 

residual limb and provides weight transfer, suspension, and control without 

reducing patient comfort or joint range of motion. Those sockets are custom 

fitted in a multistep process involving various check sockets and optimization 

sessions with a prosthetist. To reconcile such diverging objectives as tight fit 

and comfort, various suspension systems have been developed, using the basic 

function principles of hydrostatic pressure, vacuum, and material compliance. 

Many modern prosthesis sockets have a layered design where the inner layer, 

or “liner,” is made of comparably soft material (eg, silicon or polyurethane 

gel) that provides comfortable, full-surface contact and the outer layer (often 

a carbon fiber laminate) is rigid enough for stability and protection. The liner 

and outer socket are donned in sequence and connected through a locking 

mechanism or, increasingly in recent years, by means of an elevated vacuum 

maintained by a battery-powered pump. Specific considerations affect the 

design of sockets for particular amputation levels, depending on the available 

pressure-tolerant areas of the residual limb and the required range of motion 

of the adjacent joint.

Case Example: Mike

Injured at age 38 from a bomb blast while serving in Afghanistan, Mike is left 

with a below-knee amputation of his right leg and debilitating burst fractures 

in his left foot that have an increasingly poor healing prognosis. His rehabilitation goal is to become an independent community ambulatory who can 

play with his young children and engage in outdoor activities, such as hunting 

and fishing. After 2 years of healing complications in his remaining leg, he is 

faced with a decision: continue his rehabilitation efforts with the damaged 

left leg or opt for another amputation and bilateral prostheses. After intensive 

consultations with his family and rehabilitation team at Brooke Army Medical Center (San Antonio, TX), which includes a thorough study of prosthetics options, he decides for optional amputation surgery. Recovery after this 

planned procedure progresses quickly, and an early postoperative prosthesis is 

fitted within days of the amputation. Those prostheses are designed to easily 
The Promi se of the Future H 61

accommodate the changes in volume and the load-bearing capacity of the residual limb that are typical in the aftermath of a surgical procedure. A compliant foot is prescribed initially to help Mike balance on his two prosthetic legs. 

Later, the feet on both legs will be replaced with stiffer carbon fiber models 

that provide the necessary resistance and energy storage to walk briskly, but 

require more active balancing because they have a smaller area of contact 

with the floor. Definitive prostheses are built once the residual limb has 

stabilized and matured after about 6 months. Mike is aware that walking on 

two prostheses demands much more energy than able-bodied walking, but he 

is reluctant to switch to powered foot ankle systems that could help mitigate 

this drawback.18 The feet’s added weight, necessity to frequently charge batteries, and comparably high sensitivity to moisture and extreme temperatures 

appear incompatible with his desired active lifestyle.

For any amputation level, without exception, the patient should undergo preprosthetic training and then extensive training with PT and OT to 

effectively use the prosthetic device. Optimizing the rehabilitation regimen 

has been the topic of research efforts for many years. The US Military has 

assumed a leading role in this realm, establishing dedicated facilities where 

interdisciplinary teams of rehabilitation specialists utilize the latest technology to enable the best possible outcomes for wounded Service Members and 

Veterans. The CFI, located at Brooke Army Medical Center (San Antonio, 

TX), provides state-of-the-art amputee care through an in-house prosthetics laboratory, physical and occupational therapy facilities, and a number of 

military-specific training devices. Among the equipment is a virtual reality 

training system known as the Computer Assisted Rehabilitation Environment 

(CAREN). An elevated platform holding a split-belt treadmill can be tilted 

and rotated by means of a large hydraulic system to simulate a variety of 

natural surface conditions. It is surrounded by a dome-like projection screen 

in which computer-generated environments are displayed to provide the perfect illusion of any real-life scenario the rehabilitation patient may encounter, 

including combat and other military missions. The site’s personnel and equipment resources combine with the willpower and resilience of the patients to 

regularly achieve rehabilitation outcomes that would have been impossible 

just years ago.

Although the doctor, therapists, and other members of the rehabilitation 

team can answer any questions that patients may have about their prosthetic 

devices, more information can be found at the same Web sites listed in the 

section on orthotics. For more information on amputation and prosthetics, 

see www.amputee-online.com and www.amputee-coalition.org.
62 H Pr o m o t i n g Su c cess f u l I n teg r at i o n

THREE-DIMENSIONAL PRINTING

One of the newest tools that AT professionals have in their arsenal of equipment is three-dimensional (3D) printing. 3D printers take materials such as 

plastic or metal—which usually come in resin, wire, or powder form—and 

melt them into computer-designed physical objects layer by layer. The printed 

object is very light and very strong, which makes it ideal to use for AT devices 

of all kinds.

Case Example: Bill

Bill is a Veteran in his late 50s who worked as a programmer for the 

Department of Defense. One day, on his way to work, he was involved in a 

car accident that left him with a spinal cord injury. He now functions as a 

person with a C4-level tetraplegic injury, unable to move anything below his 

neck. Bill came to the AT Center at the Hunter Holmes McGuire Veterans 

Administration Medical Center in Richmond, Virginia, to receive a full AT 

evaluation. He very much wanted to get back to his work as a programmer, 

if at all possible. The AT treatment team included an OT and a rehabilitation engineer. Bill was seen by the AT team almost every day during his stay 

at McGuire. One of the cutting-edge tools that the AT team had at their 

disposal was a 3D printer that created parts designed on a computer out of 

tough, nontoxic ABS (acrylonitrile butadiene styrene) plastic (the same plastic 

LEGOs [Billund, Denmark] are made from). The following examples show 

several instances during the AT service delivery process for Bill wherein the 

rehabilitation engineer decided to use 3D printing to create custom parts that 

would have been cost- or time-prohibitive in any other way. 

Bill’s new shower wheelchair did not allow for armrest height adjustment. Because Bill was having problems with very tight shoulder and neck 

muscles, which were causing him a lot of pain, the OT wanted Bill’s arms 

raised 2 inches to alleviate excessive downward pull on his shoulders. 

Requesting custom-height armrests from the vendor would have been the 

best option, but there was not enough time for a custom order, so the team 

decided to fabricate a spacer that would raise his armrests. Because the spacer 

had to be waterproof, the materials of choice were aluminum or plastic. The 

quickest and best-looking solution was to design a custom spacer that was 

3D-printed in plastic. The rehabilitation engineer designed a 3D computer 

model of the spacer based on measurements from the shower wheelchair and 

printed the spacer on the 3D printer. Once the spacer was installed on one 

side of the shower wheelchair to confirm that it fit, the other side was 3Dprinted and installed. Bill was then able to practice bathing with his modified 

shower wheelchair before leaving the hospital.
The Promi se of the Future H 63

Bill came to the computer access evaluation with an iPhone and an iPad. 

The iPhone could use Siri for voice control, but the iPad was not new enough. 

At a previous hospital, Bill had started using a mouthstick to control the iPad, 

so this was where the AT team started. The iPhone and iPad were mounted to 

his Permobil M400 Corpus 3G Power Wheelchair (Lebanon, TN) with pieces 

from the reconfigurable REHAdapt Mounting System (REHAdapt North 

America, St Augustine, FL; http://www.rehadapt.com/). The devices were 

positioned so that Bill could reach them with his mouthstick; however, his 

mouthstick had no holder. The OT fashioned a holder out of a foam tube and 

attempted to tape it to the iPad mount, but this did not hold the mouthstick 

reliably. So, before the next day’s appointment, the rehabilitation engineer 

took the OT’s foam holder design and 3D-printed a copy of it, but added 

an extra part so the holder would be able to interface with the REHAdapt 

Mounting System to keep it firmly in place. As before, 3D printing was chosen for this situation because it was the quickest option to provide a custom 

part for evaluation. Bill tried the mouthstick with the holder for a couple of 

days and eventually decided to explore other options because the required 

neck movements proved too painful to reliably access his devices. 

At the conclusion of the computer access evaluation, Bill decided that his 

preferred option was to use Bluetooth switches to control his iPad and computer. These Bluetooth switches were controlled via his wheelchair’s output 

modules that were controlled by Bill’s Sip and Puff commands. The plan was 

to use two switches for scanning in iOS 7 on his iPad and two switches for 

left/right clicking on his desktop PC. Mouse cursor control was provided by 

a head tracking device mounted on his large screen monitor. To install the 

two Bluetooth modules and add a power supply, the rehabilitation engineer 

decided that an easily accessible enclosure was needed. The Bluetooth modules needed to be accessible because Bill’s caregiver would need to pair the 

Bluetooth module to his desktop PC at home. 3D printing was chosen as the 

way to make a custom enclosure because no other option could provide the 

high level of finished quality with customization and speed. The rehabilitation 

engineer designed and 3D-printed a custom enclosure with a magnetic latching lid to hold the Bluetooth modules and their associated wiring. The power 

supply for the modules was mounted under the wheelchair seat, and all the 

wiring was neatly secured to limit any possibilities of wires being pulled.

After leaving McGuire, Bill has continued becoming more proficient at 

using the Sip and Puff control on his wheelchair to control his iPad and desktop computer at home. He is currently going through the process of acquiring 

an adapted van so that he can drive himself to work. Once Bill has reliable 

transportation in place, he hopes that, in the near future, he will be able to 

continue working in a similar capacity at his former job. 
64 H Pr o m o t i n g Su c cess f u l I n teg r at i o n

EMERGING TECHNOLOGIES

As technologies continue to evolve, researchers seek assistive solutions not 

only for moving from point A to point B, but also for assisting in the performance of ADLs. This includes using intelligent coaching to aid with daily 

routines or wheelchair 

usage, mobility enhancement that can 

overcome difficult 

environments, and 

robotic manipulation 

for moving objects 

and housework. These 

new technologies are in 

position to be commercialized now or within 

the next few years, and 

each could have major 

transformative effects 

on the lives of injured 

Service Members and 

Veterans. 

I n tel l i ge n t

C o a c h i n g

Intelligent coaching 

helps users in two ways: 

(1) by providing appropriate suggestions or 

instructions based on contextual awareness and (2) by educating users within 

their daily activities. Two examples are (1) the Virtual Seating Coach (VSC) 

and (2) the Cueing Kitchen. The VSC (Permobil, Inc, Lebanon, TN) gives 

power wheelchair users guidance in using their seating functions effectively 

during the day, even when they are driving. The Cueing Kitchen coaches 

individuals with traumatic brain injury in completing everyday kitchen tasks 

(Figure 3-1).

Virtual Seating Coach and Phone App

The VSC19,20 provides an intelligent, tailored reminder that helps to educate 

power wheelchair users about appropriate power seating function (PSF) 

Fi g u re 3-1. Virtual Seating Coach, tablet version 

and smartphone version.
The Promi se of the Future H 65

usage to meet their pressure-relieving needs. It contains sensors to monitor the 

current PSF angles and environmental situations. Unlike a regular reminder, 

the VSC can modify its messages according to context awareness and give 

instructions based on PSF usage (Figure 3-2). For example, if the VSC user is 

resting on a slope, the VSC guides the user to adjust the PSF step by step to 

a safer sitting posture and reminds the user to wait to perform pressure relief 

until the chair is resting on a flat surface. 

As shown in Figure 3-2, the VSC smartphone version20,21 is a phone 

cradle attached to the armrest. It uses a built-in gyro sensor and additional 

accelerometers to detect the PSF. An Android application (see Figure 3-2) was 

developed to detect and record PSF usages. This app also includes instructions for PSF and wheelchair usage. Clinicians may modify the reminder and 

warning configurations remotely to meet each user’s needs. This intelligent 

coaching system expands personal care and training into each individual’s 

daily living situations.

Cueing Kitchen

The Cueing Kitchen22 (Figures 3-3 to 3-5), developed by the Human Engineering Research Laboratories at the University of Pittsburgh, is an intelligent 

coaching system built within a kitchen to assist with independent meal preparation for people with difficulties in attention, cognition, memory, and executive functions. The Cueing Kitchen contains an integrated centralized control 

network with various types of built-in sensors and prompting components. 

The Cueing Kitchen can

• guide the user through steps to prepare a recipe, 

• direct the user to find the ingredients’ location, 

Fi g u re 3-2. Snapshot of the application on the Virtual Seating Coach 

smartphone version. PHOTOGRAPH: COURTESY OF THE HUMAN ENGINEERING RESEARCH LABORATORIES,

UNIVERSITY OF PITTSBURGH.
66 H Pr o m o t i n g Su c cess f u l I n teg r at i o n

• protect the user from unsafe appliance use, and eventually 

• enable the user to prepare a meal independently. 

Mo b i l i t y E n h a n ceme n t

Wheelchairs increase mobility functions in users who have ambulatory difficulties. However, there are still architectural barriers in users’ homes and 

[t o p ] Fi g u re 3-3. The 

Cueing Kitchen is a basic residential kitchen cabinet layout 

with major appliances. This 

layout is modified with lowcost and adaptable portable 

or wireless sensing and cueing 

technologies that work with 

any modern kitchen design.

PHOTOGRAPH: COURTESY OF THE 

HUMAN ENGINEERING RESEARCH LABORATORIES, UNIVERSITY OF PITTSBURGH.

[m i d d le] Fi g u re 3-4.

The Cueing Kitchen is able to 

prompt individuals through 

multistep tasks in a timely and 

systematic manner. PHOTOGRAPH: 

COURTESY OF THE HUMAN ENGINEERING RESEARCH LABORATORIES, 

UNIVERSITY OF PITTSBURGH.

[b o t t o m] Fi g u re 3-5.

Interactive Island set up: 

Touch Interactor (area where 

pasta box is positioned), 

Count Interactor (area 

where salt and pepper are 

positioned), and Coverage 

Interactor (area where apples 

are positioned). PHOTOGRAPH: 

COURTESY OF THE HUMAN ENGINEERING RESEARCH LABORATORIES, 

UNIVERSITY OF PITTSBURGH.
The Promi se of the Future H 67

environments. These 

physical environmental 

barriers—such as curbs, 

stairs, or doorsteps—may 

hinder electrical powered 

wheelchair (EPW) users 

from visiting friends and 

family or performing 

daily activities. Mobility 

enhancement is focused 

on reducing these barriers by creating wheelchairs that can overcome 

difficult terrains. The 

TopChair-S (TopChair 

SAS, Montrabé, France) 

is a commercialized EPW 

that includes an additional 

track system, and the MeBot (Mobility Enhancement Robotic Wheelchair; 

Human Engineering Research Laboratories, University of Pittsburgh) is a 

wheelchair that has six independently moving wheels. Both of these have been 

developed to assist EPW users with traversing architectural barriers within 

their living environments.

TopChair-S

The TopChair-S is a power wheelchair available in the European market, 

designed for indoor and outdoor use. Invented by French scientist Hervé 

le Masne, the TopChair-S is designed for complete patient autonomy and 

includes the ability to climb stairs and curbs. The rear wheel–driven chair 

contains four wheels and a caterpillar track. The two rear wheels are powered 

and are used to move on flat terrain. The two tracks are for maneuvering 

around obstacles. There are sensors that detect the first and last step of a set 

of stairs, which then automatically adjusts the speed and maneuverability of 

the wheelchair. 

The TopChair-S has two driving configurations: (1) regular wheelchair 

mode and (2) climbing mode. Although it is used in the climbing function, 

the four wheels are lifted above the caterpillar track. This chair is capable 

of climbing obstacles up to 8 inches. The required width for the TopChair-S 

Fi g u re 3-6. The MeBot (Mobility Enhancement 

Robotic Wheelchair) is a wheelchair that climbs stairs 

and traverses difficult environments. PHOTOGRAPH: 

COURTESY OF THE HUMAN ENGINEERING RESEARCH LABORATORIES, 

UNIVERSITY OF PITTSBURGH.
68 H Pr o m o t i n g Su c cess f u l I n teg r at i o n

to climb up and down stairs is at least 29.5 inches wide, but preferably 31.5 

inches wide. The landing area must be at least 45.3 inches in length. The seat 

is secured in the horizontal position by an electromechanical actuator while 

climbing the slope of the terrain.23

MeBot

The MeBot mobile base uses a six-wheel design, similar to many current 

EPWs (Figure 3-6). The MeBot’s dimensions were designed to be similar 

to those of a standard powered wheelchair, taking the ISO (International 

Organization for Standardization)/RESNA standard into consideration. It is 

designed to climb steps and drive over challenging surfaces (eg, cross slopes 

and steep hills); study of the kinematic simulation has shown that the MeBot 

could successfully climb up an 8-inch curb. In addition, the MeBot can also 

perform lateral pressure relief and maintain a level seat under uneven surfaces 

and cross slopes.24,25

R o b o t i c Ma n i p u l at i o n

As reported in the consensus report Americans with Disabilities: 2010,

26

about 20 million people (8.2%) in the United States have difficulties with 

tasks using their upper extremities (eg, lifting or grasping). In addition, among 

the elderly population 65 years or older, the proportion is much higher: 

23.8%. Two commercialized assistive robotic arms—(1) iARM (intelligent 

Assistive Robotic Manipulator; Exact Dynamics, Didam, The Netherlands) 

and (2) the JACO Robotic Manipulator (Kinova, Boisbriand, Canada)—can 

be mounted on a wheelchair to assist wheelchair users in lifting and grasping 

during ADLs27; they can also be mounted on a stationary base. The KitchenBot28 (Human Engineering Research Laboratories, University of Pittsburgh) 

is an assistive manipulator that is mounted on an overhead track to help 

individuals with upper extremity impairments perform kitchen tasks. The Personal Mobility and Manipulation Appliance (PerMMA; Human Engineering 

Research Laboratories, University of Pittsburgh) integrates bimanual manipulation with a standard EPW to enhance the quality of life for people with 

severe physical impairments.26,27–31 Finally, the IMES (implantable myoelectric 

sensor) robotic arm is operated directly by a user via electromagnetic implants 

and muscle twitches.

The iARM and the JACO Robotic Manipulator

The iARM (intelligent Assistive Robotic Manipulator) and the JACO Robotic 

Manipulator, two commercialized assistive robotic manipulators, are available 

in the United States. Both mimic the range of motion of human arms and have 
The Promi se of the Future H 69

minimized fold-in positions that retract the manipulator when not in use.32

The iARM (Figure 3-7)

• is a six degrees-of-freedom robotic arm with two-fingered hands;

• is an upgraded version of the Manus ARM (Exact Dynamics, Didam, 

The Netherlands);

• is lighter than the Manus ARM, mainly because of the removal of gravity 

compensation springs; and 

• can be controlled via keypad, joystick, single-button switches, or Android 

app (iMove) through Bluetooth communication.33

Fi g u re 3-7. iARM is a commercialized 

wheelchair-mounted robotic manipulator with a two-fingered grip. It can be 

controlled by keypad, joystick, or singlebutton switches. PHOTOGRAPH: COURTESY OF 

THE HUMAN ENGINEERING RESEARCH LABORATORIES, 

UNIVERSITY OF PITTSBURGH.

Fi g u re 3-9. The KitchenBot 

is an overhead, track-mounted 

manipulator designed to aid individuals with physical impairments 

complete common kitchen tasks 

(eg, meal preparation, cleanup, 

etc). PHOTOGRAPH: COURTESY OF 

THE HUMAN ENGINEERING RESEARCH 

LABORATORIES, UNIVERSITY OF PITTSBURGH.

Fi g u re 3-8. The JACO manipulator 

is a wheelchair-mounted robotic 

manipulator. It has a three-fingered 

hand that can group objects using 

either two or three fingers. PHOTOGRAPH: 

COURTESY OF THE HUMAN ENGINEERING RESEARCH 

LABORATORIES, UNIVERSITY OF PITTSBURGH.
70 H Pr o m o t i n g Su c cess f u l I n teg r at i o n

The JACO Robotic Manipulator (Figure 3-8)

• is a wheelchair-mounted robotic manipulator,

• is also composed of six interlinked segments with a three-fingered hand, 

• is controlled by a three degrees-of-freedom proportional joystick, and 

• has additional control interfaces (eg, single-button switches) that can be 

connected through a universal interface box.34,35 

Ki t c h e n B o t

The KitchenBot (Figure 3-9), developed by the Human Engineering Research 

Laboratories at the University of Pittsburgh, is an overhead, track-mounted 

manipulator designed to aid individuals with upper extremity impairments 

with common kitchen tasks (eg, meal preparation and cleanup). It can be 

integrated into the individual’s kitchen for those who require the next level of 

assistance beyond a caregiver. The initial prototype design is transferable for 

use in residential homes with standard building materials. Additionally, the 

low-profile track requires little space above cabinets for installation consistent 

with typical residential kitchens.28 

PerMMA

Personal Mobility and Manipulation Appliance (PerMMA) is the first wheelchair to integrate bimanual manipulation for enhancing the quality of life for 

people with severe physical impairments (Figure 3-10). PerMMA integrates 

both a smart-powered wheelchair and two dexterous robotic arms to assist 

its users in completing essential mobility and manipulation tasks during basic 

and instrumental ADLs.31

PerMMA aims to improve functional performance and independence 

with three integrated user interfaces: 

1. Local control interface—the local user has full control of PerMMA; the 

user can move both robotic manipulators along the track using a track 

control box and operate them with a touch pad.

2. Remote control interface—the remote operator can conduct both robotic 

manipulators using either the haptic joysticks or the keyboard. 

3. Cooperative control interface—the local user and a remote operator 

work together to complete mobility and manipulation tasks. 

PerMMA was evaluated with end users in completing basic ADL tasks. 

Fifteen participants with both lower and upper extremity impairments were 

recruited to operate PerMMA and complete ADL tasks. Thirteen participants 
The Promi se of the Future H 71

successfully completed 

at least one task with 

both modes. Results of 

a questionnaire showed 

that the majority of the 

participants thought that 

PerMMA was easy to 

learn and easy to use. 

Participants also thought 

that PerMMA would 

make their lives easier 

and using PerMMA in 

their daily lives would 

not be embarrassing or 

cause any invasion of their 

privacy.25,29–31

Targeted Muscle 

Reinnervation

Targeted muscle reinnervation (TMR) is a 

promising approach to 

the problem of obtaining 

the multiple myoelectric 

signals that are required 

for operation of advanced upper limb prostheses.36 The issue is pronounced in 

people with an amputation at the shoulder level or higher; multiple prosthetic 

joints need to be controlled with very limited remaining muscles. TMR entails 

the deliberate surgical implantation of nerve endings that were made obsolete 

by the amputation into existing muscle tissue, which is commonly the pectoralis. The reimplanted nerves enable distinct contractions of small segments 

of this muscle, which generates a multitude of separate myoelectric signals 

that can be recorded with conventional skin electrodes. By using the nerves to 

control prosthesis motions that resemble the motions caused by their respective originally innervated muscles, the system is very intuitive to use.

Osteointegration

Various complications may arise from prolonged use of prosthetic sockets, 

including skin damage, restricted blood circulation, joint contractures, muscle 

atrophy, and bone degeneration. A possible approach to attaching a prostheFi g u re 3-10. PerMMA is a fully robotic mobility 

and manipulation device for people with disabilities. 

It is designed to accommodate a wide variety of custom and off-the-shelf interfaces. PHOTOGRAPH: COURTESY 

OF THE HUMAN ENGINEERING RESEARCH LABORATORIES, UNIVERSITY 

OF PITTSBURGH.
72 H Pr o m o t i n g Su c cess f u l I n teg r at i o n

sis to the limb without a socket was derived from dental medicine. Osteointegration entails the implantation of a metal anchor in the cut end of the 

residual bone.37 Part of this anchor protrudes through the skin and provides 

an attachment point for the more distal components of a prosthesis. The system has been tested with some success in Europe and has recently been FDA 

(US Food and Drug Administration)-approved for clinical trials in the United 

States. It is widely assumed that its indication will be limited by the specific 

requirements on density and length of the available residual bone and the 

meticulous hygiene regimen needed to prevent infections at the continuously 

damaged skin around the metal anchor.

Implantable Myoelectric Sensor Robotic Arm

The implantable myoelectric sensor (IMES) robotic arm is the most advanced 

technology ready for clinical use. To make learning the new techniques of this 

prosthesis easier, the patient activates the robotic hand with muscle twitches. 

This arm uses magnetic field lines to operate, and the coils of wire wrapped 

in a solenoid loop that are encased inside a carbon-fiber shell conduct the 

electric muscle signals from the implants to the mechanical hand to induce 

movement. A magnetic field is generated from electromagnetic implants in 

the patient’s limb. These implants are surgically put in the muscles in specific 

places, depending on which muscle movements coordinate to which hand 

movements. The implants pick up the electric pulses from the muscles and 

carry that to the prosthesis. The prosthesis also has a battery box that attaches to the outside. Because regular muscle movements to move a real hand also 

move a prosthetic hand, it is also easier to learn how adapt to the prosthesis. 

SUMMARY

Assistive technology encompasses a wide variety of tools that can give Veterans and Service Members with disabilities the ability to participate fully in 

life. Because each individual will have differing degrees and types of disability, 

it is important for Veterans and Service Members and their families to consult 

with qualified assistive technology professionals to help them select and use 

the technologies that will best help them reintegrate into the community.
The Promi se of the Future H 73

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3. Cooper RA, Pasquina P, Drach R, eds. Warrior Transition Leader: Medical Rehabilitation Handbook. Fort Detrick, MD: Borden Institute; 2011.

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6. Martinez-Mareno JM, Solana J, Sánchez R, et al. Cognitive neurorehabilitation based on interactive video technology. Stud Health Technol Inform.

2013;190:27–29. 

7. Maiti S, Kumar KHBG, Castellani CA, O’Reilly R, Singh SM. Ontogenetic 

de novo copy number variations (CNVs) as a source of genetic individuality: studies on two families with MZD twins for schizophrenia. PLoS ONE.

2011;6(3):e17125. 

8. Scherer MJ. Assessing the benefits of using assistive technologies and other supports for thinking, remembering and learning. Disabil Rehabil. 2005;27(13):

731–739.

9. Georgia Technical University. App finder. http://www.gatfl.org/favorite-search.

php. Accessed September 14, 2015.

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faculty/strategies/hearing-loss.html. Accessed September 14, 2015.

11. National Association for the Deaf. Communication access realtime translation. 

http://www.nad.org/issues/technology/captioning/cart. Accessed September 14, 

2015.

12. Eghdam A, Scholl J, Bartfai A, Koch S. Information and communication technology to support self-management of patients with mild acquired cognitive impairments: systematic review. J Med Internet Res 2012;14(6):e159. 

13. Jamieson M, Cullen B, McGee-Lennon M, Brewster S, Evans JJ. The efficacy of 

cognitive prosthetic technology for people with memory impairments: a systematic review and meta-analysis. Neuropsychol Rehabil. 2014;24(3–4):419–444. 

14. De Joode EA, Van Heugten CM, Verhey FR, Van Boxtel MP. Effectiveness of 

an electronic cognitive aid in patients with acquired brain injury: a multicentre 

randomised parallel-group study. Neuropsychol Rehabil. 2013;23(1):133–156. 

 15. Seelye AM, Schmitter-Edgecombe M, Das B, Cook DJ. Application of cognitive 

rehabilitation theory to the development of smart prompting technologies. 

IEEE Rev Biomed Eng. 2012;5:29–44.

16. Wisconsin Assistive Technology Initiative. The WATI Assessment Package. 

http://wati.org/content/supports/free/pdf/WATI%20Assessment.pdf. Accessed 

October 12, 2013. 
74 H Pr o m o t i n g Su c cess f u l I n teg r at i o n

17. Patzkowski JC, Blanck RV, Owens JG, et al. Comparative effect of orthosis 

design on functional performance. J Bone Joint Surg. 2012;94:507–515.

 18. Wright DA, Marks L, Payne RC. A comparative study of the physiological costs 

of walking in ten bilateral amputees. Prosthet Orthot Int. 2008;32:57–67.

19. Liu HY, Cooper R, Cooper RA, et al. Seating virtual coach: a smart reminder 

for power seat function usage. Technol. Disabil. (Special Issue on Quality of Life 

Technology). 2010;22(1–2):53–60. 

20. Wu Y, Liu H, Brown J, Kelleher A, Cooper RA. A smartphone application for 

improving powered seat functions usage: a preliminary test. In: Proceedings of 

the RESNA Annual Conference 2013; Alexandria, VA: Rehabilitation Engineering and Assistive Technology Society of North America; 2013:2–5.

21. Wu Y. Call up a seat. PN. 2013;8:30–32.

22. Mahajan HP, Ding D, Wang J, Ni SX, Telson J. Toward developing a “cueing 

kitchen” for people with traumatic brain injury. In: Proceedings of the RESNA 

Annual Conference 2013; Alexandria, VA: Rehabilitation Engineering and Assistive Technology Society of North America; 2013. 

23. Laffont I, Guillon B, Fermanian C, et al. Evaluation of a stair-climbing 

power wheelchair in 25 people with tetraplegia. Arch Phys Med Rehabil.

2008;89(10):1958–1964. 

24. Candiotti J, Wang H, Chung CS, Shino M, Cooper RA. Design and development 

of a step climbing sequence for a novel electric powered wheelchair. In: Proceedings of the RESNA Annual Conference 2012; Alexandria, VA: Rehabilitation 

Engineering and Assistive Technology Society of North America; 2012.

25. Wang H, Grindle GG, Candiotti J, et al. The Personal Mobility and Manipulation Appliance (PerMMA): a robotic wheelchair with advanced mobility and 

manipulation. Conf Proc IEEE Eng Med Biol Soc. 2012;2012:3324–3327.

26. Brault MW. Americans with disabilities: 2010. Household economic studies. 

Curr Pop Rep. 2012:70–131.

27. Chung CS, Wang H, Cooper RA. Functional assessment and performance evaluation for assistive robotic manipulators: literature review. J Spinal Cord Med. 

2013;36(4):273–289.

28. Telson J, Ding D, McCartney M, Cooper RA. Preliminary design of an overhead 

kitchen robot appliance. In: Proceedings of the RESNA Annual Conference 

2013; Alexandria, VA: Rehabilitation Engineering and Assistive Technology 

Society of North America; 2013. 

29. Wang H, Xu J, Grindle G, et al. Performance evaluation of the Personal Mobility 

and Manipulation Appliance (PerMMA). Med Eng Phys. 2013;35(11):1613–

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30. Xu J, Grindle GG, Salatin B, Vazquez JJ, Cooper RA. Enhanced bimanual 

manipulation assistance with the Personal Mobility and Manipulation Appliance 

(PerMMA). In: 2010 IEEE/RSJ International Conference on Intelligent Robots 

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Robotics Society of Japan; 2010:5042–5047.
The Promi se of the Future H 75

31. Cooper RA, Grindle GG, Vazquez J, et al. Personal Mobility and Manipulation Appliance—design, development, and initial testing. Proc IEEE. 

2012;100(8):2505–2511.

32. Chung CS, Cooper RA. Literature review of wheelchair-mounted robotic manipulation: user interface and end-user evaluation. In: Proceedings of the RESNA 

Annual Conference 2011; Alexandria, VA: Rehabilitation Engineering and Assistive Technology Society of North America; 2011. 

33. Wakita Y, Yamanobe M, Nagata K, Clerc M. Evaluation of single switch interface with robot arm to help disabled people daily life. In: 18th IEEE International 

Symposium on Robot and Human Interactive Communication; New York, NY: 

Institute of Electrical and Electronics Engineers; 2009:429.

34. Maheu V, Archambault PS, Frappier J, Routhier F. Evaluation of the JACO 

robotic arm: clinico-economic study for powered wheelchair users with upperextremity disabilities. In: The IEEE International Conference on Rehabilitation 

Robotics 2011; New York, NY: Institute of Electrical and Electronics Engineers; 

2011:1–5.

35. Routhier F, Archambault PS. Usability of a joystick-controlled six degrees-offreedom robotic manipulator In: Proceedings of the RESNA Annual Conference 

2010. Alexandria, VA: Rehabilitation Engineering and Assistive Technology 

Society of North America; 2010:1–7.

36. Kuiken TA, Li G, Lock BA, et al. Targeted muscle reinnervation for real-time 

myoelectric control of multifunction artificial arms. JAMA. 2009;301:619–628.

37. Van de Meent H, Hopman MT, Frölke JP. Walking ability and quality of life in 

subjects with transfemoral amputation: a comparison of osseointegration with 

socket prostheses. Arch Phys Med Rehabil. 2013;94:2174–2178.
76 H Pr o m o t i n g Su c cess f u l I n teg r at i o n

J o h n J. Fa r ley, III

(“Ja c k”), Ju d ge (Ret i red), 

US C o u rt o f Ap pea ls f o r

Veter a n s Cl a i ms On January 

10, 1969, an enemy 82 mm 

mortar round landed “gimme” 

distance from Jack Farley at FSB 

(Forward Support Battalion) 

Pershing in Vietnam. Two weeks 

later, he arrived at Walter Reed 

Army Medical Center in a fullbody cast, sporting more than 

100 wire sutures and missing his right leg above the knee. He spent the next 

14 months relearning how to walk.

Jack was a 1964 graduate from the College of the Holy Cross, where he 

captained the freshman and varsity lacrosse teams. In 1966, he received his 

MBA from Columbia University Graduate School of Business. Following his 
The Promi se of the Future H 77

retirement from the Army as a 

Captain in 1970 due to 100% 

disability, Jack was the first 

student admitted to the charter 

class of the Hofstra University 

School of Law—where he was 

the founding Editor-in-Chief 

of the Hofstra Law Review—

graduated first in his class, and 

received his JD degree cum laude 

in 1973.

Jack spent 17 years as a US 

Department of Justice litigator, 

rising to become a director 

of the Torts Branch, a Senior 

Executive Service member, and 

the Founding President of the Department of Justice Senior Executive Service 

Chapter. He was responsible for, inter alia, defending national security cases 

and the massive asbestos litigation, as well as representing federal employees 

sued personally for common law torts and constitutional violations. In 

September 1989, Jack was nominated by President George H. W. Bush and 

confirmed 1 week later by the Senate to a 15-year term as one of the founding 

judges of the US Court of Appeals for Veterans Claims. After serving as a 

senior judge for seven additional years, he retired in 2012. Ever resilient, 

Jack recently co-founded an information technology company (n2grate 

Government Technology Solutions, LLC), which assists federal agencies in 

their pursuit of complex data center and cloud integration strategies. 

If his postmilitary vocation was the law, Jack’s avocation has been serving 

Veterans. Since 2003, Jack has been a fixture at Walter Reed helping to 

establish the rehabilitation program for our Wounded Warrior amputees. 

He has been a daily amputee peer visitor for many of the more than 1,380 

Amputee-Warriors during Operation Iraqi Freedom, Operation Enduring 

Freedom, and Operation New Dawn. In addition, he has trained and certified 

more than 125 amputee peer visitors at Walter Reed and Brooke Army 

Medical Center. 
78 H Pr o m o t i n g Su c cess f u l I n teg r at i o n

Jack has joined Wounded Warriors in completing eight Marine Corps 

Marathons, as well as the New York City and Palm Beaches Marathon, on 

a handcycle. He has also taught disabled Veterans of World War II, Korea, 

Vietnam, Bosnia, Somalia, Iraq, and Afghanistan as a volunteer downhill ski 

instructor for more than 20 years at the Veterans Administration/Disabled 

American Veterans Winter Sports Clinic in Colorado. As he tells the amputees 

the first time they attack a mountain on skis, or a snowboard, or a monoski, 

“Once you conquer this, there is nothing you cannot accomplish.” 

Jack’s decorations include the Bronze Star Medal with Combat “V,” 

three Oak Leaf Clusters; the Purple Heart Medal with Oak Leaf Cluster; 

and the Army Commendation Medal. He received the Dean’s Award for 

Distinguished Hofstra Law School Alumni, as well as the Distinguished 

Alumni Medal. Jack was the first chair of the Veterans Law Section of the 

Federal Bar Association, is in the Massapequa High School Hall of Fame, 

and received the In Hoc Signo Award from the College of the Holy Cross. 

The Paralyzed Veterans of America presented him with the Harry A. 

Schweikert, Jr. Disability Awareness Award in August 2007.
As they recover from these life-altering wounds, 

my vision is that the Department of Defense,

 the [Department of Veterans Affairs] and the rest of America 

figure out a way to take care of these young people 

and their families for the rest of their lives. 

In many cases, they are trying to figure out what they 

want to be for the rest of their lives, and 

their choices have changed.

H H H

Admiral Mike Mullen

Union League

Philadelphia, Pennsylvania

April 29, 2008

C h a p ter F o u r

Psychosocial Factors in 

Reintegration

MICHELLE L. SPORNER, PhD, CRC,* and

ANNE E. BARRY, MS, CRC†

*

Assistant Professor, Rehabilitation Counseling, School of Health and Rehabilitation Sciences, University of Pittsburgh, 5049 Forbes Tower, Pittsburgh, Pennsylvania 

15260

†

Rehabilitation Counselor, Office of Vocational Rehabilitation, 531 Penn Avenue, 

Pittsburgh, Pennsylvania 15222

INTRODUCTION

To address the reintegration of Veterans and Service Members, it is 

helpful to understand more about the psychosocial adjustment of 

those who have served. The military creates a unique subculture that 

has established norms, values, and behaviors. From the time Service Members 

enlist, complete basic training, and finish their Military Occupation Specialties training, they will have adapted to this culture and its own survival of the 

fittest. For those who serve in the infantry and see combat, an added layer of 

stress and demands are connected to this unique environment. Adaptive stress 

reactions are created and then reinforced in the tense and sometimes hostile environments that translate into survival, victory, and mission complete 

status. Once a soldier is taken out of that context, he or she will find that the 

behaviors, organization, and priorities that proved successful in the military 

may not translate successfully to civilian culture. This chapter will provide 

an overview of factors affecting adjustment, particularly resilience, traumatic 
82 H Promoting Successful Integration

brain injury (TBI), and posttraumatic stress disorder (PTSD). Special emphasis will be placed on counseling approaches that may help promote successful 

reintegration.

PSYCHOSOCIAL ADJUSTMENT

Mi l i ta ry Serv i ce Mem ber t o Veter a n a n d Ci v i l i a n

Regardless of whether a Service Member has deployed, or if he or she 

sustained an injury or disability, transitioning from the military into civilian 

culture can be challenging. Members of the United States military belong to a 

unique culture and take great pride in their military identity. While individuals 

are in the service, the military places special emphasis on the values of duty, 

honor, loyalty, and commitment to comrades, unit, and Nation.1 Military 

identity promotes the ideas of self-sacrifice, discipline, obedience to legitimate 

authority, and belief in a merit-based rewards system.2 Although these values 

are vital to the safety and functioning of the military unit, these values are 

in conflict with more individualistic, liberty-based civic values that embrace 

materialism and autonomy. Individuals who are in the midst of transitioning 

out of the military often feel as if they are caught between two worlds, which 

may result in feeling alienated from friends and family members and experiencing an identity crisis.1

 As a result, for some Service Members, the process 

and experience of transitioning out of the military and back into the civilian 

world can be challenging. 

The deployment experience itself adds another dimension to adjustment. 

Service Members face many challenges as a result of deployment, including 

being away from family and important events, deteriorating relationships, 

or experiencing personal change for the worse.3 Service Members may also 

encounter negative reactions as a result of personally experienced trauma (eg, 

taking a life, being shot at, seeing/handling corpses, having a colleague killed 

or seriously wounded, etc).4 These experiences may linger with a Service 

Member long after the deployment. Deployments during the conflicts in Iraq 

and Afghanistan were longer and more frequent than in previous conflicts, 

adding to the potential for Service Members to experience these personal 

traumas.5 In addition to this increased frequency, the time between deployments was also much shorter. 

Although most people readily recognize the negative reactions to deployment, it is important to note that there may be several positive reactions. 

For example, some Service Members reported that during deployment, they 

experienced self-improvement, had time to think, were able to help others, 
Psychosocial Factors in Reintegration H 83

and had the opportunity to experience another culture.3 Further discussion on 

the impact of culture in the military is discussed in Chapter 16 (Culture and 

Reintegration of Veterans).

Ri sk Fa c t o rs f o r Ad j ust me n t Di f f i c u lt ies

Reports indicate that there is a high rate of depression, PTSD, TBI, anxiety 

disorders, and substance use disorders in Service Members who have been 

deployed.6,7 Additionally, it has been reported that Soldiers are more likely to 

experience higher levels of psychological problems (eg, acute stress) when they 

experience high or intense levels of combat (eg, being attacked, ambushed, 

or killing the enemy).8 Risk factors for adjustment difficulties include combat 

experience and can be classified into five categories: 

1. fighting, 

2. killing, 

3. threat to oneself, 

4. death or injury of others, and 

5. other atrocities.9

Longer deployments or multiple deployments may indicate additional risk 

factors. Soldiers who were deployed for at least 7 months reported the following as concerns: lack of time off, lack of privacy or personal space, separation 

from family, and long deployment lengths.10 Additionally, for individuals in 

the military, suicide is the second leading cause of death.11 

Forty-five percent of Iraq and Afghanistan War Veterans are seeking 

compensation for their service-connected disability.12 Returning from combat 

can act as a risk factor in transition, but the system of care and benefits that 

awaits a service-connected Veteran can also be a risk factor itself. There is an 

unfortunate reality that develops when benefits are provided to those who are 

given the label of “disabled.” For some, that label and status of disability will 

create a dependency on government disability compensation. Although this 

compensation is undoubtedly deserved, what was intended as a temporary 

assistance becomes a lifelong disincentive. Those who accept government 

support as their sole earnings are forgoing the optimization of skills and gifts 

that could be used in the civilian workforce.12 

It is noteworthy that Veterans of the Iraq and Afghanistan Wars are more 

educated than the typical American. The majority of these Veterans have a 

high school diploma or GED equivalent, and >80% of officers have at least a 

bachelor’s degree. In addition to education, these Veterans are held to higher 

mental and physical standards than the typical American. Moreover, this en-
84 H Promoting Successful Integration

tirely volunteer-era military includes record numbers of Reserve or National 

Guard individuals, which assumes that Service Members are older and more 

educated.12 

When a Veteran transitions to civilian life with a service-connected disability, it should not be assumed that his or her status disallows that Veteran 

to engage in a gainful, active, productive lifestyle and career. In Exhibit 4-1, 

the service-connected disability ratings are given in increments of 10%, and 

the average-awarded, service-connected percentages for Iraq and Afghanistan 

Veterans are also shown.12 

Although the technology and advancements in medicine for the care of 

war wounds are unprecedented, the injuries that result from combat and war 

wounds are not to be taken lightly. However, caution needs to be utilized 

when interpreting the definition of “disability” as the military defines it. Military disability and civilian disability can be very different concepts because 

they are rooted in two different models. The civilian world has transitioned 

from the medical model (to which the military maintains residual roots) to

a social-biopsychosocial model of disability. In this model of disability, the 

person is considered holistically, inclusive of their strengths, their limitations, 

and contextual factors. This differs from the medical model in that it does not 

focus on the impairment or diagnosis. Clinicians and counselors are trained 

and equipped to work with individual Veterans to assess their strengths as 

well as obstacles and also find suitable employment that provides meaning 

and rewarding activity to life. In this case, employment can serve as a therapeutic outlet for Veterans to once again find meaning in their lives after returning from war. The bottom line is the fine distinction between capacity and 

performance. Capacity is defined as the best an individual is expected to do, 

whereas performance is defined as what the individual actually does and what 

the individual actually achieves. The goal should always be to minimize the 

gap that exists between these two factors. Additionally, the same significance 

and attention should be given to the performance factor as has been given to 

the capacity number placed on a disability claim form.12 

SERVICE-CONNECTED DISABILITY RATINGS (%) PERCENTAGE OF VETERANS

0–20 28

30–40 26

50–60 21

70–80 17

>80 8

= 100% 4

Ex h i b i t 4-1. Distribution of Service-Connected Disability Ratings
Psychosocial Factors in Reintegration H 85

TRAUMATIC BRAIN INJURY

According to the Department of Defense (DoD) and the Department of Veterans Affairs (VA), the definition for determining whether a Service Member 

has sustained a TBI is “a traumatically induced structural injury and/or 

physiological disruption of brain function as a result of an external force that 

is indicated by new onset or worsening of at least one . . . clinical sign immediately following the event.”13(p16) The Clinical Practice Guidelines identify 

clinical signs as

• any period of loss of or a decreased level of consciousness (loss of 

consciousness),

• any loss of memory for events immediately before or after the injury 

(post-traumatic amnesia),

• any alteration in mental state at the time of the injury (confusion, disorientation, slowed thinking, etc) (alteration of consciousness/mental state),

• neurological deficits (weakness, loss of balance, change in vision, praxis, 

paresis/plegia, sensory loss, aphasia, etc) that may or may not be 

transient, and

• intracranial lesion.13(p16) 

From 2000 to 2013, the DoD reported diagnosing 294,172 Service 

Members with mild-to-severe TBI not only as a result of deployment, but also 

in nondeployed settings. Sources of nondeployment-related TBI include motor 

vehicle accidents, sports, other recreation activities, and military training.14 

The impact of sustaining a TBI and the resulting associated long-term 

consequences have been well documented. A TBI may result in physical, cognitive, sensory, language and communication, affective, and behavioral disturbances that may have both short-term and long-term consequences. Due to the 

complex nature of the brain and the functions the brain is designed to carry 

out, disruptions that result from TBI are interrelated and are closely connected, 

thus making it difficult to narrow the nature of the problem to one domain. 

Additionally, effects from TBI may affect individuals’ quality of life, especially 

in the personal, social, and vocational domains. A general overview of the 

consequences of a TBI is provided based on the categorization of functional 

limitations into cognitive, neurobehavioral, sensory, and somatic domains. 

Common cognitive dysfunctions following TBI include difficulties with

• memory, 

• attention, 
86 H Promoting Successful Integration

• language, 

• visuospatial perception,

• sensory motor integration,

• affect recognition, 

• communication,

• speed of processing, and 

• executive function.15–17 

Neurobehavioral and emotional disorders have been the least studied and 

understood, despite clinical agreement that significant problems are present.16 Research has, however, identified large disturbances in emotion and 

behavior post-TBI. Furthermore, disorders of behavior and emotion after 

TBI are the most frequently reported problem by family members, friends, 

and caregivers.18 

When an individual sustains a TBI, he or she may experience significant 

changes in equilibrium and somatosensory perception.17 Commonly reported 

sensory disruptions reported in TBI include blurred vision, dizziness, and 

fatigue.16 Additionally, persons may experience sensitivity to light and noise, 

balance problems, and transient neurological abnormalities.19 In moderate 

and severe TBI, seizures are a common long-term problem.20 Research has 

also shown that survivors of TBI often have a high prevalence rate of chronic 

headaches.16,21 

POSTTRAUMATIC STRESS DISORDER

Posttraumatic stress disorder (PTSD) is another common consequence of war 

zone deployment.22 According to the American Psychiatric Association (APA; 

Arlington, VA), PTSD is characterized by the development of specific symptoms following exposure to an extreme traumatic stressor. This exposure may 

include direct involvement in an actual or threatened death event or serious 

injury or threat to one’s physical integrity. These traumatic stressors can also 

include witnessing events that involve death or serious injury or learning of an 

unexpected death of a close friend.23 For Service Members or Veterans to be 

diagnosed with PTSD, they must meet the following criteria: 

• exposure to one or more traumatic events, 

• recurrent intrusive distressing memories, 

• avoidance of stimuli associated with the traumatic event, 

• negative alterations in cognitions and mood,
Psychosocial Factors in Reintegration H 87

• marked alteration in arousal (hypervigilance), and

• reckless or self-destructive behavior. 

Recurrent intrusive memories often occur as flashbacks or bad dreams, thus 

reliving the trauma.24 

Individuals who have PTSD often spend a lot of time and energy avoiding activities, situations, or people who are associated with the traumatic 

event and, as a result, avoid any thoughts or feelings that are associated with 

these events.23 In everyday life, these avoidance behaviors manifest as feeling 

emotionally numb or having strong feelings of guilt or worry. Individuals who 

have PTSD may also lose interest in activities they previously found enjoyable. For example, if driving through a crowded city reminds a person of his 

or her patrols, that person may have difficulty driving to work or driving 

to areas of the city to visit others.24 Individuals may also have symptoms of 

hyperarousal that served them well while they were deployed. However, when 

an individual returns home, it can be difficult to turn off this constant alertness that may result in an individual being easily startled, being constantly 

on edge, or having significant sleep difficulties or outbursts of anger.24 It is 

common for previously deployed Service Members with PTSD to express 

survivor’s guilt or guilty feelings about the things they needed to do to survive 

their combat deployment.23 

The prevalence rates for PTSD following deployment vary. According to 

the RAND Corporation (Arlington, VA) study, approximately 14% of all Service Members who served during Operation Enduring Freedom (OEF)/Operation Iraqi Freedom (OIF) have PTSD,25 whereas rates for Service Members 

who deployed to Iraq range anywhere from 9.8% to 19.9%6,7,26 Comparatively, the prevalence of PTSD in the general US population is approximately 

4% to 8%.22,23 It is important to note that female Soldiers were found to be 

2.5 times more likely to develop PTSD compared with male Soldiers.27

PTSD is an important outcome to consider because it can affect the 

whole person, causing difficulties and disruptions in psychosocial and occupational functioning and overall well-being.22,28 Additionally, PTSD has been 

found to decrease quality of life for Veterans of the OEF/OIF cohort.22 

Ad d i t i o n a l Fa c t o rs Af fec t i n g Ad j ust me n t 

The Office of the Army Surgeon General estimated that 12% of soldiers had 

anxiety and depression disorders after their first deployment. As soldiers 

continue to deploy multiple times, these rates increase to approximately 27% 

after a third deployment.29 Additional psychological health issues may include 

anger and aggressive behaviors, as well as guilt or shame.30
88 H Promoting Successful Integration

Ground troops (usually Soldiers and Marines) are more likely to report 

PTSD and depression than are Sailors and Airmen.29 Further, female military 

personnel, enlisted personnel, Hispanics, and those not currently on active 

duty—including members of the Guard and Reserve and those who have 

retired—are most likely to report PTSD and depression. Adding an additional 

layer of challenges, Military Veterans who have sustained a TBI are three 

times more likely to also have PTSD.31 

Eighty percent of individuals who have been diagnosed with PTSD 

also experience additional co-morbid psychiatric disorders, most frequently 

substance use disorders, depression, and anxiety.32 Additionally, PTSD is often 

associated with suicidal ideation and suicide attempts, as well as other chronic 

medical conditions such as arthritis and headaches. PTSD and TBI are also 

associated with self-reported disturbances in sleep. OEF/OIF Veterans with 

PTSD also report psychosocial difficulties, as well as difficulties with family, 

peers, work, money, and school.33 

For individuals transitioning out of the military, lack of social or familial 

support, fears of the future, pain, and substance abuse may also make the 

transition process for Service Members more challenging. 

Ma n i festat i o n s o f Ad j ust me n t Di f f i c u lt ies

Many Veterans and Service Members experience difficulties as they transition into a civilian life. These challenges include marital difficulties, financial 

difficulties, alcohol or substance abuse problems, medical problems,34 anxiety 

and depression,35 homelessness, and motor vehicle accidents.36 Even more 

troubling, the 2013 unemployment rate for Veterans who have served since 

September 2001 was 8.8% for men and 9.6% for women, compared with 

7.5% and 6.8% for their respective non-Veteran cohorts. This indicates that 

many Veterans experience difficulty finding civilian employment.37

In addition to transition difficulties faced by returning Service Members 

and Veterans, participation can be further impacted as a result of some of the 

challenges associated with TBI and PTSD. 

P o st t r a u m at i c St ress Di s o r der 

Service Members with PTSD have an increased likelihood of being unemployed and have a decreased likelihood of being employed after participating 

in work therapy.38,39 Additionally, while many Veterans experience homelessness, PTSD is associated with an 85% greater risk of becoming homeless 

again in the future.40 Further, PTSD is associated with a variety of problems 

across social and interpersonal functioning, marital functioning, parental and 

family functioning, and occupational functioning. PTSD is also related to 
Psychosocial Factors in Reintegration H 89

career and work difficulties, and Veterans with PTSD having an increased 

likelihood of accomplishing less, being limited in the type of work, and 

having difficulty performing work.41 Research has also shown that PTSD is 

associated with lower life satisfaction and overall well-being.22 Veterans who 

screened positive for PTSD or depression were twice as likely to report alcohol misuse compared with Veterans who did not have PTSD or depression.42

Tr a u m at i c Br a i n I n j u ry 

Service Members and Veterans with TBI face challenges in their day-to-day 

lives. There are several psychosocial implications of acquiring a brain injury. When persons sustain a TBI, they may experience difficulty adjusting 

to their new disability and may face challenges with recognizing problems 

they are now experiencing and continue to see themselves as their old selves. 

Adjustment to disability after sustaining a TBI depends on the severity and 

location of the injury, as well as the available social and family support, 

educational attainment, and premorbid functioning.43 For individuals who 

sustain moderate or severe TBIs, emotional problems are common, specifically lower frustration tolerance, agitation, excessive use of profanity, aggression, and potentially destructive behaviors. Additional emotional conditions 

that individuals experience after TBI may include anger, anxiety, depression, 

and low self-esteem.44 These common emotional challenges often negatively 

impact social relationships and can increase social problems because persons 

may become overdependent on others; become tangential in their talking; and 

display immature behavior, such as an inappropriate use of humor or inappropriate sexual behaviors.44 

Return to work following TBI can also be challenging due to the complex interaction of physical, cognitive, and emotional demands associated 

with work.45 As a result, a large set of individuals with TBI are unemployed 

or underemployed,46 with approximately only 40% returning to work rates 

1 to 2 years after TBI.47 Work plays an important role in people’s lives and 

when individuals are unable to return to work, they are more likely to have 

negative psychosocial adjustments and increased health problems. Further, 

unemployment for individuals with TBI may lead to a decreased level of 

satisfaction with life, failure to successfully reintegrate into their community, 

economic dependency, and an increase in secondary disability.48,49 

Su i c i de 

The suicide rate for Service Members across all branches has risen, with the 

Army and the Marine Corps having the greatest rise since 2001.11 Traditionally, suicide rates among military personnel were lower than the general popu-
90 H Promoting Successful Integration

lation. However, starting in 2009, the suicide rate in the military surpassed 

the civilian rate. In 2001, the suicide rate for Service Members was 9 per 

100,000; yet, in 2009, that number had risen to 24 per 100,000.50 Further, an 

estimated 6% of active duty members have attempted suicide.51 

According to the Defense Centers of Excellence for Psychological Health 

and Traumatic Brain Injury (Arlington, VA), warning signs for suicide can 

include the following:

• thinking about or talking about hurting or killing him/herself;

• threatening to hurt or kill him/herself;

• talking or writing about death, dying, or suicide;

• looking for ways to harm him/herself, such as seeking pills or firearms;

• undergoing increased substance use/abuse;

• having feelings of hopelessness or having no sense of purpose;

• being unable to sleep or oversleeping;

• withdrawing from friends, family, or society;

• experiencing excessive rage, anger, or desire for revenge;

• having feelings of anxiety or agitation; and 

• experiencing dramatic changes in mood.52

It is important to note that Service Members and Veterans who have untreated PTSD, depression, and TBI are more likely to attempt suicide.53 Risk 

factors that may increase a Service Member’s or Veteran’s likelihood of committing suicide include the following:

• male gender;

• Caucasian race;

• E-1 to E-2 rank;

• younger than 25 years of age;

• GED/less than a high school education;

• divorced;

• regular component—including those on active duty in the Army, Navy, 

Air Force, and Marine Corps;

• drug and alcohol abuse;

• relationship problems; and

• legal, administrative, and financial problems.52

Key Fa c t o rs t o Su p p o rt Ad j ust me n t 

Previous research has found that, among individuals who have experienced 

traumatic events, roughly 30% to 70% report positive change.54 Social sup-
Psychosocial Factors in Reintegration H 91

ports and intimate relationships may protect against developing PTSD or act 

as a moderating factor against PTSD symptomatology.27 It is hypothesized 

that when an individual is faced with a stressful event, he or she seeks out 

support from others to help reduce or regulate this distress.55 Further, these 

intimate relationships may help facilitate the development of coping skills 

that can be utilized during times of separation or prolonged stress (deployments).56 Additional protective factors that have been found to have a direct 

relationship to unit well-being and may serve as a buffer between deployment 

stressors and behavioral health outcomes include supportive leadership, unit 

cohesion, and perceived readiness.10,57,58

Resilience factors have been shown to protect against the negative effects 

of depression. These aspects of resilience include positive emotions, cognitive 

flexibility, meaning-making, and active coping.59 With respect to PTSD, social 

support has been found to be the strongest protector against PTSD.60,61 Furthermore, individuals who perceive themselves as having a high level of social 

support have been linked to having higher levels of resilience.62

In a recent survey of OEF and OIF Veterans, individuals who had lower 

levels of unit support and postdeployment social support were identified as 

having a higher rate of PTSD and increased depressive symptoms, as well as 

decreased resilience and psychosocial functioning.33 However, positive appraisals of one’s military service may serve as a buffer against combat-related 

PTSD symptoms.8 Service Members who describe a positive appraisal of their 

military service may view their deployments and combat as a necessary part 

of their service, as well as an opportunity for growth.63 The positive view 

of military service, in addition to having a view that the Service Member is 

supported by his or her military leaders, may promote a positive identification with the military and may encourage individuals who have experienced 

trauma to reach out to other Service Members who have also experienced 

combat trauma.64 This process may lead to finding a positive meaning in the 

trauma and encourage a healthy coping style with that trauma. 

COUNSELING AND REHABILITATION INTERVENTION

P o st t r a u m at i c St ress Di s o r der 

Only approximately one-half of the Service Members who met screening 

criteria for PTSD or major depression actually reported seeking psychological 

or counseling services within the previous 12 months.25 It has been reported, 

however, that only one-quarter of active duty troops with psychiatric diagnoses actually receive treatment services,6

 and approximately 57% of individu-
92 H Promoting Successful Integration

als who suspected they had a TBI never saw a medical professional for that 

injury.25 

In general, both the civilian and military cultures in America discourage people from seeking medical help or mental health services for cognitive 

and psychological disorders, but this is often more pronounced for Service 

Members and Veterans. Service Members often report fear of negative effects 

on careers, personal stigmatization, and potential loss of peers’ confidence as 

significant and powerful reasons to avoid professional help.65 When individuals do not receive the appropriate services for cognitive and psychological 

trauma, there are grave and negative implications for future health, including 

substance abuse and suicide, poor work outcomes, and relationship and family success.5,65 Although Service Members may report more concerns about 

seeking or following through with treatment, there are many interventions 

that have been proven effective for Service Members and Veterans during the 

transition process, including individual counseling, group counseling, and 

support groups. 

For Veterans with PTSD, the current gold standard of treatment is cognitive behavioral therapy (CBT).32 CBT is effective in treating both acute and 

chronic PTSD, particularly through prolonged exposure therapy, cognitive 

processing therapy, and eye movement desensitization and reprocessing.66 The 

overall process of change that occurs through CBT is the modifying of cognitive distortions that are associated with PTSD.67 Another CBT intervention 

that is effective is stress inoculation training. The VA/DoD Clinical Practice 

Guidelines for the treatment of PTSD recommend components of exposure 

and cognitive restructuring therapies.68 While CBT is effective in treating 

PTSD, there is a high dropout rate, and the nonresponse rate is approximately 50%.69 Additionally, individuals with co-morbid TBI may not benefit from 

CBT because of the high-level cognitive requirements; however, several case 

studies indicate that CBT may be a promising treatment for individuals with 

both TBI and PTSD, but more research is still needed.70 

There are also many advantages to group-based therapy for the treatment of PTSD. Economically speaking, the VA or other service providers 

benefit from group therapy approaches because of the increasing number of 

returning Soldiers who will be in need of these services. From a clinical perspective, the reliable evidence of the advantages of group-based treatment for 

those who have PTSD is growing. One advantage that is seen in group-based, 

exposure-style treatments is the validation that can be experienced through 

hearing other combat Veterans’ struggles. The validation and empathy experienced in the group can establish a sense of normalcy that can be a strong 

catalyst for recovery.71 
Psychosocial Factors in Reintegration H 93

Two prominent therapy interventions for this population include 

(1) group-based exposure therapy and (2) trauma-focus group therapy. 

The most common interventions in both types of treatment include:

• a psychoeducational element, 

• a focal trauma narrative presentation, 

• repeated exposure, 

• interpersonal skills training, and 

• relapse prevention. 

Another component that is usually included is cognitive restructuring. Most 

treatments of PTSD stem from the cognitive therapy school that has been 

proven reliable and effective because it is an evidence-based practice. Education and cognitive interventions are integral in the treatment of PTSD and 

enable traumatic experiences to be reintegrated into a nondistorted 

schemata of understanding.72 

Tr a u m at i c Br a i n I n j u ry

Cognitive rehabilitation is the gold standard of intervention for individuals 

who have TBI. Cognitive rehabilitation is a systematic, functionally oriented 

service of therapeutic cognitive activities and an understanding of the person’s 

behavioral deficits. Functional changes are achieved by directing cognitive 

rehabilitation services to reinforce, strengthen, or reestablish previously 

learned patterns of behavior, or by establishing new patterns of cognitive 

activity or mechanisms to compensate for impaired neurological systems. 

A major goal of cognitive rehabilitation is to provide interventions that lessen 

the cognitive impairment itself or that lessen the disabling effect of cognitive 

impairments.73,74 Cognitive rehabilitation gained popularity in the United 

States after World Wars I and II to treat injured Service Members. It focused 

on compensatory and restorative cognitive rehabilitation and has now 

become a fundamental component of TBI rehabilitation.75,76 

Su i c i de Preve n t i o n

One way to help prevent suicides among military personnel and Veterans is 

through the DoD’s ACE (Ask, Care, Escort) framework (http://realwarriors.

net). By using these three simple steps, individuals who interact with Service 

Members and Veterans, particularly family members, may have some basic 

steps to help guide how they talk with that person. 
94 H Promoting Successful Integration

1. Ask the Service Member or Veteran about his or her suicidal thoughts. 

Individuals working with Service Members and Veterans should know 

the suicide warning signs and have the courage to ask the person about 

their thoughts in a calm manner. 

2. Care for the person by staying calm and nonjudgmental while actively 

listening to the details they share. At this time, individuals should also 

remove any objects that may pose a danger to the Service Member or 

Veteran. 

3. Escort the Service Member or Veteran (if it is suspected that he or she is 

suicidal) to a chaplain or to a behavioral health professional. 

In case of an emergency, the National Suicide Prevention Lifeline (1-800-273-

TALK [8255] and press 1 for Veterans) will always react immediately. Feel 

free to call 911 in an emergency. 

Each military branch has created a suicide prevention program specific to 

the needs of its Service Members. Additionally, the DoD has identified the importance of resiliency training as an effort to decrease the number of suicides 

and suicide attempts. Resiliency is just one component of the broader concept 

of positive psychology. 

P o s i t i ve Psy c h o l o g y

For Service Members prior to deployment, as well as in the transition period, 

positive psychology interventions may be useful. Positive psychology is the 

study of how positive subjective experiences and positive individual traits 

can improve quality of life and may prevent pathology in the face of negative experiences.77 At an individual level, positive psychology focuses on the 

subjective value individuals place on their experiences. It further includes an 

examination of past well-being, contentment, and satisfaction. Additionally, it 

focuses on future hope and optimism, as well as present flow and happiness.77

Characteristics of resilience include gratitude, hope, kindness, leadership, love, 

spirituality, and teamwork.78 While traditional counseling and psychology 

approaches often look at mediating negative consequences associated with 

psychological problems, positive psychology is a strength-based approach 

that aims to foster excellence. Positive psychology is not designed to replace 

traditional counseling, nor does it deny the human pain, weaknesses, and 

disorders people face. Rather, it offers a complete view of human life in both 

happiness and suffering.79

The Army tested a Comprehensive Soldier and Family Fitness program 

consisting of three parts: (1) a psychological fitness test, (2) resilience training, and (3) courses on training others to be resilient.4,80 Individuals initially 
Psychosocial Factors in Reintegration H 95

assess their strengths through the Global Assessment Tool, which measures 

emotional, family, social, and spiritual fitness. High scores for these criteria 

indicate a lower potential for anxiety and depression.80 As of 2011, more than 

900,000 Soldiers had taken this assessment. 

After completing the assessment, Soldiers then take a course on posttraumatic growth, as well as additional optional courses on emotional, family, 

social, and spiritual fitness. The mandatory posttraumatic growth module 

teaches soldiers about five elements that contribute to this growth: 

1. understanding the response to trauma and its relationship to the normal 

responses, and how this differs from symptoms of PTSD and are not 

character defects; 

2. reducing anxiety by controlling intrusive thoughts; 

3. engaging in constructive self-disclosure and not keeping their story hidden or bottled up; 

4. creating a new story that redefines trauma as an experience that changes 

a person’s views on loss and gain, vulnerability, and strength; and 

5. articulating life principles, such as creating a new identity and being 

altruistic.80 

The final and most important component is the training to teach others 

how to embrace resilience. Master resilience trainers and resiliency training assistants are taught how to train others in their units about resiliency. 

The master resilience training includes three parts that cover (1) building 

mental toughness, (2) building signature strengths, and (3) building strong 

relationships. 

Another approach the Army is taking to increase resilience is through the 

Comprehensive Soldier and Family Fitness resilience training. This training 

is a component of the Army’s Ready and Resilient Campaign and aims to 

improve the physical and psychological health of Soldiers and their families. 

Training is provided through “Five Dimensions of Strength,” which include 

1. physical, 

2. emotional, 

3. social, 

4. spiritual, and 

5. family strength.81

The Army’s Ready and Resilient Campaign is an integrated and comprehensive approach to increasing individual and unit readiness and resilience.82
96 H Promoting Successful Integration

According to the Mental Health Advisory Team 9, soldiers who report getting 

some resilience training prior to their deployments reported lower rates of 

stress than those who did not receive any resilience training. 

BARRIERS TO ACCESSING COUNSELING SERVICES

For Service Members and Veterans with PTSD, several challenges exist that 

often prevent individuals from participating in treatment. Many Veterans 

reported challenges in engaging in the counseling process, with a decision to 

seek treatment, including concerns about treatment (40%), emotional readiness for treatment (35%), stigma (16%), and logistical issues (8%) being cited 

as reasons for not beginning treatment.83 Other reasons may include

• negative career repercussions, 

• inability to receive a security clearance, 

• concerns about confidentiality, 

• concerns about side effects of medications, 

• preferred reliance on family and friends, and 

• perceived lack of effectiveness of the medications as barriers to receiving 

mental healthcare for formerly deployed Military personnel.25

A group of OEF/OIF combat Veterans reported that perceived stereotypes 

exist around PTSD, including labels such as being dangerous/violent or crazy 

and a belief that combat Veterans are responsible for having PTSD.84 They 

also reported not seeking treatment to avoid being labeled as having a mental 

illness. Once individuals engaged in treatment, they reported resisting these 

stereotypes, but still reported challenges with reintegrating into society and 

acknowledged the fact that other combat Veterans best understood their experiences.84 As a result, peer-based groups may encourage Veterans to engage 

in treatment sooner. 

SUMMARY

This chapter provides an overview of some of the challenges Service Members and Veterans face as they transition from the military to the civilian 

world, taking into consideration military cultural changes that may impact 

this transition. In addition to the challenges Service Members may face, the 

other complications that deployment experiences bring, particularly PTSD 
Psychosocial Factors in Reintegration H 97

and TBI, are also highlighted. The transition process cannot only be examined through the Service Member or Veteran’s perspective. Further emphasis 

should be placed on the unique challenges this group and their social support 

network face. Counselors and other healthcare providers should be trained 

or provided with more information about these specific cultural factors. 

Although counseling interventions are beneficial in treating psychosocial adjustment issues, positive psychology interventions such as resilience training 

aim to teach skills that may serve people during stressful times. Veterans and 

Service Members have dedicated much more than their time. Therefore, an 

increased effort is needed to utilize approaches that aid this group to transition smoothly into their next chapter. 

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associated with PTSD: perceptions of treatment seeking combat veterans. Psychiatr Rehabil J. 2013;36:86–92.
Psychosocial Factors in Reintegration H 103

Pr i vate Fi rst Cl ass (PFC) 

Steve D o m i t r o v i c h grew 

up in Aliquippa, a small town 

on the outskirts of Pittsburgh, 

Pennsylvania. He was born 

the son of two hard-working 

Croatian immigrants and was 

part of a family that included 

12 brothers and sisters. 

In 1943, he was drafted into the 

US Army and went to California 

for training. Later, he became 

a medic. As an 18-year-old, he 

fondly recalled his first driving 

lesson, in which his training instructor asked his class, “Who here has a 

license? (All but one soldier raised his hand.) Who here does not have a 

license? (Only one person raised his hand.) Great, you’re our driver!” Shortly 
104 H Promoting Successful Integration

thereafter, he was behind the wheel of his first vehicle. He went around the 

track countless times, grinding the gears of the ambulance until he finally got 

it down pat. 

Originally, PFC Domitrovich had come ashore on the beaches of Utah as 

a member of the 479th Ambulance Company. In December 1944, he later 

found himself in the midst of what was later known as the Battle of the Bulge. 

He was a medic in the 575th Ambulance Company with a group of American 

units.

On December 17, 1944, near the town of Malmedy, Belgium, a German 

SS (Schutzstaffel) Division ambushed his convoy and took him and more 

than 100 other prisoners of war (POWs) captive. After being captured, PFC 

Domitrovich presented his Geneva Convention card that identified him as a 

medic. The SS processing soldier said, “Nix good” and tossed the card aside. 

The POWs were then led to a field and placed in lines. The SS backed up a 

truck and uncovered a crew-served machine gun. The SS troops went up and 

down the lines of soldiers collecting identification cards and dog tags from all 
Psychosocial Factors in Reintegration H 105

the American Soldiers. It was during this collection process that Domitrovich 

stepped forward undetected from his line to the line directly in front of him, 

which had already been searched by the German SS troops, thus allowing him 

to keep his forms of identification.

What occurred next was one of the greatest known atrocities to American 

Soldiers. The SS troops finished their collection process and immediately 

opened fire. Domitrovich recalls to this day very clearly hearing a voice telling 

him to “fall!” He quickly fell to the ground and played dead. When the firing 

ended, he was surrounded by blood-soaked bodies and the sounds of dying 

men moaning for God and their mothers. 

He lay there listening to the footsteps of the SS as they walked along the 

writhing bodies laughing and mocking the maimed American Soldiers. He 

also heard shots from their pistols. As the footsteps grew closer, a boot was 

placed next to Domitrovich’s head. He remained still and held his breath for 

what seemed like an eternity. Fleeting thoughts ran through his head about 

his family and how they would take the news of his death. He prayed to God 

that if he was able to survive, he would attend Sunday Mass every week for 

the rest of his life. 

A pistol went off, and blood covered his face, but it was not his own. The 

SS troops moved on and eventually left the area, leaving behind a field 

of executed American Soldiers. Domitrovich remained still in freezing 
106 H Promoting Successful Integration

temperatures until he felt safe enough to open his eyes and stand up. He will 

never forget the sight of all those bodies strewn about the field, including in 

the adjacent fields where men were mowed down trying to flee execution. 

Steve and a handful of other fortunate soldiers who miraculously survived 

gathered together and walked dazed to a nearby hilltop where they came 

upon an American patrol in the valley below. Ultimately, he finished out his 

participation in the Battle of the Bulge and supported Allied troops.

Domitrovich returned home to his family in Aliquippa, Pennsylvania. He has 

used the atrocities that took place that fateful day in Malmedy to catalyze 

and motivate himself to appreciate every moment of every day. He also met 

the love of his life, his wife Helen, a Greek immigrant living in Aliquippa. 

Steve opened his own small business, a dairy mart that he ran with his family 

for more than 30 years before finally retiring at the age of 70. He became 

an integral member of their small community, a town in which it would 

be very difficult to not run across a person who did not fondly know the 

unforgettable personality that is Steve Domitrovich. He has two children and 

two grandchildren, as well as numerous nieces and nephews. He has spent 

his days in retirement with his family and enthusiastically cheering for his 

favorite Pittsburgh sports teams. Steve’s story has been featured in multiple 

books and on various Web sites, as well as immortalized in paintings. 

Still to this day—since December 1944—he has not missed a Sunday Mass!
I am proud to serve with such dedicated 

Soldiers, families, and civilians and I’m inspired by

their resilience, sacrifice, and dedicated service 

to our mission at home and abroad.

H H H

General Daniel B. Allyn

Vice-Chief of the Staff of the Army

C h a p ter Fi ve

Spirituality and Reintegration: 

Building Strength, Fortitude,

Optimism, and Connection

DOUGLAS A. ETTER, MDiv, MSS*; AMY MOUNTAIN, MS†; and

AUDREY SCHOOMAKER, RN, BSN, E-RYT‡

*

Colonel, US Army; Joint Headquarters Chaplain, Pennsylvania National Guard and 

Chief Communications Officer, Lebanon VA Medical Center, 1700 South Lincoln 

Avenue, Lebanon, Pennsylvania 17042 

†

Director of Business Resources, Sysco Central Pennsylvania, LLC, 3905 Corey Road, 

Harrisburg, Pennsylvania 17109

‡

Integrative Health Specialist, Consortium for Health and Military Performance 

(CHAMP), Human Performance Research Center, Uniformed Services University of 

the Health Sciences, 4301 Jones Bridge Road, Bethesda, Maryland 20814

INTRODUCTION

The Soldier’s heart, the Soldier’s spirit, the Soldier’s soul are everything. 

Unless the Soldier’s soul sustains him he cannot be relied upon 

and will fail himself, and his commander, and his country in the end.

 

General George C. Marshall

US Army, Chief of Staff

(1939–1945)
110 H Promoting Successful Integration

Human beings are remarkably complicated. Although we are composed of various chemicals and compounds, many claim that we are more than just the sum of these parts. Specifically, they suggest 

that there is an element beyond our physical, emotional, or intellectual composition. Many people call this element the soul, spirit, or life force. There 

is little scientific evidence that such an element exists within human beings; 

however, there is an enormous collection of secondary literary, religious, psychological, historical, cultural, and empirical evidence that suggests such an 

element does exist. Therefore, it is not the purpose of this chapter to prove or 

disprove the existence of the human soul; rather, its existence is a presupposition of this chapter. 

There are also two more presuppositions of this chapter: 

1. We are convinced that spiritual growth is possible. Just as people can 

improve their physical well-being through a variety of exercises and practices (eg, aerobics, strength and flexibility training, good nutrition, and 

proper sleep habits), people can also improve their spiritual well-being. 

2. We are asserting that there is not a single correct pathway or platform to 

develop one’s spirituality. 

Despite our many similarities, human beings are very complex; something that helps one person develop his or her spirituality may hinder another 

person’s growth. What appeals to one might repel another. Each person 

must find the right pathway, platform, or combination to assist in his or her 

own spiritual growth and development. Thus, the purpose of this chapter is 

threefold: 

1. to provide empirical scientific data that demonstrates the positive benefits 

of spiritual development; 

2. to share a variety of pathways or platforms that one can use to increase 

or enhance spiritual development; and 

3. to suggest other resources in which the reader can learn more about spiritual development, resiliency, and reintegration. 
S p i r i t u a l i t y a n d Rei n teg r at i o n H 111

KEY CONCEPTS AND DATA

According to the journal Military Medicine, 

. . . the scientific study of spirituality and health is a very new field. There 

has been a five-fold increase in research on spirituality and religion, 

which from 1990–2007 reflects the growing increase in this topic within 

healthcare and psychology and spirituality.1(p73)

Before progressing to the scientific data, however, it is important to define 

certain key terms. The term spirituality can be confusing and easily misunderstood. For this reason, we have adopted a working definition of spirituality provided by Wong et al2

 that is drawn from an earlier work by Benson 

et al.3 In this chapter, spirituality is defined as “the intrinsic human capacity 

for self-transcendence, in which, the self is embedded in something greater 

than the self, including the sacred,”2(pp205–206) and that motivates “the search 

for connectedness, meaning, purpose, and contribution.”2(pp205–206) Spirituality is contrasted with religiosity, which is defined as, “one’s relationship with 

a particular faith tradition or doctrine about a divine other or supernatural 

power.”2(p267)

Additional key terms in this chapter include meaning, values, transcendence, and connection.

• Meaning refers to defining, making sense, understanding, or accepting 

situations or events in life. It also may refer to a driving or foundational 

motive that provides a sense of purpose or reason to think, speak, or 

behave in a certain manner. It provides an answer to the “why” questions 

in life. 

• Values are cherished beliefs and standards that provide a framework 

through which a person may think, speak, or behave. Values provide a 

person with a “moral compass,” indicating for that person what is right 

or wrong. These are the principles through which one perceives and 

defines his or her world.

• Transcendence relates to that which is beyond one’s self. It includes an 

awareness and appreciation of the vastness of the universe, as well as an 

awareness of or belief in a force, spiritual being, higher power, or entity 

that is beyond, outside, or greater than one’s self. 

• Connection refers to the link or perceived link that one has with other 

human beings, other living organisms, the earth, the universe, or a force, 

spiritual being, higher power, or entity that is beyond, outside of, or 
112 H Promoting Successful Integration

greater than one’s self. It can also relate to one’s understanding of our 

interdependence with others, as well as with the world at large.

Dr Harold Koenig, MD—Director of the Center for Spirituality, Theology, and Health; and Professor of Psychiatry and Behavioral Sciences and 

Associate Professor of Medicine at Duke University—reviewed 724 quantitative research studies examining the relation between religion and mental 

health in five areas: (1) depression, (2) suicide, (3) anxiety, (4) psychotic disorders, and (5) substance abuse.4

 The majority of these studies (476 of them) 

reported statistically significant positive associations between spirituality or 

practicing a religion and the ability to cope. Koenig states, 

Religious beliefs provide a sense of meaning and purpose during difficult life circumstances that assist with psychological integration; they 

usually promote a positive world view that is optimistic and hopeful; 

they provide role models in sacred writings that facilitate acceptance of 

suffering; they give people a sense of indirect control over circumstances, 

reducing the need for personal control; and they offer a community of 

support, both human and divine, to help reduce isolation and loneliness. 

Unlike many other coping resources, religion is available to anyone at 

any time, regardless of financial, social, physical, or mental 

circumstances.4(p285) 

Additionally, Smith et al,5 in their review of spirituality and resilience studies, 

state that 

. . . healthy spirituality may be related to increases in both resilience and 

positive emotions and that resilience and positive emotions may have a 

reciprocal influence on each other.5(p450)

The benefits of a positive and deep spirituality cannot be denied or 

ignored. There is a mountain of scientific evidence that supports the contribution of spiritual practices and well-being to physical, psychological, and social 

well-being. According to the book Spiritual Resilience: Renewing the Soldier’s 

Mind,6 numerous research studies show that spiritual practices increase health 

and physical well-being, psychological and emotional well-being, and family 

and social well-being.7 Consequently, it is clear that although the existence of a 

human soul, spirit, or life force cannot be scientifically proven, a healthy positive spirituality can have numerous benefits on one’s overall health. It is one 

more tool in the Service Member’s toolbox that can and should be leveraged to 
S p i r i t u a l i t y a n d Rei n teg r at i o n H 113

assist Warriors as they reintegrate into their circles of family, friends, acquaintances, neighborhoods, coworkers, civic organizations, volunteer service organizations, and other communities to which they belong or hope to belong. 

PATHWAYS OR PLATFORMS TO HELP DEVELOP OR 

DEEPEN ONE’S SPIRITUALITY

As noted previously, spirituality and religious observance are not the same. 

One may be a spiritual person without being religious or, conversely, one 

may be religious without having a deep spirituality. In this section, various 

pathways or platforms are discussed that can help develop or deepen one’s 

spirituality, such as:

• prayer,

• sacred writings,

• meditation,

• storytelling or journaling,

• service,

• alms,

• spiritual direction,

• fasting,

• yoga, and 

• artistic expression.

Pr ayer

Prayer is not an old woman’s idle amusement. Properly understood and 

applied, it is the most potent instrument of action.

Mahatma Gandhi

Indian Political Activist (1869–1948)

It is not an accident that prayer is the first pathway or platform we offer as 

a means to deepen one’s spirituality. Many people believe that prayer is the 

most basic method of developing spirituality. Some even argue that prayer is 

instinctual. However, despite certain exceptions, prayer is a discipline that can 

be practiced by anyone, at any time, and anywhere. Some faith groups believe 

prayers may be more efficacious, depending on who is offering the prayer and 

where they are offering the prayer. But, prayer is almost universally seen as a 

practice that is available to all humanity.
114 H Promoting Successful Integration

At its most fundamental level, prayer is best described as a form of communication. It is communication between human beings and that which they 

identify as God, a god, a natural force, a spiritual force, Mother Earth, or 

something greater or beyond themselves. It can involve adoration, confession, 

thanksgiving, and supplications. It can be deliberate or spontaneous. Prayer 

can follow prescribed formats based on different traditions or cultures or it can 

be wide open and enable the person “to go where Spirit leads.” Prayer can be 

performed corporately as a group (with or without a leader) or by individuals. 

It can be done at prescribed times or destinations, or it can be done when one 

is emotionally, intellectually, or spiritually moved to say or offer a prayer. 

Prayers may even involve different tangible objects, sacred items, or other 

materials (eg, books, candles, prayer beads, incense, etc). They can be vocalized in words or songs. Prayers may also be offered silently. Some traditions 

include repetitions in their individual and corporate prayers; other traditions 

steer clear of repetition. The common threads that run through the wide 

diversity of beliefs, traditions, and cultures are threefold: 

1. A higher power exists. 

2. This higher power commands, demands, or offers prayer as an avenue 

by which human beings may seek divine wisdom, guidance, or power. 

3. The practice of prayer leads people to become better; that is, by practicing 

the discipline of prayer, they become more compassionate, empathetic, 

sympathetic, sensitive, kind, merciful, focused, and thoughtful. 

Although it is beyond the limitations of this chapter to provide specific 

methodologies on the wide range of how various traditions or cultures 

practice prayer, we can offer a few general guidelines. For specific ways to 

practice prayer according to specific belief systems, consult a religious leader 

from that tradition or consider observing the following: 

• Find space that is conducive to prayer (ie, distractions should be minimized in order to maximize focus). This selected space may also provide 

a sense of calm, inspiration, or both. The space can be one created by 

human hands or be one that occurs in the natural environment. 

• Prepare for prayer. In some traditions, this means moving through certain 

rituals physically, emotionally, or intellectually to reach a preferred state 

for prayer, whether it means to be cleansed, centered, or connected to the 

faith community or others. It may involve elements like water, music, or 

sacred items. Sometimes, the preparation can take just a few moments, 

and at other times and in other traditions, it can take much longer.
S p i r i t u a l i t y a n d Rei n teg r at i o n H 115

• Assume a comfortable position, whether sitting, standing, kneeling, or lying prostrate. Depending on the religious tradition, hands may be folded, 

raised, or placed across the chest or at the sides. Different religious 

systems also permit accommodations for those individuals who may 

be physically challenged or unable to follow their tradition’s prescribed 

methods.

• Begin prayer. It may be initiated by singing, saying prescribed statements, 

performing certain actions, or reading from prayer books or sacred 

scriptures. Follow the tradition that is most comfortable and that is most 

meaningful. In group or directed prayer, there may be times when each 

individual may offer his or her own prayers. These prayers should reflect 

the genuine desires of the heart.

• Conclude prayer. Individuals may once again be encouraged to move 

through certain rituals to officially end this time. Their prayers may be 

concluded with certain phrases, words, or actions.

The most important thing to remember is to find a prayer tradition that 

resonates with you, one that is comfortable, and one that can be practiced 

routinely. Prayer is most beneficial when it becomes part of a normal routine.

Sa c red Wr i t i n gs 

When we follow the counsel of our leaders to read and 

study the scriptures, benefits and blessings of many kinds come to us. 

This is the most profitable of all study in which we could engage.

 

Howard W. Hunter

Attorney (1907–1995)

Every major religion has written materials that contain its traditions, beliefs, 

philosophies, instructions, and rituals. Some religions believe these texts are 

the very word of God. Others acknowledge they are the teaching or instruction of their leaders or founders. Yet some religions believe that these texts 

should be widely distributed, while others believe the texts should be reserved 

only for adherents of their faith or certain individuals within their tradition. 

Oftentimes, these writings will be translated into a variety of languages to 

give greater access to more individuals. Yet, in other situations, the writings 

are only considered to be sacred in their original language. The common 

theme that runs through all of these texts is their authority and instruction 

in relation to the faith that claims them. There is often, although not always, 

stern warnings against adding to or subtracting from the texts.
116 H Promoting Successful Integration

Whatever faith one embraces, it should be acknowledged that all of these 

religious texts contain wisdom, guidance, and advice, which if followed can 

lead to a fuller, richer, and happier life. The wisdom, instruction, and inspiration found within these texts are major reasons that we encourage Warriors 

who are reintegrating into their communities and who are seeking to build 

their spiritual resiliency to intentionally involve themselves in this type of 

study because there is so much to be gained. 

But how should one go about studying the sacred texts of his or her faith? 

As in the section on prayer, we encourage Warriors to seek out religious leaders, teachers, or scholars in the tradition that specifically interests them. Different faiths suggest different approaches to the study of sacred texts. If, however, 

one is seeking general guidance, then we offer the following suggestions.

• Find a place and time to read or study without distraction. Interruptions 

should be avoided if at all possible. Pause for a few moments to separate 

yourself from all concerns in order to focus on the text. If your tradition 

encourages it, pray to receive divine guidance.

• Read slowly and deliberately according to your tradition. Some faiths 

encourage the texts to be read aloud, even if one is alone, and other faiths 

permit the texts to be read silently. Still some faiths demand that the reading be done in its original “tongue,” whereas other faiths permit reading 

in the reader’s “native tongue.”

• Ask yourself these questions: 

— What is this telling me about God or the Divine? 

— What is it teaching me about humanity? 

— What is it telling me about myself? 

— What is the proper response to what I have read?

• Take time to offer prayers or to journal about your experience. Journaling has the added benefit of the person being able to return to it and to 

see again the inspiration or instruction perceived through personal study.

The simple truth is that Warriors would do well to avail themselves of the 

wisdom, instruction, and guidance of these sacred texts. They have provided 

information and inspiration to countless people and can do the same for 

today’s Warrior. 
S p i r i t u a l i t y a n d Rei n teg r at i o n H 117

Med i tat i o n

Meditation is the life of the soul; action, the soul of meditation; 

and honor, the reward of action. 

Francis Quarles

English Poet (1592–1644) 

The practice of meditation, active for centuries in the Eastern tradition, has 

had a popular following in Western culture for less than a century. People 

who practice meditation do so for many reasons:

• to consciously increase nonanalytical attention,

• to emphasize and engender positivity,

• to increase the internal capacity for healing, and 

• to reduce symptoms of pain and alleviate discomfort. 

Many people meditate simply to create a quiet place of solitary focus and 

to develop a serene, internal ability to dispel random or mindless thoughts 

and ruminations. Advocates of meditation say the ability to calm thoughts 

and focus the mind through meditation is a life-changing experience. This 

fairly simple and low-cost practice, essentially available to anyone who seeks 

to learn the techniques, is believed to be a powerful and healing tool—one 

that can conquer the cacophony of thoughts that often serves as a barrier to 

pursuing and achieving a life of meaning. 

 Initially, meditation was conceived within the religious framework of 

Eastern cultures. Prayer and meditation are still linked today as personal 

activities designed to quiet inner conflict and open mind and soul to the influence from a different power typically not thought to be emanating from the 

individual. Although many types of techniques exist, the family of meditation 

practice falls generally into three specific categories:

1. concentrative meditation, 

2. mindfulness meditation, or 

3. contemplative meditation. 

As the term conveys, concentrative meditation, on one hand, focuses on 

a specific object or concept. Sometimes a word, phrase, or mantra is the tool. 

The goal is to focus thought in a nonanalytical way, using the sole object as 

an aid to prevent distracting intellectual or emotional noise from interfer-
118 H Promoting Successful Integration

ing with the session. Mindfulness meditation, on the other hand, applies a 

broader technique in which the individual remains aware of the environment 

(ie, sounds, scents, etc), but prevents definitions or judgments about it—that is, 

the person is conscious of the environment, but does not ruminate or engage 

in targeted thinking about anything that he or she might hear, sense, smell, or 

feel. Contemplative meditation seeks to create a quiet place where the individual can engage with the presence of a higher power, whether interpreted as the 

presence of God or some other religious/nonreligious entity. This model applies 

aspects of concentrative and mindfulness meditations, in that the individual is 

focusing on the potential of engaging with a specific entity or source of power, 

as well as creating an open mind that allows greater awareness. 

When an individual chooses to meditate, he or she may follow a number 

of common rituals to prepare for each session. Although meditation practices 

differ, most techniques are easily adapted to any environment. Consider these 

techniques and suggestions: 

 

• Begin with brief sessions lasting a few minutes and build to longer 

periods.

• Be aware that some meditation sessions may be more successful or 

beneficial than others.

• Ask a friend or family member who meditates to lead a session. 

• Wear comfortable clothing that does not restrict movement.

• Choose a physical position that is comfortable and supports the back, 

hips, and neck whether sitting, fully reclining, leaning against a wall, or 

standing. 

• Select a quiet location: A brightly lit patio sheltered from the elements; a 

dark, comfortable interior room; or a park or garden that offers privacy.

• Choose the same time of day to meditate: Morning meditation can 

prepare the individual to meet each day with focus; mid-day meditation 

can help reduce stress and anxiety that has built up during the day; and 

evening meditation may support the reduction of tension, thus enabling 

more restful sleep.

• Utilize a meditation audio or video track: Essential sounds like rain, 

wind, or waves are commonly used as background elements; bells or 

chimes are often used to signal pacing during the session; a meditation 

track can be recorded using sounds, voices, or music that is personally 

meaningful.
S p i r i t u a l i t y a n d Rei n teg r at i o n H 119

St o ry tel l i n g o r J o u r n a l i n g

Storytelling reveals meaning without committing the 

error of defining it.

Hannah Arendt

German Historian (1906–1975) 

How often are favorite stories told over and over, with the storyteller relishing the details and possibly even gaining greater insight into different aspects 

of the tale unrealized in earlier versions? The history of storytelling is as long 

and diverse as humankind. In most cultures, the telling of stories—either 

orally or in written form—serves as documentation of the past and may come 

to play an important function in that culture’s future. Although generally we 

might consider storytelling a form of entertainment, one of the major properties of self-disclosure may be healing, particularly for those who have suffered 

trauma. 

More than 95% of emotional experiences are typically shared within a 

few hours.8 Although talking about traumatic events may be the norm for 

many people, some experiences are too difficult to share in conversation 

with others. Under these circumstances, storytelling through writing—often 

referred to as “journaling” in the psychotherapy field—can serve as a therapeutic tool to help individuals explore trauma without attempting to define 

or solve it. 

The benefits of therapeutic writing can result in emotional, cognitive, and 

social improvements. An individual who has experienced trauma may have 

difficulty disclosing the incident, resulting in isolation and depression. Because 

of overwhelming emotions, many individuals find themselves inhibited from 

disclosing the experience. A research effort documented that individuals who 

experienced a significant and specific traumatic incident and did not disclose 

it were more likely to have significant health issues over an extended period of 

time, including hospitalization, ulcers, and high blood pressure.9 Because talking about trauma may not come easily, writing can act as an emotionally safe 

way in which to disclose the incident, even if no one ever reads the writer’s 

words. The process of releasing the trauma through words may foster an 

emotional release, and the writer may find some relief in sharing the incident, 

if only on a piece of paper or a computer screen. 

Gestalt psychologists’ views of perception reveal that when individuals 

experience trauma, they disconnect from their core identity. The disconnect 

from “themselves” continues to deepen as they repress thoughts and feelings about the trauma.10 The unfortunate outcome is often that individuals 
120 H Promoting Successful Integration

who have experienced trauma behave in exactly a manner that prevents 

them from processing what happened; they cannot confront the experience 

in their minds or through their emotions. This cognitive challenge may not 

be resolved easily. Writing or storytelling, however, can provide a structured 

and prescribed process for documenting experiences that may help the writer 

realize possible connections that occurred during trauma. Even if there is no 

indication of a cause and effect related to the trauma, documenting it through 

storytelling may help the individual gain a sense of control and predictability 

by evaluating the experience through writing and recording the circumstances 

in his or her own words, without fear of reprisal or judgment. 

From a social perspective, the isolation an individual experiences in the 

wake of a trauma incident only exacerbates the inherent instinct to retreat 

and withdraw from contact with the outside world. However, writing circles 

mirror the conversational and social structure of book clubs, in which participants write on an assigned topic and share their stories with members of the 

group. Not only have members of writing circles expressed satisfaction with 

the personal insights gained by writing together, but also they report receiving 

immediate benefit from the feedback and input provided by other members 

of the circle in response to sharing stories. An added benefit with technology 

advances is that many writing circles are virtual and do not require members 

to travel to be able to write and share stories. 

Another benefit of therapeutic writing is not actually the writing process 

itself, but the preparation to write. The rituals that writers often engage in 

prior to writing serve as a kind of meditation. Going through the same motions every time an individual tells a story may create an environment of control and order, particularly if the outcome of the trauma incident was a sense 

of chaos or unpredictability. Some rituals storytellers might use to prepare 

themselves include the following: 

• Create a quiet place in which to write—a home office, a comfortable 

chair, or a corner in a favorite room.

• Choose to tell your story at the same time every day—dedicate a halfhour that is your time to think about your story, tell it, or write about it.

• Fuel yourself with a favorite cup of coffee or tea.

• Begin your writing or storytelling session with physical rituals, such as 

stretching exercises or deep breathing techniques.

• Reward yourself for completing a story with a pleasurable activity, such 

as reading, meeting a friend for coffee, or taking a bike ride.
S p i r i t u a l i t y a n d Rei n teg r at i o n H 121

Service Members who are reintegrating into their communities may think 

about whether storytelling or writing is an activity they want to pursue and 

should consider the following: 

• Use a digital recorder to talk about your story instead of telling it to 

another person. 

• Tell or write your story with a different beginning or ending, and evaluate 

your thoughts and feelings about the impact.

Think over these questions:

• If you could tell anyone your story, who would it be?

• Is your story something that you want future generations to hear or read? 

• How can someone benefit or learn from hearing or reading your story? 

• How might sharing your story prevent something negative or bad from 

happening to someone? 

• Might there be a time in the future when you no longer want or need to 

write or tell your story?

Serv i ce

In the end, the number of prayers we say 

may contribute to our happiness, but the number of prayers we answer 

may be of even greater importance.

Dieter Friedrich Uchtdorf

German Aviator (1940– )

For centuries, human beings have helped one another, demonstrating a 

long-standing legacy of altruistic behavior. There are countless examples of 

individuals—both famous and not—throughout history for whom service 

to people and community represented a life philosophy. Milton S Hershey 

(1857–1945) was a leading figure in philanthropy and gave economic and 

educational support to the community of central Pennsylvania. Mother 

Teresa (1910–1997) was an international symbol for selflessness and the 

power of collective service to those in great need. Myriad other individuals—

ranging from Clara Brown (1800–1885) to Andrew Carnegie (1835–1919) 

and from Dana Reeve (1961–2006) to J P Morgan, Jr (1867–1943)—have 

committed time, energy, money, and other valuable personal resources for the 

honorable purpose of helping humankind and the broader society. 
122 H Promoting Successful Integration

Social and psychological research have identified several underlying 

motivators for why we help others. The most common altruistic motivator 

is what researchers call an “other-oriented emotional reaction,” typically 

defined as empathy, compassion, sympathy, or sometimes, pity.11 For decades, 

philosophers and psychologists have written about empathy as the primary 

foundation for why humans continue to help one another without expectation of anything in return. Two other motivators—perhaps not as familiar to 

the general public—have been suggested: (1) collectivism and (2) principlism. 

Collectivism, on one hand, stems from the need to benefit a group as a whole, 

which is thought to be connected to our need for group identity. Principlism, 

on the other hand, is defined by the instinct to act simply to uphold a broad 

and impersonal moral principle, such as justice. 

Regardless of the motivation that moves someone to help another person, 

the benefit from giving and being in service to individuals or a community has 

been well documented. Because empathy can motivate behavior to give to 

others, therapeutic programs are now suggesting the use of empathy-based tactics directed toward enhancing positive social interactions. These practices are 

very different from traditional therapy programs that often focus on controlling or inhibiting negative behavior. Instead, empathy-based tactics encourage 

developing a broader perspective and improving interpersonal relationships 

through the pursuit of common goals. Empathy-based tactics are also being 

used to reduce negative attitudes toward groups of people who are stigmatized 

by various factors, including gender, race, culture, and military service. 

There are thousands of groups and organizations that provide service 

opportunities, from nonprofits, schools, and foundations to churches and 

other faith-based institutions. Many resources exist to identify and select 

a cause that can benefit from your expertise. In considering if you want to 

engage in service to individuals or the broader community, think about the 

following questions as you weigh your options: 

• What do you enjoy doing in your free time that could benefit others?

• Is there a specific mental or physical health issue in your background 

that you would like to resolve? If so, is there a nonprofit organization 

located in your community that could benefit from your experience with 

a specific issue? 

• What unique expertise or experience have you gained that could benefit 

someone else?

• What type of service work could include your partner and/or family? 

• How much time or money do you want to commit in service to individuals or your community?
S p i r i t u a l i t y a n d Rei n teg r at i o n H 123

Al ms

Prayer carries us half way to God, 

fasting brings us to the door of His palace, and 

alms-giving procures us admission.

The Quran

(c. 651 ad)

Alms can be defined as money, goods, or certain sentiments given to others. 

Almost all faith traditions encourage or even require their adherents to participate in sharing their material resources with those in need. The word alms

comes from an old English word, ælmes, which can be translated as mercy. 

Therefore, when one is giving alms, that individual is also showing mercy 

and/or respect. Many traditions suggest that because God shows humanity 

mercy, it is incumbent upon the entire human race to show mercy, kindness, 

and respect to others. This may be accomplished through the giving of alms.

Alms-giving can be done voluntarily or as an act of obligation. Some 

faith traditions (eg, Judaism, Christianity, and Islam) establish guidelines as 

to what percentage of one’s income or business resources should be given as 

alms. Other faith traditions (eg, Buddhism or Hinduism) restrict financial 

dispersements and instead encourage the distribution and sharing of food and 

drink. It is important for Warriors to discuss with others who share their faith 

tradition, the rationale, expectations, and options for alms-giving.

One common thread that weaves the various tapestries of alms-giving 

together is that alms should be given secretly or privately. They should not 

be given because of a desire to show off, to impress others, or to gain something for oneself. Instead, alms should be given discreetly without the desire 

of seeking the praise or approval of others. One should not seek reward or 

recognition for oneself while sharing what is that person’s. Thus, the amount 

of one’s gift is not as important as the purity or sympathy of one’s heart. The 

more pure or more sympathetic the gift, the better. Various traditions suggest 

that the giver will be rewarded for his or her altruistic behavior. Some traditions believe that the reward will come in this life, others believe it will come 

in the next life, and still other traditions believe there will be a combination 

of the two.

There are a wide variety of methods that can be used to donate alms, 

depending on one’s faith tradition and community’s culture. There are also 

an almost seemingly endless number of recipients to whom one may donate, 

again depending on the traditions and teaching of one’s faith community. 

Some methods encourage giving only to charities within their own religious 
124 H Promoting Successful Integration

tradition, other methods encourage a broad array of charitable possibilities, 

and other methods permit secular nonprofit organizations or charities. The 

Warrior and his or her loved ones will be best served by seeking the counsel 

of authorities within their tradition. Nevertheless, we still offer the following 

words of counsel:

• Do your due diligence. In other words, verify that the charity, organization, or person to whom you intend to donate is legitimate and not simply seeking to play on your heartstrings to steal from you. Be sure that 

the receiver will use the gifts wisely. Some charities have higher overhead 

and thus fewer dollars reaching their intended audiences.

• Follow your heart or personal interest (if permissible within your faith 

tradition) to the charity of your choice. Perhaps you would rather give to 

a Wounded Warriors fund than a religious charity or maybe give to some 

other 501(c)(3). When you donate to a 501(c)(3), your donation can be 

written off on your tax return. Be sure to consult your tax preparer for 

specific details.

• Consider including your favorite charity in your will. Gifts of this type 

can have a long and lasting legacy. Consult your financial advisor or 

attorney for details. Whatever decisions you make, and although it may 

seem counterintuitive, many people from a variety of faith traditions will 

testify that the more they give away, the more they have.

S p i r i t u a l Di rec t i o n

What we need to do is bring the director into contact with 

our real self, as best we can, and not fear to let him see what is false in 

our false self. . . .We must let the director know what we really think, 

what we really feel, and what we really desire, even when 

these things are not altogether honorable. . . . Hence, we should 

approach direction in a spirit of humility and compunction, 

ready to manifest things of which we are not proud.

Thomas Merton

Trappist Monk (1915–1968)

Long before personal trainers existed for athletes or personal financial advisers sprang onto the scene to assist investors, spiritual guides or directors were 

teaching neophyte seekers the deeper truths and mysteries of their faith. The 

spiritual guides or directors did not claim to possess all knowledge or all 

truth. They possessed knowledge, wisdom, and patience and gladly invested 
S p i r i t u a l i t y a n d Rei n teg r at i o n H 125

themselves in their students or devotees to make their experience of faith 

richer or deeper. Together, the director and devotee explore the various ways 

in which God may be touching the devotee’s life; calling the devotee to action; 

and bringing the devotee to a place of more meaningful peace, joy, service, 

and satisfaction. Although a guide and seeker may discuss relationships, finances, work, and other aspects of life, the guide is not a counselor, therapist, 

or financial advisor. Guides are deeply contemplative people who are committed to assisting other people grow closer to their God, find deeper meaning 

in life, and tell their personal stories in ways that reveal the movement of the 

Holy. It is this focus on seeing life through the lens of the Divine and always 

returning each conversation to the Divine that distinguishes spiritual direction 

from other forms of mentor and mentee relationships.

Spiritual directors can be found in almost every faith tradition, although 

they may be called by different names or titles. Some traditions are even 

beginning to steer away from the verbiage “spiritual direction” because they 

interpret such language as pedantic or condescending. They prefer to describe 

the relationship as a spiritual friendship or companionship. Whatever the case 

may be, 

The director is one who knows and sympathizes, who makes allowances, 

who understands circumstances, who is not in a hurry, who is patiently 

and humbly waiting for indications of God’s action in the soul. He is 

concerned not just with this or that urgent problem, this or that sin, but 

with the whole life of the soul. He is not interested merely in our actions. 

He is much more interested in the basic attitudes of our soul, our inmost 

aspirations, our way of meeting difficulties, our mode of responding to 

good and evil. In a word, the director is interested in our very self, in all 

its uniqueness, its pitiable misery and its breathtaking greatness. A true 

director can never get over the awe he feels in the presence of a person, 

an immortal soul. . . .12(p21)

 

For those who are interested in such a relationship or seek a deeper, more 

meaningful way of seeing and describing the movement and mystery of God 

in their lives, we offer the following suggestions:

• Before you seek a spiritual guide or director, spend time contemplating 

what you are seeking or what you hope to achieve from spiritual direction. You should also ask the following questions:

— Are you ready or prepared to invest yourself as will be required by 

your spiritual guide?
126 H Promoting Successful Integration

— Are you prepared for the brutal honesty required? 

— Are you prepared to invest the necessary time? 

— Are you prepared to immerse yourself totally in this platform of 

growth and discovery?

• Once you know what you are hoping to achieve, gain, or experience 

from spiritual direction, and you know that you are willing to pay the 

price required, you can begin to seek a guide. You might ask the leaders of your community of faith for their recommendations. You can ask 

friends or other adherents to your faith where they have found spiritual 

guides. You might also search online according to your particular tradition. 

• Once you have found spiritual directors who meet your desired religious 

affiliations, meet with them. Discuss your hopes and aspirations. Test the 

waters to see if you intuitively trust and respect them. There may be times 

during the course of your direction when you are uncomfortable, and 

you must be sure you can completely trust this person.

Fast i n g

I fast for greater physical and mental efficiency.

Plato

Greek Philosopher and

Mathematician (428–348 bce)

Making the conscious decision not to eat, for a prescribed period of time 

(fasting), is an increasingly popular method by which to cleanse and rebalance 

the physiological structure of the body. Therapeutic fasting is a treatment 

philosophy advocated by the International Association of Hygienic Physicians (IAHP; Youngstown, OH), an association comprised of primary care 

physicians who specialize in the supervision of therapeutic fasting. Certified 

members must be a licensed medical doctor, chiropractor, or osteopath who 

has completed a minimum 6-month residency program in an accredited institution specializing in therapeutic fasting.

There are many forms of fasting or cleansing available to consumers, 

using juices and supplements, specific food groups, and different combinations of ingredients and additives. Anyone considering entering into a fasting 

or cleansing program should have a forthright conversation with his or her 

primary care physician to discuss the positive and negative implications of a 

fasting program. For the purposes of this chapter, therapeutic fasting, as 
S p i r i t u a l i t y a n d Rei n teg r at i o n H 127

defined by the IAHP, will be the primary focus. It is defined as abstinence 

from all substances, except for pure water, under conditions of complete rest 

and with the supervision of an IAHP-certified physician.

13

Physicians who attend to fasting under the IAHP guidelines identify 

therapeutic fasting as a tool for isolating issues within the body and stimulating an acute response to address the issues. If the body is focusing solely on 

processing only pure water and sitting at complete rest, it is more likely to 

target a directed and intense response to a specific symptom or condition. Often, therapeutic fasting is recommended for patients with an acute illness, and 

that fasting process is designed to isolate and address particular symptoms.13

Therapeutic fasting has been successful in treating patients with chronic illnesses. It has also been used as a tool to create a clean, physiological foundation for the patient to engage in treatment. 

When a patient is fasting, the body undergoes a purification of its tissue, 

organs, and metabolic processes. This process allows the body to let stressed 

and abused areas slough off any abnormal elements and return to a clean 

state. Scientific and medical literature contain hundreds of references on the 

use and implications of therapeutic fasting. The practice has been used extensively, and successfully, in the treatment of a variety of conditions—including 

obesity, diabetes, cancer, and autoimmune diseases—applied to psychiatric 

disorders (eg, schizophrenia), and utilized as a desensitization tool in the 

treatment of hypersensitivity and allergies. 

Many people associate fasting with the concept of rejuvenating and 

“cleaning house,” both mentally and physically. Often accompanied by 

meditative practices, fasting can provide a medically sound tool for eliminating accumulated debris in the body’s systems and supporting a heightened 

internal focus on emotional, intellectual, and physical wellness. 

When considering a fasting regimen:

• Consult your primary care physician first, before selecting a fasting or 

cleansing process.

• Follow all directions and guidelines associated with any specific fasting 

program.

• Monitor a fasting program as determined by your doctor’s recommendation.

• Ask a friend or family member to participate in the program with you, 

for support and as a resource to discuss your progress and outcome.
128 H Promoting Successful Integration

Y o g a

Blessed are the flexible, for they shall not be bent out of shape.

Anonymous

There are estimates that somewhere between 15 and 20 million Americans 

practice yoga.13 At its core, the word yoga means to “yoke, to unite, to join 

together” and can provide a bridge from the body to one’s own inner wisdom.14 Beyond the pain relief, boost in mental performance, stress reduction, 

and overall strength and flexibility it claims to offer,15,16 yoga is a tool people 

can draw upon to deepen their connection with their inner spirit. The practice 

of yoga is one tool for providing a timeless answer for those who quest for a 

deeper meaning in life and who desire abiding peace. Yoga classes are offered 

on many military installations. From elite Soldier–athletes who use yoga to 

build strength and flexibility to those recovering from posttraumatic stress 

disorder and other war injuries, the 4,000-year-old tradition of yoga offers 

resilience-building skills for Service Members, Veterans, and their families. 

There are many forms and specific practices of yoga. Hot yoga classes 

offer fast-moving posture flows, and therapeutic yoga helps to rehabilitate 

people recovering from physical injuries. Other yoga classes emphasize balancing the nervous system before building strength in order to relieve stress, 

anxiety, depression, or even posttraumatic stress disorder. The many different 

styles and techniques of yoga offer something for everyone. The inner focus; 

the combination of practicing breathing exercises; and the practice of moving 

the body into poses with mindful, compassionate, present-moment awareness 

is part of the recipe that creates a sense of ease, calm, openness, strength, and 

flexibility in both body and mind. 

For the purpose of reintegration, offering therapeutic, trauma-sensitive 

yoga classes invites a sense of safety or “groundedness” in one’s inner self. It 

can foster a deep connection internally to one’s spiritual side, thus connecting or yoking that person’s soul to God—however that individual sees God. 

It also bolsters a sense of community when offered on military installations 

where practitioners share the gifts of practice together. Consider the following 

story of a military wife: 

Our life was somewhat chaotic. While raising three young kids with 

moves every year or two (once moved four years in a row), it was my 

job to keep the home together and children educated in good schools 

as we packed and unpacked one year to the next. I was under so much 

pressure—way more than I understood. I lost my faith as I felt like God 
S p i r i t u a l i t y a n d Rei n teg r at i o n H 129

wasn’t listening to me. I had a lot of pain, and not much less sorrow. 

My husband’s work kept him away far too much for the kids and me. 

I stepped onto a yoga mat with some skepticism to experience almost immediate relief from my endless aching back. I felt a quiet in my body and 

soul that had left me. That sense of stillness returned my soul to life, and 

inspired me—with far more peace and wholeness than I had felt in 

years. (Name withheld by request, oral communication, January 2013.)

For people who are seeking another tool for their toolbox to assist with inner 

healing, resilience-building, and stress management while reintegrating after 

deployment, yoga may just be the answer.

Art i st i c Ex p ress i o n

The purpose of art is washing the dust of daily life off our souls. 

Pablo Picasso

Spanish Artist (1881–1973)

The link between being creative and expressing emotion has a long and 

complex history. Creativity has been defined as a neocortical activity, whereas 

emotions are often considered, psychologically speaking, as a “lower” form 

of thought process. Many scientists, psychologists, psychiatrists, and other 

professionals across different areas of expertise have studied the connection 

between expressing creativity through artistic pursuits and the impact it has on 

emotions. Regardless of what historical and academic research document, the 

end result is this: for thousands of years, artists have created works that have 

changed their lives and the lives of others who experienced or viewed their art. 

So, how can creativity and expressing emotions and thoughts through the 

creative process be helpful? The American Art Therapy Association (Alexandria, VA) defines the practice as a mental health profession in which clients—

facilitated by the art therapist—use art media, the creative process, and any 

resulting artwork to

• explore their feelings, 

• reconcile emotional conflicts, 

• foster self-awareness, 

• manage behavior and addictions, 

• develop social skills, 

• improve reality orientation, 

• reduce anxiety, and 

• increase self-esteem. 
130 H Promoting Successful Integration

PRAYER

Online resources:

• http://www.churchofengland.org/prayer-worship/learnpray.aspx

• http://www.arabacademy.com/en/downloads/learn-how-to-pray

• http://www.myjewishlearning.com/practices/Ritual/Prayer.shtml

Books:

• Bennet S. Wisdom Walk: Nine Practices for Creating Peace and Balance from the 

World’s Spiritual Traditions. Novato, CA: New World Library; 2007.

• Blythe TA. 50 Ways to Pray: Practices from Many Traditions and Times. Nashville, TN: 

Abington Press; 2006.

SACRED WRITINGS

Online resources:

• http://www.faithology.com/

• http://www.sacred-texts.com/index.htm

MEDITATION

Myriad resources exist on meditation, ranging from its history and practice to specific techniques. 

Searching the Internet will result in a number of sites to explore. Essential health and wellness 

information are cited on the National Institutes of Health and the Mayo Clinic sites. Two sites—

(1) Learning Meditation and (2) Zen Habits—offer, respectively, free downloadable meditation 

sessions and specific calming and focus tactics for beginners. In-depth information about the 

therapeutic effects of meditation can be found in numerous scientific and academic journals, 

including the American Journal of Psychotherapy, the Journal of Counseling Psychology, the 

Journal of Social Behavior and Personality, etc. 

Health and wellness:

• http://nccam.nih.gov/health/meditation/overview.htm

• http://www.mayoclinic.com/health/meditation/HQ01070

Free tools and techniques:

• http://www.learningmeditation.com (offers downloadable meditation sessions)

• http://zenhabits.net/meditation-for-beginners-20-practical-tips-for-quieting-the-mind

STORYTELLING OR JOURNALING

Resources for storytelling and journaling:

• Andrew EJ. Writing the Sacred Journey: The Art and Practice of Spiritual Memoir. Boston, 

MA: Skinner House Books; 2005.

• Jepson J. Writing as a Sacred Path: A Practical Guide to Writing with Passion and Purpose. 

Berkeley, CA: Ten Speed Press; 2008.

• Shapiro R. Writing—The Sacred Art: Beyond the Page to Spiritual Practice. Woodstock, VT: 

Skylight Paths Publishing; 2012.

Ex h i b i t 5-1. Available Resources on Spirituality
S p i r i t u a l i t y a n d Rei n teg r at i o n H 131

SERVICE

Online resources:

• www.serve.gov—The Corporation for National and Community Service provides information and opportunities to engage in community service at local and national levels.

• www.charitynavigator.org—Charity Navigator is a comprehensive Web site that provides 

information about the viability and transparency of nonprofit organizations, helping volunteers to select the right charity for their interest. 

• www.unitedway.org—Visit the United Way agency for your specific community. Agencies 

like the United Way offer specific days of service during the year that are organized by 

local coordinators and designed to introduce individuals to ongoing community service 

options. 

ALMS-GIVING

Online resources:

• http://www.allahsword.com/free_islamic_books_zakah.html

• http://www.catholiceducation.org/articles/apologetics/ap0413.htm

• http://www.telegraph.co.uk/travel/destinations/asia/laos/9808241/Luang-PrabangRespecting-the-alms-giving-ritual.html

SPIRITUAL DIRECTION

Online resources:

• http://www.shalem.org/index.php/resources/publications/pamphlets-on-spiritualdirection/spiritual-direction

• http://www.rootedinspirit.org/spiritual-direction/definition/

• http://www.sdiworld.org/find-a-spiritual-director/what-is-spiritual-direction

Books:

• Merton T. Thomas Merton: Spiritual Direction and Meditation. Collegeville, MN: 

The Order of St. Benedict, Inc; 1960.

• Nouwen HJM. Wisdom for the Long Walk of Faith. New York, NY: Harper Collins 

Publishers; 2006.

• Vest N, ed. Tending the Holy: Spiritual Direction Across Traditions. Harrisburg, PA: 

Morehouse Publishers; 2003. 

FASTING

Online resources:

• http://www.healthpromoting.com/learning-center/articles/fasting

• http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1274154/

• http://www.cancer.org/treatment/treatmentsandsideeffects/complementaryandalternativemedicine/dietandnutrition/fasting

YOGA

Online resource:

• http://www.yogajournal.com/category/beginners/ 

Books:

• Feuerstein G, Payne L, eds. Yoga for Dummies, 2nd ed. Indianapolis, IN: Wiley Publishing 

House; 2010.

• Perlmutter L. The Heart and Science of Yoga. Averill Park, NY: AMI Publishing; 2005.
132 H Promoting Successful Integration

Documented art therapy results have been realized for patients experiencing 

cognitive decline. In addition, aggressive behavior has decreased through the 

use of art therapy. 

Whether experiencing art by putting a paintbrush to paper, molding 

a clay figure, layering colored sand in a glass jar, or beating on drums, the 

creative process allows the artist to focus on an activity that creates a window for evaluating emotions from afar—often enabling the artist to resolve 

thoughts about those emotions. Some have described the process of creating 

art as a state of meditation, away from day-to-day stressors. The end result 

of creating the art, regardless of the finished product, often provides a 

feeling of accomplishment and satisfaction for the artist. 

The American Art Therapy Association offers extensive background 

and information about art therapy options. It recommends seeking a trained 

and certified art therapist, particularly if the process involves treating fragile 

patients working out deep-seated issues. In these situations, art therapy must 

be performed in a private environment that allows patients to safely forget 

the outside world and express their innermost feelings.

RESOURCES

The number of resources available to develop one’s own spirituality is virtually unlimited. As noted previously, we encourage Warriors and their loved 

ones to seek the guidance of leaders, teachers, and guides within their own 

traditions or the traditions that interest them to gain instruction related to 

these spiritual disciplines. The resources listed in Exhibit 5-1 should not be 

considered an endorsement of these products, materials, books, or sites. They 

ART

Suggestions for learning more about art as a spiritual discipline:

• Visit www.arttherapy.org—The American Association for Art Therapy has more information about the history of art therapy, recommendations for local art therapy resources, and 

details about the education and certification requirements for certified art therapists. 

• For the artist who simply wants to explore art as a therapeutic tool, a number of books can 

be found online, such as Art as Therapy by Alain de Botton and John Armstrong (London, 

UK: Phaidon Press; 2013), which serves as a tool for the reader to use art as a way to 

explore and interpret daily life challenges. 

• Local craft stores and art schools are resources for classes or sessions. Look for class listings 

that include “interpretive” or “process” in the title. 

• Visit www.artastherapy.com—Art as Therapy offers various artistic works to explore when 

facing questions about life, work, self, and love, along with other topics. 
S p i r i t u a l i t y a n d Rei n teg r at i o n H 133

are simply starting points for the beginner seeker, but many more are available. Consult your faith tradition’s authorities for further guidance.

SUMMARY

There is no single best pathway or platform to develop one’s spirituality. 

Because human beings are so complex, despite our many similarities, what 

helps one person develop his or her spirituality may hinder another person’s 

growth. What appeals to one might repel another. Each person must find the 

right pathway, platform, or combination to assist with individual spiritual 

growth and development. This chapter provided empirical scientific data that 

demonstrate the positive benefits of spiritual development; shared a variety 

of pathways or platforms that Warriors and their families can use to increase 

or enhance their spiritual development; and suggested resources in which the 

reader can learn more about spiritual development, resiliency, and reintegration. Consider using the long-accepted practice of deepening your spirituality 

to accomplish this goal. Not only may you find your spirit renewed, but you 

may also find your life changed in ways you never anticipated.

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2. Wong YJ, Rew L, Slaikeu KD. A systematic review of recent research on 

adolescent religiosity/spirituality and mental health. Issues Ment Health Nurs.

2006;27:161–183.

3. Benson PL, Roehlkepartain EC, Rude SP. Spiritual development in childhood and 

adolescence: toward a field of inquiry. Appl Dev Sci. 2003;7:205–213.

4. Koenig H. Research on religion, spirituality, and mental health: a review. 

Can J Psychiatry. 2009;54:283–291.

5. Smith BW, Ortiz JA, Wiggins KT, Bernard JF, Dalen J. Spirituality, resilience, 

and positive emotions. In: Miller LJ, ed. Oxford Handbook of Psychology and 

Spirituality. Oxford, UK: Oxford University Press; 2012.

6. The Army Chaplaincy. Spiritual Resilience: Renewing the Soldier’s Mind. Fort 

Jackson, SC: Center for Spiritual Leadership; 2009. Professional Bulletin of the 

Unit Ministry Team 16-09-2.

7. Brinsfield JW, Baktis P. The human, spiritual, and ethical dimensions of leadership in preparation for combat. In: Marshall J, Franks FM, eds. The Future of the 

Army Profession. Boston, MA: McGraw-Hill Companies, Inc; 2005: 463–490.
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8. Rime B. Mental rumination, social sharing and the recovery from emotional 

exposure. In: Pennebaker JW, ed. Emotion Disclosure and Health. Washington, 

DC: American Psychological Association; 1995: 271–291.

9. Pennebaker JW. Opening Up: The Healing Power of Expressing Emotions 

(rev ed). New York, NY: Guilford; 1997.

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S p i r i t u a l i t y a n d Rei n teg r at i o n H 135

Ser gea n t (SGT) 

Mi les Ka ms o n

has found a way 

to embody a lively 

and very optimistic 

character that serves 

as a springboard for 

everyone he meets. SGT 

Kamson is a current 

active duty Soldier in 

the 1st Squadron, 104th 

Cavalry Regiment in the 

Pennsylvania National 

Guard. He was retained 

in the military after a severe motorcycle accident in which he lost his left leg 

above the knee. He continues to serve honorably, showing Soldiers that once 

we are Warriors, we can never be anything less. 

SGT Kamson was 

born in Philadelphia, 

Pennsylvania, where he 

encountered poverty, 

violence, and drugs 

in his neighborhood. 

He enlisted in the 

Pennsylvania Army 

National Guard directly 

out of high school 

in 2006 when our 

country was at war. In 

2007, he was called to 

active duty and deployed to Sinai, Arab Republic of Egypt. In 2009, once he 

returned home and back to being a traditional drilling Soldier, he pursued a 

college degree at Temple University. Quickly derailed because of a motorcycle 

accident in 2010, he not only fought for his life, but also fought for his mind 

and career. This began his toughest fight. 
136 H Promoting Successful Integration

SGT Kamson asked himself many times, “How can 

I be an asset to my commander with just one leg?” 

He has since served as a Battalion Career Counselor, 

Resilience Trainer Assistant, and Retention Noncommissioned Officer. In his community, he has 

volunteered as an Amputee Peer Visitor, Blood 

Drive Coordinator, and Red Cross Disaster Action 

Team member. SGT Kamson’s road to reintegration 

was no easy trip, and every day remains a battle. He 

believes the world has given him so much that he 

can never stop giving back. 

Not defined by his amputation, he uses patience, perseverance, professionalism, and pride to repeatedly conquer obstacles that make him resilient. 

SGT Kamson will never quit. He is not only an irreplaceable asset to his 

Commander, but also his 

unit, his community, and 

his country. 

SGT Kamson’s awards 

and decorations 

include two Army 

Commendation Medals, 

Army Achievement 

Medal, National Defense 

Service Medal, Global 

War on Terrorism 

Expeditionary and 

Service Medals, Armed 

Forces Reserve Medal 

with M Device, Army 

Service Ribbon, Overseas Service Ribbon, Multinational Force and Observers 

Medal, Army Superior Unit Award, Noncommissioned Officer Professional 

Development Ribbon, Pennsylvania Recruiting and Retention Medal, and the 

Army Reserve Components Achievement Medal. 
One of my main priorities is taking care of our 

Soldiers, Airmen, and their families. They are the foundation 

of our force and I am committed to their safety and well-being. 

Overall our families are resilient and cope with the 

stresses of deployments. Deployment is an extremely stressful 

time for all of our families. Each family is unique, 

so the circumstances of deployments affect them differently. 

Typically, they turn to various sources of support; with friends, 

family members, their spouse, Family Support Groups, and 

other family readiness personnel.

H H H

General Frank J. Grass

Chief of the National Guard Bureau

March 14, 2014

C h a p ter Si x

The Role of Friends and Family in 

Reintegration: Building Insights 

and Strategies That Promote

Reintegration and Resiliency

CHRISTINA BERCHOCK SHOOK, PsyD, ABPP*

*

Clinical Psychologist, Behavioral Health Consultation Liaison and Primary Care 

Mental Health Integration Program Leader, Lebanon VA Medical Center, 1700 South 

Lincoln Avenue, Lebanon, Pennsylvania 17042

INTRODUCTION

The wars in Iraq and Afghanistan have created significant stressors 

for Military Service Members and their families. According to the 

Department of Defense,1 more than three million family members 

have been affected by the deployment of more than two million troops to the 

Iraq and Afghanistan theaters. The challenges of reintegration on families 

are significant, given that 50% of Military personnel are married, 40% have 

children, and 64% of Military families live on military bases in more than 

4,000 communities throughout the United States.1 In addition, the duration 

of operations during the conflicts in Iraq and Afghanistan resulted in the 

deployment of unprecedented numbers of National Guard and Reserve 

forces. On average, National Guard and Reserve personnel are more likely to 

be older, partnered, and parenting, compared with their active duty counterparts.2

 In addition, multiple and longer deployments have been a hallmark 

of the conflicts in Iraq and Afghanistan. The duration of operations, the high 
140 H Pr o m o t i n g Su c cess f u l I n teg r at i o n

operational tempo, the unprecedented numbers of military Service Members 

involved, as well as the extensive use of National Guard and Reserve 

personnel in these conflicts, have highlighted the need for services to promote 

resiliency and reintegration efforts for those transitioning back to civilian and 

family life. 

Family and social relationships are impacted tremendously during the 

process of reintegration. As Service Members work to readjust to civilian life, 

their families, friends, and communities must also adjust to changes in the 

Service Member. Thus, the aims of this chapter are to describe the most common concerns related to negotiating family and social relationships throughout the deployment cycle, provide an overview of strategies to improve 

reintegration efforts in the domains of family and social relationships, and 

share resources designed to help Service Members and their families promote 

reintegration more successfully.

NEGOTIATING RELATIONSHIPS 

THROUGHOUT THE DEPLOYMENT CYCLE 

Fa m i ly

The resiliency of our Service Members and their families cannot be overstated. Military families proactively manage and adapt to unique stressors, 

including deployments, frequent relocations, and reconfigurations of the 

family system. Nevertheless, the prolonged duration of the Iraq and Afghanistan conflicts has contributed to multiple and longer deployments for Service 

Members and their families, which has resulted in increased challenges with 

reintegration. Deployments strain family relationships as spouses and children attempt to cope with the absence of a parent, fear of death or injury to 

a loved one, high levels of stress, and significant changes in the psychological 

and emotional well-being of the returning Service Member.3–5

Despite these challenges, the majority of Service Members and their families demonstrate positive adaptation during and after deployment.6

 Although 

we do not have a complete understanding of what distinguishes families who 

adapt positively from families who adapt negatively, it appears that the most 

robust protective factors for positively adapting to stressors are sensitive and 

responsive parenting and supportive family and social networks.7 Simply, the 

healthier the Service Member and family members are emotionally, spiritually, 

physically, and psychologically, the more resilient they are to stressors during 

the deployment cycle.

To understand more fully how deployment impacts family relationships, 

it is important to discuss the basic dynamics of family attachment. Attach-
The Role of Friends and Family in Reintegration H 141

ment is defined as how human beings respond within relationships when 

hurt, separated from loved ones, or perceiving a threat.8 Family attachments 

are inherently impacted by the deployment cycle because the deployment constitutes a threat to all family members’ sense of safety, causes separation from 

loved ones, and results in powerful emotional responses. 

Attachment styles—or the way in which individuals respond in relationships when they are hurt, separated, or threatened—are developed early 

in life. They provide internal working models of how to cope with stress, 

regulate emotions, and interact in close relationships.9 Individuals with secure 

or positive attachment styles (which are characterized by healthy communication, loving and supportive relationships, and strong emotional well-being) 

generally cope and adapt more easily to stress. These individuals have high 

self-efficacy and psychological well-being, are more likely to have secure relationships with their spouses, and provide sensitive and responsive parenting, 

all of which contributes to secure attachment and interpersonal relationships 

for their children. In contrast, individuals with insecure attachment styles

demonstrate anxiety and avoidance in their relationships. Individuals with 

a history of rejection by early caregivers develop internal working models 

characterized by

• distrust, 

• avoidance, 

• denial, and 

• minimization of emotions to cope in relationships. 

However, individuals with a history of inconsistent or intrusive early caregivers develop relationships characterized by

• fears of abandonment, 

• exaggerated emotional reactions, and 

• dependency. 

Any combination of these unhealthy attachment styles can result in confusion, 

fear, ineffectiveness, and the inability to develop effective coping strategies for 

stress and healthy relationships in adulthood.10

Strength and the overall health of family attachment relationships are 

important in promoting resiliency during the deployment cycle. When Service 

Members and their families are notified of deployment, the way that they respond to the anticipated separation is impacted by their degree of attachment 

to one another and the overall health of the family relationships. Regardless of attachment styles, it is completely normal for all family members to 
142 H Pr o m o t i n g Su c cess f u l I n teg r at i o n

experience anxiety, tension, and a sense of sadness and impending loss that 

may contribute to marital and family conflict, interference with parenting and 

family routines, and subsequent negative behaviors from children (eg, fear 

responses and acting-out behaviors).11

During deployment, family members often experience a sense of abandonment, numbness, mood and sleep problems, as well as anger and resentment.11 Upon return from deployment, Service Members and their families 

must resume civilian life and the multiple roles and responsibilities they have 

as partner, parent, employee, coworker, and friend. At the same time, the entire family may also be coping with a Service Member facing physical injuries 

and/or mental and behavioral health concerns (eg, depression, substance use, 

posttraumatic stress disorder [PTSD], or traumatic brain injury [TBI]) that 

further complicate the process of reintegration. All of these factors inevitably 

place stress on family relationships; but families characterized by healthy, 

strong, supportive family attachment relationships often demonstrate more 

resiliency throughout the deployment cycle. Understanding the unique reactions of each member of the family can be helpful in learning how to promote 

healthier, stronger, and more resilient family relationships.

Nondeployed Spouse/Parent Reactions

The nondeployed spouse/parent assumes responsibility for raising children, 

running the household, and maintaining the integrity of the home during a 

deployment. Spouses of Military members report that deployment results in 

loss of emotional support, loneliness, role overload, role shifts, and concerns 

about the safety and well-being of the deployed spouse.12 The response of the 

nondeployed spouse/parent is associated with a variety of coping and emotional reactions that contribute to different outcomes for the family.

A positive, healthy, and secure attachment style or mindset serves as a 

buffer against maladaptive responses to stress, and activates the individual 

to utilize internal sources of strength and external support systems.13 This 

adaptive coping response contributes to the spouse/parent’s ability to maintain psychological well-being, provides responsive parenting, and establishes 

new functional family processes in the absence of the deployed parent.10 In 

contrast, nondeployed spouses/parents with unhealthy attachment and interpersonal relationship styles often become distressed and find that their coping 

strategies break down under the added stress of loss of emotional support, 

loneliness, financial strain, role shifts, and single parenthood.10

Differences in attachment styles and stress responses affect the psychological functioning of the nondeployed spouse/parent, which in turn affects the 

entire family. A growing body of research shows increased risk for psychological distress in the nondeployed spouse/parent during deployment, which 
The Role of Friends and Family in Reintegration H 143

is associated with higher rates of depression, sleep disturbance, anxiety, acute 

stress reactions, and adjustment disorders.14 It is likely that the increased rates 

of abuse perpetrated by spouses who remain at home during deployment15

are associated with extremely elevated levels of emotional distress and lack of 

healthy coping skills among nondeployed spouses/parents. Thus, healthy coping strategies and interpersonal relationships promote adaptive stress responses, support positive parenting, and help to maintain psychological well-being 

among nondeployed spouses/parents during the deployment phase.

After deployment, during the process of reintegration, the family has to 

reorganize and shift roles to accommodate the return of the deployed parent. It is inevitable that this period of time will cause stress, confusion, and 

disagreement about role shifts, child-rearing, decision-making, and control. 

The major tasks of redefining family roles and managing strong emotions 

represent some of the greatest challenges during the process of reintegration. 

If the nondeployed spouse/parent functionally or emotionally excluded the 

deployed spouse/parent from the family system, there will likely be a power 

struggle to reassert previous family roles that the nondeployed spouse/parent 

resents because it means giving up hard-earned independence and decisionmaking authority.11 Subsequently, the parenting unit and the diligence of both 

parents/spouses in redefining roles are immensely important in promoting 

successful reintegration. Families that maintain psychological health, flexibility, 

good communication, supportive relationships, and healthy boundaries during 

deployment typically are most successful with the reintegration process. 

Children’s Reactions

Research suggests that many children exhibit high levels of resilience throughout the deployment cycle; however, more frequent or longer deployments 

result in some military parents being absent for large portions of their children’s lives.16 Separation from a key attachment figure because of deployment 

represents a significant loss for a child, and the child’s response to this loss 

will vary depending on their developmental stage, degree of attachment with 

the deployed parent, and the overall psychological and behavioral functioning 

of the nondeployed parent.10 There is a wealth of literature documenting the 

adverse psychosocial impact of deployment on children. For instance, the 

children of deployed parents demonstrate increased rates of anxiety, withdrawal, anger, conduct, and depression symptoms.4,17

In response to deployment, younger children tend to exhibit more difficulty with deployment and reintegration transitions. They are more likely 

to exhibit fear and regressive behaviors (eg, clinginess, crying, wetting the 

bed, etc),11 whereas older school-age and adolescent children may experience 

emotional dysregulation, anger, aggression, sense of abandonment, withdraw-
144 H Pr o m o t i n g Su c cess f u l I n teg r at i o n

al, or academic difficulties.5,18 The negative impact of the deploying parent’s 

departure is minimized when children feel securely attached to a nondeployed 

parent who copes adaptively and maintains responsive and stable parenting 

practices. Nondeploying parents who are unable to cope adaptively or modify 

family structure and routines may find that children respond with discomfort, 

distress, and emotional and behavioral dysregulation.

The same factors that influence a child’s response before and during 

deployment are also important during the reintegration process. It is typical 

for children to display a range of emotions and behaviors during this time. 

Very young children will often respond to the return of the deployed parent 

with normal fear responses, whereas older children may remain detached and 

ignore the returned parent for a period of time.10 Generally, the longer the 

duration of deployment separation, the greater the length of readjustment.17

Children who were securely attached and had healthy relationships prior to 

deployment are more likely to adapt and settle into a positive relationship 

with a returned parent who demonstrates healthy adjustment.10 In contrast, 

children who did not have healthy attachment relationships prior to deployment will be at the most increased risk for difficulties, such as anxiety, depression, anger, and oppositional behavior.10 Secure attachment relationships with 

the deployed parent and the nondeployed parent, as well as healthy coping 

skills, will ultimately serve as the most protective and advantageous in facilitating adaptation to reintegration.

Deployed Spouse/Parent Reactions

Most Service Members demonstrate remarkable resilience when facing a 

range of challenges at all stages of the deployment cycle. Nevertheless, reintegrating to civilian life following return from a combat deployment can often 

be the most difficult stage to navigate. Upon return from deployment, Service 

Members may have to renegotiate multiple roles and responsibilities as

• partner, 

• parent,

• employee, 

• coworker, and 

• friend.

Simultaneously, they may also face physical injuries and/or mental and 

behavioral health concerns (eg, depression, PTSD, TBI, etc) that further complicate the process of reintegration and can be significantly associated with 

parenting impairment.19
The Role of Friends and Family in Reintegration H 145

During deployment, Service Members develop and strengthen their 

vigilance and responsiveness to danger while suppressing strong emotions and 

fears. These abilities, while undoubtedly adaptive in combat, may result in difficulty adjusting to family life and the civilian world. Moreover, these responses 

that were once adaptive may now increase volatility; argumentativeness; and 

negative, coerced interactions within the family unit. Returning Service Members are at greater risk for difficulties with family relationships, parenting, and 

child adjustment, particularly if they are experiencing psychological problems. 

The health and strength of family relationships and the way in which 

the family responds to stress can mediate how much psychological difficulty 

the deployed spouse/parent will experience. A healthy and secure attachment 

relationship with the entire family system is associated with better adaptation upon return from deployment, and contributes to more effective coping 

throughout the deployment cycle. In contrast, Service Members who have 

unhealthy family relationships and poor coping skills are more likely to experience difficulty with reintegration, especially when they are experiencing mental 

health concerns. 

Service Members with trauma symptoms and PTSD are more likely to 

exhibit anger, fear, avoidance of intimacy and emotional expression, hostility, and denial, which negatively impacts the romantic relationship and the 

ability to bond and remain attached to children.13,20–22 Research with combat 

Veterans has shown that PTSD symptoms (eg, numbing and arousal) are 

especially predictive of family distress, and anger is associated with troubled 

family relationships and secondary traumatization (ie, vicarious traumatization) among family members.23

In addition, the use of substances and sleep disturbance in combination 

with psychological problems after deployment can contribute to an increased 

tendency for the Service Member to be physically present in the family unit, 

but essentially absent from the family emotionally and functionally.10 This situation represents an ambiguous loss for families and affects their reorganization 

and adaptation due to the lack of clarity regarding family roles and boundaries. This creates further confusion, disorganization, tension, and chaos within 

the home environment.12,24 Ultimately, this also creates a situation in which 

the family is confused and without a healthy sense of organization, which 

results in greater tension, exacerbation of the Service Member’s psychological 

symptoms, and further problematic family interactions. The degree to which a 

deployed spouse/parent can effectively reintegrate will be related to the degree 

in which psychological symptoms impact his or her parenting skills, as well 

as the health of the relationship with the nondeployed spouse, the degree of 

parental attachment with children, and the level of hostility and disorganization within the home. 
146 H Pr o m o t i n g Su c cess f u l I n teg r at i o n

STRATEGIES FOR IMPROVING 

RELATIONSHIPS AND REINTEGRATION

Fa m i ly Rel at i o n s h i p s a n d Res i l ie n c y

Given the wealth of literature identifying the strong associations between individual health and family health,25,26 it is crucial for Service Members and their 

families to have opportunities to not only understand the impact of deployment on themselves, but also to avail themselves of the initiatives that support 

them in reintegrating more successfully. Recommendations from the Defense 

Centers of Excellence for Psychological Health and Traumatic Brain Injury27

to improve total force fitness, as well as the Department of Defense’s1 pledge 

to strengthen Military Families, have resulted in a more holistic approach to 

reintegration programs. Studies suggest that strengthening and supporting 

parenting in Military Families for the nondeployed parent/spouse and the deployed Service Member can support the entire family unit’s adjustment during 

and following deployment. 

Integrative community care for Service Members and their families to 

strengthen resilience skills and promote more seamless transitional assistance 

has become the focus of many military organizations.28 These programs focus 

on resiliency training because higher levels of resilience are associated with 

more personal growth, less distrust in others and the world, increased selfesteem and optimism, improved self-control, and less avoidance of negative 

emotion.29 In addition, the strength of family relationships plays an important 

role in the development of Military–Family resiliency.10 Thus, military organizations and programs designed to build Military–Family resiliency emphasize 

effectively adapting to stress and maintaining physical and psychological wellbeing within the individual, the family, and the community.30

To enhance and strengthen family relationships and resiliency, an overview of strategies is provided that emphasizes the role of the family attachment network in promoting resilient family processes.10 When seeking to 

improve family resiliency and strengthen the family unit, consider the following strategies:

• Strengthen the family belief system—Families adapt well to deployment 

when they are able to find meaning in deployment. 

— Military Families exhibit higher levels of functioning when they 

display optimism for the future, a sense of mastery, spiritual 

philosophies, and a positive outlook on military life and its purpose. 

This includes patriotism and a sense of pride in the deployed 

spouse/parent.
The Role of Friends and Family in Reintegration H 147

— Families can talk about how they were changed by the experience of 

deployment, which promotes empathy and understanding. 

— Families can talk about how the family has grown stronger from the 

deployment experience, and focus on plans and goals for the future. 

— Storytelling, drawing family pictures, and reading children’s books 

about deployment are healthy ways that parents can alleviate stress 

associated with a deployment for their children. This also creates 

opportunities for children to communicate about their experience 

during the deployment cycle.

— Families can create scrapbooks about deployment that include letters, pictures, artwork, and writings to and from family members 

during the deployment. This helps to reconnect the family and create 

a family story of the time spent apart.

• Improve organizational patterns and problem-solving—Family roles and 

responsibilities inevitably shift during deployment and postdeployment. 

Reestablishing mutual support and a “secure family base” that provides 

all family members with a sense of feeling cared for contributes to better 

overall family functioning. To facilitate adjustment:

— Frame transitions as opportunities for couples/families to create a 

new normal, and renegotiate roles and tasks of family members. 

Maintain an open mind about traditional gender roles. Acknowledge 

that roles change and fluctuate to adjust successfully. Couples with 

flexible gender roles fare better in adjusting to a deployment.

— Maintain simple routines, such as family meals and bedtime rituals.

— Consider creating new rituals to replace lost ones. Parents should 

also maintain a strong hierarchical organization with clear structure 

and boundaries inside the family, as well as between the family and 

the outside world. 

• Mobilize family resources—Establish a support network between the 

family and the outside world.

— This network allows the family to benefit from social and economic 

resources. 

— Extended family and friends, as well as community and military 

support organizations, can serve an important role in supporting the 

family both during and after deployment.

— Explore opportunities to connect with the Military community, 

other Military Families, and with the deployed Service Member via 

online forums that support and enhance the flow of information and 

provide support, outreach, and information to family members.
148 H Pr o m o t i n g Su c cess f u l I n teg r at i o n

• Improve the quantity and quality of communication—Communicating 

openly about emotions and with honesty enhances family functioning 

and displays the importance of expression of feelings to children. Children and adults should be encouraged to express their feelings about 

impending deployment throughout the deployment process and upon 

return of the deployed parent/spouse. 

— It is important to avoid the tendency to “shut down” emotional 

expression within the family because it limits the ability of family 

members to support one another and obtain assistance from outside 

the family.

— Adolescents are especially perceptive of heightened negative family emotions and conflict during deployment, and will often choose 

to withhold their emotions as an attempt to minimize conflict. It is 

important that they are encouraged to express their own emotions 

and thoughts throughout the deployment cycle. 

— Encouraging open, honest, and healthy communication also provides 

opportunities for the returning Service Member to reengage with the 

family after deployment.

— Although there are practical limitations on communication during 

deployment, avoid cutting off contact between family members 

and the deployed spouse, if possible. Although some families who 

close off communication are able to establish a fairly organized 

system during deployment, they tend to have more difficulty during 

reintegration.

• Maintain an emotional and psychological presence—The stress of 

deployment and the assumption of new roles for nondeployed parents 

can be overwhelming. 

— Nondeployed parents can practice mindfulness-based exercises aimed 

at increasing one’s present awareness or the capacity to be present 

and pay attention to their children, family members, and themselves. 

Paying attention to the responses of children and their emotions is 

vital to building healthy relationships and moderating emotions.

— Nondeployed parents can also work to keep a strong bond with the 

absent parent. The ways in which this can be done are varied. You 

are limited only by your own creativity.

• Define new roles and promote healthy parent–child boundaries—Nondeployed parents are responsible for filling in the roles and responsibilities 

of the deployed spouse/parent. Defining clear roles and boundaries for 

the family during deployment helps to reduce confusion, while promoting 

task completion and adaptive reorganization of the family system. 
The Role of Friends and Family in Reintegration H 149

— Role reversals and enmeshment (ie, unclear boundaries) can be destructive to parent–child relationships and adaptation. Avoid spousification (ie, parent turns to child for companionship, friendship, and 

intimacy) and parentification (eg, excessive caregiving responsibility 

for siblings).

— Some degree of assistance from older children contributes to positive 

adaptation and functioning during deployment, but avoid extensive 

parent–child role reversals and enmeshment because it can have a 

negative impact on the psychological well-being of children and all 

family members.

• Attend a retreat focused on postdeployment reintegration that provides a 

holistic approach to enhancing community-building and resilience—The 

Coming Home Project has been recognized as a model program,27 and it 

provides retreats to Veterans, Service Members, their families, and professional care providers. 

— Activities are presented in a variety of formats, including large group 

meetings and instruction, small peer-based support and discussion 

groups, and free individual and family time. 

— Also offered is psychoeducational training in wellness (eg, relaxation, 

mindfulness, parenting, and couples communication). 

St re n g t h e n i n g Pa re n t i n g

To build healthy families that are resilient and promote more successful 

well-being during deployment and reintegration, it is necessary to strengthen 

parenting in military families as a means to support children and their parents. Decades of developmental research have demonstrated the importance 

of parenting for children’s healthy development and promoting children’s 

resilience.31 Effective parenting is critical for mediating deployment-related 

stressors and child adjustment. Effective parenting practices provide a protective buffer for children and youth during the deployment cycle.

Parent management training interventions have strong evidence for their 

efficacy and effectiveness,32 and they focus on enhancing positive parenting 

practices. Following separation due to deployment, parents often have difficulty reestablishing their roles within the family and working collaboratively 

to co-parent. It is tremendously important that parents collaborate to set 

rules, develop routines, and reestablish roles to successfully promote reintegration as a family. Parents must have joint goals for their children, practice 

effective and balanced discipline strategies, and problem-solve parenting challenges as a cohesive parenting unit. 
150 H Pr o m o t i n g Su c cess f u l I n teg r at i o n

One unique, empirically supported program that is modified specifically 

for National Guard and Reserve military families is the After Deployment: 

Adaptive Parenting Tools (ADAPT) program.2 This parent training program 

targets school-age children and focuses on military culture and the influence 

of combat stress reactions while seeking to enhance five positive parenting 

practices: (1) skill encouragement, (2) positive involvement, (3) family problem-solving, (4) monitoring, and (5) effective discipline. The ADAPT program 

is unique in that it also accounts for the challenges associated with parenting 

after combat, accounting for the unique experience of the deployed parent in 

a combat zone. Most Service Members understand and recognize the challenges of reintegration in that, while deployed in a combat zone, it is crucial 

to maintain order, vigilance, and readiness for action at any time. Although 

these skills contribute to life-saving action when needed and are highly valued 

in a combat zone, they can contribute to difficulties, such as increased volatility and argumentativeness within the family unit upon return from deployment. When returning to one’s family, Service Members must learn to adapt 

their emotional responsiveness and readiness, as well as recalibrate patience 

with their children, partners, and the civilian world. 

To enhance and strengthen parenting, it is necessary to develop parenting 

skills, encourage positive parental involvement, enhance problem-solving as 

a family, monitor child behaviors effectively, and promote effective discipline 

strategies. It is helpful to consider addressing family stress and parenting 

throughout the entire deployment cycle: predeployment, deployment, and 

postdeployment/reintegration. An overview of practical strategies is provided 

and is consistent with those promoted in the ADAPT program2 because it 

is tailored specifically for Service Members and focuses on the influence of 

combat stress. When seeking to improve parenting practices and strengthen 

the family unit throughout the deployment cycle, consider the following 

strategies:

• Build healthy emotional responding within the family—Parents can socialize their children in healthy emotional responding to reduce children’s 

deployment-related anxiety and other adjustment difficulties. It is normal 

to worry during deployment, but parents can learn and understand 

children’s cognitive capacities and how much information children can 

absorb at particular developmental stages. Parents can also teach their 

children skills for talking about their feelings related to deployment and 

utilizing media and other resources directed at children facing the deployment cycle. These resources are most beneficial when the family views or 

reads them together.
The Role of Friends and Family in Reintegration H 151

• Build mindfulness skills—Parents can learn to control and regulate 

their own emotional responses through the use of mindfulness exercises. Mindfulness-based exercises are aimed at increasing one’s present 

awareness, or the capacity to be present and pay attention. In terms of 

parenting and families, it is important for Service Members to be present 

and pay attention to family members, as well as their children. Paying attention to the responses of children and their emotions is vital to building 

healthy relationships with them.

• Build resilience within the family—Parents can learn to promote coping 

skills for stress and teach the family how to utilize these skills together. 

In addition, the family is encouraged to identify their own strengths as a 

military family and promote the use of these skills as a unit.

• Teach new behaviors and guide children effectively—Parents can encourage the cooperation of children through utilization of effective parenting 

directions, as well as teaching new behaviors for managing life. Parents 

are role models for children and their first teachers. The importance of 

effective teaching strategies, as well the use of positive reinforcement 

contingent on desired behavioral responses, is very important. 

— Learn to set consistent limits with children and identify effective 

versus ineffective discipline strategies.

— Establish family rules and strategies for managing undesirable and 

negative behaviors.

— Communicate effectively within the family by encouraging active 

listening skills, having family meetings, and learning to moderate 

strong emotions.

— Manage conflict in a healthy manner through the use of assertive 

communication skills.

• Develop family problem-solving skills to anticipate and address stressful 

events and family conflicts that are inevitable during the deployment 

cycle—Parents can teach their children problem-solving skills that 

increase communication and provide a method for solving everyday 

conflicts in a cooperative manner. Problem-solving reduces anxiety in 

children by increasing predictability and self-efficacy. When children feel 

prepared with skills they can use to manage problems, they feel more 

secure, confident, and stable during periods of transition.

• Create positive family activities—It is important to create positive family 

activities that develop the family unit and encourage group cohesion 

and fun.

• Promote school success—Parents can work to be positively involved in 

the academic development of their children. It is important to ensure that 
152 H Pr o m o t i n g Su c cess f u l I n teg r at i o n

the school administration understands and is sensitive to the process of 

reintegration, and that parents communicate effectively with the school 

regarding deployment. 

• Plan for the future—Parents can plan family events to continue to build 

cohesion as a family unit. Planning for the future also involves being 

mindful about preparing children and partners about future deployments 

so that there is a balance between “work” and family time.

Me n ta l a n d Be h av i o r a l Hea lt h

Family members and friends play an important role in the care and rehabilitation of individuals with behavioral and mental health conditions. Service 

Members returning home from deployment often have increased rates of 

depression, anxiety, suicidal ideation, interpersonal conflict, aggressiveness, 

PTSD, TBI, and substance use disorders.33 More specifically, Department of 

Defense data show that, among soldiers returning from combat operations 

in Iraq, 27.7% of active duty and 35.5% of National Guard and Reserve 

component Service Members screened positive for clinically significant mental 

health concerns (PTSD, depression, suicidal ideation, interpersonal conflict, or 

aggressive ideation) 3 to 6 months after returning from deployment.34 Despite 

the awareness of mental health concerns among Service Members, many 

families and friends struggle with assisting the Service Member who is seeking 

help—or failing to seek help—during the reintegration process. 

Anxiety, Depression, Posttraumatic Stress Disorder, and Substance Use

It is not uncommon to experience symptoms of anxiety and depression in 

response to significant stressors. Exposure to combat while deployed places 

the human body and brain under a large amount of stress, which can subsequently result in acute readjustment reactions that consist of symptoms of 

anxiety, depression, sleep disturbance, irritability, or difficulty concentrating. 

For most Service Members, over time, these symptoms naturally resolve on 

their own. In fact, the majority of combat-exposed Service Members will not 

develop long-term mental health problems at all.35 Nevertheless, with multiple 

deployments and repeated combat exposure, the incidence of anxiety, depression, and PTSD begins to increase. Multiple exposures to combat stress and 

the subsequent impact on the body and mind often result in a shift from more 

acute stress symptoms to more chronic and persistent symptoms of anxiety, 

depression, and PTSD. 

As previously described, symptoms of anxiety, PTSD, and depression are 

associated with poor family functioning during postdeployment readjustment. 
The Role of Friends and Family in Reintegration H 153

Common concerns associated with PTSD, depression, and substance use 

include the following:

• increased role confusion, 

• emotional numbing, 

• parenting difficulties, 

• relationship dissatisfaction, 

• poor cohesion within the family unit, 

• problems outside the home, and 

• physical aggression.36

Some Service Members engage in adrenaline-seeking behaviors to re-create 

the intense emotions experienced in combat by playing violent video games, 

driving recklessly, or using illicit substances to experience a high similar to 

combat.37 In addition, irritability and anger outbursts interfere with the ability 

to reconnect with family and friends, and result in low frustration tolerance. 

Clark and Messer37 suggest that Service Members who feel out of control or 

overwhelmed by anger may act out and attempt to assert power and control 

in their relationships that may lead to domestic violence, child maltreatment, 

or physical altercations. 

Research shows that, for Service Members experiencing PTSD, the active 

avoidance and emotional numbing symptoms are most closely associated 

with family functioning problems and difficulties with readjustment in the 

postdeployment stage.38,39 When Service Members avoid conversations about 

trauma that would engender feelings of closeness, or activities that friends 

and family may have once enjoyed together, their loved ones subsequently feel 

physically and emotionally disconnected. Often, this is a significant change 

from predeployment functioning, which can further exacerbate relationship 

problems, alienate friends and family, and prevent successful reintegration. 

Service Members, family members, and friends can use a number of strategies to successfully navigate the challenges of postdeployment stress, anxiety, 

depression, and PTSD. The level of intervention or strategy used will depend 

on the severity and chronicity of the mental and behavioral health concerns. 

Service Members, family members, and friends seeking to improve overall 

mental health and address symptoms of anxiety, depression, substance use, 

and PTSD may wish to consider the following strategies:

• Manage strong emotions by learning skills that help to deescalate powerful feelings—Working with feelings and emotions can often help people 

to overcome their problems/issues and improve their mental health.
154 H Pr o m o t i n g Su c cess f u l I n teg r at i o n

— Relaxation strategies (eg, deep breathing, visual imagery, and 

progressive muscle relaxation) are effective for managing strong 

emotions and reducing the nervous system response to anxiety and 

tension.

— Mindfulness-based stress reduction40 techniques incorporate focusing and building awareness to manage stress, illness, psychological 

distress, and promote wellness. 

— Cognitive behavioral therapy is a powerful type of psychotherapy 

that can help with learning how to change your thoughts, emotions, 

and behavioral responses to stressors.

— Spiritual practices or meditation are also helpful tools to reassure 

and assist with deescalating power feelings (discussed in depth in the 

previous chapter).

— Conflict disengagement strategies (eg, time-out) help to avoid the 

negative consequences of explosive anger outbursts. 

• Address avoidance and emotional numbing in relationships—It is important for friends and family to engage in activities aimed at strengthening 

relationships through healthy emotional expression and the creation of 

closeness. 

— Recognize that it is normal to have challenges with emotional reconnection. Go slowly and give everyone permission to adjust at their 

own pace.

— Try to reconnect at an emotional level with yourself and with others. 

Letting down the wall can cause feelings of uncertainty, but with 

time it gets easier.

— Take time for families and friends to recognize that everyone has 

changed, and getting to know each other again takes time and energy.

— Take time to engage in activities that family and friends shared before deployment.

— Plan family nights, date nights, and activities with friends to support 

emotional reconnection.

• Seek conjoint family and couples therapy if you are having trouble reconnecting as a family—If partners are finding that they feel emotionally and 

physically disconnected and struggling with improving this on their own, 

it is important to seek outside counsel on methods to improve the marital 

and/or family relationship. Couples counselors can assist with helping 

partners to improve their relationship using strategies to enhance communication, emotional connection, physical exercises, and relationship 

guidance. 
The Role of Friends and Family in Reintegration H 155

• Stimulate aspirations for betterment—Seek out opportunities for psychological, spiritual, and social growth. This may manifest in the form 

of educational pursuits, occupational achievement, or a rededication to 

family life.

• Seek support groups for Service Members, Military Families, and friends 

who are coping with mental and behavioral health concerns—Often, 

Service Members miss the structure and camaraderie of military service, 

and find it helpful to be around other Service Members who are struggling with managing their own mental and/or behavioral health concerns. 

Support groups are ideal for family, friends, and Service Members to 

experience a sense of community and shared experience.

• Seek mental and/or behavioral health assessment from a professional if 

you are having difficulty managing symptoms—There are evidence-based 

treatments available for depression, anxiety, PTSD, and substance use 

disorders. 

— Research supports the use of cognitive behavioral therapy41 and 

interpersonal therapies for treating depression, anxiety, family/relationship distress, and substance use concerns. Mental health concerns can be treated individually or conjointly with family members 

present. 

— There is strong research evidence supporting the use of cognitive behavioral therapies, such as prolonged exposure therapy and cognitive 

processing therapy, for the treatment of PTSD.42

Traumatic Brain Injury 

In addition to exposure to combat and the trauma of witnessing difficult 

events, many of the men and women serving in Iraq and Afghanistan have 

experienced a TBI. TBI is often associated with changes in mood and behavior (eg, depression, anxiety, impulsiveness, and memory impairment). Most 

Service Members with a TBI recover within the first few months following 

injury with minimal intervention. Individuals with more moderate-to-severe 

or penetrating brain injuries will typically improve; however, the recovery 

process is often more unpredictable and indeterminate. Family and friends 

play an important role in the recovery and rehabilitation of Service Members 

with brain injuries given the emotional, cognitive, physical, social, and vocational impact associated with TBI. Family and friends experience the impact 

of TBI in all of these domains and may have difficulty adapting to the changes 

they see in their loved ones. Adjustments and accommodations may need to 

be made for the injured person. For Service Members with more severe injuries, family members may assume the role of lifelong caregiver. The shifting of 
156 H Pr o m o t i n g Su c cess f u l I n teg r at i o n

roles within the family can be a difficult process and require flexibility, 

resilience, and a strong support system. Service Members, family members, 

and caregivers seeking to adapt to living with an individual with TBI and/

or who are seeking to enhance and strengthen the family unit may wish to 

consider the following strategies:

• Learn more about TBI—Brain injuries can be difficult to diagnose, but 

advanced neuroimaging and neuropsychological evaluations can assist in 

the diagnostic process. 

— Most people recover from TBI quickly and completely, whereas 

others require more intensive rehabilitation. Learning more about 

treatment and recovery from TBI is one of the most valuable things a 

Service Member and his or her loved ones can do for themselves.

— A neuropsychological evaluation can provide insight into the brain 

areas impacted by injury and provide valuable recommendations for 

functional adaptations that help Service Members and their families. 

• Manage symptoms of TBI—Cognitive, emotional, and behavioral 

changes in the brain after TBI can disrupt multiple domains of a Service 

Member’s life.

— Building awareness of the common cognitive, emotional, and behavioral changes that a Service Member will experience can be beneficial 

to family, friends, and caregivers. With insight as to why a loved one 

has changed comes the ability to develop an understanding of how 

to adapt as a family unit to more successfully support the Service 

Member in recovery.

— Assessment and treatment are important. Treatment may include 

cognitive rehabilitation, adaptations within the home, psychotherapy, academic accommodations, or vocational rehabilitation.

• Promote recovery—For most people with TBI, life will return to normal, 

or a new normal, over time. Not all brain injuries are alike, and recovery rates vary depending on the severity of injury. Even individuals with 

severe brain injuries can have fulfilling and meaningful lives.

— Family and friends can promote the return to normal functioning 

by talking about the changes they have witnessed and having open 

dialogue about the proactive strategies they are using to promote 

reintegration into the family and civilian life. 

— TBI recovery programs exist throughout the country and offer invaluable resources.

— Talk to children about TBI and involve them in the recovery process. 

It is important that children understand that the family is learning to 
The Role of Friends and Family in Reintegration H 157

cope as a unit. Promoting family coping skills for stress and teaching 

children how to utilize these skills as a family helps to build the cohesion of the family unit and to adapt to the changes they are experiencing within the family.

• Utilize caregiver support—Becoming a caregiver for a Service Member 

with a moderate-to-severe brain injury is typically an unexpected event. 

Caregivers often feel unprepared for their new role and have difficulty 

adapting to the sudden change of lifestyle, as well as the impact on the 

family unit.

— Caregivers can experience innumerable strong emotions while 

adjusting to life after a TBI. Feeling discouraged or overwhelmed is 

normal, and it is important to seek support.

— It is important to have friends and family members to talk to 

about your feelings. Talking about your stress and anxiety can help 

relieve it.

— It is also important to think about joining a support group for other 

families affected by TBI.

— The Department of Veterans Affairs offers caregiver support programs at all Veterans Affairs medical centers. 

— It is essential to engage in self-care activities, such as relaxation, exercise, maintaining a healthy diet, and engaging in enjoyable activities.

— It is important to accept help from others, and enlist family or friends 

to allow for you to have a few hours “off duty” as a caregiver.

— If stress, anxiety, or sadness begin to escalate, seek professional help 

from a psychologist, counselor, or spiritual leader.

Ho w t o Fa c i l i tate Hel p 

Despite recognition of mental health and readjustment concerns among 

Service Members, families, and friends, it can be challenging to begin talking 

about mental health concerns and how to seek help. Service Members report 

multiple barriers to seeking help: societal stigma about mental health; a military culture that promotes the warrior ethos of loyalty, strength, self-sacrifice, 

and intolerance of weakness; fear that unit leaders and peers will view them 

as weak or lose confidence in them; concern over loss of rank, promotion, 

or career stability; skepticism about the effectiveness of mental health treatment and medication; and perceived difficulties in navigating the military or 

Veteran healthcare systems.43

Service Members, family members, and friends seeking to facilitate mental health treatment may wish to consider the following:
158 H Pr o m o t i n g Su c cess f u l I n teg r at i o n

• Recognizing and accepting mental health concerns and the need for help 

are often the first steps.

• Enhancing treatment-encouraging beliefs, such as “getting help is okay,” 

eases the anxiety of asking for help.

• Identifying resources available for treatment reduces the perception that 

care is not available or accessible.

• Utilizing your entire social network to encourage the Service Member’s 

participation in mental health treatment can be the impetus for the Service Member to reach out for treatment.

Family and friends often report concerns related to how they should best 

talk to and encourage Service Members to seek help. Research shows that 

the most common dilemmas loved ones face when talking to Service Members about seeking help are: getting the Service Member to recognize that he 

or she is having problems without implying that the Service Member is not 

“normal”; convincing the Service Member to seek help without implying 

weakness; being persistent, but also patient; and wanting the Service Member 

to open up without implying that the family or friend understands what he or 

she is going through.43

The following strategies are a resource for assisting families and friends in 

talking to their loved ones about seeking help for mental health and readjustment concerns:

When to talk

• Be mindful about when/how much to talk. Make choices about when 

and how often to discuss the topic to prevent the Service Member from 

withdrawing or avoiding.

• Be available when the Service Member is ready to talk. Make it clear that 

you are available and willing to communicate on the Service Member’s 

terms.

How to talk

• Communicate care and commitment: “I am here no matter what.”

• Be polite and show respect by modulating your tone of voice.

• Listen without judgment. Focus on listening rather than talking and share 

that the Service Member will not be judged for sharing how he or she 

feels and thinks.
The Role of Friends and Family in Reintegration H 159

How to frame talk

• Frame things positively. Frame help-seeking as a way to become healthy, 

happy, and productive rather than as a way to attempt to treat a deficiency or illness within the Service Member.

• Frame things cooperatively. Frame help-seeking as an opportunity to 

work on the problem together as a partnership.

Where to turn

• Enlist the help of third parties. Call on friends, other Service Members, 

or extended family to speak to the Service Member about symptoms and 

help-seeking.

• Use prayer. Families and friends of Service Members frequently suggest 

using prayer as a means to cope and as strength. There are other spiritual 

practices that can also help. These can be found in Chapter 5.

• Treat yourself positively. Family members and friends must take care 

of themselves so that they are healthy enough to care for the Service 

Member. This may involve seeking help for yourself even if the Service 

Member refuses and recognizing that it is not your fault if the Service 

Member is not ready to seek help at this time.

There are coaching and support services available to assist family members and friends of Service Members in obtaining help for their loved ones. 

Patience, early intervention, and support are key in reducing the development of chronic mental health problems and negative outcomes for families 

during the deployment cycle. The negative impact of deployment on Service 

Members and their families can be buffered by encouraging the overall health 

and well-being of the entire family unit, and by encouraging families to seek 

effective interventions when needed.

REINTEGRATION RESOURCES FOR 

SERVICE MEMBERS AND THEIR FAMILIES

A range of interventions and services are available to support Service Members and their families throughout the deployment cycle and beyond. Accessing these resources and services is vital in promoting the overall health, wellbeing, and resiliency of Military Families. The resources provided represent 

the more robust and evidence-based interventions available to our Nation’s 

Military Service Members and their families.
160 H Pr o m o t i n g Su c cess f u l I n teg r at i o n

Br o a d a n d C o m p re h e n s i ve Webs i tes

• After Deployment—This website is tailored for Service Members and 

their families to provide wellness resources for the military community. 

This extensive website offers resources that cover a wealth of topics 

(including but not limited to) on mind, body, spirit, family, community, 

finances, and work. Website: http://afterdeployment.dcoe.mil/

• Department of Defense Military Family Support—Caring for military 

families has become a national priority with the launch of the White 

House’s “Strengthening Our Military Families” initiative and the related 

“Joining Forces” campaign. This website provides regular updates on all 

Department of Defense and related efforts to help improve the lives of 

military families. Website: http://www.usa4militaryfamilies.dod.mil/

• Deployment Health Clinical Center—This center provides a gateway 

to information on deployment, health, and healthcare for healthcare 

providers, Service Members, Veterans, and their families. Website:

http://www.pdhealth.mil/

• Military OneSource—This site offers a central hub and resource for the 

military community to browse topics related to military life, deployment, 

parenting, relocating, retirement, and much more. Website: http://www.

militaryonesource.mil/

• National Resource Directory—The Department of Veterans Affairs and 

the Department of Defense provide this directory to connect Wounded 

Warriors, Service Members, Veterans, their families, and caregivers with 

resources, support, and education. Website: https://www.ebenefits.va.gov/

ebenefits/nrd

• The Real Warriors Campaign—This campaign is an initiative launched 

by the Defense Centers of Excellence for Psychological Health and 

Traumatic Brain Injury to promote the processes of building resilience, 

facilitating recovery, and supporting reintegration of returning Service 

Members, Veterans, and their families. Website: http://www.realwarriors.

net/

• US Army Family Readiness Group—Family Readiness Groups within 

the US Army, the US Army Reserve, and the Army National Guard 

communities are command-sponsored organizations of family members, 

volunteers, soldiers, and civilian employees associated with a particular 

unit. They provide activities and support to enhance the flow of information, increase the resiliency of unit soldiers and their families, and 

provide practical tools for adjusting to deployments. Website: https://

www.armyfrg.org
The Role of Friends and Family in Reintegration H 161

• Yellow Ribbon Reintegration Program—This program provides National 

Guard and Reserve Service Members and their families with deployment 

cycle information, resources, programs, services, and referrals. Programs 

include webinars and courses on strengthening resiliency, helping military 

families, preparing for deployment, and more. Website: http://www.

yellowribbon.mil/yrrp

• Warrior Gateway—This website caters to the unique needs of Service 

Members and Military Families by providing a virtual community 

center equipped with consolidated and validated resources for connecting, learning, and communicating with others before, during, and after 

deployment. Website: http://www.warriorgateway.org/

Ca reg i ver Su p p o rt

• Defense and Veterans Brain Injury Center—The Center’s mission is to 

serve active duty military, their beneficiaries, and Veterans with TBIs 

through state-of-the-art clinical care, innovative clinical research initiatives and educational programs, and support for force health protection 

services. The program offers family and caregiver support throughout the 

country and at military medical centers. Website: http://dvbic.dcoe.mil/

audience/family-friends

• Department of Veterans Affairs—This organization has caregiver support programs and services nationwide at their Veterans Affairs Medical 

Centers. The programs are available both in and out of the home to help 

support and care for Veterans. Website: http://www.caregiver.va.gov/

Ed u c at i o n a n d Em p l o y me n t

• Education and Employment Initiative—This initiative is a Department 

of Defense program. It assists wounded, ill, and injured Service Members 

early in their recovery process to identify their skills and match them 

with the education and career opportunities that will help them successfully transition to civilian life. Website: http://warriorcare.dodlive.mil/

wounded-warrior-resources/e2i/

• Operation Warfighter—This program is a Department of Defense internship program that matches qualified wounded, ill, and injured Service 

Members with nonfunded federal internships for them to gain valuable 

work experience during their recovery and rehabilitation. Website:

http://warriorcare.dodlive.mil/wounded-warrior-resources/operationwarfighter/
162 H Pr o m o t i n g Su c cess f u l I n teg r at i o n

Oper at i o n E n d u r i n g Freed o m/Oper at i o n Ir a q i Freed o m/

Oper at i o n New Daw n Res o u r ces

• Department of Veterans Affairs—This organization offers cost-free 

medical care for any condition related to service in the Iraq/Afghanistan 

theater for 5 years after the date of discharge or release. Website: http://

www.oefoif.va.gov/

Me n ta l a n d Be h av i o r a l Hea lt h

• Center for the Study of Traumatic Stress—This is one of the Nation’s 

oldest and most highly regarded academic-based organizations dedicated 

to advancing trauma-informed knowledge, leadership, and methodologies. Resources, publications, and more are available. Website: http://

www.cstsonline.org/

• Coaching into Care—This Veterans Affairs program offers free, confidential, telephone-based coaching services for family members who would 

like to help a Veteran seek mental health care. Coaches work with families to help them discover new ways to talk with a Veteran in their lives 

about their concerns and about treatment options. Website: http://www.

mirecc.va.gov/coaching/ 

• Department of Veterans Affairs—This organization offers an expansive 

array of mental and behavioral health services to Veterans and their 

families. Veterans receive coordinated care, mental health treatment 

coordinators, evidence-based psychotherapies, and personalized treatment plans developed to focus on recovery, reintegration, and wellness. 

Website: http://www.mentalhealth.va.gov/VAMentalHealthGroup.asp

• Department of Veterans Affairs Vet Centers—These centers serve combat 

Veterans, Service Members, and Military Families by providing no-cost 

visits for readjustment counseling, military sexual trauma counseling, and 

bereavement counseling services. Website: http://www.vetcenter.va.gov/

• InTransition—This is a free, voluntary program with coaches who 

provide psychological health care support to Service Members, Veterans, 

and their healthcare providers during times of transition. Website: http://

intransition.dcoe.mil/

• Military and Veterans Crisis Line—This hotline is available for military 

Service Members, Veterans, families, and caregivers in crisis. It puts individuals in touch with the support of trained professionals 24 hours a day 

through a toll-free number or online chat. Phone: 800–273–8255, press 1

• Mindfulness-Based Stress Reduction—This program is a well-defined 

and systematic patient-centered educational approach that uses relatively 

intensive training in mindfulness meditation as the core of a program 
The Role of Friends and Family in Reintegration H 163

to teach people how to take better care of themselves and live healthier 

and more adaptive lives. Website: http://www.umassmed.edu/cfm/stressreduction/

• National Center for Posttraumatic Stress Disorder—This is a special 

center within the Department of Veterans Affairs created to advance the 

clinical care and social welfare of America’s Veterans through research, 

education, and training in science, diagnosis, and treatment of PTSD and 

stress-related disorders. Website: http://www.ptsd.va.gov/

• PTSD Coach—This app is a mobile phone application for Veterans, 

Service Members, and others to learn about PTSD symptoms and treatment, track their symptoms, and develop tools for coping. It is available 

online as well as on Apple and Android devices. Website: http://www.

ptsd.va.gov/public/materials/apps/PTSDCoach.asp

Pa re n t i n g a n d C h i l d re n

• Department of Veterans Affairs—This organization offers parenting 

resources and tools, including online training and education for 

Service Members, families, and their loved ones. Website: http://www.

veterantraining.va.gov/parenting/

• After Deployment, Adaptive Parenting Tools (ADAPT)—This program 

aims to strengthen parenting skills. Website: http://www.cehd.umn.edu/

fsos/projects/adapt/default.asp

• Love and Logic—There are excellent curricula available for parents 

related to the topics of discipline and expectations, including the 

Parenting with Love and Logic series of books. Website: https://www.

loveandlogic.com/

• Military Kids Connect—This is an online community for military children (6–17 years old) that provides access to age-appropriate resources 

to support children dealing with the unique psychological challenges of 

military life. Website: http://militarykidsconnect.dcoe.mil/

• Talk, Listen, Connect—Sesame Street’s program designed for military 

families offers strategies and resources to help children through difficult 

periods of transition and separation that can come with military service. 

Website: http://www.sesamestreet.org/parents/topicsandactivities/

toolkits/tlc

P o st dep l o y me n t Ret reat

• Coming Home Project—This project is a nonprofit organization devoted 

to providing retreats that emphasize expert, compassionate care, support, 

education, and stress management tools for Iraq and Afghanistan Veter-
164 H Pr o m o t i n g Su c cess f u l I n teg r at i o n

ans, Service Members, their families, and their care providers. Website: 

http://www.cominghomeproject.net/

Tr a u m at i c Br a i n I n j u ry

• Concussion Coach—This is a mobile phone application for Veterans, 

Service Members, and others who have experienced a mild-to-moderate 

concussion. It provides portable tools to assess symptoms and to facilitate 

use of coping strategies. It is available for Apple devices. Website: https://

itunes.apple.com/us/app/concussion-coach/id713590872

• Defense Centers of Excellence Outreach Center—This center is designed 

to provide a source of psychological health and TBI information and 

resources for Service Members, families, friends, and clinicians. The 

center is available 24 hours per day, 7 days per week via phone, chat, 

or email. Website: http://www.dcoe.mil/Families/Help.aspx

• Defense and Veterans Brain Injury Center—This center’s mission is to 

serve active duty military, their beneficiaries, and Veterans with TBIs 

through state-of-the-art clinical care, innovative clinical research initiatives and educational programs, and support for force health protection 

services. Website: http://dvbic.dcoe.mil/

• Department of Veterans Affairs—The Veterans Affairs Polytrauma/TBI 

System of Care is an integrated network of specialized rehabilitation 

programs dedicated to serving Veterans and Service Members with 

both combat and civilian-related TBI and polytrauma. Services include 

interdisciplinary evaluation and treatment, case management, patient 

and family education and training, psychosocial support, and advanced 

rehabilitation and prosthetic technologies. Website: http://www.polytrauma.va.gov/

SUMMARY

Recognizing and responding to the needs of Service Members, Military Families, and their communities can improve the overall health and well-being of 

our military force. Family and social relationships are impacted tremendously 

during predeployment, deployment, and postdeployment reintegration into 

civilian life. Although the majority of Service Members, families, and friends 

adapt appropriately during the deployment cycle and demonstrate a great degree of resilience, there are also some who struggle with the process. The goal 

of this chapter was to provide insight to readers about the various challenges 

and changing dynamics related to renegotiating relationships throughout the 

deployment cycle, as well as provide strategies aimed at improving resiliency 
The Role of Friends and Family in Reintegration H 165

and reintegration for Service Members, families, and friends. Although the deployment cycle can be a challenge, it also provides an opportunity to learn, to 

develop coping skills, and to enhance a sense of cohesion and shared purpose 

in relationships. As Service Members work to readjust to civilian life, their 

families, friends, and communities must also adjust to changes in the Service 

Member and themselves. It is hoped that this chapter serves as a resource for 

helping Service Members, families, and communities promote reintegration of 

our nation’s heroes more successfully.

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42. National Center for PTSD. Overview of psychotherapy for PTSD. http://www.

ptsd.va.gov/professional/treatment/overview/overview-treatment-research.asp. 

Accessed July 30, 2015. 

43. Wilson SR, Gettings PE, Hall ED, Pastor RG. Dilemmas families face in talking 

with returning U.S. military service members about seeking professional help for 

mental health issues. Health Commun. 2015;30:772–783. 
168 H Pr o m o t i n g Su c cess f u l I n teg r at i o n

Lieu te n a n t C o l o n el

(LtC o l) Ti m Ma x wel l

“After a while, my unit, the 

24th Marine Expeditionary 

Unit, who had just returned 

from Iraq, went back to 

work. But my abilities 

had not improved. I tried. 

Believe me. I tried to get 

involved in the upcoming 

operations. I tried to be 

more productive. I tried to be useful in some way. But I could not, and that 

was unpleasant. I was a Warrior! At least, I used to be. And so, to spend my 

time productively, I started going to the hospital at Camp Lejeune. I met and 

chatted with Marines who had been sent there directly. I learned that these 

Marines would not be in this hospital forever. When they got out, their unit 

would still be deployed. I wondered what they were going to do. One thing 

led to another and, somehow, I had an idea.”

LtCol Tim Maxwell, US Marine Corps (Retired)—well educated, 

accomplished triathlete, and leader—suffered a severe penetrating traumatic 

brain injury on October 7, 2004 in Iraq. The lessons he learned from his 

convalescence and recuperation inspired the formation of both Maxwell Hall 

(the US Marine Corps Wounded Warrior Barracks) and the Marine Corps 

Wounded Warrior Regiment.

While serving as the 24th Marine Expeditionary Unit Operations Officer 

during his sixth and final deployment, LtCol Maxwell’s base was mortared, 

and the left side of his brain was damaged by fragments. During the initial 

phase of LtCol Maxwell’s lifelong recovery—an additional left arm injury 

and enduring physical (right side), cognitive, and psychological challenges 

subsequent to the brain injury—he discovered that he did better when 

surrounded by other Wounded Warriors because they truly understood what 

he was going through, just as he had understood them.

“In those first months, as soon as he could sit up in a wheelchair, he was 

visiting other Wounded Warriors. He continued to do this at the Veterans’ 
The Role of Friends and Family in Reintegration H 169

Hospital and with General [James] Amos on trips to various military 

hospitals,” noted his wife, Shannon.

The experience of sharing his frustrations and victories with his fellow 

Marines, as well as recognizing that the time he spent by himself was not 

helpful to his recovery, led LtCol Maxwell in 2005 to present the idea of the 

US Marine Corps Wounded Warrior Barracks (now named “Maxwell Hall” 

in his honor) to then II Marine Expeditionary Force Commander, Lieutenant 

General James Amos. With fellow wounded Marines, then Gunnery Sergeant 

Ken Barnes and Chief Warrant 

Officer 4 Chris Hedgecorth, 

LtCol Maxwell stood up 

the barracks to provide 

recovering Marines a place to 

heal together. The unqualified 

success of this program, and 

the insights learned from its 

founding, led directly to the 

creation of the US Marine 

Corps Wounded Warrior 

Regiment. 

Today, LtCol Maxwell and 

his wife run the SemperMax 

Support Fund (www.semper 

max.org) to continue that 

legacy of team healing, and to 

bring Veterans, wounded, ill, 

injured, and families together 

to learn from each other and 

to move forward.

LtCol Maxwell has a Bachelor of Science degree in Industrial Engineering 

from Texas A&M University (College Station, Texas), as well as a Master’s 

degree in Operations Analysis from the Naval Postgraduate School 

(Monterey, California). 
170 H Pr o m o t i n g Su c cess f u l I n teg r at i o n

LtCol Maxwell’s awards include the Legion of Merit, Bronze Star Medal, 

Purple Heart, Navy/Marine Corps Commendation Medal (3), Navy/Marine 

Corps Achievement Medal (2), Global War on Terrorism Expeditionary 

Medal, Global War on Terrorism Service Medal, Iraq Campaign Medal, the 

Sea Service Deployment Ribbon (6), and others. He has also been recognized 

with The Marine Corps League’s Military Order of the Iron Mike Award, 

the R. Lee Ermey’s Ooh Rah Award, the President of the Veterans Leadership 

Program of Western Pennsylvania Award, Esquire Magazine’s Best and 

Brightest Recognition, the Mack McKinney Award, and the Bobby Simpson 

Memorial Award.

His awards and decorations include the Purple Heart, Meritorious Service 

Medal, three Army Commendation Medals, seven Army Achievement 

Medals, Army Reserve Component Achievement Medal, two National 

Defense Service Medals, Korea Defense Service Medal, Iraq Campaign 

Medal with Campaign Star, Global War on Terrorism Service Medal, 

Noncommissioned Officer Professional Development Ribbon, Army Service 

Ribbon, five Army Overseas Service Ribbons, Combat Action Badge, 

Parachute Rigger Badge, Parachutist Badge, and Air Assault Badge.
While the MHS [Military Health System] is highly valued as a 

system of care, we also recognize that it remains a 

microcosm of American medicine. We are buffeted by 

some of the same challenges as our civilian peers.

We must migrate from a system of healthcare 

to a system of health.

H H H

Lieutenant General Douglas Robb

Defense Health Agency

Congressional Testimony

April 14, 2014

C h a p ter Seve n

Sexuality and Intimacy

STANLEY H. DUCHARME, PhD*; REBECCA P. CAMERON, PhD†; and

LINDA R. MONA, PhD‡

*

Clinical Psychologist, Departments of Rehabilitation Medicine and Urology, Boston 

University School of Medicine, 725 Albany Street, Suite 3B, Boston, Massachusetts 

02118

†

Assistant Professor, Department of Psychology, California State University, 6000 J 

Street, Sacramento, California 95819-6007 

‡

Clinical Psychologist, Behavioral Health, VA Long Beach Healthcare System, 5901 

East 7th Street, Long Beach, California 90822

INTRODUCTION

S

exuality and intimacy are important aspects of personal and interpersonal well-being and resilience. Yet, these highly valued areas of 

functioning may present challenges for Veterans and returning military 

personnel who have experienced significant illness or who have acquired a 

disability.1 Healthy sexuality is often portrayed as something very narrowly 

defined and inextricably linked to being able-bodied, young, and conventionally attractive (Figure 7-1). In fact, people with disabilities are often 

stereotyped as asexual, even childlike. The reality of resilient sexuality is far 

different from these requirements and stereotypes, and instead involves partnership, flexibility, and pleasure.2

 The goals of this chapter are to affirm that 

sexuality and intimacy can be viewed from a much broader vantage point 

than is typically presented and to provide straightforward information about 

sexuality and sexual functioning so that Veterans and Military personnel can 
174 H Pr o m o t i n g Su c cess f u l I n teg r at i o n

be empowered in their sexual experiences and knowledgeable when they talk 

to their healthcare providers about this topic.

SEXUALITY AND INTIMACY

Military service, deployment, and combat create particular challenges for 

relationships and for the development of a sense of sexual well-being (Figure 

7-2). Military service can have profound effects on social, psychological, and 

physical aspects of sexual functioning because of long separations from loved 

ones, exposure to sexual harassment and traumatic events, and experiences of 

physical injury and disability. Given that the majority of people entering the 

military are young adults, military service may have a significant impact on 

sexual development and identity formation.3

For couples, military service-related separations lead to communication 

and role changes. For example, the partner who remains at home must fill 

in the gaps apparent in household management. Also, in the case of parents, 

the partner who remains home must attend to gaps apparent in childrearing 

responsibilities. These adjustments often require renegotiation when deployments end and responsibilities shift back to the traditional family format. 

In the case of significant illness or acquired disability, there are direct effects 

on the physical aspects of sexual functioning and psychological effects via 

changes to body image or identity. Intimacy may also suffer because it may 

be difficult to nurture the erotic aspects of a relationship when an able-bodied 

Fi g u re 7-1. Healthy 

Sexuality Is Inextricably Linked to Being 

Able-bodied, Young, 

and Attractive.

PHOTOGRAPH: DACOWITS. 

DEFENSE ADVISORY COMMITTEE ON WOMEN IN THE 

SERVICES: 1951–2013, 62 

YEARS OF DACOWITS—

2013 REPORT. WASHINGTON, DC: DEPARTMENT OF 

DEFENSE; 2013.
Sexuality and Integration H 175

partner takes on significant 

caregiving or assistance tasks 

for an ill or injured partner or 

a partner with a disability. 

Despite the potential 

for sexual difficulties among 

active and returning military 

personnel, few healthcare 

providers have the knowledge 

and comfort level to address 

issues of sexuality. Although 

healthcare providers need to 

incorporate questions regarding sexual functioning into their intake assessments, this is not always done 

as standard practice.4 In particular, healthcare providers may be inadequately 

trained to assess and respond to sexuality concerns among patients with disabilities. Those healthcare providers who become comfortable and knowledgeable about sexuality may be able to substantially improve psychological 

and physical functioning through appropriate interventions and/or referrals to 

specialists. 

At the very least, healthcare providers should ask active and returning 

Veterans about past and recent sexual abuse, molestation, and harassment. 

They should inquire as to relationship status, as well as past and present 

sexual difficulties in the areas of erections, orgasms, premature ejaculation, pain during sexual intercourse, lubrication, and sexual desire. Issues 

regarding fertility may also be a concern and should be addressed whenever 

relevant. Healthcare providers should always be sensitive to the presence of 

psychological issues, including body image concerns, depression, anxiety, and 

relationship stress that might contribute to sexual adjustment difficulties. It is 

important for providers to find a balance in addressing physical and emotional concerns, as well as issues regarding the relationship. For some individuals, 

fears regarding failure, performance, body image, or issues of mistrust may 

result in an avoidance of relationships.

In mainstream culture, people with disabilities are rarely perceived 

as having sexual needs and enjoying an active sexual life. Instead, there is 

the false perception that one’s sexual interest and abilities are lost with the 

onset of a chronic illness or disability.5 These outdated and negative views 

of disability tend to focus on issues of loss and deficit rather than on a more 

positive model in which disability is seen as an opportunity for growth and 

well-being. 

Fi g u re 7-2. Military Service Can Also Affect 

the Family. PHOTOGRAPH: COURTESY OF THE NATIONAL 

MILITARY FAMILY ASSOCIATION, ALEXANDRIA, VIRGINIA.
176 H Pr o m o t i n g Su c cess f u l I n teg r at i o n

In contrast, a modern approach to disability views people with disabilities as adults, with the right to make their own decisions and choose their 

own path in life; and whose physical, sensory, cognitive, or psychological 

impairments or differences become disabling in a world that fails to prioritize 

their full participation.6,7 If our environments were designed for universal 

access or with functional impairments in mind, there would be less disability.

Similarly, a modern view of sexuality and disability understands sexuality as an opportunity for creativity and self-expression, joy and pleasure, and 

intimacy and connection. People with disabilities often grow in sexual wellbeing as they become 

• clearer about their sexual needs, values, and priorities; 

• more comfortable with vulnerability and human imperfection; 

• more open in their communication with partners; 

• more direct about sexual expression; and 

• more flexible in their strategies for pleasure. 

Sexual expression may 

require preparation, or even 

assistance, and sex aids like 

toys, positioning pillows, and 

lubricants may be helpful.8–10 

For the returning Veteran, it may be important 

to take a proactive stance in 

locating a healthcare provider who has a more modern view of disability and 

who feels comfortable and 

knowledgeable in addressing 

sexuality issues. In general, 

it is important that issues of 

sexuality be prioritized as a 

standard part of medical and behavioral healthcare. If this is not done as a 

routine part of a comprehensive evaluation, the Veteran may have to take the 

initiative in raising the topic. 

Because, unfortunately, many healthcare professionals continue to be 

uncomfortable about discussing issues relating to sexuality, it is important 

that the Veteran be aware of basic genital anatomy and be observant of any 

potential sexually related issues that may occur (Figure 7-3). These issues 

Fi g u re 7-3. Genital Wounds Primarily From 

Improvised Explosive Device Blasts. GRAPHIC: 

COURTESY OF THE US ARMY, OFFICE OF THE SURGEON GENERAL.

0

50

100

150

200

250

300

2008

170

153

259

299

2009 2010 2011
Sexuality and Integration H 177

include the possibility of infections, masses, or symptoms of sexually 

transmitted diseases.

MEN’S PHYSICAL SEXUAL HEALTH AND SELF-MONITORING

Good sexual health for men includes conducting regular self-examinations of 

the penis and scrotum to help ensure that infections or potential cancers are 

caught and treated early. At least once a month, a man should examine his 

entire penis and scrotum; compare the testicles; and check for pain, lumps, 

masses, or any significant changes in skin texture. If there is a foreskin, pull 

it back and examine the area underneath. Note any signs of redness, rash, or 

discharge that might be an indication of an infection. The skin of the penis 

and scrotum can be prone to the growth of bacteria and infection as a result 

of the warm, moist environment. Anything unusual should be evaluated by 

a physician. A primary care physician is helpful; but, for deeper concerns, 

consider seeing a urologist (a specialist who focuses on the urinary tract).11

For men with various disabilities, self-examinations may be difficult due to 

pain, limited mobility, or other factors. Often, a personal care attendant can 

be helpful in these matters. 

WOMEN’S PHYSICAL SEXUAL HEALTH AND 

SELF-MONITORING

Because a woman’s genitals are not as visible as a man’s, many women 

are unfamiliar with the structure, shape, and appearance of their genital 

area. Self-examinations allow each woman to recognize what is normal for 

her. Thus, she will be able to recognize problems at an early stage and ask 

relevant questions if a doctor’s visit becomes necessary. For women, selfexaminations should consist of both a vaginal self-examination and a breast 

examination.

Undertaking a self-examination of the vulva requires some background 

reading and some basic instructions from friends or healthcare professionals. Relevant reading materials can usually be obtained from women’s health 

clinics, hospital clinics, physicians’ offices, and some pharmacies. In order to 

perform a thorough self-examination, a woman may need to obtain a speculum, an instrument that will open the walls of the vagina so that she can look 

inside. Disposable plastic speculums can easily be obtained from a pharmacy 

or medical supply store. Other materials that a woman may need are a 
178 H Pr o m o t i n g Su c cess f u l I n teg r at i o n

mirror, pillow, flashlight, and a water-soluble gel lubricant. Before beginning, 

it is important to wash the hands thoroughly and to empty the bladder. 

To examine the vulva, 

• position the mirror so that the vagina and labia can be viewed;

• note the color, size, and shape of the clitoris, labia, and opening of the 

vagina; and

• pay attention to any secretions from the vagina. 

Vaginal secretions of certain types are normal, and will vary in thickness and 

consistency according to the phase of the menstrual cycle. 

Breast self-examinations are generally painless and simple. However, with 

a disability they can be difficult. Generally, exams only take a few moments. 

The best time to do a breast examination is usually a day or two after the 

menstrual period when any related tenderness and fullness have subsided. It 

is normally a good idea to perform the exam at the same time each month so 

that the breast tissue is consistent from one examination to another. In front 

of a mirror, 

• check the size and contour of each breast;

• squeeze (gently) each nipple to check for any unusual discharge; and

• feel the breast for any unusual lumps or thickness, using the three middle 

fingers of one hand to palpate the breast in a circular motion. 

Specific instructions for conducting breast and vaginal examinations should 

be obtained from a physician or from a women’s health clinic. Often, for 

women with various disabilities, self-examinations may not be possible because of pain, limited mobility, or other factors. In these cases, the assistance 

of personal care attendants or other trusted individuals may be helpful.

SEXUAL FUNCTIONING AND BIOMEDICAL INTERVENTIONS

Difficulties with how the body functions sexually include decreased desire 

among men or women; problems with arousal, vaginal lubrication, pain, 

and orgasm among women; and problems with attaining and maintaining 

erections and experiencing orgasm among men.11 Options for treatment of 

sexual dysfunctions include medications, medical devices, surgery, counseling, 

and sex therapy. Often, a combination of treatments may provide the best 

solution. For example, many couples find that medications, such as Viagra 
Sexuality and Integration H 179

(Pfizer, Inc, New York, NY), are most effective when used in conjunction with 

couples or relationship counseling.12

Problems in reaching orgasm for men and women are another source of 

distress that is often discussed in sex therapy clinics and urology/gynecology 

offices.12 Without sufficient sexual desire and arousal, achieving an orgasm 

can be difficult. Understanding the range of factors—including cultural factors that may have affected early sexual experiences and current issues (eg, 

the length of foreplay, encouragement of partner, sexual technique, and the 

presence of medications)—is important to develop a comprehensive approach 

to treating women and men with orgasmic difficulties.

Researchers have been focusing on developing biological interventions 

to increase desire among men and women for whom low desire leads to dissatisfaction. Until the last several years, instruments to measure physiological 

arousal were inaccurate and of little value. Today, this situation has changed 

dramatically. New diagnostic tools to measure the degree of arousal and 

lubrication have now been developed. Armed with these newer strategies, 

scientists hope that they will gain approval from the US Food and Drug 

Administration to explore new biological forms of treatment, especially for 

women. 

In addition to the biological issues, sexual well-being and functioning 

can be affected by problematic relationships, trauma, emotional turmoil, and 

unresolved issues. Such factors may complicate a healthy and positive sexual 

life either while in military service or after returning home. Working with 

a counselor may be beneficial for couples who are seeking to improve their 

sexual communication or to increase their sense of partnership. In addition, 

individuals who have undergone experiences and trauma (eg, sexual abuse or 

harassment) or who are dealing with depression or other emotional concerns 

may find it helpful to speak with a counselor who can offer suggestions and 

guidance aimed at improving general and sexual well-being (Figure 7-4). 

Fi g u re 7-4.

Service Member With 

Counselor. PHOTOGRAPH: 

PATRICIA DEAL, US ARMY, 

CARL R. DARNALL ARMY 

MEDICAL CENTER, OFFICE OF 

PUBLIC AFFAIRS.
180 H Pr o m o t i n g Su c cess f u l I n teg r at i o n

Seeking a counselor who is disability-affirmative and sex-positive, and who 

focuses on pleasure and intimacy rather than just dysfunction, can be very 

helpful.

SEXUAL FUNCTIONING AMONG MEN

Over the last decade, the availability of medical and psychological treatments 

to improve sexual functioning has grown considerably. Medications, in 

particular, have become well-known and accepted by the general public, and 

people have become much more open in discussing difficulties of a sexual 

nature.13

A common sexual experience among men is erectile dysfunction. There 

are a number of treatments for sexual problems like erection difficulties. 

Issues such as age, financial resources, relationship status, health issues, and 

frequency of sexual activity may all play a role in deciding the treatment of 

choice. For these reasons, seeing a physician (ie, a urologist) may be helpful 

in deciding which options best fit the life situation of an individual Veteran or 

Service Member. For example, single men who are dating may prefer treatment methods that can be somewhat more portable and spontaneous. Yet, 

for other men, certain erection medications may be preferred because of their 

long-lasting effectiveness or quick-acting characteristics. 

As a general rule, it is best to explore the least invasive treatment method 

before exploring other options that may produce an adverse reaction. Many 

individuals who choose to pursue interventions to address sexual difficulties 

such as erectile dysfunction start by talking with a counselor either individually or with their partners. In some cases, reducing anxiety, addressing 

symptoms of posttraumatic stress disorder (PTSD), improving one’s mood, 

and/or enhancing communication may be enough to provide some relief. This 

may, in turn, result in a more positive sexual experience either alone or with 

a partner. It is also important to remember that positive sexual and intimate 

experiences are not dependent on the presence of an erection. However, there 

are a number of medical interventions available to men and couples who wish 

to pursue this approach.

Oral medications to improve erections were first introduced in the United 

States in 1998. Over time, they have proven to be very effective for many men 

who do not have significant physical conditions that reduce blood flow to the 

penis. At the present time, there are four medications that are currently available in the United States:
Sexuality and Integration H 181

1. sildenafil (Viagra; Pfizer, New York, NY), 

2. vardenafil (Levitra; Bayer AG, Leverkusen, Germany), 

3. avanafil (Stendra; Endo International, Inc, Malvern, PA), and 

4. tadalafil (Cialis; Eli Lilly and Company, Indianapolis, IN).

These medications have an excellent safety record and have been well tolerated by most men. Typical adverse reactions sometimes include stuffy nose, 

blurred vision, and occasional mild muscle ache. However, these medications 

are not indicated if the man has certain medical conditions (eg, hypotension 

or low blood pressure) or takes certain medications (eg, nitrates). For this 

reason, they are given by prescription and should be used under the guidance 

of a physician.12 Although similar over-the-counter erection medications are 

available, there is a danger in taking these medications or herbal supplements 

because they may contain unknown or potentially harmful substances. In 

addition, these compounds or herbal treatments often lack a list of ingredients 

or warning labels. 

When oral medications are considered to be ineffective, penile injections 

are commonly considered the next alternative. The medications are injected 

into the corporal chambers of the penis and usually include one or several 

medications that relax the smooth muscles of the penis so that blood flow 

into the penis can occur more efficiently. After determining the proper dose 

and receiving training from a urologist, the man and his partner can use this 

technique at home prior to sexual activity. Some men with intact sensation 

in the penis report some minor burning in the shaft of the penis. This can be 

reduced with proper training in the injection technique.13

Ideally, a proper dose and mixture of the medication should result in 

an erection that will last approximately one hour. Should the erection last 

for several hours, the man is instructed to go to the nearest emergency room 

where he will be given medications to allow the erection to subside. This condition is termed priapism and can harm the tissue of the penis if the erection 

persists for a prolonged period of time. Finally, care should be taken to avoid 

penile scarring at the injection site. This is usually avoided by applying pressure on the injection site for several minutes after injection. 

A vacuum constrictive device consists of an elongated tube that is placed 

over the shaft of the penis. A vacuum is then created in the tube either by 

a battery-operated device or a manual pumping action. As the vacuum is 

created in the tube, blood gradually flows into the corporal chambers of the 

penis. When the penis achieves a satisfactory degree of rigidity, an elastic band 

or penile ring is slipped off the tube and placed over the base of the penis. The 

penile ring traps the blood in the shaft of the penis and maintains the erection 
182 H Pr o m o t i n g Su c cess f u l I n teg r at i o n

so that sexual intercourse can occur. The ring should never be left in place for 

more than 30 minutes; otherwise, blood flow to the penis is inadequate to 

maintain healthy penile tissue.13

In general, vacuum devices tend to be more accepted by men in long-term 

sexual relationships where spontaneity is not a major concern. Complaints 

about the vacuum device frequently include comments regarding unnatural 

erections, coldness of the penis, pain, and difficulty in maintaining an adequate seal at the base of the penis. Although these devices are less popular 

than they were before the introduction of oral medications, there are still 

some men for whom this is the preferred treatment strategy.

Because it is so important to remove the ring after sexual intercourse, the 

vacuum constrictive device is often discouraged if the man has been drinking alcohol or using other medications that may cause fatigue or drowsiness 

following sexual activity. Alertness and vigilance are necessary to prevent any 

medical complications from occurring with the use of such devices.12

Although penile implants can be highly effective and satisfying, they 

remain typically the option of last resort for restoring erections because insertion of the penile implant destroys the tissue of the two corporal chambers of 

the penis. Currently, this method of erection enhancement is generally only 

used when other options have proven to be ineffective. This is more typical 

in older men who have medical complications such as diabetes, hypertension, 

and elevated cholesterol that impact blood flow and tissue integrity. At times, 

an implant may be a consideration among men who have a long history of 

polysubstance abuse in which medications or injections are not effective. The 

decision to have an implant is not one that should be taken lightly and should 

be decided after other treatments have failed and after a serious discussion 

with one’s partner and a healthcare professional.12

There are two types of implants currently on the market:

1. a malleable silicone prosthesis and 

2. a more complex inflatable hydraulic prosthesis. 

The malleable prosthesis consists of two bendable rods that are surgically 

implanted in the corporal chambers of the penis. With this device, the penis is 

always semirigid and ready for sexual intercourse. It only needs to be moved 

into the correct position for sexual penetration at the appropriate time. The 

inflatable prosthesis consists of two inflatable chambers that are surgically 

implanted in the two chambers of the penis. In addition, a fluid reservoir is 

implanted into the abdominal cavity, and a valve is placed within the scrotal 

sac. When the man wishes to achieve an erection, either he or his partner 
Sexuality and Integration H 183

squeezes the valve, allowing fluid to enter the inflatable chambers, thereby 

causing an erection. With a penile implant, orgasm and ejaculation are not affected. Therefore, with adequate stimulation, the man is usually able to reach 

an orgasm unless there are other issues that may make this difficult.13

SEXUAL FUNCTIONING AMONG WOMEN

Epidemiological studies such as the National Health and Social Life Survey 

suggest that sexual dysfunction affects 30% to 50% of American women.3

Sexual desire and physiological arousal are areas in which many women 

experience difficulties; in addition, women may have difficulty experiencing 

orgasm as readily or as often as they would like. Although women’s sexual 

responses are influenced by multiple factors (including emotions, relationships, trust, comfort, religion, stress, culture, age, and safety), biological 

factors (eg, hormones [specifically androgens such as testosterone]) may also 

play a critical role in women’s sexual interest. Certain medications (including 

birth control pills and some antidepressants) may interfere with testosterone 

levels and result in lower sexual desire. In addition, hysterectomy, breast cancer, childbirth, and menopause all potentially contribute to the depletion of a 

woman’s testosterone level.12

 There are a range of issues for women who are considering the use of 

birth control to prevent or delay pregnancy. Choosing a type of birth control 

method is dependent on personal choice, physical ability to use any given 

method, and medical issues that might affect the use of any given method. 

Although contraception is best discussed by both partners in a sexual relationship, most methods are a woman’s choice and should be practiced in 

consultation with a healthcare provider. 

The hormonal IUD (intrauterine device) is a 

small, T-shaped device that is inserted and removed 

by a trained physician (Figure 7-5). It stays in the 

uterus for up to 5 years. The IUD releases a small 

amount of hormone each day that causes the 

cervical mucus to thicken. This acts as a barrier 

to prevent sperm from entering the uterus. It may 

cause some irregular bleeding for a few months 

and may decrease or eliminate menses over time. 

Risks include the possibility of having a reaction to the hormone. Another 

option is the copper IUD, which is inserted and removed by a physician and 

can last for up to 10 years. It stops the sperm from reaching and fertilizing the 

Fi g u re 7-5.

Intrauterine Device (IUD).
184 H Pr o m o t i n g Su c cess f u l I n teg r at i o n

egg. This IUD is sometimes used as an “emergency birth control” because it 

can be inserted up to 5 days after intercourse to prevent a fertilized egg from 

implanting in the uterus. With either IUD, there is no need to remember to 

take a pill and no requirement of fine motor dexterity by the woman or her 

partner. Both carry the risk of a perforation (small tear) or, rarely, an infection, which may go unnoticed in women with decreased sensation due to a 

disability.

The diaphragm is a barrier method of birth control that is usually inserted into the vagina by the woman just before having intercourse. Usually, 

some form of spermicidal gel is placed on the diaphragm before it is inserted. 

Because both squeezing the tube of gel and inserting the diaphragm require 

some degree of manual dexterity, this is usually not a choice for women with 

disabilities that affect hand functioning. Occasionally, in longer term relationships, the device is inserted and removed by the partner. 

The subdermal hormonal implant is a small rod, about the size of 

a matchstick, that is inserted under the skin by a physician. Usually, it is 

implanted in the upper arm and is effective for up to 3 years. It can cause 

irregular bleeding for some women. Occasionally, it can affect a woman’s 

mood and sex drive. 

The birth control pill is a combination of hormones that are taken orally. 

Like other hormonal methods, the pill suppresses ovulation, thickens cervical 

mucus, and thins the lining of the uterus to help block sperm. For maximum 

effectiveness, it is best if the pill can be taken at the same time each day; the 

need to remember daily dosages for three weeks each month can be a disadvantage, particularly if a woman has memory or cognitive impairments. The 

pill can cause nausea, headaches, breast tenderness, and spotting between 

periods. Some doctors are concerned about giving the pill to women with 

spinal cord injury (SCI) because of the dangers of developing deep vein 

thrombosis (blood clots) in the legs, although some physicians feel that newer 

versions of the pill are safer or that progesterone-only pills have fewer risks 

for women with disabilities. If considering a hormonal form of birth control, 

consult with a physician. 

 The patch is placed on the upper arm, shoulder, abdomen, hip, or upper back. It delivers a combination of hormones that function like the birth 

control pill, thus suppressing ovulation and blocking sperm. The patch only 

needs to be changed once per week, offering some advantage over the pill. It 

has many of the same potential side effects as the pill. If skin under the patch 

becomes irritated, the location of the patch can be changed. Again, potential 

risks, such as blood clots, should be reviewed with a physician. 
Sexuality and Integration H 185

 The vaginal ring is inserted into the vagina and slowly releases hormones into the body. Typically, the ring is inserted by the woman or her 

partner, and some degree of manual dexterity is required for proper positioning. In addition, the use of hormones requires a consideration of individual 

risks versus benefits.

 The condom is a barrier method and is presently the only form of male 

contraception. Female condoms exist, but can be difficult to insert and possibly difficult to fit for some women who have atrophy in vaginal muscles due 

to certain disabilities. Both male and female condoms offer protection against 

sexually transmitted infections. Condoms may limit spontaneity because they 

are used just prior to intercourse. On the plus side, they have few side effects, 

except in the case of latex allergies. Male condoms involve men in the birth 

control process more directly than some of the other forms of birth control 

discussed, because either partner can roll the condom over the penis at the 

appropriate time. Using condoms effectively involves good communication 

between partners and a sense of mutual responsibility for sexual health. 

PSYCHOLOGICAL HEALTH AND DISABILITY ISSUES

Dep ress i o n 

Although circulatory and hormonal issues are important factors in sexual 

health, emotional issues also play a large role in the quality of sexual functioning. Certain psychological disorders (eg, depression) often contribute to 

sexual problems and can interfere with pleasure and intimacy. Depression can 

also complicate physical functioning among people with chronic illnesses or 

disability. 

Individuals with clinical depression vary in the daily pattern of their 

symptoms; some people feel worse in the morning and better as the day goes 

on, whereas others experience the opposite pattern. Because increasing pleasurable and rewarding activities may be a part of the treatment or recovery 

process, engaging in intimate activities might be helpful for some people. 

Considering time of day and aiming for sensual pleasure rather than orgasm 

or even intercourse may increase the chances of a positive experience.

Clinical depression has long been shown to negatively affect sexual 

functioning. Depression can reduce overall energy levels, as well as sexual 

desire, and can make it more difficult to experience pleasure. Becoming sexually aroused is often difficult for those who are feeling depressed. Although 

people who are depressed may have feelings of shame or embarrassment 
186 H Pr o m o t i n g Su c cess f u l I n teg r at i o n

about it, depression is commonplace in today’s society (Figure 7-6). Untreated 

depression, however, can be self-defeating and potentially dangerous. Typically, counseling and medications either alone or in combination with one 

another are the most common and effective treatments of depression. These 

treatments can significantly improve appetite and sleep, restore energy, and 

ultimately renew sexual interest.

However, further complicating the direct effects of depression on libido 

is the fact that many antidepressants also have sexual side effects. Commonly 

used antidepressants (eg, Prozac, Zoloft, Paxil, and others) can influence 

sexual functioning by 

• reducing sexual interest, 

• decreasing the ability to achieve erections, 

• reducing vaginal lubrication, 

• prohibiting male ejaculation, and 

• diminishing the capacity for orgasm in both men and women. 

Medications may be indicated if suicidal 

ideation is present or if the individual with 

a disability is neglecting self-care routines. It 

should be noted, however, that the efficacy 

of antidepressant medication has not been 

adequately studied in double-blind randomized trials in the population of people with 

disabilities.14 As such, psychotropic medications should be used sparingly in favor of a 

more active, person-centered approach. The 

process of adjustment may be enhanced by a 

behavioral appraisal and coping process instead of or in conjunction with medications. 

Behavioral techniques to reduce depression 

and anxiety may include guided imagery, 

relaxation training, or cognitive behavioral 

therapy. 

In addition to depression, other reactions (eg, anger, hostility, and withdrawal) are 

often seen as well. One study demonstrated 

that 28% of Veterans who received rehabilitation between 1997 and 2007 

were diagnosed with depression. Among people with SCI and depression, 

Fi g u re 7-6. Depression Can 

Complicate Physical Functioning and Negatively Affect 

Sexual Functioning. PHOTOGRAPH: 

PFC PAIGE PENDLETON, 1ST BRIGADE 

COMBAT TEAM, OFFICE OF PUBLIC 

AFFAIRS, 1ST CAVALRY DIVISION.
Sexuality and Integration H 187

70% were also diagnosed with another psychiatric disorder, with PTSD and 

anxiety disorders being the most common.15 These can be short lived or can 

be present throughout rehabilitation. For some people, there is an absence 

of depression, which is often confusing to staff members and other members 

of the rehabilitation team. However, there is no convincing evidence that the 

absence of strong negative emotions or depression indicates a poor psychological adjustment in the future.

P o st t r a u m at i c St ress Di s o r der 

Increasingly, over the past few decades, psychologists have explored and recognized the occurrence of PTSD among people with disabilities and returning 

Veterans.16 Traumatic events may include a previous time in which a person 

was exposed to actual or threatened death, serious injury, or sexual violation. PTSD is an array of psychological and physiological reactions that are 

expected, normal reactions to a life threat, but that persist beyond a normal 

period of recovery. It is not uncommon for symptoms of PTSD to persist for 

many years. 

The traumatic nature of deployment and exposure to combat would 

appear to place individuals at risk for symptoms of this psychiatric disorder. 

Typical symptoms experienced by people with PTSD often include flashbacks; 

nightmares; problems sleeping; hypervigilance; and intrusive recollections of 

the event, along with efforts to avoid thoughts, feelings, or recollections of 

that event. This effort at avoidance is credited with the chronicity of the disorder because it leads to inaccurate interpretations of the event and increased 

psychological distress. 

Many returning Service Members and Veterans of recent conflicts experience PTSD. This disorder has been associated with high rates of relationship 

difficulties, as well as sexual dysfunction.3,17,18 These difficulties are related 

to biological, cognitive, behavioral, and emotional effects of PTSD. PTSD is 

often treated with psychotherapy, which may be supplemented with medications (including antidepressants). Cognitive behavioral therapy—and other 

forms of psychotherapy that focus on changing problematic thought processes and disruptive behavioral patterns—is often utilized to decrease the 

anxiety, guilt, anger, and disconnection that are part of PTSD. In addition, 

couples therapy may help. Couples who work together to resolve intimacy 

issues related to PTSD and to create emotional safety in their relationship 

may find this to be an important part of the overall healing process for the 

Service Member or Veteran with PTSD.1
188 H Pr o m o t i n g Su c cess f u l I n teg r at i o n

Tr a u m at i c Br a i n I n j u ry a n d Serv i ce-Rel ated

P h ys i c a l Di sa b i l i t ies 

Traumatic brain injury is the result of concussive injuries that have affected 

almost 20% of Operation Enduring Freedom and Operation Iraqi Freedom 

Veterans.19 Like PTSD, it can affect relationships and sexual functioning 

through physical, psychological, and relationship changes. These include 

lower sex drive and problems in sexual functioning, such as disruptions to 

arousal and problems with orgasm.1 Counseling can help couples identify the 

ways in which traumatic brain injury may be affecting their relationship and 

develop coping strategies that facilitate their sexual connection.

Military service-related disabilities are varied, and include SCI, amputation, and sensory impairments. Due to the prevalence of injuries sustained 

from improvised explosive devices, injuries may include damage to or loss 

of genitalia or other injuries to the genitourinary system.20,21 These kinds of 

injuries can have profound effects on sexual well-being by changing 

• body image, 

• physical sexual responsiveness, 

• relationship roles, and 

• well-being.1,22

Ultimately, changes to the former structure and dynamics of life create a 

shift in the relationship dynamics within the partner dyad, and the caregiver 

often assumes the dual role of lover and caregiver. This shift in relationship 

dynamics can create conflict between the couple, which puts the relationship 

under strain. 

Adapting to these changes can involve an initial period of grieving and 

adjustment. Ultimately, sexual well-being may involve redefining what it 

means to be a sexy, sensual person; and conventional, outward attractiveness 

may matter less than one’s inner experience. Approaches to sexual expression may need to expand to include a wider range of pleasure- and intimacyenhancing behaviors. 

Sexuality after a disability is a topic that has been widely explored and 

should be well understood by the mental health professional working with 

returning Veterans and other military personnel.23 In addition to education, 

people with a disability may need specific suggestions regarding exploration 

and resuming sexual activities. In many cases, sensate focus exercises and 

improved communication may help a couple to avoid the performance 

anxiety often associated with intercourse. Early after injury, mutual pleasuring and sexual exploration may be the preferred method to gain sexual confidence and resume sexual activity in a safe, nonthreatening manner. 
Sexuality and Integration H 189

Couples may benefit from therapy that is disability-affirming to redefine 

their assumptions about and approach to sexual expression. A variety of 

counseling strategies (including cognitive, behavioral, and mindfulness) can 

help individuals and couples with disabilities to challenge negative thinking, 

develop good self-care and relationship-care strategies, plan for enjoyable 

sexual expression, and learn to be fully present in their current experiences. 

In addition to disability-affirmative counseling, sex therapy can help 

clients learn techniques to improve sexual functioning. Masters and Johnson23

developed a treatment plan that removed all pressures from the couple and 

gradually encouraged people to focus on the feelings and sensations of sexual 

pleasure. With this technique, termed sensate focus, individuals and couples 

are encouraged to enjoy their physical responses and to disengage from their 

thoughts, including worries and judgments that could interfere with sexual 

experience.22 Additional sex therapy techniques include specific strategies for 

overcoming difficulties with orgasm and erectile functioning. A disabilityaffirmative sex therapist can develop a specific, tailored treatment plan to 

improve sexual functioning and maximize sexual enjoyment and pleasure 

whether in solo sexual activities (eg, masturbation) or in partnered sexual 

encounters.1

C o m m u n i c at i o n 

For those in relationships, increasing a sense of partnership and shared 

responsibility for sexual intimacy is critically important. It can be challenging 

for many Veterans to talk honestly about sex with their partners. Sometimes, 

people find it easier to discuss these topics with same-gender friends. Part of 

that may have to do with embarrassment or self-consciousness, but there can 

also be differences in what men and women tend to focus on when discussing sex. Although we will suggest some generalizations about gender differences in communication style about sexuality, it is important to recognize 

that individual men and women vary considerably and may not match these 

generalities.

To the extent that there are gender differences, however, men may focus 

on the physical aspects of sex. They may focus on the mechanics of sex and 

on issues like positions, erections, and orgasm. This can be problematic when 

it leads to all-or-nothing thinking about the “correct” way to have sex (eg, 

sex must include erection, penetration, and orgasm; men must be physically 

and psychologically ready for sex at any time, etc). For men whose physical 

or psychological functioning during or after military service does not match 

these preconceived ideas, there may be a risk of feeling like a failure and 

experiencing distress. Being overly concerned with performance (eg, the 

ability to delay orgasm) can interfere with sexual pleasure and satisfaction. 
190 H Pr o m o t i n g Su c cess f u l I n teg r at i o n

In contrast, for many women, sexual priorities emphasize a sense of closeness, 

emotions, intimacy, and sharing in addition to or as an integral part of the physical pleasures. Feeling connected in a loving way may be more important than 

the sexual position, the intensity of an orgasm, or the rigidity of an erection. 

When there are differences in priorities, focus, or communication style 

within a couple’s relationship, these differences can become either a source of 

conflict or a means of helping one another to grow in intimacy by exploring 

each other’s perspectives. It is important to note that these individual differences are not completely gender-linked. Thus, in same-gender relationships, 

as in heterosexual relationships, these differing foci and values may still be 

present and affect communication and intimacy.

However difficult it may be, sexual intimacy benefits from a certain 

amount of talk and honest communication. For example, in new relationships, partners may have to ask about sexually transmitted infections and 

negotiate the use of condoms or other safe sex strategies. This is also true 

for anyone whose sexual functioning is affected by their disability. People 

who have changes in functioning with regard to desire, arousal, lubrication, 

erections, ejaculation, or orgasms may have to explain how things work now 

and what their partners can expect. They may also want to talk about how 

partners can be helpful and what kind of assistance they can provide. 

When physical or emotional factors lead to fatigue, planning for intimacy 

may be helpful. Although it may limit spontaneity, partners can plan to enjoy 

sexual activities when they are well rested and refreshed. Sexual activities in 

the morning may be more satisfying for some because nighttime blood flow 

that leads to nocturnal erections for men, combined with the physical and 

mental relaxation of sleep, may facilitate sexual responsiveness. Later in the 

day, partners can try a short nap before making love. If making love in the 

evening, having sex before eating a heavy meal or before drinking alcohol 

may be more satisfying. For men using Viagra, taking it on an empty stomach 

when well rested may maximize effects.

Sexual partners should be realistic about their desires and communicate 

these to each other. Although men in particular may internalize societal messages about being ready for sex at any time, it may be important to challenge 

these expectations and help men to internalize that it is actually okay for men 

to not be in the mood for sex or to realize that they are too tired at a given 

time. Partners who are not in the mood for sex should not try to fake it. By 

assisting Veterans and their partners with developing comfort and facility 

in communicating their needs and desires, these newly developed skills can 

reduce performance anxiety and lessen the chance that sexual encounters will 

end in disappointment and frustration.
Sexuality and Integration H 191

Veterans’ sexual expressions or attitudes about sex may be affected by 

past sexual trauma. Sexual trauma may affect interest in sex or overall comfort regarding sex. Assisting Veterans in performing even short discussions 

with their partners may be important. Gradually becoming more comfortable in tolerating the emotional vulnerability that accompanies conversations 

related to sex is critical. This allows the development of emotional closeness, 

safety, and intimacy within the relationship. Behavioral healthcare providers 

may be particularly helpful in working with Veterans who have a history of 

trauma to develop resilience in this area.

Because open communication about sex is so important for a positive 

sexual encounter, it may be helpful to coach Veterans to keep the following 

principles in mind: 

• Focus on communication goals. They may help in those difficult moments when Veterans are trying to figure out what to say or how to say 

it. Ultimately, the most important thing to remember is to be honest in 

talking about sex. 

• Do not hesitate to share insecurities or anxieties. Put any ego aside and 

let true feelings come through. This is not the time to be defensive or to 

appear to have it all together. It is a time to be clear, open, and honest.

• Express your needs from a personal perspective by sharing private 

information with your partner. This includes talking from the first person 

and using words like “I” and “my.” Over time, you will find that talking 

about yourself will put your partner at ease and will be much more 

constructive. 

People with disabilities should avoid waiting until the very last moment 

to explain how their bodies work and what their partners can do to provide some assistance. It is more comfortable and intimate to be sexual when 

partners know what to expect about each other’s functioning. Conversations 

about sex are best and more natural when they unfold gradually over time. 

Sharing a little bit about one’s sexual needs and desires is best when both 

partners feel close and emotionally connected. 

Each partner should not only express his or her own feelings, but also 

listen to their partner’s feelings. Each partner should have an open mind, realizing that difficulties in sexual intimacy involve both parties. It can be helpful 

to think about what can be personally changed rather than trying to lessen 

discomfort by making excuses, blaming, or distancing oneself from the concerns that are being expressed. Listen with an open mind and with compassion for your partner’s vulnerability.
192 H Pr o m o t i n g Su c cess f u l I n teg r at i o n

Pay close attention to verbal and nonverbal responses. Take each other’s 

feelings into consideration and be open to any questions that come up. Be 

sensitive to each other’s reactions and be willing to have a conversation 

according to each partner’s willingness and openness to hear the information 

that is being communicated. 

Do not be afraid to say things such as “that feels nice” or “I like it when 

you touch me here.” Partners can suggest different things to try and let each 

other know when they are enjoying something. Be careful not say to a partner 

that they are doing things wrong, and partners should avoid sounding like 

they are shouting out orders or instructions in bed. 

Although it is important to explain about things like positions, erections, 

lubrication, and orgasms, partners should not forget to leave time to talk 

about their feelings. Share some positive feelings, including feelings about 

the relationship. Sexual encounters are times to be vulnerable by letting one’s 

guard down. If sex is stressful, partners should communicate that sex is an 

anxiety-provoking experience. Do not fake a level of comfort or experience; 

be genuine. Partners should let each other know that this may be a time of 

discovery for both of them and enjoy the journey together.

If conversations about sex are rare in a relationship, there is a good 

chance that they will be more awkward and difficult than if the topic is 

discussed regularly. Frequent conversations about sex become increasingly 

relaxed. Try to have conversations about sex on a regular basis to become 

more at ease and natural with the topic. It is important to remember that 

good sex is a goal and it takes some time, effort, and communication to get 

there. Sex is not going to be perfect every time, and, in fact, “good-enough 

sex” is a better goal than aiming for perfection.2 As a matter of course, some 

sexual encounters are going to be more enjoyable than others. By communicating consistently about sex, there is a better chance for mutual pleasure 

during each sexual encounter.

SUMMARY

Achieving sexual intimacy and pleasure proves to be challenging for many 

people, and those who have served often face additional challenges related 

to the practical, psychological, relational, and medical consequences of their 

service. Resilience in the face of those challenges includes arming oneself with 

knowledge about the workings of the sexual system and about options for 

medical interventions that may enhance sexual functioning. Resilience also 

means being willing to challenge ideas that can be limiting. An important first 
Sexuality and Integration H 193

step is recognizing that disability is a function of the interplay between 

impairments and environments that are not designed to be universally 

accessible. Sexual expression and fulfillment are important to people with 

disabilities, and sexual well-being is a function of creative engagement in 

understanding your body and your relationship. Self-care, medical care, 

counseling, and sex therapy are all important strategies for achieving sexual 

well-being. In addition, it is important to be prepared to seek out healthcare 

providers who support you in your treatment goals and who are disabilityaffirmative and supportive of sexual expression.

Refere n ces

1. Cameron RP, Mona LR, Syme ML, et al. Sexuality among wounded Veterans of 

Operation Enduring Freedom (OEF), Operation Iraqi Freedom (OIF), and 

Operation New Dawn (OND): implications for rehabilitation psychologists. 

Rehabil Psychol. 2011;56:289–301.

2. Metz ME, McCarthy BW. The ‘‘good-enough sex’’ model for couple sexual satisfaction. Sex Relation Ther. 2007;22:351–362.

3. Allen ES, Rhoades GK, Stanley SM, Markman HJ. Hitting home: relationships 

between recent deployment, posttraumatic stress symptoms, and marital functioning for Army couples. J Fam Psychol. 2010;24:280–288.

4. Reissing ED, Di Giulio G. Practicing clinical psychologists’ provision of sexual 

health care services. Prof Psychol Res Pract. 2010;41:57–63.

5. Olkin R. What Psychotherapists Should Know About Disability. New York, NY: 

Guilford; 1999.

6. Mona LR, Cameron RP, Fuentes AJ. Broadening paradigms of disability research 

to clinical practice: implications for conceptualization and application. In: 

Hagglund KJ, Heinemann A, eds. Handbook of Applied Disability and 

Rehabilitation Research. New York, NY: Springer; 2006: 75–102.

7. National Institute on Disability and Rehabilitation Research. NIDRR LongRange Plan 1999–2003. Washington, DC: Office of Special Education and 

Rehabilitative Services; 2000. 

8. Mona LR. Sexual options for people with disabilities: using personal assistance 

services for sexual expression. Women Ther. 2003;26:211–220.

9. Syme ML, Mona LR, Cameron RP. Sexual health and well-being after cancer: 

applying the sexual health model. Couns Psychol. 2013;41:268–285.

10. Mona LR, Syme ML, Cameron RP, et al. Sexuality and disability: a disabilityaffirmative approach to sex therapy. In: Binik YM, Hall KSK, eds. Principles and 

Practices of Sex Therapy (5th ed). New York, NY: Guilford; 2014.

11. Ducharme S, Gill K. Sexuality After Spinal Cord Injury: Answers to Your Questions. Baltimore, MD: Paul Brookes Publishing Co; 1997: 7–8, 69–70, 82–90. 
194 H Pr o m o t i n g Su c cess f u l I n teg r at i o n

12. Ducharme S, Kewman D, Chase T, et al. Sexuality and Reproductive Health in 

Adults with Spinal Cord Injury: A Clinical Practice Guideline for Health-care 

Professionals. Washington, DC: Consortium for Spinal Cord Medicine, Paralyzed 

Veterans of America; 2010: 28–33.

13. Ducharme S. Sexuality and spinal cord injury. In: Nesathurai S, ed. The Rehabilitation of People with Spinal Cord Injury: A House Officer’s Guide (2nd ed). 

Boston, MA: Artbuckle Academic Publishers; 2000: 83–89. 

14. Elliott TR, Frank RG. Depression following spinal cord injury. Arch Phys Med 

Rehabil. 1996;77:816–823.

15. Ullrich P, Smith B, Blow F, Valenstein M, Weaver F. Depression, healthcare 

utilization and comorbid psychiatric disorders after spinal cord injury. J Spinal 

Cord Med. 2014;37:40–45.

16. Radnitz C, Schlein I, Walczak S, et al. The prevalence of post-traumatic stress 

disorder in Veterans with spinal cord injury. SCI Psychol Proc. 1995;8:145–149. 

17. Cosgrove DJ, Gordon Z, Bernie JE, et al. Sexual dysfunction in combat Veterans 

with post-traumatic stress disorder. Urology. 2002;60:881–884.

18. Letourneau EJ, Schewe PA, Frueh BC. Preliminary evaluation of sexual problems 

in combat Veterans with PTSD. J Trauma Stress. 1997;10:125–132. 

19. Tanielian T, Jaycox L, eds. Invisible Wounds of War: Psychological and Cognitive Injuries, Their Consequences, and Services to Assist Recovery. Santa Monica, 

CA: RAND Center for Military Health Policy Research; 2008.

20. Bray JR. Genitourinary trauma: a battle cry for integrated collaborative 

Veteran-centric care. J Mens Health. 2013;10:121–123.

21. Han JS, Edney MT, Gonzalez CM. Genitourinary trauma in the modern era of 

warfare. J Mens Health. 2013;10:124–129.

22. Mona LR, Cameron RP, Goldwaser G, Miller AR, Syme ML, Fraley SS. 

Prescription for pleasure: exploring sex positive approaches in women with 

spinal cord injury. Top Spinal Cord Inj Rehabil. 2009;15:15–29.

23. Masters WH, Johnson VE. Human Sexual Response. New York, NY: 

Little Brown and Company; 1966.
Sexuality and Integration H 195

Ret i red Ma r i n e C o r p s Ser gea n t

Ba re n Ber g knows that second chances 

are possible. His high school wrestling career 

ended in disappointment, when he was ruled 

ineligible for competition after arriving at school 

too late in the semester to qualify. The reality 

of his career on the mat being over was harsh. 

He had been recruited by top college programs 

and was looking forward to the opportunity to 

participate in collegiate wrestling. This was no longer possible, so he left high 

school and received his GED shortly after.

Responding to the declaration of war in Iraq, Berg joined the US Marine 

Corps in 2003. After training, he found himself on the front lines of a 

historical battle with India Company, 3rd Battalion, 5th Marines. During the 

battle, Berg was rendered unconscious by an explosion. This incident was 

later declared the cause of his mild traumatic brain injury.

Upon returning 

home from the 

war, Berg was 

accepted as a 

full-time student 

at Penn State 

University and, 

before long, he 

walked right on 

to the wrestling 

team. Later 

that year, he won his first college match. Berg even received an award for 

Scholastic Athletic Achievement for making the dean’s list while competing 

in Division 1 athletics. However, the elation of reaching these milestones was 

short lived. There was an ongoing war inside his head, and he found himself 

surrounded by problems with relationships and colleagues on campus. He 

tried self-medicating with alcohol, but soon found himself in real trouble 

with the law.
196 H Pr o m o t i n g Su c cess f u l I n teg r at i o n

Berg’s command leadership recognized 

his need for treatment. After a stint at 

the National Naval Medical Center in 

2007, he enrolled at Clarion University 

looking for another chance. 

On May 21, 2009, Berg graduated, 

wearing his Marine dress blue uniform as 

a symbolic gesture of respect. When the 

commencement keynote speaker posed 

the question, “How many of you plan on 

serving your country after graduation?,” 

Berg slowly raised his white-gloved hand. Looking around, he realized he was 

the only one raising his hand. Slowly, a thunderous clap erupted throughout 

the building, and everyone rose to their feet while he remained sitting 

completely in shock. It was a beautiful close to that chapter in his life.

In 2011, Berg deployed once again to Helmand Providence, Afghanistan, 

as an E-5 Sergeant. While there, he trained, developed, and mentored 

Marines. Simultaneously, he earned a Master’s degree in science. During his 

demobilization, an examination determined that he had sustained a mild 

traumatic brain injury during his first deployment. He was also diagnosed with 

posttraumatic stress disorder. Healthcare providers informed him that new 

technologies were available for treatment that had not been in place in 2007. 

After leaving the Marine Corps in 2013, Berg was selected as a Presidential 

Management Fellow. His family then relocated to Washington, DC. Despite 

facing difficulty within the workplace due to a lack of accommodations, he 

authored reports and drafted solutions to help shape policies and strategies 

for other Veterans. Finally, in 2014, Berg started his own business (A Few 

Good Leaders) to help other Veterans through the recovery process.

Currently, Baren Berg is working as a consultant by helping other Veterans 

start their own businesses; is pursuing a PhD in Workforce Development 

at Penn State; and is a member of Penn State’s Ability Athletes and Team 

Semper Fi for running, wrestling, and Brazilian jiu-jitsu.
If wounded, injured, or ill, we will seek out every available 

resource to restore Marines to health.

H H H

General James F. Amos

Commandant of the Marine Corps

C h a p ter Ei g h t

The Role of Sports and

Recreation in Promoting

Successful Reintegration

RORY A. COOPER, PhD*; MICHAEL MUSHETT, MS†; and

THOMAS WILLIAMS, PhD‡

*

Director and Senior Career Scientist, Human Engineering Research Laboratories, 

Rehabilitation Research and Development Service, US Department of Veterans Affairs, 

6425 Penn Avenue, Pittsburgh, Pennsylvania 15206, and Distinguished Professor and 

FISA Foundation–Paralyzed Veterans of America Chair, Department of Rehabilitation Science and Technology, University of Pittsburgh, 6425 Penn Avenue, Suite 400, 

Pittsburgh, Pennsylvania 15206

†

Executive Director, Turnstone Center for Children, 3320 North Clinton Street, Fort 

Wayne, Indiana 46805

‡

Director, Senior Leader Development and Resiliency, US Army War College, 122 

Forbes Avenue, Carlisle, Pennsylvania 17013

INTRODUCTION

We build the comprehensive physical, mental, emotional, and 

spiritual resiliency of our Soldiers, Civilians, and their Families to 

enable them to thrive personally and professionally.

 

General Ray Odierno

US Army, Chief of Staff
200 H Promoting Successful Integration

S

ports and recreation are important components of military life and 

therefore can serve as an excellent modality in the rehabilitation and 

reintegration of Service Members and Veterans with disabilities.1 They 

help emphasize a commitment to a team effort while effectively providing 

motivation, purpose, and emotional reward for remaining physically active, 

which is increasingly recognized as important for all of us. Sports and 

recreation can help to make Service Members and Veterans become more 

efficient, effective, and self-aware. This enhances their ability to perform as 

Service Members or to become successful Veterans in their communities. An 

holistic approach is required that includes physical, mental, and behavioral 

components to build resilience, maintain health through the benefits of 

physical activity, and maximize the likelihood of successful reintegration.2

Military and Veteran healthcare providers and communities need to both 

understand and leverage the various military programs focused on enhancing 

resiliency to develop fitness, confidence, and resilience.3 These programs 

include the mental, physical, and emotional readiness to confront the 

challenges of continuation on duty or to succeed as a Veteran in civilian 

communities.

This increased understanding of military resiliency programs raises the 

acceptability and likelihood for the success of an approach that then helps 

Service Members and Veterans gain greater self-awareness; achieve the ability to sustain themselves long-term; and find the most effective and efficient 

ways of living, learning, and reintegrating. Successful rehabilitation and 

reintegration involve learning about personal strengths and weaknesses, and 

channeling physical and mental strength to achieve goals. Rehabilitation and 

reintegration require learning to manage stamina and maintain motivation 

during periods of physical and mental stress. This helps to ensure that our approaches build on the mental and physical resiliency that our military service 

resiliency programs seek to promote. 

Movement is essential to maintaining both physical and mental health. 

Furthermore, sports and recreation

• help to improve or maintain health, 

• build communities, and 

• change perceptions of disability and impairment. 

Participating in sports and recreation early in the rehabilitation and reintegration process helps to build a healthy perception of self, improve self-confidence, and increase strength and stamina. Although many individuals have 

good intentions to stay active, participation in sports and recreational activi-
Role of Sports and Recreation in Reintegration H 201

ties may positively influence the social cognitions to increase peer-motivated, 

leisure-time physical activity opportunities that move individuals from “intention” to “activity.”4

 Many organizations and military communities provide 

a wide variety of opportunities for sports and recreation. Fortunately, nearly 

anyone can participate in some activity, and many activities can be performed 

with friends and family both with and without disabilities. Integrated activities 

also help to promote connections to other people with and without disabilities. 

Importantly, individuals often underestimate the positive impact that increased 

physical activity will have because they too often focus on the unpleasantness 

and/or difficulties that are associated with “getting started.”5 All of us need to 

focus some of our efforts onto three factors that have a significant impact on 

our physical and mental health:

1. attaining adequate sleep, 

2. performing regular exercise, and 

3. maintaining a healthy diet.

Given the importance of overall health and well-being, successful reintegration of wounded, injured, and ill Service Members and Veterans and their 

families is dependent on the Performance Triad of Sleep, Activity, and Nutrition that promotes successful rehabilitation, healthy behaviors, and informed 

decisions. Teaching Service Members and Veterans to incorporate healthy 

sleep, activity, and nutrition behaviors can help to optimize the performance 

of their bodies and brains. An important goal of performance in rehabilitation 

and reintegration involves focusing on developing more mentally and physically resilient spouses, parents, Service Members, and Veterans to help set 

the conditions for better decision-making, stronger relationships, and higher 

overall effectiveness in outcomes.6

A BRIEF HISTORY OF ADAPTIVE SPORTS IN 

REHABILITATION AND REINTEGRATION

The concept of adaptive sports and recreation as a component of rehabilitation dates back nearly 100 years. After the First World War, wounded Service 

Members began returning to their home countries.7 At the same time, in 

many Western countries, a self-sufficiency movement was taking place. In the 

United States, this movement was in part stimulated by the rising costs of caring for Veterans of the American Civil War, because the US Congress had become concerned that Civil War pensions were consuming a growing portion 
202 H Promoting Successful Integration

of the federal budget.7 Thus, people began to think that wounded, injured, 

and ill Veterans could return to productive roles in society if they were given 

the proper training and equipment.8

Walter Reed Army Medical Center (Washington, DC) was at the forefront 

of this movement. At Walter Reed, wounded Veterans were provided with 

a program of exercise and adaptive sports, which was the precursor to the 

physical therapy and physical medicine and rehabilitation programs that we 

use today.9 To implement the program, the Army hired graduates of physical 

education programs, many of whom were women, who worked with Army 

physicians to adapt baseball, volleyball, and other sports for Veterans with 

disabilities. Often, physical education instructors participated in the sports 

alongside with or competed against the Veterans. Along with the sports and 

recreation programs, Wounded Warriors were required to learn to cook and 

clean for themselves, and repair their prosthetic devices. Self-sufficiency was 

equated with being manly and whole, and became the goal of rehabilitation.10

This model of rehabilitation became formalized during World War II; 

by this time, physical therapy, occupational therapy, and physical medicine 

and rehabilitation programs had become established. Sports, exercise, and 

learning to maintain one’s equipment were standard, with two very important 

changes:10

1. there was greater emphasis placed on vocational rehabilitation, and

2. (because of the need for trained Soldiers) there was the opportunity to 

continue on active duty after being severely wounded and undergoing 

rehabilitation. 

With the advent of new treatments and medications, Veterans with wounds 

such as spinal cord injuries showed an improved rate of survival and faced 

the challenge of determining if and how they could return to their homes and 

families.11 The demands of new Veterans with disabilities—primarily Veterans 

with major limb amputations and spinal cord injuries—led to investment in 

assistive device research in the United States and other countries.12

In 1948, Sir Ludwig Guttman searched for a means to improve the fitness 

of wounded Veterans under his care while at the Stoke Mandeville Hospital 

in England.13 He created competitions in various sports and included Veterans who used wheelchairs. His methods caught on in several other countries 

and led to the first international competition in 1952. As the competitions 

gained momentum, more countries joined and eventually the Paralympics was 

established. In 1989, the International Paralympic Committee was founded, 

which entered into a cooperative agreement with the International Olympic 
Role of Sports and Recreation in Reintegration H 203

Committee to share venues.13 Today, the Paralympics provides a world-class 

showcase for people with disabilities around the world to exhibit their sporting prowess. Many of these world-class athletes are military Veterans.

In 1981, the US Department of Veterans Affairs (VA) created the National Veterans Wheelchair Games in part to celebrate the International Year 

of People with Disabilities, but also to use sports as a vehicle for rehabilitation 

and reintegration of wounded, injured, and ill Veterans.14 Today, the National 

Veterans Wheelchair Games (NVWG) include Veterans from the United 

States, Puerto Rico, and Great Britain. It has become the world’s largest annual wheelchair sporting event and is an integral part of the VA’s rehabilitation and reintegration programs. Furthermore, the NVWG served as a model 

for public–private partnerships, and the Paralyzed Veterans of America cohost 

the games each year. In 1986, the VA partnered with the Disabled American 

Veterans to create the National Disabled Veterans Winter Sports Clinic that 

introduces wounded, injured, and ill Veterans to adaptive winter sports.15 In 

2010, the US Paralympics, the Department of Defense, and the VA—along 

with a number of corporate and not-for-profit partners—created the Warrior 

Games using the NVWG and Paralympics as models.16 The Warrior Games 

use sporting competition teams from the Army, Navy/Coast Guard, Air 

Force, and Marine Corps to promote healthy activity, rehabilitation, and successful reintegration. All of these events are held annually, but are supported 

by year-round programs at local Veteran and military medical centers.

IMPORTANCE OF SPORTS AND RECREATION IN 

REHABILITATION AND REINTEGRATION

The primary goals of rehabilitation and reintegration are to restore as much 

function as possible and to learn compensatory strategies for lost functions or 

those yet to be restored. The military and the VA are at the forefront of advancing rehabilitation and reintegration, and they rely heavily on sports and 

recreation for this purpose. For civilians, insurance reimbursement restrictions 

for private rehabilitation centers has led to the focus being on learning basic 

skills that allow people to return home; and, if that fails, they allow people to 

be transferred to a long-term care facility. However, the military and VA target higher goals for wounded, injured, and ill Service Members and Veterans, 

with the ultimate goal of returning Service Members to duty or helping Veterans to become successful members of their communities. To attain either of 

these goals, physical and mental agility are important, and can be promoted 

through sports and recreation. For example, being able to walk with a pros-
204 H Promoting Successful Integration

thetic limb may be sufficient to return home, but more is required to return to 

duty or to become a fully contributing member of society. One would need to 

learn how to run and negotiate rough terrain using a prosthetic limb in order 

to return to duty, and one would need to learn to carry a child or to walk on 

a hiking trail to more fully participate in society.

Either of the aforementioned goals requires the completion of a series 

of smaller steps that, when added together, make significant progress. Sports 

and recreation can help to teach such practical skills as doing a “wheelie” in 

a wheelchair. The ability to do a “wheelie” is an important skill necessary for 

negotiating curbs and for progressing over uneven terrain. Sports and recreation also help those with disabilities to relearn teamwork and restore esprit 

de corps. At the Warrior Games, participants transform into athletes and 

develop a strengthened affinity for their respective branches of the military 

service. The sense of making a valuable contribution through participation in 

sports has a powerful effect on self-esteem and self-confidence. 

BENEFITS OF SPORTS AND RECREATION FOR 

SUCCESSFUL REINTEGRATION

Without regular exercise, the body begins to lose strength and stamina, 

making it more susceptible to injury and illness.17 Even within the Military 

community, there are many people who do not get sufficient exercise, and the 

problem is much worse among Veterans and the general population.18 Obesity and overall poor health are a growing epidemic within the United States, 

and people with physical or cognitive impairments are at even greater risk.19,20

Partially, this is due to a shortage of accessible facilities and the low availability of adaptive equipment. Fortunately, this is less of a problem for Veterans 

because the VA recognizes the need to promote health and fitness, and hence 

provides adaptive equipment.

Adaptive sports and recreation are important modalities in the rehabilitation of wounded, injured, and ill Veterans and Military personnel.21 During 

the initial phases of rehabilitation, adaptive sports and recreation are used to 

rebuild strength and stamina due to deconditioning from inactivity. After prolonged bedrest or minimal activity, the body begins to become weaker, stiffer, 

and fatigue more easily. These are common barriers to successful rehabilitation and reintegration because most forms of assistive devices require energy 

for mobility and other activities. Cognitive impairments can lead to changes 

in balance, coordination, and stamina.22 Therefore, an exercise routine that 

involves some aerobic activity, strength training, and flexibility training is 
Role of Sports and Recreation in Reintegration H 205

important. Sports and recreational activities can serve to augment an exercise 

routine to build these attributes. Sports also have the added benefit of being 

fun, competitive, and can make exercise more enjoyable. Further, they can 

improve endurance, strength, flexibility, mental acuity, and coordination. 

Scientific studies have shown that sports and recreation are also effective at 

reducing the symptoms of depression.23 Nearly all sports have been adapted 

for people with various disabilities; therefore, most rehabilitation programs 

for military and Veterans include a variety of sports and recreation opportunities to help people find something that they enjoy and in which they can participate when they return home to their communities. Events like the NVWG 

and the Warrior Games reflect this philosophy and, combined, offer nearly 15 

different adaptive sports that are only a small subset of the possible activities.

Rebuilding a healthy self-image, learning confidence, and developing skill 

building are important outcomes that can be constructed through adaptive 

sports and recreation.24 For example, wheelchair basketball is a great way for 

wheelchair users to 

• build their mobility skills, 

• learn balance, 

• develop a sense of the position and movement of the chair in space, and 

• learn to multitask by moving and dribbling or moving and shooting. 

These skills translate directly into better mobility on crowded sidewalks or 

when crossing busy streets. Sitting volleyball helps to teach balance, coordination, and cooperation. Learned confidence helps us to take on new challenges 

and get closer to the goal of successful reintegration into the community. Integrated activities are also excellent for rehabilitation. At the National Disabled 

Veterans Winter Sports Clinic (NDVWSC), Veterans are matched with an 

instructor who has the training and skills that matches their particular needs. 

Together, they go out onto the ski slopes with other skiers, and this provides 

many benefits. 

• Learning or relearning to ski builds strength, balance, agility, coordination, and self-confidence. 

• It requires rapid integration of multiple skills and processes. 

• The activity is fun, and the Veteran is participating in an activity along 

with other people of varying skill levels, as well as varying physical and 

mental abilities. 

• Often, a day of skiing can achieve practical rehabilitation goals that cannot be achieved through weeks of clinical therapy. 
206 H Promoting Successful Integration

Sports and recreation also help to build on existing relationships or 

increase the number of supportive relationships.25 These relationships can 

be peer-to-peer, within families, or within a mixed group of people with and 

without impairments. Sports and recreation help to build unit cohesion and 

are a defining feature of the Military community. These relationships are 

essential for building social capital and overcoming physical and emotional 

barriers. They are also excellent learning opportunities. For example, during a 

wheelchair track meet, the elevators broke down and the athletes were stuck 

on some of the upper floors of the dormitory where they were staying. Many 

of the athletes had experienced similar circumstances before and began to descend the stairs in their wheelchairs using a handrail. Other athletes had never 

done this before and wondered how people were getting down the stairs in 

their wheelchairs. This situation provided an opportunity for the more experienced athletes to mentor the new wheelchair users and, eventually, everyone 

was able to get down the stairs. 

Similarly, when watching a group learn to play wheelchair basketball, new 

players quickly learn that if their chairs tip over, they can roll onto their backs 

and call another player over to roll them back up, instead of crawling out 

and working to climb back into the chair (thus disrupting the game). Often, 

relationships established through sports and recreation activities last for years, 

or even a lifetime. These shared experiences help to form bonds and promote 

the health of participants. At the NVWG, teams participating in wheelchair 

rugby are established by having a group of officials assign players to teams: 

blue team, black team, red team, etc. The goal is to spread the players by skill 

level equally across all of the teams. Ideally, this results in each team having an 

equal number of outstanding players, good players, and novices. 

Once assignments are made, each team meets and selects a captain, and 

then the tournament begins. Because the teams are relatively evenly matched, 

an interesting phenomenon occurs nearly every year: the group that comes 

together as a team the fastest nearly always wins the tournament. The key is 

to use all of the talents of the team and to support each other to win. If one 

ego dominates, more often than not the team will lose the tournament. Therefore, the concept of winning is as much about building functional relationships as it is about playing the game.

MAINTAINING HEALTHY EXERCISE HABITS OVER A LIFETIME

Rehabilitation and reintegration are lifetime processes. Although acute rehabilitation after becoming wounded, injured, or ill may take weeks to months, 
Role of Sports and Recreation in Reintegration H 207

the follow-up often takes a lifetime because physical, sensory, and cognitive 

impairments are not static. As people age with a disability, there may be the 

need from time to time to make adjustments or even to undergo another 

rehabilitation stay. Therefore, it is important to maintain a routine of exercise across the life span. This is best accomplished by learning healthy sports 

and recreation habits and incorporating them into a daily routine. For most 

people, simply walking or propelling a wheelchair is insufficient exercise to 

remain healthy. As people age, they tend to lose

• stamina, 

• strength, and 

• flexibility. 

Therefore, these three factors need to be incorporated into an exercise regimen that may include adaptive sports and recreation.

People with disabilities tend to be more sedentary than the general population and are at greater risk for the health-related risks of deconditioning. 

This can be excessively troubling for Veterans who use prosthetic limbs or 

wheelchairs as a source of mobility because these devices often require more 

energy for ambulation. For health maintenance, about 1 hour of activity per 

day with a heart rate elevated above 60% of maximum heart rate is a good 

rule to follow.26 However, it is best to consult a physician before beginning 

or making a significant change in an exercise routine. A recreation therapist 

or physical therapist can be an excellent resource when planning an exercise 

routine or when learning adaptive sports.

Sports and recreation can reduce the risk of developing secondary conditions related to an impairment.27 Common secondary conditions include joint 

injuries, skin breakdown, and neuropathies.28 Often, a routine that includes 

building or maintaining strength improves or maintains cardiovascular fitness, and promotes muscle balance will help to mitigate the risk of developing 

a secondary condition that can exacerbate the impact of the original impairment.29 When a person has a physical impairment, the person develops strategies using other muscles and joints to compensate for the deficit in another 

part of the body. This can lead to strain on these joint and limbs, resulting in 

pain and new injuries over time. To help prevent this from happening, it is 

important to maintain balance across the joints. 

If the muscles on one side of the joint become notably stronger than the 

other side, the imbalance places strain and can result in injury. For example, 

wheelchair propulsion primarily uses the anterior muscles of the arms, chest, 

and shoulders. Subsequently, the posterior muscles in the arms, shoulder, and 
208 H Promoting Successful Integration

back may become weaker by comparison. This is often evident by a rounding of the shoulders forward. This muscle imbalance can lead to injury, often 

manifested when performing some other activity such as a transfer, where a 

tear may occur in one of the weaker muscles, tendons, or ligaments. Exercise also helps with blood flow to the limbs. As we age, our skin becomes 

less supple, and blood flow is reduced. Exercise can help to slow or reverse 

this process. Individuals who have scarring from burns or who use prosthetic limbs are at greater risk of skin breakdown as they age. Therefore, a 

nonweight-bearing exercise routine, such as swimming, may be helpful in 

promoting skin health.

Success leads to increased confidence and a greater willingness to set new 

goals. Moreover, a skewed perception of personal capabilities brought on by 

low self-esteem may be more limiting than a physical, sensory, or cognitive 

impairment. This is particularly important in Veterans and Service Members. 

Many persons who have served in the military put a high value on physical 

prowess and their ability to handle difficult and stressful situations. For this 

reason, Veterans with traumatic and acquired disabilities are at increased 

risk for decreased self-esteem due to alterations in self-perception related to 

traumatic and acquired disabilities. Adaptive sports, exercise, and recreation 

provide effective modes through which self-esteem can be enhanced by providing the individual with

• a meaningful mastery experience, 

• positive interactions with others, and 

• an improved perception of the physical self.30

There also seems to be a positive relationship between sports, exercise, 

and recreation and achieving educational and career goals.31 This is likely due 

to regular participation in sports, exercise, and recreation, which promotes 

improved physical health and mental well-being. More colleges and universities are offering adaptive sports and recreation programs for their students 

with disabilities, in part because of the requirements of the Americans with 

Disabilities Act, but also because of the greater demand by students with 

disabilities for access to this important aspect of campus life. Sports and 

recreation are an important part of career advancement in some professions, 

where important social relationships are established on the golf course, tennis 

court, or even while walking or jogging. Sports and recreation are an integral 

part of the military culture and lifestyle.
Role of Sports and Recreation in Reintegration H 209

PROVIDING SPORTS AND RECREATION OPPORTUNITIES:

CREATING INCUSIVE ACTIVITIES

When a wounded, injured, or ill Service Member or Veteran returns to his 

or her Military or civilian community, it is important to have inclusive sports 

and recreation activities available and to ensure the widest possible participation by people of all abilities. When people have fun together participating in 

healthy activities, it builds supportive relationships that benefit the individual 

participants, as well as strengthens the community as a whole. Strong communities are communities in which everyone has a sense of belonging. This 

does not mean that everyone has to be alike or contribute in the same way, 

but it is important that the needs of all are considered. However, such strong, 

participatory communities are unfortunately currently not the norm in US 

society. It will take time and effort on everyone’s part to transition communities (both Military and civilian) to offer more inclusive sports and recreation 

activities in which people of all ages and abilities can participate together in 

an array of programs. 

The Army Ten-Miler and the Marine Corps Marathon are examples of 

inclusive activities that are important components of the military rehabilitation process. They promote full inclusion of the Military community to 

include the wounded, injured, and ill, as well as the civilian community. These 

events are often set as fitness goals for wounded, injured, and ill Service Members. They allow people to participate using necessary assistive devices (eg, 

wheelchairs, handcycles, prosthetic limbs, etc) and include events for people 

of wide age ranges and abilities. Military communities place great value on 

promoting health across the age span, and offer a wide variety of free and 

low-cost sports and recreation programs.

Integrated and team-building activities are important for forming 

cohesiveness of units and communities. For several decades, people with 

disabilities have been expanding the number of adaptations for sports and 

recreation, and nearly every form of sport or recreational activity can be 

modified to be accessible to people with a variety of impairments. There are 

some activities that lend themselves naturally to being inclusive. For example, 

sitting volleyball is a Paralympic sport for individuals with lower limb amputations or impairments; however, it can be a lot of fun when played as a unit 

or even when played as a community with games arranged for people with 

and without impairments. Further, little equipment beyond a gym floor, a net 

the height of that used in tennis, and a volleyball are needed. If wheelchairs 

are available, wheelchair basketball can also be a great activity for people of 

varying physical abilities. In some cases, equipment may already be available. 
210 H Promoting Successful Integration

Many gyms are equipped with spinning cycles and arm ergometers that can 

be used together to create programs for people of all abilities.

Healthy communities promote the welfare of their members. The design 

of communities can help to promote activity among members, as well as 

healthy lifestyle habits. This can be accomplished by offering formal programming and assistance with more everyday conveniences that encourage people 

to incorporate more movement into their daily lives (eg, walkways to local 

facilities, bicycle paths, and local shopping opportunities). Low- or no-cost 

community facilities can also play an important role. Gyms, swimming pools, 

and ball fields can further encourage activity and health. The key is to create a 

culture that values participation in sports, exercise, and recreation as a natural 

part of daily living.32 The military values these activities, but everyone must 

assume a role for them to become a core part of the community.

ORGANIZATIONS PROVIDING SPORTS AND 

RECREATION OPPORTUNITIES

The adaptive sports movement as we know it was founded as a rehabilitation 

and reintegration tool for wounded World War II Veterans. It provided rehabilitation, postrehabilitation, and reintegration support to Service Members 

who sustained physical and cognitive injuries.13 Currently, Veterans with 

disabilities are introduced to adaptive sports during their rehabilitation and 

reintegration programs at military treatment facilities and subsequent engagement in sports at VA medical centers. Long-term participation takes place in 

an individual’s home and in civilian or Military communities. Communitybased providers of adaptive sports programs are the “hometown anchors” 

and catalysts for lifetime sporting opportunities. These program providers 

include the following:

• not-for-profit organizations, 

• parks and recreation departments, 

• military or Veteran service organizations, 

• rehabilitation facilities, and 

• colleges and universities. 

Table 8-1 is a sampling of “best practice” program resources, but this list is 

by no means complete or comprehensive. 
Role of Sports and Recreation in Reintegration H 211

Ta b le 8-1. Program Resources

Program Web Site Description

USA Paralympic 

Resource Network

findaclub.

usparalympics.org

The USA Paralympic Resource Network is 

designed to connect individuals with disabilities, 

including Service Members and Veterans, to ongoing programs in their communities. The network 

links individuals with disabilities to communitybased adaptive sport program providers. The site 

includes a national listing of programs that are 

searchable by state and zip code.

Veterans Administration Adaptive Sports 

Program—Advance 

Sports Club Finder

va.gov/

adaptivesports/

va_clubAdvanced

Finder.asp

The Advance Sports Club Finder connects disabled 

Veterans and youth and adults with disabilities with 

community-based programs—such as the Paralympic Sports Clubs—that have been developed to 

provide sports programming and physical activity 

opportunities regardless of skill level. All programs 

and activities at these organizations are based in 

the community and are run by local organizations.

SportsAbilities sportsabilities.com SportsAbilities touts itself as “the premier resource 

for people with disabilities to find recreational, advocacy, support, and adaptive sporting activities 

in the nation.” They list activity calendars for every 

state and 25 different activity categories ranging 

from team sports to social gatherings.

Paralyzed Veterans of 

America (PVA)

pva.org PVA fights for the needs of spinal cord-injured Veterans and ensures that their members receive the 

quality care and benefits they have earned through 

their military service. The organization is also 

engaged in spinal cord research, public education 

and sports, and recreation. PVA is also co-presenter 

of the National Veterans Wheelchair Games, the 

largest annual wheelchair sport event in the world.

Team Semper Fi/

Semper Fi Fund

semperfifund.org The idea for Team Semper Fi was inspired by the 

wounded Marines and Sailors who refused to let 

their challenges prevent them from competing in 

athletic events. The team is made up of military 

personnel who have overcome significant challenges in their service to our country and who 

have embraced the fighting athletic spirit of those 

on the road to recovery. The Semper Fi Fund 

provides coaches, specialized sporting equipment, 

entry fees, and travel expenses to athletic events. 

Team members are also given the opportunity to 

receive high-level training from former and current 

Olympic and Paralympic athletes through a partnership with US Paralympics.
212 H Promoting Successful Integration

Wounded Warrior 

Project

woundedwarrior

project.org

Through partnerships with high-quality, specialized 

disabled sports providers, the Wounded Warrior 

Project delivers dynamic and engaging year-round 

sports and fitness programs to help injured Service 

Members gain confidence and independence 

while adapting to life after injury. With adaptive 

equipment and trained instructors, Warriors can 

participate in almost any sport or fitness activity, 

moving them beyond rehabilitation and toward 

a full and productive life. These programs are 

designed to encompass all areas of fitness and 

exercise, including nutrition and physical training, 

to build a healthy and fit lifestyle.

Disabled Sports USA disabledsports

usa.org

The mission of Disabled Sports USA is to provide 

national leadership and opportunities for individuals with disabilities to develop independence, 

confidence, and fitness through participation in 

community sports, recreation, and educational 

programs. Each year, Disabled Sports USA serves 

more than 60,000 youth, Wounded Warriors, 

and civilian adults through a nationwide network 

of more than 100 community-based chapters in 

37 states in more than 40 different sports. Sports 

include alpine and nordic skiing, snowboarding, 

biathlon, kayaking, water skiing, sailing, scuba, 

surfing, rafting, outrigger canoeing, fishing, hiking, 

golf, athletics, archery, cycling, running/wheeling, 

rock climbing, equestrian, and others.

Wheelchair & Ambulatory Sports, USA 

(WASUSA)

adaptivesportsusa.org The mission of WASUSA is to provide multisport 

and recreational opportunities for individuals 

with a disability by facilitating, advocating, and 

developing a national community-based outreach 

program; providing resources and education; 

conducting regional and national competitions; 

and providing access to international competitions 

in conjunction with the International Wheelchair & 

Amputee Sports Federation. WASUSA offers programs in archery, handcycling, powerlifting, shooting, swimming, table tennis, and track & field.

Ta b le 8-1. Program Resources, continued
Role of Sports and Recreation in Reintegration H 213

US Association 

of Blind Athletes 

(USABA)

usaba.org USABA provides life-enriching sports opportunities 

for individuals with a visual impairment. A member 

of the US Olympic Committee, USABA provides 

athletic opportunities in various sports, including—

but not limited to—track and field, nordic and 

alpine skiing, biathlon, judo, wrestling, swimming, 

tandem cycling, powerlifting, and goalball (a team 

sport for the blind and visually impaired).

BlazeSports America blazesports.org By cultivating local, state, national, and international strategic partnerships with like-minded 

organizations, BlazeSports America is advancing 

the equality, visibility, and human rights of people 

with physical disabilities through sport. The mission 

of BlazeSports America is to change the lives 

of children and adults with physical disabilities 

through sport. Operation Blaze offers a wide range 

of sports and activities for Veterans and active-duty 

Service Members with physical disabilities. These 

programs are offered free of charge and provide 

excellent year-round health, fitness, and social 

opportunities.

Challenged Athletes 

Foundation (CAF)

challengedathletes.

org

It is the mission of the CAF to provide opportunities 

and support to people with physical disabilities so 

they can pursue active lifestyles through physical fitness and competitive athletics. Operation Rebound 

funds equipment, training, and travel expenses that 

can help injured troops and first responders to harness the healing power of sports. Sports clinics are 

held throughout the year at military medical centers 

and other locations in the community. Expert 

coaches and CAF elite athletes provide instruction 

and mentorship to introduce beginner athletes to a 

range of sports, including bicycling, handcycling, 

running, swimming, basketball, etc.

Ta b le 8-1. Program Resources, continued
214 H Promoting Successful Integration

SUMMARY

A responsive and reliable healthcare system and community support system 

can positively and proactively improve reintegration and resilience. It can 

also influence the health of Service Members, Veterans, and their families. 

Approaches that focus on adaptive programs to enhance physical and mental 

resiliency are very familiar to our Veterans and their families. They can serve as 

great motivational foundations for their reintegration and overall well-being. 

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32. Hargreaves J, ed. Sport, Culture and Ideology. London, UK: Routledge & Kegan 

Paul; 1982: 30–32.
216 H Promoting Successful Integration

Ret i red Ar m y

Nat i o n a l Gu a r d

Ser gea n t Ma j o r

J o A n n Tresc o

After combat, no one 

is ever the same. When 

JoAnn Tresco came home 

from Iraq, her boss of 

5 years—himself a war 

Veteran—asked her, “What 

happened to the smart 

lady that used to run this 

place? Don’t you remember 

anything?” Although only 

1 year had passed since she had left the busy training center that she ran with 

an iron hand, it seemed like 10 years had gone by when she returned. 

“Trying to remember anything was like trudging through thick sand,” said 

JoAnn. “I changed.” Her combat tour had sapped her of her vitality, trust, 

and all of her zest for life she had been known for. Although she hoped that 

it did not show, it did. 

Back in Iraq, completely by accident, JoAnn had discovered salsa dancing. 

She credits learning to salsa dance with having improved her life in the 

midst of a war zone. Her unimproved base in Iraq had no MWR (Morale, 

Welfare, and Recreation), no gym, and nothing to do. However, deploying 

with a large Hispanic community had its benefits, and she soon realized that 

dancing took her out of her wartime reality and moved her heart to a better 

place. 

“When I took someone’s hand to dance, the synergy of our movement 

connected me to another human being at a time and a place where 

connections were nearly impossible,” explained JoAnn. “When I salsa 

danced in Iraq, I was able to forget the war, forget where I was, immerse 

myself into the music, and, for a time, my heart was free.” So, she 

concluded, if dancing could help her in Iraq, maybe it could help her back 
Role of Sports and Recreation in Reintegration H 217

home as well. She soon 

began taking ballroom 

dance lessons.

“That began a 

partnership with dance 

that has saved my 

life.” Working with her 

was dance instructor 

Jonathan Kopatz, an 

Airborne Ranger with 

the 82nd Airborne 

Division. He challenged 

JoAnn to move with 

grace and elegance; to 

trust him while dancing 

figures that demanded that she put herself completely in his hands; to learn 

to instinctively follow his lead without hesitation; and to show emotion on 

her face and convey emotion with her arms that showed her vulnerability. 

Each of those things enabled JoAnn to relearn how to feel, to soften, to love, 

and to move.

“I discovered that the 

showcases that I danced 

in with Jon gave me 

different opportunities 

to use courage and 

presence as a beautiful 

woman,” said JoAnn. 

“In the process, I began 

to extend my arms and 

body into delicate lines 

that soothed my soul.”

Today, after retiring from the Pennsylvania Army National Guard after 34 

years of service, JoAnn Tresco is the owner and operator of PA DanceSport 
218 H Promoting Successful Integration

Ballroom (Hummelstown, PA), the very ballroom that gave her the gift 

of dance. After 12 years of operation, the owners of the ballroom offered 

JoAnn the opportunity to buy the business and continue to use her training 

and management skills to help others. As the owner, she continues to work 

with Jonathan Kopatz, Premier Instructor at the ballroom, to improve her 

dancing and to teach others to dance. She has now joined him as the newest 

member of the instructional staff and has defined the mission of the business 

as “enhancing lives through dance.”

“Whenever I step onto a ballroom floor, I step into a safe space where I 

can feel and move without any pain or threat of attack. I leave whatever is 

troubling me behind. It doesn’t follow me onto the floor. . . . When I begin 

to dance, the cry of my soul is to ‘make my heart a better place.’ Dance does 

just that.” 
Who wouldn’t consider themselves fortunate 

to stay in [the] . . . ranks and claim the title of a 

United States Marine for even just one day.

H H H

General Joseph F. Dunford, Jr.

Marine Corps Base

Washington, DC

September 24, 2015

C h a p ter Ni n e

Virtual Reality and Telemedicine 

to Support Reintegration and 

Health Maintenance

DEEPAN C. KAMARAJ, MD, MS*, and RORY A. COOPER, PhD†

*

Research Associate, Human Engineering Research Laboratories, Rehabilitation 

Research and Development Service, US Department of Veterans Affairs, 6425 Penn 

Avenue, Pittsburgh, Pennsylvania 15206, and Graduate Student Researcher, Department of Rehabilitation Science and Technology, School of Health and Rehabilitation 

Sciences, University of Pittsburgh, 4028 Forbes Tower, Pittsburgh, Pennsylvania 15260

†

Director and Senior Career Scientist, Human Engineering Research Laboratories, 

Rehabilitation Research and Development Service, US Department of Veterans Affairs, 

6425 Penn Avenue, Pittsburgh, Pennsylvania 15206, and Distinguished Professor and 

FISA Foundation–Paralyzed Veterans of America Chair, Department of Rehabilitation Science and Technology, University of Pittsburgh, 6425 Penn Avenue, Suite 400, 

Pittsburgh, Pennsylvania 15206

INTRODUCTION

Avirtual environment (VE) is a simulation of a real world that is 

generated through computer software and is experienced by the user 

through a human–machine interface.1 This phenomenon of human–

machine interaction that allows users to engage in different tasks in real 

time is referred to as virtual reality (VR).2 A VR-based system is comprised 

of multiple hardware and software devices that work in unison to provide 

varying degrees of complexity and a sense of “presence” in the VE. Presence 
222 H Pr o m o t i n g Su c cess f u l Rei n teg r at i o n

is conceptualized as the subjective perception that the virtual world is 

somewhat real,3 meaning that “At some level and to some degree . . . objects, 

events, entities, and environments are perceived as if the technology was 

not involved in the experience.”3,4(p1) In the real world, we gain knowledge 

about our environment directly through our senses—vision, hearing, touch, 

proprioception, and smell. By contrast, in the VR-based system, we use 

these same senses to obtain information about the VE through the human–

machine interface.1 This interface provides information specific to one or 

more senses, depending on the type of device used by a specific configuration 

of a VR-based system, which is then used to guide interactions of the 

participant within the VE.1

With the dawn of evidenced-based medicine, there is growing literature 

supporting the scientific rationale for the use of VR-based systems, specifically in the realm of rehabilitation. The applications of VR-based systems are 

thought to impact two key areas of rehabilitation—(1) motor learning in the 

context of musculoskeletal injuries or disorders1; and (2) exposure therapy in 

the context of mental illnesses, such as posttraumatic stress disorder (PTSD), 

anxiety disorders, and phobias.3,5,6

The three key concepts of motor learning include the following:

1. repetition, 

2. feedback, and 

3. motivation.

They are affected by VR.1 VR-based systems act as powerful tools to promote 

repetitive practice, provide feedback about performance, and supply motivation to endure practice.1

 In addition, there is strong evidence suggesting that 

motor skills learned in the VE transcend and improve real-world performance 

of similar tasks.7–9 Similarly, VR exposure therapy (VRET) facilitates emotional engagement of patients with PTSD (or other phobic disorders) during 

exposures to the multiple sensory stimuli in the VE.10 The presence provided 

by a VE facilitates the emotional processing of memories related to a similar 

life event10 (eg, a traumatic situation that happens to many Veterans). By 

allowing gradual exposure to these feared environments or traumatic life 

events—according to the needs of each patient—VR can be used in situations 

that are difficult to control or that are unpredictable, which could put the 

patient at risk if the exposures were performed in a real situation.3

The advent of better design and the increasing availability of sustainable 

and reliable technology have made VR-based therapy regimens much more 

readily available and advantageous in comparison to standard therapy.1,2,11–14
Virtual Reality and Telemedicine H 223

The ability of VR and gaming-based technology to provide different interactive environments that can be progressively challenging, considering the user’s 

capacity to perform a task, has been utilized to address the same underlying 

deficit over time. This feature—combined with the ability to monitor users’ 

performance—has proven to be a vital adjunct to the evidence-based, realworld rehabilitation regimen.15,16 Virtual worlds also provide a controlled 

setting in which users can confidently perform tasks or movements that may 

compromise safety in the real world,17 thus enabling activities that may not 

otherwise be attempted.15,16 Although resources (time, space, and money) become a challenge to replicate a variety of environmental conditions required 

to perform tasks in the real world, a VR-based system can be easily modified to accommodate the needs of the individual through adjusting the user 

interface. In addition, VR-based systems enable the manipulation of multiple 

forms of sensory feedback (visual, auditory, and force) to enhance the learning experience or to focus attention on particular aspects of task performance 

to more closely reflect the user’s goals in the real world.15,16

Although VR-based systems simulating a presence within an environment 

can be advantageous when inducing learning behavior, they can also potentially induce cybersickness (a constellation of motion sickness-like symptoms) 

among users.1 Common symptoms of cybersickness include the following:

• nausea, 

• vomiting, 

• headache, 

• somnolence, 

• loss of balance, and 

• altered eye–hand coordination.1

However, it is essential to note that, with newer equipment and better technology, the incidence of cybersickness has greatly decreased. In spite of this 

decrease in incidence, the effects of different VR systems on various patient 

populations to potentially induce cybersickness are still widely questioned and 

studied to understand and design better VR-based systems.18,19

These VR systems offer interactive and engaging platforms that increase 

user motivation for and participation in therapy. VR- and gaming-based technologies (Figure 9-1) have a vast array of applications in rehabilitation and 

have contributed significantly to the 

• treatment of movement disorders, 

• musculoskeletal injuries,
224 H Pr o m o t i n g Su c cess f u l Rei n teg r at i o n

• visual impairments, 

• cognitive deficits, 

• dizziness, 

• phobias, and 

• pain.16

This chapter provides an overview of some of these applications and lists a 

few resources that provide more information for anyone who might be interested in pursuing VR-based therapy.

VIRTUAL REALITY IN MENTAL HEALTH

VR is an effective tool for delivering exposure therapy to a wide range of 

mental health conditions, specifically phobias and anxiety disorders (eg, 

PTSD).6,20 The Diagnostic and Statistical Manual of Mental Disorders, Fourth 

Edition, characterizes PTSD as causing high-frequency, distressing, intrusive 

Fi g u re 9-1. Virtual reality systems can be used for computer-based gaming. 
Virtual Reality and Telemedicine H 225

memories, and amnesia about the details of an event.21 PTSD involves a 

constant feeling of fear generated by inadequate consolidation of the autobiographical trauma memory.10,22 To attain adequate processing of the traumatic 

memory and the consequent extinction of the fear, the memory must be 

activated, and safe components must be inserted. Prolonged exposure therapy, 

proven to be highly efficacious in the treatment of PTSD, aims to access the 

traumatic memory, including information about the traumatic situation and 

related emotions, thoughts, and behaviors.10,23,24 This helps the patient to understand the context of the traumatic experience, as well as its impact in the 

patient’s life. The therapy also enables the patient to achieve a realistic perspective about the traumatic event and its aftermath.10,25 Despite the fact that 

imaginal exposure therapy stimulates emotional engagement, some patients 

find it difficult to immerse themselves in the traumatic scene and, therefore, 

may quit treatment. In some case studies, dropout and nonresponse rates may 

reach 50%.10,25 These setbacks lead researchers to explore newer ventures and 

opportunities to treat PTSD.

In 2001, Rothbaum et al26 reported that VRET could be used for 

Vietnam Veterans with PTSD. In a multicase report published in 2007, Beck 

et al3 demonstrated that VRET could be used effectively in treating motor 

vehicle accident-related PTSD. In the same year, a quasiexperimental waitlistcontrolled study of survivors of the 9/11 World Trade Center attack showed 

that VR is an effective treatment tool for enhancing exposure therapy for 

both civilians and disaster workers with PTSD. VR may be especially useful 

to those patients who cannot engage in imaginal exposure therapy.27 Case 

studies have been reported indicating that clinical outcomes for VR exposure 

with individual Veterans28 and active duty Soldiers29 have been very positive. 

In 2011, Reger et al6—in a study of 24 active duty Soldier participants—

found that 62% of patients reported a reliable change of 11 points or more in 

comparison to their pretreated, self-reported symptoms on the PTSD Checklist–Military Version.

The success of these studies prompted researchers to utilize VR-based 

therapy in combination with other resources (eg, telehealth). Stetz et al30 studied the usefulness of VR technology in a sample of medics (n = 60). This study 

examined the emotional levels of participants in one of three groups: 

1. saving a virtual patient (VR group), 

2. practicing relaxation techniques only (coping or CT [coping training] 

group), or 

3. participating in a group that practiced relaxation techniques while attempting to save the patient (CT/VR group). 
226 H Pr o m o t i n g Su c cess f u l Rei n teg r at i o n

The VR group showed higher levels of hostility than the rest of the groups, 

suggesting an effective immersion and thus greater inoculation potential due 

to interaction with the VR world. The following year, the same researchers demonstrated that many individuals who practiced relaxation via VR 

scenarios would continue to practice after the conclusion of the study, which 

suggests participant buy-in.30

There is growing supportive evidence to demonstrate that VR-based 

therapy is effective in treating mental illness. Functional magnetic resonance 

imaging helps researchers to better understand the neurological pathways 

involved in PTSD. With functional magnetic resonance imaging, measured 

activation of the amygdala, prefrontal cortex, and anterior cingulate gyrus 

following exposure therapy for PTSD showed significant improvement (or 

normalization), and such evidence is continuing to grow.31

VIRTUAL REALITY IN PHYSICAL HEALTH AND REHABILITATION 

Neu r o m usc u l a r Re h a b i l i tat i o n

VR for neuromuscular rehabilitation has been studied extensively among 

able-bodied individuals and among people with specific conditions, such as 

amputations, traumatic brain injury, and vestibular dysfunction. VR has two 

broad groups of applications in the realm of neuromuscular rehabilitation: 

1. VR aids in the study of biomechanical parameters that assist with identifying and studying injury prevention strategies. With increasing availability of complex VR-based simulators, such as the Computer-Assisted 

Rehabilitation ENvironment (CAREN),32 studying the biomechanics of 

human movement and motion has soared to new heights (Figure 9-2). 

Beltran et al33 used CAREN to study the margins of stability among 

individuals with transtibial amputations. They concluded that, based on 

the mean margin of stability, unilateral transtibial amputation was shown 

to have affected lateral walking stability during platform perturbations.33

Similarly, Beurskens et al34 studied the dynamic stability of individuals 

with transtibial amputation walking in destabilizing environments. They 

demonstrated that, in the absence of other comorbidities, patients with 

unilateral transtibial amputation appear to retain sufficient sensory and 

motor functions to maintain overall upper body stability during walking, 

even when substantially challenged.34

2. VR has been useful in providing a training platform to deliver motor 

rehabilitation that promotes such injury prevention strategies in addition 
Virtual Reality and Telemedicine H 227

to strength training regimen. For example, Park et al35 conducted a study 

to determine the effect of VR-based exercise using the Nintendo Wii Fit 

(Kyoto, Japan) on the muscle activities of the trunk and lower extremities of normal adults. Participants of the study were 24 normal adults 

who were divided into a VR exercise group (VREG; n = 12) and a stable 

surface exercise group (SEG; n = 12). The exercises of the VREG using 

the Nintendo Wii Fit and the SEG using a stable surface were conducted 

three times a week for 6 weeks. Electromyography was used to measure 

the activity of the following muscles:

• tibialis anterior (TA), 

• medial gastrocnemius (MG), 

• erector spinae, and 

• rectus abdominis. 

VREG showed significant within-group differences in TA and MG muscle 

activities, whereas the SEG showed a significant difference in the muscle 

activity of the MG. VR exercise using the Nintendo Wii Fit was an effective 

intervention for the muscle activities of the TA and MG in normal adults.35

Fi g u re 9-2. The Computer-Assisted Rehabilitation ENvironment (CAREN) 

system in use. 
228 H Pr o m o t i n g Su c cess f u l Rei n teg r at i o n

Dr i v i n g Re h a b i l i tat i o n

Driving is an activity that most people identify as being an important part 

of their lives. For many people, driving is essential to maintain functional 

independence. Cognitive deficits, motor impairments, and visual changes have 

all been linked to poor driving. Consequently, there are numerous clinical 

conditions that could negatively affect driving skills. Increasingly, rehabilitation physicians are asked to make difficult decisions about the driving safety 

of their patients, but there are no well-established guidelines for determining 

when a patient should relinquish or reinstate his/her driver’s license. 

The gold standard for assessing driving ability is an on-road assessment. However, there are a number of potential problems with this method 

of evaluation. In addition to the issue of safety, such evaluations can also be 

costly, stressful, and time-consuming. Furthermore, for safety and practical 

reasons, road tests do not always allow assessors to evaluate driving ability 

in challenging driving conditions (eg, in heavy traffic, at night, or in various 

types of weather). Road tests infrequently allow for the observation of critical, but low-frequency, events (eg, collision avoidance or a pedestrian in the 

road). Although neuropsychological test performance can predict driving ability, it has been recommended that neuropsychological assessments not be used 

in isolation when determining driving safety because they assess only some 

components of the underpinnings of successful driving. Driving simulators 

seem to offer a promising alternative (or addition) to the previously described 

methods of driving assessment.36

It is important to note that simulators have certain input/output parameters, and it is essential for users and clinicians to be familiar with these 

parameters to understand completely the effect that they have on the Veteran 

using the system. Driver input parameters (eg, how the driver interacts with 

the vehicle) reflect the decision-making skills of the person operating the simulator. In addition to driver input variables, it is also common to use vehicle 

output as an outcome parameter of driving simulators.36

Even with an established and standardized set of parameters to evaluate 

this population, additional sources of information may be useful to make a 

big-picture determination about the ability to drive safely. Brief screening of 

motor functioning (eg, strength and reaction time) and visual acuity are also 

recommended to identify sensory impairments that might negatively impact 

driving safety. Detection of unsafe drivers may be improved when neuropsychological assessment is used in conjunction with the simulated driving 

evaluation. 
Virtual Reality and Telemedicine H 229

Mo b i l i t y Re h a b i l i tat i o n

Similar to the applications of VR to improve car driving performance, power 

wheelchair driving simulators have made significant advancements in recent 

years to help Veterans learn electric-powered wheelchair driving. To assist 

people with disabilities in increasing their mobility, a great variety of mobilitysupporting devices are available (eg, walking sticks and manual wheelchairs). 

Powered-mobility devices (eg, electric-powered wheelchairs and electric-powered scooters, discussed in Chapter 3, The Promise of the Future: Assistive 

Technology, Transportation, and Emerging Technologies) are increasingly 

seen in daily practice. Training is required for (elderly) people to use these 

(powered) devices safely and to maintain the required physical condition to 

participate in daily life. Such training, however, is expensive in terms of human resources, and can potentially be unsafe for both the drivers and their 

instructors.37 According to Desbonnet et al,38 a poorly controlled electricpowered wheelchair can cause severe damage to the furniture at home or 

injure other persons. They also stated that a large practice area is required 

when training a person—with a minimum risk of collision injury—how to 

control an electric-powered wheelchair. VR is an emerging technology that 

can possibly address the problems encountered in training (elderly) people to 

handle a mobility device.36,39–42 Recent work has shown promising results in 

using such technology for clinical applications and in home use.43,44 Furthermore, VR could be used as a tool to deliver other tested neurocognitive training modalities that have been known to improve mobility and driving as well.

Advanced VR simulators have also been instrumental in the design and 

development of newer technology, such as robotic wheelchairs and prosthetic devices. Candiotti et al43 developed an alternative wheel-legged robotic 

wheelchair—the Mobility Enhancement RoBot (MeBot)—to address limitations commonly noted among current electric-powered wheelchair designs 

and to provide better maneuverability in outdoor terrains.43 MeBot is a novel, 

electric-powered wheelchair that utilizes a dual system of electric and pneumatic actuators to maintain the seat orientation, which is aimed to reduce the 

risk of tips and falls. They used the CAREN system to simulate real-world 

outdoor driving terrains and to demonstrate that the seat orientation controller in MeBot maintained its orientation when driving up and down hills (pitch 

angle) or across slopes (roll angle).43 Similarly, CAREN has also been used 

either in design and testing of newer prosthetic devices or novel prosthetic 

simulators that aid along with the design process.44 
230 H Pr o m o t i n g Su c cess f u l Rei n teg r at i o n

Obes i t y/Di a betes

Today’s epidemic of obesity and diabetes poses challenges to healthcare 

similar to those facing Soldiers who return with postdeployment mental 

health issues. These include geographic barriers, social stigma, and the need 

for behavioral change. Researchers at the University of Southern California’s 

Institute for Creative Technologies (Los Angeles, CA) are adapting their 

extensive experience with technological solutions into training and techniques 

that can aid Veterans in need. These techniques show promise for concerns 

in the growing crisis of diabesity (diabetes + obesity). VR has already demonstrated itself as an impactful treatment method for several behavioral and 

mental health domains. Virtual worlds—the successor technology of original 

VR—not only inherit many of their predecessor’s strengths, but also present 

the new affordances of accessibility, social connectivity, and avatar usage that 

pave the way toward future treatment options on a broader scale.38

Hea lt h c a re I n f o r m at i o n a n d Su p p o rt

People with intellectual disabilities have poor access to healthcare, which 

may be further compromised by a lack of accessible health information. To 

be effective, health information must be easily understood and remembered. 

People with intellectual disabilities learn better from multimodal information 

sources, and VR offers a three-dimensional, computer-generated environment 

that can be used for providing information and learning. Rizzo et al46,47 describe the virtual revolution in the use of VR simulation technology for clinical purposes over the last 15 years. A major movement in clinical VR accompanied by the “birth” of intelligent virtual humans is seen as being the natural 

consequence of shifts in the social and scientific landscapes. The availability 

of highly interactive, artificially intelligent, and natural language-capable 

virtual human agents has resulted in the appearance of seminal research and 

development in this realm.45 These virtual human beings can be engineered to 

interact with the real world in a way that is human-like, in that they can exist 

in a three-dimensional virtual world, speak to real users, and display reactions 

that are emotional and akin to human.46

People with disabilities also have to contend with deterioration in their 

health and medical status, putting further burdens on the adaptive resources 

essential for preserving functional independence and quality of life. The 

gradual curtailment of functional independence and increased reliance on 

external factors for transportation can also jeopardize one’s access to medical and rehabilitation care. A variety of factors—including economic hardships, medication side effects, loss of caregiving family members, psychosocial 

disorders, etc—can exacerbate existing challenges. With average life spans 
Virtual Reality and Telemedicine H 231

in industrialized societies on the rise, these challenges have led to a crisis in 

care for people with disabilities. Rizzo et al46 point to evidence that functional 

motor capacity can be preserved, recovered, or maintained through consistent participation in a motor exercise and rehabilitation regimen. However, 

outside of the clinical context, independent adherence to such programming 

is extremely low.47 To enhance, maintain, and rehabilitate sensorimotor 

processes essential to enhance quality of life and preserve independence, it is 

vital to address the needs of the population of those aging with disabilities. 

Development and promotion of home-based access to low-cost, interactive 

VR systems to engage and motivate recipients to participate in game-driven 

physical activities and rehabilitation programming are crucial steps undertaken by the scientific research community to promote better quality of life 

among Veterans with disabilties.47

SUMMARY

Over the past 3 decades, VR and gaming-based technology have made tremendous strides due to significant advancements from the entertainment sector. Recent studies have begun to demonstrate the viable clinical applications 

of such technology, and shed light on the future that awaits the use of devices 

that utilize such technology in clinics, particularly in rural and remote settings 

where accessibility to healthcare has been restricted. This chapter provides a 

brief overview of such technology and discusses few clinical applications that 

have demonstrated viable applications of such VR technology.

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Virtual Reality and Telemedicine H 235

Sta f f Ser gea n t

Am ber Bl a n t o n , 

Pe n n sy lva n i a Ar m y

Nat i o n a l Gu a r d

Sunday, December 12, 

2004, is a day Staff Sergeant 

Blanton will never forget. 

At the time, she was 

stationed in Afghanistan 

at the Kandahar Airfield, 

where she worked as a 

Paralegal Specialist for the 

25th Infantry Division. 

She had already experienced rockets and mortars being shot into the base. 

Amber had been in the country for 7 months. It was not unusual for officers 

or noncommissioned officers to wake her in the middle of the night and ask 

questions about the rules of engagement. 

But what was different about the night that would forever change her life 

is that when she was summoned to the Tactical Operations Center, she was 

told to report immediately. She was told to leave her PT (physical training) 

uniform on and dispense with putting on her DCUs (desert camouflage 

uniform) as she normally did. When she arrived at the Tactical Operations 

Center, her battle buddy (another female) was sitting outside the Commander’s Office weeping. “When I saw her crying so hard outside that 

office, I was afraid that something had happened to her husband because 

they had gotten married right before we deployed,” Amber remembers 

vividly.

“The CO (Commanding Officer) called me in, and he was crying too,” 

Amber states with a note of disbelief. “Jeff’s been shot,” he said. “What?” 

I asked. “I just talked to him on Friday. He was finally cleared to RTD 

(return to duty) after the last time he was shot.”

Amber’s husband, a Lance Corporal in the US Marine Corps, had been 

deployed to Iraq after his wife shipped out for Afghanistan. He had been 

wounded after he had been in the country for a couple of months. The 
236 H Pr o m o t i n g Su c cess f u l Rei n teg r at i o n

wound was serious enough that he was hospitalized for a month before he 

was allowed to RTD.

“You don’t understand,” said the CO. “Your husband is dead. He was 

killed in action during a house-clearing raid. He was the first man in a stack, 

going up a set of stairs when an enemy combatant shot him multiple times 

before the Marines could return fire. I’m sorry.” Later, SSG Blanton, who 

just turned 21, would learn that her husband had traded places so that 

another Marine could have a break. “I’m very proud of him,” she says with 

a glowing smile. “He was very brave.”

The whirlwind that followed was a blur. SSG Blanton met her husband’s 

parents for the first time at his funeral. They disagreed about some of the 

choices she was making for her husband’s memorial. They fought one 

another and the Army, but the young widow persevered.

After the funeral, things began to spin out of control. While she was able 

to keep her military life squared away, things in her personal life began to 

unravel. She made choices that were not a part of who she is, ultimately 

resulting in an unplanned pregnancy. Nine months later, she gave birth to a 

handsome son.

Now, the combat Veteran, 

widow, and single mother 

has found peace. Through 

counseling and strengthening 

her faith, SSG Blanton has 

discovered who she is and 

what she was meant to do. 

Her circumstances have led 

her to stay in the military and 

mentor young Soldiers, as well 

as try to be an example of 

what true resilience looks like. 
Our collective strength depends on our people — 

their mental and physical resilience is at our core. . . .

We must always treat each other with respect and lead with 

integrity. Our soldiers are the crown jewels of the Nation; 

we must love them, protect them, and 

always keep faith with them.

H H H

General Mark A. Miley

39th Chief of Staff of the Army

August 28, 2015

C h a p ter Te n

Community/Peer

Support and Services

AL CONDELUCI, PhD*; RORY A. COOPER, PhD†; 

MELVA GOODEN-LEDBETTER, MS‡; and D. JOSHUA MARINO, MS§

*

Chief Executive Officer, Community Living and Support Services, 1400 South Braddock Avenue, Pittsburgh, Pennsylvania 15218, and Adjunct Professor, Department of 

Rehabilitation Sciences and Technology, University of Pittsburgh, 4028 Forbes Tower, 

Pittsburgh, Pennsylvania 15260 

†

Director and Senior Career Scientist, Human Engineering Research Laboratories, 

Rehabilitation Research and Development Service, US Department of Veterans Affairs, 

6425 Penn Avenue, Pittsburgh, Pennsylvania 15206, and Distinguished Professor and 

FISA Foundation–Paralyzed Veterans of America Chair, Department of Rehabilitation Science and Technology, University of Pittsburgh, 6425 Penn Avenue, Suite 400, 

Pittsburgh, Pennsylvania 15206 

‡

Chief Professional Officer, Community Living and Support Services, 1400 South Braddock 

Avenue, Pittsburgh, Pennsylvania 15218, and Field Instructor, Department of Social Work, 

University of Pittsburgh, 2117 Cathedral of Learning, 4200 Fifth Avenue, Pittsburgh, 

Pennsylvania 15260

§

Veteran Mentor, Human Engineering Research Laboratories, Rehabilitation Research 

and Development Service, US Department of Veterans Affairs, 6425 Penn Avenue, 

Pittsburgh, Pennsylvania 15206
240 H Promoting Successful Integration

INTRODUCTION

Most people know that no one person is an island. This is powerfully true when we think about military service; but, in essence, it is true for anyone. Certainly individuals can achieve much, and 

are often glamorized and idolized when they do. Individual heroes, inventors, 

leaders, scientists, etc, have brought accomplishments to our society that have 

been outstanding. Yet, in the end, it is the synergy of people and community 

that is often at the core of any individual success. People must recognize that 

myriad other individuals assisted them in getting where they are. Parents, 

family, teachers, coaches, priests/rabbis, friends, neighbors, coworkers, supervisors, spouses, children, and many others all play roles in the formation of a 

person. Community is essential, in greater or lesser degrees, to all that is good 

in society and life. 

The core of our perspective is that when a person joins the military, he or 

she leaves civilian life and joins a new community of allies who work together 

to forge a powerful alliance. This “band of brothers” aligns and in a holistic 

way (inclusive of families) creates a full community experience that supports 

all those who participate. The longer one commits to the community, the 

more difficult it is to leave.

There are many examples of how challenging a transition back to civilian 

life can be for many Service Members and families. The lifestyle and relationships—also known as social capital—that people forge, nurture, and then 

bond around are very difficult to break. As hard as these kinds of transitions 

are for any long-term military individuals or families, when one adds the 

compromising developments of a disability, the transition can be even more 

complex. The ravages of change brought on by disability create both internal 

and external barriers that can not only be perplexing, but also disconnecting. 

HISTORICAL DEVALUATION

In today’s society, when the Veteran returns to the community, he/she arrives 

as a hero and commands a powerful culture of respect. However, in time, 

this “honeymoon” ends, and the Veteran and his/her family moves out of 

the spotlight and into the mainstream community. As this transition occurs, 

the Veteran becomes somewhat anonymous; rather than being seen as a war 

hero, the Veteran is instead seen as the obvious (or not so obvious) effects of 

his/her disabilities. This can be a setup for devaluation.
Community/Peer Support and Services H 241

All forms of discrimination and devaluation have some common tracks 

that are easily seen. Subsequently, devalued people are

• labeled and stereotyped,

• congregated in formal ways into their own space,

• thought to be a problem or pose a threat to those in authority, 

• seen through their label or difference from those in authority, and

• regarded as a cost to society in either material or economic ways.

Perhaps the most discriminated block of people in the world today are people 

with disabilities. Every society on Earth has had difficulty including and 

welcoming people with disabilities. Although progress has been made, the climate for inclusion and full community participation for people with disabilities is still a major challenge. People with disabilities, including our Veterans 

and Wounded Warriors, are clearly caught in this web of devaluation. In spite 

of services, treatment, legal rights (eg, Americans With Disabilities Act), and 

charitable approaches, people with disabilities may be viewed quite harshly:

• People with disabilities are quickly labeled. Usually these labels are medical in nature and create huge cultural stereotypes. Once labeled, people 

with disabilities become that label in the greater community. Terms such 

as Jerry’s Kids, TBIs, CPs, MRs, and VA Retreads are all labels that 

seemingly identify a class of people. These labels begin to dwarf any 

similarity that people might have to others.

• People with disabilities are still readily institutionalized. Although these 

institutions have shifted from large, gothic settings to smaller group facilities, they are still institutions in format. Public funding for community 

supports for people with disabilities is only offered as a “waiver” to the 

institutional bias of Medicaid.

• People with disabilities are thought to be a problem for society. Our 

federal and state governments offer funds to address the “disability problem.” Beyond this, citizens have grown cautious of having people with 

disabilities move into their neighborhoods via group homes. Even with 

the Fair Housing Act, some communities actually have ordinances that 

specify how much distance must be allowed between homes or places 

where people with disabilities live. For any given classification of disability, there are efforts to promote funding to address the problems posed by 

that disability. To this extent, disability has economic costs to society.
242 H Promoting Successful Integration

INCLUSION

One of the major goals of rehabilitation and reintegration is inclusion. Inclusion is defined as being incorporated and welcomed back into the community 

the way one is. Inclusion is not “integration.” On one hand, the concept of 

integration demands that people fit in, be alike, and reach for similar standards. However, the notion of having to fit in or be like the majority is not 

realistic in the disability rights movement. To expect people who might not be 

able to achieve a sense of similarity to be like the majority is insensitive and 

inappropriate.

On the other hand, inclusion is the concept of bringing people into the 

community regardless of their differences. Rather than attempting to change 

or alter their differences, or trying to create a forced similarity, inclusion suggests that people join in as they are. Inclusion respects differences and honors 

diversity, but still allows for full community participation. It is a term that 

implies a welcoming to all.

In thinking about traditional efforts to achieve inclusion for the Wounded 

Warrior, the emphasis is typically on functional or technical elements. The system has been lured into thinking if only people would be able to walk, talk, 

or think better, these gains would lead to greater options for success in the 

community. Consequently, the majority of programs for Veterans with disabilities focus on these technical or clinical efforts. Still, Wounded Warriors, 

and to a large extent their families, find themselves excluded from the greater 

community. The traditional medical/clinical model of Veterans Administration (and civilian) rehabilitation has not achieved the outcomes that everyone 

wants. In some simple way, this should not seem strange or odd because the 

nature of the medical/clinical model is to exclude. To address inclusion or to 

create an inclusive rehabilitation effort is to find ways for people to become 

included in their communities as they are. To suggest that people must pass 

some readiness test, be fully fixed, or jump through any other hoop is to focus 

energy on the wrong aspects. Thus, the microscopic medical model format 

of most typical Wounded Warrior programs is often a detriment to inclusion 

rather than a path to the community.

THE MEDICAL MODEL

The lens that society has generally used to address disabilities is found in 

medical models. The framework for treatment and the overarching perceptions that typical members of a community have about disability are that of 
Community/Peer Support and Services H 243

illness or sickness. As regards the Wounded Warrior, the medical model is 

prominent and influential.

Many theorists have looked at the medical model as a framework for 

services. This framework is summarized by the medical paradigm1 as follows: 

• the problem—the person with the condition,

• core of the problem—rests in the person,

• actions of the paradigm—to classify/congregate/treat,

• power person—the expert (doctor or therapist), and

• goal of the paradigm—to fix/heal/change the patient. 

Because the medical paradigm is so persuasive in human services, a deeper 

examination is warranted. Consider the following variables2:

• The professional is the expert and is in charge of care/treatment.

• Care/treatment is administered through a chain of authority.

• The person who receives treatment is labeled and expected to cooperate.

• The main purpose of entry to the paradigm is to restore or fix the person 

to fit in.

• The ailment that brings the person to the paradigm is labeled via a 

diagnosis.

• Literature examination and research are performed and utilized to 

understand the specific features of the ailment.

• The patient is usually congregated with others in like situations.

• The expert/professional typically has the control. 

• The ailment is normally overshadowed through the therapeutic approach.

• The ailment can only be treated by the expert or his/her agent.

• The expert usually has some credentials or license to treat the ailment.

• The patient is exempt from any real responsibility.

• Most aspects of the ailment are treated in separate and distinct facilities 

designed for the ailment.

Further exploration of the medical model identifies the following six aspects: 

(1) deficiency orientation, (2) cause and effect, (3) treatment from a diagnosis, (4) the sick role, (5) microchange, and (6) clinical efficacy. Each of these 

aspects has both internal and external ramifications. Internally, they begin to 

shape how the “patient” sees him- or herself and creates a “sickness identity.” 

Externally, these elements begin to shape how the greater community comes 

to think about, and then treat, people with disabilities.
244 H Promoting Successful Integration

• Deficiency orientation: Without question, medical paradigms focus on 

what is wrong with the person. They focus on problems, abnormalities, 

deficits, and struggles. Classic medical interpretations ask: 

—What is wrong with you?

—Where does it hurt?

—How long have you had this problem? 

• Cause and effect: Because medical paradigms are scientific in nature, they 

usually function from a point of cause and effect. Simply, as the paradigm 

prompts a study and analysis of the ailment, it is drawn to make predictions about what to expect. This focus on predictability is not necessarily 

negative; however, when coupled with a deficiency orientation, it has a 

tendency to lean toward the negative.

• Treatment from a diagnosis: Most people with disabilities have some 

diagnosis that sets them apart from the norm. This diagnosis defines the 

parameters of the deviance and gives the expert some anchor to understand the ailment. Indeed, the labeling process creates an entire tone 

about the person and sets everyone up to expect certain events to occur. 

In this process, the professional begins to look for problems.

• The sick role: Perhaps the most powerful manifestation of the medical 

paradigm is found in review of the concept of the sick role. Here, the 

person is given the authority to be sick and to surrender autonomy to 

the agent of the paradigm in order to be made better. In most cases, it is 

the paradigm that defines what is well and what is sick. Further, only the 

paradigm can decide if sickness has indeed turned to wellness. It sets the 

rules, decides who fits, determines what the outcomes should be, establishes its own mechanisms to measure success, and then retains authority 

to proclaim wellness.3

• Microchange: A key point in the medical model is that of fixing people. 

The onus for change rests squarely on the shoulders of the patient. It is he 

or she who must change, adapt, or adjust to the existing world. Very little 

attention is paid to macro (environmental) change.

• Clinical efficacy: This concept relates to the strong drive that medical 

model agents have to validate their practice. Most agents of the medical paradigm must have a license or some sort of sanction to practice. 

To achieve this, the budding professional must put in countless hours 

of schooling and tutelage under the direction of those thought to be 

“masters.” However, these same masters, in a way, are guardians of the 

paradigm. They are rewarded and validated by the paradigm so that 

protection and defensiveness are not difficult to understand.
Community/Peer Support and Services H 245

Although the medical model is not bad in and of itself, the goal of 

rehabilitation and reintegration is not to eradicate sickness, but to return the 

Wounded Warrior to his/her community, and to help change the community 

to accept and respect differences of Veterans with disabilities. 

THE BIOPSYCHOSOCIAL MODEL

In May 2001, the World Health Organization (WHO) published the International Classification of Functioning, Disability, and Health (ICF), a revision 

and update of the International Classification of Impairments, Disabilities, 

and Handicaps4 (ICIDH) first published in 1980. In looking at models of 

disability and the nature in which it is approached in countries and cultures 

around the world, the WHO set out to create a standardized method in 

which levels of functioning could be identified. As they approached health 

from two domains (health, health-related), the ICF conformed strongly to the 

biopsychosocial model of disability.

Although clinicians have conformed to past treatment paradigms based 

on the medical model, the ICF sought to address disability in a more inclusive, holistic manner. Instead of viewing the disability purely as a medical or 

mental state that requires curing in the traditional sense, the WHO identified 

the three domains that combine to form the disability as a whole:

1. physical and biochemical presentations of a disability are considered to 

be in the biological domain;

2. a person’s mood, behavior, and outlook fall under the psychological 

aspects of disability; and

3. the nature in which disability impacts an individual’s interactions with 

society, to include barriers they may encounter, is considered as social 

implications. 

By accounting for all aspects of a disability and not only the physical, 

clinicians can provide a more comprehensive treatment plan and facilitate 

inclusion and full participation in society. Rehabilitation and reintegration 

efforts should be provided by a team of health professionals, including physicians, psychiatrists, social workers, and counselors. This approach of viewing 

and treating disability as a multifaceted, intricate system affords numerous 

avenues of providing accommodations and support while always putting the 

individual, not the disability, first. Applying this model of disability to efforts 

of reintegration and inclusion is not only beneficial to the individual, but also 

to the community and society in general.
246 H Promoting Successful Integration

INTERDEPENDENCE

Framing a philosophy for community reintegration requires a paradigm 

beyond the medical model. To this extent, the interdependence paradigm has 

been suggested.1 The term interdependence implies an interconnection or interrelationship between two entities and a connection or partnership between 

these entities that maximizes potential for both groups.

Interdependence is about relationships that lead to mutual acceptance 

and respect. Although it recognizes that all people have differences, as a paradigm it promotes an acceptance and empowerment for all. It also suggests 

a fabric effect in which diverse people come together in a synergistic way to 

create an upward effect for all. As we prepare individuals to return to a civilian community, the services that are designed to be offered in the community 

must be addressed from an interdependent model.

The framework of the interdependence paradigm consists of the 

following:

• the problem—limited or nonexistent service and lack of community 

acceptance,

• core of the problem—in the system or community,

• actions of the paradigm—creates supports and empowers,

• power person—person with the disability, and

• goal of the paradigm—develop relationships (eg, social capital).

A comparison of paradigms reveals the following:

Treatment Paradigm Biopsychosocial Paradigm Interdependence Paradigm

Focuses on deficiencies Focuses on interaction of factors Focuses on capacities

Stresses congregation Stresses relationships Stresses relationships

Driven by the Driven by the Driven by the

expert/professional person/disability person/disability

Promotes that the Promotes multifaceted Promotes micro-/

person is “fixed” approaches macrochange

SELF-DETERMINATION

Self-determination is a key concept in understanding and utilizing an interdependent model. Building on the concept of consumer choice and control, 
Community/Peer Support and Services H 247

self-determination means that Warriors or Veterans have authority over how, 

where, and with whom their lives will be lived. They also have control of the 

resources needed for their support.

Many self-determination researchers agree that the concept revolves 

around four critical principles:

1. Freedom: The ability to plan a life with support rather than be referred 

to a program.

2. Authority: The ability to control a certain sum of dollars to purchase 

support.

3. Support: Through the use of resources, arranging formal and informal 

support to live within the community.

4. Responsibility: Accepting a role within the community through competitive employment, organizational affiliations, and general caring for others 

within the community; and accountability for spending public dollars in 

life-enhancing ways.

Recently, a number of states have begun to incorporate the concept of selfdetermination into the publicly funded human service system. The key actions 

they recommend to achieve self-determination include the following:

• transfer financial control to the consumer through individual budgets;

• use person-centered planning to encourage individual choice; 

• promote cooperation and collaboration;

• develop awareness of community activities and resources;

• encourage communication and information sharing;

• change laws, rules, policies, and procedures to empower people;

• promote training, education, and leadership development for people with 

disabilities;

• use data gathering and analysis; and

• incorporate quality enhancement and evaluation activities.

Beyond these items, self-determination is a principle that will continue to 

influence rehabilitation and community resources. To this extent, an understanding of the community is critical to framing a philosophy of treatment. It 

is imperative to know that rehabilitation is not really the target or endpoint of 

our efforts; it is the successful return to community.
248 H Promoting Successful Integration

COMMUNITY AND SOCIAL CAPITAL

A community is a network of different people who come together on a 

regular basis for some common cause or celebration. Traditional notions of 

communities bring to mind a shared geography. However, with the advent of 

the information age, people from around the world can join together in a virtual community (eg, message boards, social media groups, online role-playing 

games). A community is in actuality based on the relationships that form, not 

on the space. The term culture is analogous to community, but culture relates 

more to the intricacies in the way of life manifested by the community. People 

who bind together around a common cause create a community. However, 

as soon as they begin to establish common symbols, values, language, and 

norms, they become a culture. Thus, from this perspective, culture is the 

learned and shared ways that members of the community act among themselves and interact with other communities.

Social capital is a term that describes not only the notion of friendship 

and connectedness, but also the value that these relationships bring to our 

lives. Like physical capital (the tools used by communities), or human capital 

(the people power brought to a situation), social capital is the value brought 

on by our relationships. Clearly, all people have some form or network of 

social capital, but sociologists have come to realize its power and potency 

only fairly recently.

Social capital is critical to individual success and achievement, but its 

potency is even more advanced. Sociologists have now confirmed that it is 

related to the following critical issues: health, happiness, achievement, and 

prosocial behavior.

• Health: The evidence is now conclusive that the more social capital a 

person has, the healthier that person is. Theorists contend that it is due 

to the scientific principle of stress buffering.

5

 Thus, the more relationships 

one has, the lower the stress levels because there are more people to offer 

emotional support. Although acute stress is associated with short-term, 

positive immune response, chronic stress adversely affects the immune 

system.6 As chronic stressors are negated or minimalized, the individual’s 

stress level declines and his/her overall health improves. Simply put, 

friends make a person healthier.

• Happiness: Over the years, psychologists have initiated the practice of 

positive psychology. In this arena, they are always measuring and gauging factors related to happiness. These factors may vary from culture to 
Community/Peer Support and Services H 249

culture, but the one constant is the variable of social capital. It is difficult 

to be happy when one is isolated.

• Achievement: Studies have concluded that people who are connected and 

liked are promoted more quickly and go further than sullen and disconnected people. Likewise, test scores in high schools and colleges are finding that connected students do better.7–9

• Prosocial Behavior: Everyone wants a society in which people are honest, 

fair, tolerant, and kind. These prosocial behaviors create a better, more 

caring community. Evidence is now clear that these positive behaviors 

increase in settings where people know each other and have some basic 

relationship.10,11 Although people often think that institutions or organizations are keys to their safety, in reality it is social capital that these 

bodies provide that keeps them secure in their identity and place in the 

community as a whole. The opportunity for relationships that community offers is at the core; circles of support and the reciprocity they create 

are the most important aspects in both safety and health.

RETURNING TO COMMUNITY AND BUILDING SOCIAL CAPITAL 

The challenge of building social capital in the community is best understood 

when thinking of the concept of a bridge. Bridges are interesting structures 

because they blend two important notions: (1) the simplicity of connecting 

two points and (2) the complexity of the engineering necessary to make the 

connection. The challenge of reconnecting people to a community is simple 

as we try to find ways for people who are disconnected to be reunited. The 

complexity is in making this happen.

With this metaphor of a bridge, the change agent can consider that 

the individual with a disability is on one side of reality and the community 

is on the other side. The goal for rehabilitation is to assist the person with 

the disability to move from being excluded on the one side to joining the 

community at large on the other side. In this example, the gap between the 

Veteran and the community can be represented in the problems or deficiencies 

the person is seen as having.

When considering this metaphor, it seems clear that the problem or the 

reason that the Veteran with a disability is distant from the community is due 

to his/her differences, disability, or perceived problem. Given this reality, the 

medical model suggests that the best way to get people from one side to the 

other is to focus on the problem or, in this case, the disability. In most human 

service programs, this is exactly how the issue of inclusion is addressed. 
250 H Promoting Successful Integration

Conventional wisdom (ie, the medical model) tries to mitigate the differences 

so that the person can be more easily included into the community. This 

conventional approach is a linear, microscopic approach to the inclusion of 

people with disabilities. It suggests that if problems can be fixed or masked, 

the Veteran will be more likely to become included. Although this approach 

has been practiced for years, it has not led to viable community inclusion. 

Even though people have been moved into the community, they have not 

really become of the community. 

A rethinking of the approach is necessary. Consider the example of a 

disconnection between two points: A and B. If there is a river in the way 

(point A), one might see the river as a problem. We might seek out help from 

an engineer as to how we might mitigate or get rid of the river so that we can 

pass to point B safely. In some ways, this is how the medical model frames the 

problem of inclusion for Veterans with disabilities. It suggests that the way to 

get people included in the community is to fix the problems they have (ie, fill 

in the river). 

However, when we use the metaphor of a bridge, the challenge changes 

from seeing the river as a problem to thinking about what other ways we 

might safely pass over it. Obviously, the focus turns to what it might take to 

build a bridge. With this shift in thinking, the river is not a problem, but a 

reality to be addressed based on the strength and stability of the shorelines 

where we plan to anchor the bridge. Consequently, the more important 

factors are not the problems posed by the river, but the strength that can be 

garnered to build the bridge.

The creation of a real shift in culture demands that the people supporting 

Veterans think about four critical steps: (1) find the passion or point of connection, (2) find the venue or connection point, (3) understand the elements of 

culture, and (4) find or enlist the gatekeeper.12 These steps are contrary to the 

medical model and are in many ways contrary to how most human service 

systems relate to people with disabilities.

Step 1: Fi n d t h e Pass i o n o r P o i n t o f C o n n ec t i o n

Finding the key points of strength and passion is the first step to cultural 

shifting. To build a strong bridge, there must be a solid foundation to ensure 

that the bridge will be safe for passage. The passage of people, products, 

or ideas into the culture requires the same strength. Consequently, we must 

identify all that is strong or good about that which we hope to shift the 

culture toward.

In many cases, people know their passions and interests. For others, 

this is a discovery process. An interest inventory is powerful because it is 
Community/Peer Support and Services H 251

not only empowering, but can also set the groundwork for the possibilities 

of community connections. This process is the same one often used with 

children in that the process of looking at connectors is one already used 

by parents. One primary effort as a parent is to discover the interests and 

capacities of children to connect them to communities that celebrate those 

same interests. 

Step 2: Fi n d t h e Ve n ue o r C o n n ec t i o n P o i n t

With cultural shifting, once the change agent has identified the positive 

capacities for inclusion or incorporation, the next critical step is to find the 

place that the person, idea, or product will relate to. In other words, find the 

setting where the Veteran might discover like-minded people who set the stage 

for building social capital. 

The concept of venue and connection point has a clear importance. To 

find a framework of new friends, one has a better chance of connection by 

taking up a hobby, passion, or capacity, and joining up with others who share 

that same passion. There are many interactive Web sites (eg, Meetup.com) 

or smartphone apps that allow people to identify their interests and locality, 

and then introduce them to a variety of clubs, groups, or associations that 

correspond to their wants/needs. 

Simply, people tend to gather for all kinds of reasons and interests. For 

every capacity or passion, there is a place where people gather to celebrate 

these passions. Such places can offer a starting point for acquiring new social 

capital. 

Step 3: U n dersta n d t h e Eleme n ts o f Cu lt u re

From a sociological perspective, the elements of a culture are defined by the 

practices and beliefs that a community assimilates as its own. These include 

symbols recognized by the group as having certain meanings; a shared system 

of laws, values, and norms; and language/dialect. Within the context of 

interdependence, the key elements of culture include rituals, patterns, jargon, 

and memory: 

• Rituals: These are the deeply embedded behaviors of the culture that the 

members expect others to uphold. These behaviors can be formal actions 

or symbolic activities that members just pick up. A vivid example can 

be found with religious institutions. All cultures are ritualistic; however, 

churches demand common actions, signs, and movements that create 

commonality and similarity among and between members.
252 H Promoting Successful Integration

• Patterns: The patterns of a culture refer to the movements and social 

space occupied by the members. Patterns are captured in how the members relate to each other as they go about the business of their culture. 

Patterns almost always revolve around the territory occupied by the 

members. As territorial animals, we are very rigid and defensive of that 

which we have laid stake to when joining the culture.

• Jargon: This relates to the language, words, expressions, and phrasing 

members of the culture use to describe or discuss that which they hold 

as important. Oftentimes, these words might be technical or very specific 

to the cultural theme. Other times, the jargon might manifest in sayings 

or expressions that are not technical, but are widely understood by other 

members and become important to the exchange of the culture. Understanding the jargon of the culture helps one make an easy transition into 

the community.

• Memory: This refers to the collective history of the culture. The memory 

is honored in formal ways by producing yearbooks, annual reports, and 

other official documents or celebrations that chronicle the actions of the 

culture. Other types of informal memory also happen within cultures 

through the weaving and telling of stories or anecdotes. Both of these approaches create a living history of the culture and establish the bond that 

causes members to want to continue the work and fully participate in the 

culture. Memory leads to communal wisdom. 

Step 4: Fi n d o r E n l i st t h e Gatekeeper

The final step in building social capital revolves around the gatekeeper. 

The only way new people successfully enter an existing community is when 

they are introduced and endorsed by a viable gatekeeper. A gatekeeper is an 

indigenous member of the community who has either formal or informal 

influence within the culture. These gatekeepers can be formally elected or 

selected leaders, or they might be one of the members everyone can count on 

to get things done. Further, gatekeepers can either be positive or negative or 

assertive or unassertive about the person, idea, or product being introduced.

The gatekeepers are powerful because they transition their influence to 

the person, idea, or product they are endorsing or rejecting. This transition of 

influence is the first step to the inclusion of the new thing into the culture. The 

mere fact that the gatekeeper likes or dislikes the idea is enough to sway other 

members to the gatekeeper’s side. 
Community/Peer Support and Services H 253

To effectively shift a culture to accept something new requires that the 

change agent identify and then enlist a gatekeeper to facilitate the passage. 

When the gatekeeper endorses a person, other members observe this and 

subsequently align their thoughts with the gatekeeper’s. The more enthusiastic 

the gatekeeper is about the new person, the more apt others are to be the 

same. Although finding and enlisting gatekeepers may be difficult, it is an 

essential ingredient for building relationships and shifting the culture.

COMMUNITY RESOURCES AND SUPPORT

Community resources are vital to Veterans with a cognitive, emotional, or 

physical disability in order for them to make a smooth transition to civilian 

life. Social capital and community inclusion can be complemented by the 

community support chosen. With these types of support, the transition back 

to the community is more successful. 

Community support services can be framed in a number of ways. One 

framework is nonprofit agencies that are mission driven to support people 

with disabilities around community support needs. These nonprofit agencies 

are guided by volunteer board members and are funded through contracts 

and donations through governments, local sources, corporate, etc. There are 

also many for-profit companies that have been developed to meet human 

services needs. These companies differ from nonprofits in that they are usually privately owned and are profit motivated. Lastly, there are governmentsupported organizations that are funded by tax dollars, such as the Veterans 

Administration and its services. Along with these support organizations, there 

are other governmental bodies that can be helpful to Veterans, but one might 

have to meet certain criteria to be eligible. 

Community support services can include, but are not limited to, attendant care, transportation, accessible housing, and vocational support. The 

amount of support needed to be successful in the community will vary from 

person to person; that is why it is critical that Veterans know their passions 

and interests. Although the abundance of services available from state to state 

may vary, most states offer the core community resources that will assist the 

Veteran with living in the community of his/her choice. In more rural areas, 

Veterans may be more reliant on family and neighbors to assist them in the 

community. Building a successful community support team that consists of 

family, friends, and neighbors will be important to ongoing participation in 

the community. 
254 H Promoting Successful Integration

At te n d a n t Ca re

Attendant care provides personal care assistance in the Veteran’s home. The 

attendant can assist with helping the Veteran complete all activities of daily 

living, including light housekeeping and assistance in the community (eg, 

grocery shopping, banking, attending medical appointments, etc). In some 

states, home- and community-based services are prevalent. The Veteran can 

access these services through any home health care agency or human service 

agency that may also provide the service. State resources like the Center for 

Independent Living can provide a number of community options to a person 

seeking these types of services.

Tr a n s p o rtat i o n

Transportation is a key component to community success. If one does not 

have access to transportation, it is difficult to participate in the community. 

The Veteran will need to access what transportation options are available. 

The options may include public transportation, paratransit, driving with 

accessibility, and reliance on community resources to provide the transportation. If a Veteran is interested in transportation support, several options 

might be explored. Driving oneself is certainly the ultimate option. However, 

the Veteran will need to evaluate if this is an option for him/her. If accessibility is required, driver’s evaluations can be obtained to assist the person 

with evaluating what assistive technology will be required to drive a car. One 

might need hand controls or wheelchair accessibility. All of these features can 

be built in to accommodate the Veteran. Public transportation is available in 

many communities, including paratransit systems that provide door-to-door 

transportation to seniors and people with disabilities. If these options are not 

feasible, and the family lives in a very rural area, then purchasing a vehicle 

with a conversion package would allow for accessible transportation. The 

conversion package will provide needed accessibility to the vehicle, thus making it easier for the Veteran to travel. 

Ac cess i b le Ho us i n g

Accessible, affordable, and safe housing is another component to community 

success. All people want safe and affordable housing. People, regardless of 

their situation, want to live in the community and stay in their homes. To 

participate in the community, one must be able to navigate his/her home and 

the community. Thus, a person who has physical and/or cognitive challenges 

may now find it difficult to negotiate his/her home without support. In this 

instance, the Veteran will want to evaluate his/her home for accessibility and/
Community/Peer Support and Services H 255

or the need for home modifications, assistive technology, or durable medical 

equipment that might allow the Veteran to maintain independence. 

V o c at i o n a l Su p p o rt

Most adults want to feel productive and know that they are making a difference. Participation in the community for some may include having a job, 

returning to school, or volunteering in the community. Whatever their choice, 

there are many resources that are available to assist with making a decision of 

how they can now contribute to the community. Adults may want to return 

to their previous employers or seek a new career choice. These individuals 

may have to make some vocational compromises in the job they did before 

or they may be able only to do a part of the job or transfer their skills to do 

work in the same field, but in a different capacity.13

When considering the community and how to access available community resources, many resources are available, such as the following:

• Aging and Disability Resource Centers (ADRCs): Many states have an 

ADRC that serves as a one-stop shop that can assist Veterans in connecting to state resources. The ADRC consists of many collaborative agencies 

that provide a variety of services and information that can help Veterans 

obtain the services they need.

• Association of Assistive Technology: Assistive technology is a critical 

growing area to the success of the Veteran being able to live, work, and 

participate in the community. This resource can help the Veteran gather 

information on resources for equipment, potential funding for assistive 

technology, and home modifications. 

• Bureau of Vocational Rehabilitation: Many states have a vocational rehabilitation service that can assist Veterans with evaluating employment 

readiness, education, and job placement. 

• Brain Injury Association of America: The Brain Injury Association of 

America is an excellent resource to provide information to Veterans regarding living with a brain injury, locating a local brain injury association 

in their state, and utilizing the services that are available for people with 

brain injury. 

• National Center for Independent Living (NCIL): NCIL can lead Veterans 

to the Center for Independent Living (CIL) that is available in their state. 

The services that the CIL offers include attendant care, housing, vocational options, etc. They can also lead Veterans to many other resources 

that are available within their states.
256 H Promoting Successful Integration

• National Association for Mental Illness (NAMI): NAMI advocates for 

access to services, treatment, support, and research. The organization will 

find information about your local NAMI organization, as well as other 

services for Veterans with mental health issues. 

• US Department of Veterans Affairs: Veterans should utilize the resources 

that are available within the Veterans Administration system. However, if 

the area where the Veteran resides has limited resources, then contacting 

the previously described resources will assist the Veteran with developing 

a comprehensive support system in addition to benefits from the Veterans 

Administration.

SUMMARY

What we know about social capital is that it works. A person remaining in 

his/her home and community is by far the better option to facility-based care. 

The strategies that are previously suggested are designed to assist the person 

and/or family with making those community connections one step at a time. 

Successful community reintegration will start with a plan that includes knowing what one wants/needs, exploring all of those agencies that can help assess 

their desires, and, lastly, implementing the plan. Anyone can complete this 

process with little to no assistance from others, or the Veteran might want to 

consider eliciting the assistance of a person who can help facilitate the connections that he/she needs to make. 

In whatever manner the Veteran chooses to approach community inclusion and build social capital/relationships, failure should never be an option. 

This process can be successful when it is recognized that there is more than 

one way to the mountain’s summit. Thus, exploring all options is critical; if 

one option does not work, then try another way. Community participation 

does not limit people based on ability because options are many and diverse. 

Veterans have served their country well, and now their community is 

available to serve them. As they approach exploring various options in their 

communities, Veterans should remember to be patient, positive, and enthusiastic about available opportunities. Further, it is more important to be 

creative, to reach out, and to be unafraid to take risks.
Community/Peer Support and Services H 257

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FL: CRC Press; 1995.

2. Zola IK. Reasons for non-compliance and failure of the elderly to seek care. 

In: Moskowitz RW, Haug M, eds. Arthritis and the Elderly. New York, NY: 

Springer; 1986.

3. Illich I. Limits to Medicine; Medical Nemesis: The Expropriation of Health. 

London, UK: Marion Boyars Publishers; 1976.

4. World Health Organization. International Classification of Functioning, 

Disability, and Health. Geneva, Switzerland: WHO; 2001.

5. Segerstrom SC, Miller GE. Psychological stress and the human immune system: a 

meta-analytic study of 30 years of inquiry. Psychol Bull. 2004;130(4):601–630.

6. Bowen K, Uchino B, Birmingham W, Carlisle M, Smith T, Light K. The stressbuffering effects of functional social support on ambulatory blood pressure. 

Health Psychol [serial online]. 2014;33(11):1440–1443.

7. Brouwer J, Jansen E, Flache A, Hofman A. The impact of social capital on selfefficacy and study success among first-year university students. Learn Individ 

Differ. 2016;52:109–118.

8. Lai G, Wong O, Feng X. Family, school, and access to social capital among high 

school students in urban Nanjing. Am Behav Sci. 2015;59(8):946–960.

9. Sands MM, Heilbronner NN. The impact of direct involvement I and direct 

involvement II experiences on secondary school students’ social capital, as measured by co-cognitive factors of the Operation Houndstooth Intervention Theory. 

Gifted Child Q. 2014;58(4):297–310.

10. Parsons CA, Jacobson JA, Krupp DB. Self-resemblance and social rejection. 

Evol Psychol. 2016;14(4):1–8.

11. Virdee G, Frederick T, Tarasoff LA, McKenzie K, Davidson L, Kidd SA. Exploring the contours of religion and spirituality in creating community: a focus on 

persons with psychosis. J Commun Psychol. 2016;44(8):1081–1087.

12. Condeluci A, Burke K, Gooden-Ledbetter M, Evans McGuirck M, Ortman D. 

Together Is Better: A Guide to Fostering Community Inclusion for Individuals 

with Disabilities. Pittsburgh, PA: United Cerebral Palsy; 2004.

13. Condeluci A, Gooden Ledbetter MG, Ortman D, Fromknecht J, DeFries M. 

Social capital: a view from the field. J Vocat Rehabil. 2008;29:133–139.
258 H Promoting Successful Integration

Pr i vate Sec o n d Cl ass (PV2) 

Greg Cr o use joined the US 

Army right out of high school. 

He served overseas as a Cannon 

Crewman on a howitzer battery. 

While on a weekend furlough, 

Greg was struck (as a pedestrian) 

by a drunk motorcyclist. He 

ruptured his stomach, cracked his 

hips, shattered his left femur in 

four places, and severed his left leg 

below the knee. Crouse was helilifted to the nearest hospital for 

treatment, flatlining twice, once on 

the helicopter en route and once 

on the operating table.

He underwent recovery and physical therapy stateside for more 

than 18 months. He suffered 
Community/Peer Support and Services H 259

through nerve damage, hip infections, numerous skin grafts, and learning to 

walk again. After his honorable discharge, Greg drifted aimlessly and fell into 

a bleak period of drugs and alcohol during the 1990s. He did not find himself 

again until after regaining his sobriety in 2000. Also, he discovered that he 

enjoyed participating in adaptive sports alongside other disabled Veterans and 

adaptive athletes in 2001.

In 2003, at a disabled sports event, Crouse uncovered a passion for canoeing. 

Soon after, he was introduced to Coach Cheance Adair who trained and 

tutored him in the ancient South Pacific Islander art of outrigger canoeing. 

He began traveling with her and other disabled athletes to various venues 

where they exhibited outrigger canoe racing as a possible Paralympic event, 

and sought consideration for this sport from the Paralympic Committee. 

After entering several demonstration-only events in Hawaii, California, and 

Pennsylvania, an adaptive division was then accepted on a Championship level 

beginning in 2008. Greg was part of the first races to compete for an Adaptive 

Class Medal, earning a Silver Medal with a 6-man adaptive crew. Thanks to 

these efforts, Paracanoe was accepted as a Paralympic sport in 2010.

Greg has been actively working with the adaptive program PossAbilities at 

Loma Linda University Health, and the program participants have awakened 

a new passion in him. He seeks to share his failures and triumphs with 

anyone dealing with an adversity in life. With the support of PossAbilities, 

he has become a Registered Amputee Peer Counselor, enlightening amputees 

during their bleak periods of body acceptance and the psychological 

readjustments that lie ahead. He has spoken with foster children, 

academically at-risk youth, and posttraumatic stress disorder transitional 

soldiers about the parallels of losing a limb and overcoming adversity in one’s 

life, yet choosing not to let that adversity define you as a person. He was 

voted as PossAbilities’ Member of the Year, and inducted into the Hall of 

Heroes for PossAbilities and the Loma Linda Medical Rehabilitation Centers.

Greg Crouse has also been called on to coach at disabled activity camps 

around the country. He has worked with the Wounded Warrior Project, the 

Endeavor Games, and various camps introducing water sports to Wounded 
260 H Promoting Successful Integration

Soldiers and their families. 

He is also a spokesman for 

hiring Veterans and speaks to 

prospective employers about 

the benefits of employing a 

Veteran. 

He has branched out into 

the community, seeking to 

share outrigger canoeing with 

fellow disabled Veterans and 

other adaptive athletes. He 

has joined a local Southern 

California “able-bodied” 

team, Imua Outrigger Canoe Club (Newport Beach, California), and 

competes on the local race circuit. Greg also finds time to coach the kids in 

his canoe club and mentor new paddlers, whether able-bodied or disabledbodied. He successfully used the employment grants and education processes 

to become an Orthotic Technician and returned to school later in life to earn a 

degree in Communications.

Greg is a husband and father, supported and encouraged by his wife, Aimee, 

and his three children Krystal, Kasey, and Chase.

Crouse has won the US National Rudderless Single Man Canoe title three 

times (2012, 2013, and 2014), taking a Gold Medal in the 200 meter, 500 

meter, and the 5 kilometer. He has also proudly represented Team USA eight 

times in outrigger canoeing in international competition, appearing at races 

held in Hawaii (2004), California (2008), Poland (2010 and 2012), New 

Caledonia (2010), Canada (2012), Germany (2013), and Brazil (2014). 

Greg has partnered with PossAbilities and strives to achieve his ultimate goal 

of securing the first ever Open Men’s “Para-canoe” selection in the 2016 

Paralympic Games in Rio de Janeiro.

Greg Crouse loves his family and his new lease on life, and proudly serves the 

United States as a Para-athlete and Adaptive Mentor.
The fact is, whether in prosthetics, geriatrics, 

PTSD and TBI treatment, or polytrauma care—to say nothing 

of disability and education benefits, home loans or homeless 

rescues, and final honors in our national cemeteries—

there’s no other one institution like the VA positioned to deliver 

a broad spectrum of Veteran-specific care and services to the 

one percent of our population that currently serves in uniform.

H H H

Robert MacDonald

Secretary of the US Department of Veterans Affairs

October 20, 2014 

C h a p ter Eleve n

Financial Management

DANIEL J. FISHER, MHA*; JOSEPH A. WINEMAN, MHA, 

DMD, ABGD†; and RANDY LEVANDER‡

*

Colonel (Retired), US Army; Assistant Chair for Administration and Operations, 

Department of Rehabilitation Science and Technology, University of Pittsburgh, 

School of Health and Rehabilitation Sciences, 6425 Penn Avenue, Suite 401, 

Pittsburgh, Pennsylvania 15206

†

Colonel (Retired), US Army; CEO, Wineman Dental, 1701 North Green Valley 

Parkway, Suite 4D, Henderson, Nevada 89074

‡

Technical Sergeant, US Air Force; Veterans Treatment Court Coordinator; also 

US Air Force Combat Arms Instructor, Financial Coach, and Advocate for Veterans, 

Pittsburgh, Pennsylvania

INTRODUCTION

This chapter is devoted to the financial health and well-being of not 

only Service Members and Veterans, but also all Americans. Having 

a good understanding of the key elements associated with a strong 

financial foundation is critical for resilience and effective reintegration. It 

is also important for personal and professional well-being. In addition, we 

will discuss the fundamentals of financial management and planning, give 

helpful hints about developing a working monthly personal budget, provide 

an overview of the fundamental financial vehicles used to obtain and maintain financial stability and independence, and explain how to avoid some 

of the most-often encountered financial pitfalls. We all face financial chal-
264 H Pr o m o t i n g Su c cess f u l I n teg r at i o n

lenges throughout life. The good news is that understanding the basics can 

significantly decrease the bumps in the road and help keep you on the path to 

financial stability.

As you assess your current situation, you must begin to face the reality 

of your personal finances, whether entering active duty, reenlisting, serving 

overseas, recovering from injuries, or transitioning out of the military. Each 

stage brings new concerns, including financial issues. Fortunately, there are a 

variety of programs and benefits, both in and out of the military, that can help 

along the way.

MILITARY TRANSITION PLANNING

Departing the military can be planned or unexpected. When the Service 

Member makes the decision to leave the military, it often takes 12 to 18 

months to develop a comprehensive plan that can prevent a lot of potential 

headaches. However, when someone else makes the decision or when there 

are circumstances beyond the Service Member’s control, the departure can be 

laden with problems. Having a 3- to 6-month cash reserve for living expenses 

can make the transition easier. 

How can one accumulate such an amount? Pay yourself first. Allocating between 2% to 5% of each and every paycheck into a contingency fund 

or an emergency fund can help when the unexpected occurs. All members of 

the military know that even the best-written operation orders can change at 

any time, but having a contingency plan can greatly increase your chances of 

success. 

So what constitutes an emergency? The transmission goes out in your car, 

or the wind blows the roof off of your house and you have to pay the deductible on your homeowners insurance, or you lose your job, etc. The emergency fund should be reserved for true, unplanned events and circumstances. 

Therefore, consider opening a separate savings or money market account 

for this fund with a bank that you do not normally go to for most of your 

primary banking needs. This money should be accessible for emergencies, but 

not so easily accessible that it ends up being used for other things. Having the 

contingency money available to cover your transition expenses will help to 

alleviate the stresses caused by a life-changing event. 

The biggest challenge for the departing Service Member is often the lack 

of predictability in his/her daily life. From knowing where to be, what to 

wear, where to go to get healthcare, where to buy food, where to exercise or 

knowing one’s salary, many things change when one enters the civilian sector. 
Financial Management H 265

In addition, it often takes significant time and effort to obtain a civilian job. 

Although there has been substantial progress made with helping Veterans 

find meaningful civilian employment, Veterans can and often do experience 

lengthy delays in landing well-paying jobs. Whereas some Military Occupation Specialties and Areas of Concentration are transferable, some human 

resource directors do not necessarily understand how military leadership and 

real-world experience translate into the civilian workforce. 

There are a number of programs available to help Veterans transition 

to civilian employment. Many of these programs will be explored later in 

this chapter. Service Members departing active duty and choosing to relocate 

to a new geographical area may wish to consider working with a respected 

headhunting company tailored to their specific area of expertise. Some Service 

Members may want to return to their hometown for additional family support. However, a satisfying job that pays a decent income may be the determining factor in where they choose to move. 

FOLLOWING A TRAUMATIC INJURY OR ILLNESS

Following a traumatic injury or illness, Service Members and their families 

not only find themselves having to deal with immediate physical effects, but 

also addressing the long-term personal impact and changes. One of the more 

significant impacts is the possible negative financial effect caused by traumatic 

injury or illness, including the possibility of losing a job; the need to transition from the military; the dependence on family members to stay at home 

and care for a loved one; and the burden of having to supply home modifications, medical equipment, assistive technology, etc. Generally, individuals and 

families do not have the financial means to withstand a financial impact of 

that magnitude.

Fortunately, the military has programs in place to decrease or defer some 

of the financial burdens, such as programs that help to pay for 

• medical care, 

• prosthetics, 

• orthotics, 

• transportation, 

• vehicle modification, 

• home modification,

• adaptive sports equipment, etc. 
266 H Pr o m o t i n g Su c cess f u l I n teg r at i o n

While still on active duty, Service Members continue to receive income and 

medical care with often little modification. After transitioning from the military, many things change, such as medical care that often transitions to the 

Department of Veterans Affairs (VA) healthcare system for individuals with 

service-connected disabilities. Veterans may be eligible for a broad range of 

benefits and services, including monetary disability compensation, based on 

their discharge from active military service. 

During the transition process, Service Members need to work with their 

local military treatment facility to conduct a final physical and document any 

illnesses or injuries that may have occurred or been aggravated while serving 

in the military. Once an individual transfers out of the military, this information is the basis for determining a service-connected disability rating and for 

determining eligibility requirements within the VA healthcare system. Eligibility for VA benefits, including medical benefits, varies greatly. Veterans receive 

VA care and medication at no cost for any condition that may be related 

to their combat service. Individuals can apply for VA enrollment online at 

https://www.1010ez.med.va.gov/sec/vha/1010ez/. Veterans are not required 

to enroll, but are urged to do so to permit better planning of future health 

resources. Disability compensation benefits are not subject to federal or state 

income tax.

As previously noted, there are numerous benefit programs available to 

help address the financial and personal impacts of military service-related 

illness or injury. There are myriad Veterans benefit-related websites available 

online. A good starting point is eBenefits at http://www.ebenefits.va.gov/. 

This site allows Service Members, Veterans, and their families to manage 

their government benefits online. Additionally, the VA has personnel to assist 

individuals transitioning from military to civilian life who can be reached at 

the nearest VA office or by calling 1-800-827-1000.

Another good starting point is the National Resource Directory at http://

www.nrd.gov/. This website brings together countless services and resources 

to support the recovery, rehabilitation, and community reintegration of 

Wounded Warriors. 

Military OneSource provides Wounded Warrior specialty consultation 

services. Through this service, Wounded Warriors and their families can 

access immediate assistance with issues related to healthcare, facilities, or benefits. Specialty consultants work collaboratively with the services’ Wounded 

Warrior programs and the VA to ensure that callers are promptly connected 

to resources that can help address their needs. To reach a consultant, call 

1-800-342-9647. Additional information is also available at http://www.

militaryonesource.mil.
Financial Management H 267

OTHER TRANSITION ASSISTANCE

There are many programs available to Veterans specifically developed to assist 

with transition from the military and programs developed to aid injured and 

ill Veterans. Additional programs come from other federal agencies, such as 

the VA, the Internal Revenue Service, the US Department of Housing and 

Urban Development Veterans Resource Center, and the US Department of 

Health and Human Services. In addition, there are many others programs and 

benefits that originate from profit and not-for-profit organizations around the 

country. 

S o l d ier f o r Li fe-Tr a n s i t i o n Ass i sta n ce Pr o g r a m

The Soldier for Life-Transition Assistance Program (SFL-TAP) is designed to 

assist Service Members as they transition from military to civilian life. The 

program includes information on job searching, employment, training, and 

VA benefits. Active duty Service Members and Mobilized Reserve Component 

Soldiers are eligible to receive transition assistance for up to 180 days following separation or retirement from active duty. After the 180-day window, 

active duty Army, Reserve, or National Guard SFL-TAP services are available 

for life to the retiree and eligible family members on a space-available basis. 

Additional information is also available at SFL-TAP at https://www.sfl-tap.

army.mil/.

C o m b at-Rel ated S pec i a l C o m pe n sat i o n

Individuals with combat-related disabilities may be eligible for a tax-free 

monthly payment titled Combat-Related Special Compensation (CRSC). 

This payment helps restore retired pay lost with a VA disability compensation 

offset. Veterans must apply for CRSC through their branch of service. 

Additional information can be found in the VA Health Benefits Handbook1

or at http://www.va.gov/opa/publications/benefits_book/benefits_chap02.asp.

Ho us i n g Gr a n ts f o r Di sa b led Veter a n s

Eligible Service Members or Veterans may be entitled to a housing grant 

from the VA to adapt a home they already own or reside in; to build a 

new, specially adapted house; or to buy a house and modify it to meet their 

disability-related requirements (see Chapter 13 for an in-depth discussion 

of accessible home considerations). Depending on the severity of the illness 

or injury and for certain permanent disabilities, individuals can receive up 

to $70,465 through Specially Adapted Housing (SAH) grants that assist in 

building a new, specially adapted home. If a Veteran chooses to modify an 
268 H Pr o m o t i n g Su c cess f u l I n teg r at i o n

existing home, or purchase a residence already equipped with special features, 

then the VA may approve up to $14,093 for the cost of necessary adaptations. This program is known as the Special Housing Adaptation (SHA) 

grant. In addition, if a Service Member or Veteran is living temporarily in a 

home owned by a family member, he/she may be eligible for a Temporary 

Residence Adaptation in the form of either a $30,934 SAH grant or a $5,523 

SHA grant, depending on the severity of the illness or injuries. The Home 

Improvement and Structural Alternations (HISA) program provides up to 

$6,800 to make medically necessary improvements and structural alterations 

to a Veteran’s primary residence. Veterans may also be entitled to a direct loan 

from the VA to supplement the grant to acquire a specially adapted home. 

These grant and loan amounts are adjusted every October 1 based on a 

cost-of-construction index. For more information on these programs, consult 

the handbook on Federal Benefits for Veterans, Dependents and Survivors.

2

Additional information is also available at http://www.benefits.va.gov/

homeloans/adaptedhousing.asp.

Au t o m o b i le Al l o wa n ce a n d Tr a i n i n g

If a Veteran or Service Member has a service-connected disability that results 

in a permanent loss of vision of both eyes or a permanent impairment of use 

of one or both hands or feet, he/she may be eligible for a one-time payment of 

approximately $20,000 toward the purchase of an automobile or other form 

of transportation. In addition, individuals may be eligible for a full range of 

services, including driver’s evaluations and training, repair, replacement, or 

reinstallation of automobile adaptive equipment (AAE) for the safe operation 

of a vehicle purchased with VA assistance. To apply, contact a VA regional 

office at 1-800-827-1000 or the nearest VA healthcare facility.

Al l o wa n ce f o r Ai d a n d At te n d a n ce a n d

Ho useb o u n d Pe n s i o n Be n ef i ts

A Veteran may be eligible for additional disability compensation or pension 

payments if it is determined that he/she requires regular aid and attendance 

from another person or is permanently housebound. 

To access the VA Aid and Attendance and Housebound Pension Benefits, you must write to the VA regional office where you filed a claim for 

pension benefits or any VA regional office. It is important to include copies 

of any evidence that validates the need for this type of care. Additional 

information can be found at http://www.benefits.va.gov/pension/aid_

attendance_housebound.asp.
Financial Management H 269

V o c at i o n a l Re h a b i l i tat i o n a n d Em p l o y me n t

One VA program that has the potential of being a significant benefit during 

transition is the Vocational Rehabilitation and Employment program (also 

known as Voc Rehab). The program provides service-connected Veterans 

with the tools necessary to prepare them to achieve independence or to obtain/maintain appropriate employment. Based on needs of the individual, the 

program may assist with providing additional education or training for employment, job development and placement services, and on-the-job training. 

Benefits may also include a subsistence allowance for a determined number of 

months during the training period. 

Ed u c at i o n a n d Tr a i n i n g

The education and training benefits program is quite extensive and has 

tremendous potential to aid Service Members and Veterans in acquiring an 

education and obtaining a head start in the transition process. Eligibility 

requirements can be complex and may vary based on when individuals served 

and length of active duty service. However, generally, Veterans may receive 

extensive education benefits under the Montgomery GI Bill and receive up to 

36 months of tuition entitlement and monthly housing allowance under the 

Post 9/11 GI Bill (2001). Chapter 12 has a detailed discussion of educational 

benefits. Additional information is available at www.benefits.va.gov/gibill or 

by calling 1-888-GI-Bill-1 (1-888-442-4551).

Rec reat i o n T h er a p y Serv i ces

The VA also recognizes that there are a number of positive health outcomes 

resulting from participation in recreational therapy programs (see Chapter 8). 

The VA supports this effort by providing or lending equipment through the 

Adaptive Sports Program. If a Service Member is particularly interested in a 

specific sport, a detailed assessment is conducted. In various circumstances, 

the VA can also assist with the purchase of equipment, including sport prostheses, mono-skis, sport model wheelchairs, sledges for sled hockey, and other 

adaptive sports equipment. 

CONDUCTING A CURRENT FINANCIAL ASSESSMENT

Whether you are a current Service Member or a Veteran, if you have questions about your financial state of affairs, one of the most important things 

you can do for yourself (and for your family) is to conduct a financial 

assessment. Even if you are financially up to date, it is a good idea to reassess 
270 H Pr o m o t i n g Su c cess f u l I n teg r at i o n

yourself to see where you stand. This will give you a big picture view of your 

current financial status and help you plan more effectively for the future.

Wh ere t o Beg i n

Start with some questions to honestly assess your finances:

• How much do you make and what are your routine monthly expenses?

• If you are part of a family unit, does anyone else bring in an income?

• Are all bills paid on time and in full each month? 

• Is the checkbook balanced? If so, how often?

• Are you a saver or an impulse buyer?

• How much cash do you have immediately available in case of an emergency (not using credit cards)?

• Are you saving money every month?

The importance of maintaining financial stability cannot be overlooked. In 

a survey of 4,500 couples, researchers at Kansas State University found that 

no matter how much income a family has, fights about money are the biggest 

contributors to divorce.3 The study also revealed that couples take longer 

to recover from an argument about finances than any other issue because 

these disagreements tend to last longer (more information available at http://

www.k-state.edu/media/newsreleases/jul13/predictingdivorce71113.html).

Military couples are no different; financial trouble can affect your 

relationship with your spouse and interfere with your military career or your 

post-military life. If you are worried about a possible repossession of your car 

or foreclosure of your home, staying focused while on the job can be difficult. When you add in deployment to a hostile wartime environment, your 

personal stress level can increase exponentially. The best solution is to remain 

on a solid financial footing at all times. 

Many of us think that we know where our money goes each month, but 

few of us can actually list all of the ways we spend our monthly income. The 

best way to complete this task is to sit down with a notebook, a calculator, 

the monthly bills, and credit and debit statements for the month. Next, start 

listing exactly how your monthly finances are divided. If you are not that organized, start at the beginning of the month and keep a spending journal. Record when, where, and how much is spent for the entire month. Most people 

can tell you what they pay in monthly rent or mortgage and perhaps what 

they spend for car payments. However, few of us know the exact amount of 

our cell phone bill, utility costs, or monthly transportation expenses. Track 
Financial Management H 271

everything. At the end of the month, simply add up all of your expenses and 

deduct the amount from your total monthly take-home income. This will 

provide you with a great starting point and help you to determine if you are 

living above or within your means.

Prepa r i n g a Bu d get

Spending Plan

The first step in preparing a budget is to develop a personal spending plan. It 

is designed to help outline where income is earned and how it is spent. The 

key element in the spending plan is learning to incorporate reasonable financial goals. These goals (eg, saving money for a new home, car, or vacation) 

help individuals determine how much money should be diverted from living 

expenses into savings and investments. By combining income and expenses 

with financial goals, a road map for monitoring spending can be created to 

help determine the most appropriate methods for saving. By documenting 

and categorizing all sources of spending, we can better understand whether 

funds are being spent on items that detract from our ability to save and reach 

financial stability. Additional information is also available at http://www.

investopedia.com/terms/p/personal-spending-plan.asp.

Most American families know that they should create a monthly budget 

and stick to it in order to achieve their financial goals. Individuals and families 

need to know where every dollar goes each month. The only way to truly 

monitor every dollar is to create a monthly budget and follow it. When possible, couples should create budgets together to increase communication and 

to set up a “hierarchy of expenses.” An honest discussion of expenses should 

result in a prioritized list with either the current dollar amount or proposed 

dollar amount available to spend attached specifically to that item. Consider 

listing the expenses in the order of need: 

• food, 

• utilities, 

• transportation, 

• shelter, 

• insurance, etc. 

(Note: Most people agree that food is the top priority.) Single individuals will 

have greater flexibility in spending, but may also face greater temptations to 

go off-budget.
272 H Pr o m o t i n g Su c cess f u l I n teg r at i o n

Avoiding Pitfalls

Tracking and decreasing items that detract from our ability to save require 

effort and discipline. They are key factors in avoiding the pitfalls that allow 

debt to accumulate. Try to avoid making unnecessary purchases. Take a step 

back before you make an impulsive purchase, and then take action to prevent 

damage to your budget. 

For example, rather than purchasing a new car just because your neighbor recently bought one, consider the impact on your spending plan. Be wary 

of the urge to have the latest and greatest items. If your goal is to get out and 

stay out of debt, then discipline will play a major role in your daily financial 

life. Financial discipline will help you to assess your goals and consequences 

when faced with a decision that could potentially run you off course. 

Having a credit card is very convenient because you do not have to carry 

a lot of cash to make purchases. Establishing a good line of credit also helps 

with securing loans for big purchases. However, along with the advantages 

also come the disadvantages. Because you do not have to carry around large 

sums of money and you may have funds available on your card, you may be 

tempted to buy something impulsively. Before you know it, you hardly recognize your spending plan any more. Maintaining discipline with credit card 

purchases is key to successfully having credit cards, as well as tracking what 

purchases you make, knowing what the interest rates are, paying charges on 

time, and being aware of not spending more than you can afford.

Housing

Housing costs normally take the biggest bite out of a budget. The US Bureau 

of Labor Statistics reported that about 34% of Americans’ spending goes 

toward housing costs, with 38% of individuals renting.4 Potential lenders 

use this budget line item to determine how much mortgage you qualify for. 

Potential lenders should limit your basic housing expenses (including mortgage 

payment, real estate taxes, and homeowners insurance) to not more than 30% 

of your gross annual income. This is a limit, not the goal. There are also numerous hidden costs associated with homeownership. In addition to monthly 

mortgage payments, there are costs for landscaping, water, gas, garbage, 

maintenance, etc, that quickly increase monthly expenses. Keeping housing 

expenses as low as possible, while living comfortably, should be the target.

Transportation

Transportation is normally the second largest expense in a household budget, 

although this amount can vary depending on your personal situation. The 

transportation expenses of the average American two-car household account 
Financial Management H 273

for more than 17% of the overall budget.4 This expense may run as low as 

10% or as high as 20% if you work from a home-based office, use public 

transportation frequently, own your vehicles outright, are making payments 

on one or more cars, or have an extended commute.4

Food

A large chunk of most household budgets goes toward food. Although 

budgeting 15% to 20% of your expenditures for food is acceptable, food 

spending for most Americans is closer to 13% of their overall expenditures.4

At-home food consumption accounts for almost 60% of all food costs, 

whereas eating out absorbs the remaining 40%.4

Fi g u re 11-1. Simple Monthly Budget.
274 H Pr o m o t i n g Su c cess f u l I n teg r at i o n

Savings, Insurance, and Healthcare

Personal savings, life insurance, healthcare expenses, retirement savings, and 

cash contributions can take a toll on your budget; but, nonetheless, they are 

important line items. Life insurance and retirement amount to more than 

10% of the average household budget. Healthcare is roughly 6%, and cash 

contributions are almost 4%.4 Although Americans sometimes falter when it 

comes to personal savings, you should budget from 5% to 10% of your budget toward it. Many experts recommend taking a “pay yourself first” attitude 

when it comes to savings to ensure that you have enough reserves built up in 

case the unforeseen happens.

Personal Expenses

Roughly 10% of the average American’s spending is for 

• clothing, 

• personal care services, 

• gym memberships, 

• education, 

• reading, 

• entertainment, 

• tobacco, 

• alcoholic beverages, and 

• other miscellaneous expenses.4

Entertainment costs should not include meals eaten away from home. They 

should be incorporated into your food budget.

Figure 11-1 is an example of a personal monthly budget report. It is only 

an illustration of possible monthly expenses. This will vary from month to 

month and year to year. The working budget report must accurately reflect 

your true monthly income and expenses.

PAYING DOWN DEBTS

After you have mapped out a budget and reviewed your finances, you may 

feel a little discouraged if you still carry debt. However, like most things in 

life, motivation is often the key to success. What motivates people to get their 

financial house in order differs per individual (eg, never-ending bills, countless 

sleepless nights, trouble with relationships, wanting a long-awaited vacation, 

etc). Whatever it is that provides inspiration, turn it into a positive motivator.
Financial Management H 275

If your goal is to pay off debt, it goes without saying that you should 

not accumulate more. Therefore, it is imperative for you to be a disciplined 

spender and bank a small cash cushion to use for unexpected expenses. Everyone should have an emergency fund of at least $1,000 (or one month’s pay 

would be better) to use for such occurrences.

First, break the habit of paying only the minimum required each month. 

Paying the minimum—usually 2% to 3% of the outstanding balance—only 

prolongs payoff. It is precisely what the banks want you to do. The longer 

you take to repay the charges, the more interest they make, and the less cash 

you have in your pocket. Instead, pay as much as you can each month. If your 

minimum payment is $100, double that to $200 or more. Examine your normal expenses, and see if you can find the money to do that. For example, you 

may want to brown bag your lunch, eliminate buying coffee daily, or perhaps 

even give up happy hour. By making small, daily sacrifices, you will accumulate the extra dollars to put toward your debt payments. 

Second, take a long, hard look at all of your credit card interest rates. 

Identify the one with the lowest rate and consider transferring the balance 

from a higher interest card to a lower interest card. If your entire balance is 

too large to fit on one low-interest card, pay at least the minimum amounts 

due on all of your cards except one. Pay a majority of your debt repayments 

against that one credit card, and pay it off as quickly as possible. When the 

balance on that card reaches zero, move on to the next card with the same 

aggressive repayment plan. Some financial experts suggest you first attack the 

account with the highest interest rate, regardless of its balance. Other experts 

suggest attacking the smallest debt first.

If you are someone who is really motivated by numbers, you will realize the account that is doing you the most damage is the one with the highest 

interest rate. If the account with the highest interest is utilizing more than 

30% of that credit line, focus on repaying that one first to get it under that 

threshold. Doing so will improve your credit score because debt utilization—

which is how much you owe compared with how much available credit you 

have—is an important factor in determining your score. The lower your debt 

utilization, the better.

You could also cash out your savings (while maintaining your emergency 

fund) and use the proceeds toward debt repayment. Even when debt interest 

is at 12%, your savings account would have to pay more than 18% before 

federal and state taxes to equal that outflow of dollars. Pay off the debt, and 

it is the same as getting that 18% return without any risk on your part. The 

higher the interest rate on your debt, the more attractive repayment versus 

savings becomes. 
276 H Pr o m o t i n g Su c cess f u l I n teg r at i o n

Whatever method you choose to repay your debts, simply do it over and 

over again. As the debts disappear, you will be energized by the satisfaction 

that you get from accomplishing your goal. This method of repayment is 

called snowballing. As your debts decrease, the amount of money you have to 

pay them with increases. Sooner, rather than later, your debts are eliminated. 

Plan the work and work the plan. 

If you have depleted your savings and cannot keep up with your payments, let your creditors know your situation. Ask for a new and lower 

repayment schedule, request a lower interest rate, and appeal to their desire to 

receive payment. Faced with the prospect that you may resort to such a drastic step, many creditors will be willing to work with you in order to protect 

themselves against a total loss. Bankruptcy should be your last resort. 

SAVINGS AND INVESTMENT CONCEPTS AND TOOLS

Some components of saving and investing can be much like planning for a 

combat operation. Reverse planning that takes place when writing a military 

operation order is similar to establishing a savings or retirement investment 

goal and working backward on paper prior to executing your plan. The 

concept of “defense in depth” can be easily related to diversification of assets 

with investments. We will examine these and other savings and investment 

concepts in the next sections. 

Emer ge n c y Sav i n gs

In military training, we strategize and rehearse our operations. In life, we 

plan by budgeting and by being disciplined with our spending. Having some 

money tucked away for emergency savings will have a great psychological 

impact on your life. The stress that is relieved by knowing that you have a 

safety net is much like the comfort that is felt by knowing that close air support or a quick reaction force is nearby.

Most financial experts recommend that you have 3 to 6 months of 

expenses saved in an emergency or “rainy day” fund. This probably seems 

like a significant amount of money to save. Thus, you should start by setting an initial emergency savings goal of at least $1,000. Then, you should 

consider opening a savings account at a different bank from the one where 

you do most of your banking. This money should be accessible to you for 

emergencies, but not too easily accessible or for nonemergencies.
Financial Management H 277

I n vest i n g f o r Ret i reme n t

With the exception of military retirement, those days of working for the same 

company for more than 40 years, retiring, and then collecting a pension are 

pretty much in the past. Nowadays, it takes disciplined saving and investing using a combination of Individual Retirement Accounts (IRAs), such as 

a Traditional IRA or a Roth IRA, and employer-sponsored plans, such as 

the 401(k), the Thrift Savings Plan, or the 403(b). These types of accounts 

or plans are usually defined by the Internal Revenue Service and provide different features based on how they are defined in the Internal Revenue Code 

(eg, a 401(k) is called a 401(k) because it is in Section 401(k) of the Internal 

Revenue Code). 

All of these types of accounts have to be funded by some kind of underlying investment, such as mutual funds, bonds, annuities, or CDs (Certificates 

of Deposit). Accounts such as the 401(k), 403(b), and defined benefit pensions are considered as employer-sponsored plans, whereas a Traditional 

IRA and a Roth IRA are accounts that you own individually through an 

investment company away from the workplace. IRAs can be opened through 

banks, insurance companies, or investment firms. The IRA or employersponsored plan is just an account. There has to be some type of investment 

that funds it. 

A stock is one share of ownership in a company that may sell thousands 

of shares of their stock (pieces of ownership in the business) in an effort to 

raise money to be used by the company. A mutual fund is a collection of 

stocks of various companies. Each fund has a fund manager that buys and 

sells the various stocks within the fund to keep the fund moving toward its 

objective. Mutual funds are designed to spread the risk of possible investment 

losses across the various stocks that it owns. You could buy individual stocks 

in a single company. However, putting all of your eggs in one basket would 

be a risky scenario. Instead, you could invest in a mutual fund that holds hundreds of shares of a variety of companies’ stocks. Most funds will hold stocks 

from a hundred or more different companies. 

A term that should be considered by an investor when analyzing the 

investment objectives of various funds is risk tolerance. When purchasing 

investments, each investor needs to consider how much risk he/she is willing 

to take and how much he/she could endure the potential for losses versus the 

potential for gains. Periodically, an investment company will require an investor to complete a risk tolerance questionnaire that is composed of a series of 

questions to help an investor determine risk tolerance. Something to consider 

when determining risk is the investor’s “time horizon” or length of time until 

the investor will have until he/she needs to begin using the money that was 
278 H Pr o m o t i n g Su c cess f u l I n teg r at i o n

invested. For example, a 25-year-old individual could take significantly more 

risk with investments than a 55-year-old individual because the 25-year-old 

would have much more time to endure the ups and downs of the stock market, whereas the 55-year-old (who is approaching retirement) should consider 

safer investments because there is a much shorter time available until he/she 

will have to begin using the money invested for retirement. 

Another common term that is used with mutual funds is load. Basically, 

the load is a sales charge that is imposed by the fund company. It is the cost to 

buy shares of the fund. There are three types of funds: 

1. Front-end load fund: a sales charge that is attributed when you initially 

buy the shares. 

2. Back-end load fund: a sales charge that is paid when you sell or redeem 

your shares of the fund; frequently, the sales charge that you would have 

to pay decreases for every year that you own the shares.

3. No-load fund: a fund that does not impose sales charges; an investor is 

more likely to purchase a no-load fund directly from an investment company that does not have sales agents. 

The Traditional IRA and the Roth IRA are often discussed in retirement planning. Comparing these types of IRAs is similar to comparing the use of a B-52 

on an airstrike versus a constant barrage of ground artillery. Both IRAs will 

achieve a similar result, but there are pros and cons to each. The greatest difference between the two is how taxation works. With Traditional IRAs, the 

federal government has not yet taxed the money that has been invested, and 

the contributions may be tax-deductible for the year that the contribution is 

made to the IRA. However, when you retire, the distributions will be taxed at 

your ordinary income tax rate. In contrast, the contributions that you make 

to a Roth IRA have already been taxed. Therefore, based on current tax law, 

the distributions will not be taxed when you take them in retirement. Be sure 

to consult with an accountant before making decisions on investments that 

may impact your tax situation. 

Diversification of assets can be thought of as “defense-in-depth” of your 

investment portfolio. Basically, diversification is spreading your monetary 

assets across high-, medium-, and low-risk investments to achieve the desired outcomes of protecting your investments. You might consider having 

some high-risk investments in your portfolio that have the potential to make 

tremendous gains. However, you should be aware that large losses are also 

a possibility. Your investment portfolio should contain some medium-risk 
Financial Management H 279

investments that have a moderate potential for gain and less potential for loss. 

The investment portfolio should also contain some low-risk investments (eg, 

bonds) to create some stability as a backup force in the event that the other 

investments sustain major losses. This is the “don’t put all of your eggs in one 

basket” concept. 

INSURANCE

Most people spend little time learning about insurance (whether automobile, 

homeowners, renters, flood, health, life, or disability) or even reviewing their 

own policies. It is important to keep in mind that one brief moment can be 

financially devastating if you do not have the proper insurance coverage. 

Consider taking time to review all of your insurance policies with a qualified 

insurance professional at least once each year and anytime a major life event 

occurs (eg, marriage, birth of a child, divorce, purchase of a home, etc).

Au t o I n su r a n ce

Even though automobile insurance policies will differ slightly from state to 

state, all of them require that you carry some level of liability coverage. 

Liability coverage is the most important coverage on your automobile policy 

because it pays for the damages that you might cause. This coverage is typically broken down into 

• bodily injury liability—pays for injuries to another person or people due 

to an automobile accident, and 

• property damage liability—covers the damage to another vehicle, someone’s house, or other property. 

Call your automobile insurance company to get prices on increasing your 

liability coverage. You will probably be surprised at how inexpensive it is to 

increase your liability coverage. In addition, remember that minimum coverage does not always mean minimum prices. 

Other important coverages to consider on your automobile insurance 

policy include comprehensive, collision, medical payments, towing, and rental 

reimbursement. Be sure to evaluate each item and understand how it might 

relate to your circumstances when shopping for or reviewing your automobile 

insurance policy. 
280 H Pr o m o t i n g Su c cess f u l I n teg r at i o n

Ho me o w n ers I n su r a n ce

When most people think of homeowners insurance, the typical fear associated 

with it is a large house fire. Although “total-loss” house fires do occur, they 

only represent a small number of actual homeowners insurance claims. The 

majority of homeowners insurance claims are typically only a few thousand 

dollars and involve events such as the wind ripping shingles off of the roof, a 

tree falling on the house, water damage from a broken pipe, etc. 

Some of the major elements to consider with homeowners insurance are

• dwelling amount, 

• contents coverage, 

• liability coverage, 

• deductible, and 

• replacement cost versus actual cash value (ACV) coverage. 

Dwelling Amount

With most homeowners insurance policies, many things are based on the 

dwelling coverage amount or the amount that the house itself is insured for. 

The dwelling coverage amount is based on a replacement cost figure. This 

replacement cost figure is a calculation of what it would cost to rebuild the 

home completely using like kind and quality materials. Often, people will 

confuse replacement cost with market value (the amount you could sell your 

home for) and, quite frequently, the replacement cost figure is significantly 

higher than the market value. 

Contents Coverage

The contents coverage amount is typically determined as a percentage of the 

dwelling amount. Thus, if the dwelling coverage on your homeowners policy 

is $200,000 and your policy provides 75% for contents coverage, then you 

would have $150,000 of contents coverage. 

Liability Coverage

The liability coverage on a homeowners policy provides coverage for many 

different types of incidents that could occur on or off the premises of your 

home. The policyholder selects the amount of coverage on the policy: the 

available coverage amounts are typically $100,000, $300,000, or $500,000. 

Some of the most common claims that occur under homeowners insurance liability coverage are dog bites and slips and falls. Typically, some type of negligence has to occur for claims to be paid under homeowners liability coverage. 
Financial Management H 281

Deductible

The deductible is how much the policyholder is responsible for contributing 

to repair the damage when the policyholder files a claim. For example, if there 

was a windstorm and your roof sustained $4,000 worth of damage and you 

had a $1,000 deductible, you would pay $1,000 and your insurance company 

would pay $3,000 to fix your roof if you had replacement cost coverage. Keep 

in mind that increasing your deductible will decrease your premium, but it also 

increases the amount that you are responsible for paying if you file a claim. 

Replacement Cost Versus Actual Cash Value Coverage

When choosing various options on your homeowners insurance policy, you 

may have the opportunity to select from replacement cost or ACV coverage. 

You will find that ACV costs significantly less than replacement cost coverage 

because ACV provides significantly less coverage and, often, mortgage companies may not accept ACV coverage. Basically, ACV coverage is replacement 

cost coverage minus depreciation. If you had a $4,000 damaged roof claim 

and a $1,000 deductible, with ACV coverage the insurance company would 

then subtract money from that $3,000, depending on the age of the roof. 

For example, if your roof is 15 years old and is expected to last 30 years, the 

insurance company could reduce your payment by 50%. Now your $4,000 

roof claim just turned into you paying $2,500 (your $1,000 deductible plus 

$1,500 in depreciation) and your insurance company paying $1,500 to have 

your roof repaired. In most cases, selecting replacement cost coverage will be 

your best option.

Keep in mind that homeowners insurance policies, like any other insurance policies, will have exclusions, limitations, items that are covered, and 

items that are not covered. Do not fall into the trap of believing that your 

homeowners policy will cover anything and everything that could go wrong 

with your house. Be sure to read the policy booklet that is mailed to you with 

your homeowners policy declarations page. 

Re n ters I n su r a n ce

A renters insurance policy is very similar to a homeowners insurance policy 

minus the coverage for the dwelling or house. It is primarily intended to 

cover contents and liability. Many people believe that the landlord’s insurance 

will cover their contents in the event of a loss, such as a fire; however, this is 

probably not the case. Renters can purchase renters insurance policies very inexpensively that may also cover “loss of use,” which may pay for you to stay 

somewhere else temporarily while damage is being repaired at the apartment 

or house that you are renting. 
282 H Pr o m o t i n g Su c cess f u l I n teg r at i o n

Li fe I n su r a n ce

Life insurance is often a topic that most people do not want to discuss. 

Fortunately, the military has made life insurance easy to obtain with Servicemember’s Group Life Insurance (SGLI). What options exist when leaving the 

military? Most importantly, you need to figure out how much life insurance 

you should have, then determine where you are going to get it. 

Liabilities

Liability primarily includes any money that you owe to anyone else that 

should be paid in the event of your death. Therefore, make a total of all 

mortgage payments, vehicle loans, credit card balances, loans from family 

members, and any other money owed to anyone else. 

Income

One of the major reasons to have life insurance is to allow your dependents 

to maintain a similar standard of living after your death. Consider what life 

would be like for your family if they did not have your income. Something 

that is often overlooked in life insurance planning is the “income” of a nonworking spouse. For example, if you lost your nonworking spouse, would 

you need money to pay for child care or for someone to prepare meals and do 

shopping that you do not have time to do?

Final Expenses

Most people think of “final expenses” as funeral expenses. Even though funeral expenses need to be discussed, final expenses go beyond just that. Consider spending about $5,000 per person for cremation expenses and $10,000 

to $15,000 for a burial. However, also consider if some money should be 

included for things such as uncovered medical bills, charitable giving, and 

other miscellaneous fees (eg, changing vehicle registrations, drafting a new 

will for surviving dependents, etc). If you are currently setting aside money 

for your children’s education, your life insurance plan should incorporate a 

strategy that completes that education fund in the event of a premature death. 

Consider your surviving spouse as well. If you died, would he/she need to go 

back to school in order to enter the workforce? 

Once you have calculated how much life insurance you (and your spouse, 

if applicable) should have, consider where that life insurance will come from. 

Keep in mind that some of your life insurance may come from more than one 

of these sources. Some elements to consider when deciding where your life 

insurance will come from are cost, medical history, and portability. 
Financial Management H 283

Service Members Group Life Insurance to Veterans Group Life Insurance

Upon separation or retirement, Service Members are given the option to 

convert their SGLI to Veterans Group Life Insurance (VGLI). If this option 

is exercised at the time of separation, there is no medical underwriting or 

proof of good health that is necessary. However, if you wait, you will have to 

medically qualify. The option to convert SGLI to VGLI might make sense for 

Veterans who have health issues that might prevent them from purchasing individually owned life insurance. Keep in mind that the rates increase on VGLI 

policies every 5 years, so they can be very expensive later in life. 

Group Life Insurance

Most civilian employers will offer group life insurance as part of a benefits 

package. Group life insurance is typically inexpensive. However, if it has a 

portability option (an option to take it with you when you leave that employer), the cost of the new policy will be significantly more expensive.

Individually Owned Life Insurance

These types of policies are purchased through a private insurance company 

(eg, automobile or homeowners insurance). Most individually owned policies 

require medical underwriting, and some will require a brief physical. The 

costs of these policies depend on the type of policy that is purchased. The 

types of individually owned life insurance policies are term and permanent 

(including whole life, universal life, and variable). The simplest way to understand the differences in these types of life insurance is to compare renting an 

apartment versus owning a home. 

Term life insurance is similar to renting an apartment. With an apartment, you sign a lease that allows you to live there for a certain period of 

time, a term. You purchase term life insurance policies in specified terms 

such as 10, 20, or 30 years. Also, like an apartment, you are not building 

any equity in a term life insurance policy. Term life insurance policies are less 

expensive than permanent policies, just as renting an apartment would be less 

expensive than owning a home, in most cases. With permanent life insurance 

policies, you have life insurance coverage, but you are also accumulating cash 

value. This cash value is similar to equity in a home that could be withdrawn 

or borrowed against. 

Often, the best-case scenario is owning a combination of these types of 

life insurance policies. Owning a large amount of term life insurance to cover 

temporary needs (eg, a mortgage or having children at home) and owning a 

smaller amount of permanent life insurance to cover permanent needs (eg, 

final expenses) can be a great life insurance planning solution. Any group life 
284 H Pr o m o t i n g Su c cess f u l I n teg r at i o n

insurance that you have through an employer could come into play for any 

gaps in your plan that are not covered by the other policies. 

Certainly, insurance is typically not a topic that most people get overly 

excited about. However, neglecting your insurance plans can have a devastating impact on your overall financial plan, and they can have quite an impact 

on your family’s well-being. 

CAREGIVER CHALLENGES, 

CONSIDERATIONS, AND ASSISTANCE

Caring for a wounded Service Member or Veteran can add a new set of 

financial issues. Although thousands of Service Members have been wounded 

in military conflicts, advancements in battlefield medicine have allowed many 

of our most seriously injured troops to survive catastrophic injuries. These 

wounds result in traumatic brain injuries, loss of limbs, permanent paralysis, 

loss of sight, severe burns, and other invisible wounds. Consequently, many 

of these Service Members will ultimately need long-term, perhaps around-theclock, care and support. 

Most Americans are unaware of the challenges faced by the families of 

Wounded Warriors. Before the service-related injury, their lives were packed 

with normalcy—a predictable 5-day work week, the occasional 4-day training holidays, trips to the field, planning for vacations, and dreaming about life 

after the military. Then, suddenly, families receive word that their loved ones 

have been gravely injured or wounded, and the normalcy of everyday life ends. 

The Elizabeth Dole Foundation commissioned the RAND Corporation to assess the needs of the military caregivers and made the following statement:

Those caregivers often toil in relative obscurity, and they are challenging 

to count or describe. They are spouses, parents, children, and relatives of 

the wounded veteran, but many coworkers, neighbors, and friends also 

take on responsibilities. They provide care and assistance, promoting 

faster recovery for their loved ones and thus saving our nation millions 

of dollars in health care costs. However, the personal impact of providing this care is enormous. The time required can result in lost jobs, lost 

wages, and a possible loss of health insurance; in addition the physical 

and emotional toll can be substantial.5

The report presented information gleaned from military caregivers 

themselves and from policymakers and program officials who either directly 
Financial Management H 285

support, or advocate on behalf of, military caregivers. It also provided a snapshot of the number and characteristics of military caregivers, the roles they 

serve, the physical and emotional impact caregiving has on their lives, and the 

resources available to them.

The RAND report estimates between 275,000 and 1 million men and 

women have cared, or are caring for, wounded, ill, or injured Service Members and Veterans, but the actual number may be even more. Caregivers 

perform a wide variety of roles and functions in support of their Wounded 

Warriors, including the following:

• assisting with the normal activities of daily living, 

• serving as mental health counselors, 

• advocating for new and better treatment, and 

• even serving as the family’s legal and financial representatives. 5

All totaled, these functions or services equate to more than a full-time job. 

According to the 2010 report6 released by the National Alliance of 

Caregiving (Bethesda, MD) and the United Health Foundation (Winnetonka, 

MN), caring for a Wounded Warrior can have a significant impact on a person’s professional life. Approximately 59% of these caregivers have stopped 

working to provide the around-the-clock care needed by the family member. 

Additionally, about 28% of caregivers who still work outside the home report 

they have voluntarily accepted a reduction in pay/benefits to have the flexibility they need to care for an injured Veteran.6

 Even though their take-home 

income decreases, their medical expenses skyrocket. The RAND Corporation estimates that the family caregiver’s out-of-pocket medical expenses are 

2.5 times higher than their noncaregiver counterparts. 5 Unfortunately, VA 

services support a small portion of the 1.1 million caregivers nationwide. 

P o ss i b le Ca reg i v i n g Ex pe n ses

There are many types of additional expenses that can crop up when caring for 

a loved one. Although this list is not exhaustive, it gives an idea of the kinds 

of financial challenges that may need to be addressed:

• Medications, equipment, and co-pays—Costs of medications, medical 

adaptive equipment, and co-pays for doctor visits can quickly add up. 

Although co-pays might not seem like much for each visit, they can put a 

dent in your wallet if you are visiting many doctors and specialists.
286 H Pr o m o t i n g Su c cess f u l I n teg r at i o n

• Home modification costs—It may be necessary to make modifications to 

your home so that it is suitable for your loved one. Ramps to entrances, 

wider doorframes, and grab bars may be needed to help you and your 

loved one navigate around home.

• Caregiving services (respite, day services)—If you work, you may have to 

find services for your loved one while you are away, or you may just need 

a break for your own emotional well-being from time to time.

• Travel/transportation fees—If your loved one uses a wheelchair or requires transportation via stretcher, traveling to each doctor’s appointment 

or outing could incur additional costs if you need to hire a service each 

time to get you there and back home.

• Reduced work hours, reduced pay, or loss of job for the caregiver—Your 

caregiving responsibilities may mean that you have less time for your 

own work or career. You might need to reduce your hours, take a lower 

paying position, or even take a leave of absence.

Fi n a n c i a l a n d J o b Su p p o rt t o Ca reg i vers

The policy landscape is undergoing changes in this domain. However, these 

changes are still relatively new, and whether they effectively address needs is 

unclear. In recent years, lawmakers have amended the Family Medical Leave 

Act (FMLA) to permit family members of “covered” Service Members up to 

26 work weeks of leave to care for their Service Member. In 2010, this was 

extended to include family members of Veterans. These amendments do not 

provide direct financial remediation for the long-term needs of caregivers. 

A 2012 report7 from the Quadrennial Review of Military Compensation 

(QRMC) addressed this issue specifically. 

The QRMC highlighted two programs currently in their infancy that 

attempt to alleviate potential negative financial consequences associated with 

caregiving: 

1. the Department of Defense’s (DoD’s) Special Compensation for Assistance with Activities of Daily Living (SCAADL) program and 

2. the VA Program of Comprehensive Assistance for Family Caregivers. 

These new programs are slated for caregivers who assist their Service Members or Veterans with activities of daily living (eg, feeding, dressing bathing, 

grooming, toileting, transferring, etc). Although important, these programs 

are in the early stages of implementation and serve only a small fraction of 

military caregivers.8 In addition, as noted in the QRMC report, the programs 

are already disjointed.8
Financial Management H 287

For example, each program imposes different eligibility criteria: the DoD 

definition covers injuries and illnesses, but the VA definition only covers injuries (eg, physical injury, traumatic brain injury, psychological trauma, or other 

mental disorders). The VA also requires that the caregiver be a family member 

or live with the care recipient and that the caregiver has already provided at 

least 6 months of continuous assistance. SCAADL imposes neither of these 

requirements.8

SCAADL was authorized by the National Defense Authorization Act in 

fiscal year 2010. This special monthly compensation is for Service Members 

who incur a permanent catastrophic injury or illness. SCAADL helps offset 

the loss of income by a primary caregiver who provides nonmedical care, support, and assistance for the Service Member.

Some nonprofit organizations offer retreats intended to engage both caregivers and their Veterans or Service Members. Military-specific online support 

communities and forums are also available. Although some caregivers noted 

that it was difficult to carve out time to attend a retreat or group meeting, 

many caregivers emphasized that interacting with other caregivers was critically important to them.

Res o u r ces f o r Ca reg i vers

Once you have a better sense of the kinds of costs that might arise while 

caring for your loved one, it is time to develop a sound spending plan that 

takes both anticipated and unanticipated expenses into account. There are a 

number of military benefits and resources available to help you take some of 

the financial stress out of caregiving.

If your loved one is covered under TRICARE, he/she may be eligible to 

receive home healthcare benefits. The TRICARE website (http://www.tricare.

mil) has a wealth of information and can help you determine the benefit 

eligibility of your loved one. If your loved one meets the eligibility requirements for Medicare or Medicaid caregiving and financial management for 

the Wounded Warrior, financial coverage may be available for medical costs, 

transportation, respite care, home modifications, and equipment expenses. 

Additional information is also available at the Centers for Medicare & Medicaid Services at https://www.cms.gov.

Ta ke Ad va n ta ge o f t h e Res o u r ces

Caregiving is a demanding responsibility. Worrying about your finances 

should not keep you from caring for your loved one and yourself. If you also 

find that you need some support while undertaking your role as a military 

caregiver, consider reaching out for help. You can access nonmedical counsel-
288 H Pr o m o t i n g Su c cess f u l I n teg r at i o n

ing services through Military OneSource (http://www.militaryonesource.mil 

or by calling 800-342-9647).

FINANCIAL COUNSELING SUPPORT

If you live on or near your military installation, you can reach out to the 

installation personal financial management program. A financial counselor 

can help you develop a spending plan that works for you while taking into 

account those often unanticipated expenses. The program also offers workshops and classes that might be helpful as well. If you are not located near an 

installation, you can also access financial counseling services through Military 

OneSource or through the Military and Family Life Counselor (MFLC) program. Contact information for MFLCs can be accessed through your military 

and family support center. All of these services are provided at no cost to 

Service Members and their families. 

Mi l i ta ry Rel ief S o c iet ies

Each service has a private, nonprofit organization that assists families in times 

of need. Areas of assistance may include the following:

• emergency transportation; 

• help with medical bills, child care expenses, food, rent, utilities, and 

other household bills; 

• vehicle repair; and 

• family emergency assistance. 

For more information on the relief societies, contact the Army Emergency 

Relief (http://www.aerhq.com), the Navy–Marine Corps Relief Society (http://

www.nmcrs.org), or the Air Force Aid Society (http://www.afas.org).

Wo u n ded Wa r r i o r Pr o g r a ms

The military’s Wounded Warrior programs provide assistance and advocacy 

for severely wounded, ill, and injured Service Members, Veterans, and their 

families. These programs assist Service Members and their families as they 

return to duty or transition to civilian life.

Each of the individual branches of service operates a Wounded Warrior 

program to assist Service Members and their families with nonmedical issues 

associated with the transition back to duty or to civilian life. The Wounded 
Financial Management H 289

Warrior programs work with the Service Member and his/her medical team 

to develop a comprehensive recovery plan that addresses specific recovery, 

rehabilitation, and reintegration goals. These programs provide lifetime support for the Service Member. Eligibility for participation in the program does 

not conclude when the Service Member is discharged from a military treatment facility. Typical nonmedical support provided by the Wounded Warrior 

programs may include, but is not limited to, assistance with the following:

• pay and personnel issues,

• invitational travel orders,

• lodging and housing adaptations for the Wounded Warrior,

• child and youth care arrangements,

• transportation needs,

• legal and guardianship issues,

• education and training benefits,

• respite care, and 

• traumatic brain injury/posttraumatic stress support services.

Eligibility for Wounded Warrior programs is not limited to those with combat 

injuries. These programs also assist those battling serious illnesses or who 

are injured in accidents. Generally, the military Wounded Warrior programs 

support Service Members who incur a serious illness or injury requiring longterm care that may result in a Medical Evaluation Board/Physical Evaluation 

Board to determine fitness for duty.

SUMMARY

Keeping one’s financial house in order is a key factor to reducing stress and 

living a more joyful life. Dealing with financial issues is never easy, regardless 

of one’s personal situation in life or financial means. However, financial challenges should be addressed as soon as they arise and before they become a 

crisis. Achieving or even maintaining financial stability frequently requires initiative and often aggressive action; it does not happen on its own. Fortunately, 

Service Members and Veterans are not on their own. There are many useful 

tools and invaluable resources available to assist them. Take full advantage 

of existing programs and benefits. Remember to have a plan, be positive, and 

stay resilient.
290 H Pr o m o t i n g Su c cess f u l I n teg r at i o n

Refere n ces

1. US Department of Veterans Affairs/Veterans Health Administration. Veterans 

Health Benefits Handbook. Washington, DC: DVA/VHA; 2014. Chapter 2.

2. Department of Veterans Affairs. Federal Benefits for Veterans, Dependents and 

Survivors. Washington, DC: DVA; 2014. Chapter 2. 

3. Researcher finds correlation between financial arguments, decreased relationship 

satisfaction [press release]. Manhattan, KS: Kansas State University, News and 

Communications Services; July 12, 2013.

4. Reichenberger A. Consumer Expenditure Survey. A comparison of 25 years 

of consumer expenditures by homeowners and renters. U.S. Bureau of Labor 

Statistics: Beyond the Numbers, October 2012, vol 1, no 15, p 4. http//www.

bls.gov/opub/btn/volume-1/a-comparisonof-25-years-of-consumer-expendituresby-homeownersand-renters.htm. Accessed December 8, 2015.

5. Tanielian T, Ramchand R, Fisher MP, Sims CS, Harris RS, Harrell MC. Military 

Caregivers: Cornerstones of Support for Our Nation’s Wounded, Ill, and Injured 

Veterans. Santa Monica, CA: RAND Corporation; 2013. http://www.rand.org/

pubs/research_reports/RR244.html. Accessed August 15, 2016.

6. National Alliance for Caregiving and the United Health Foundation. http://www.

caregiving.org/data/2010_Caregivers_of_Veterans_FULLREPORT_WEB_

FINAL.pdf. Accessed December 8, 2015.

7. Office of the Under Secretary of Defense. The Eleventh Quadrennial Review of 

Military Compensation—Main Report. Washington, DC: Author; June 2012: 

293 pp. Accession Number ADA563239.

8. Special Compensation for Assistance with Activities of Daily Living (SCAADL) 

Eligibility. DD Form 2948, September 2011. http://www.wtc.army.mil/documents/

factsheets/wtc_SCAADL_fact_sheet.pdf. Accessed December 8, 2015.
Financial Management H 291

C h ief Wa r r a n t Of f i cer 2 

S h er m a n Gi l l u ms , Jr

When Sherman Gillums, Jr 

received his orders to transfer to 

1st Marine Division in December 

2001, months after the 9/11 

attacks, he imagined that he 

could end up catastrophically 

injured in some way. However, 

when he awoke after 3 days of 

unconsciousness following a 

vehicle multiple rollover at Marine 

Corps Base Camp Pendleton in 

February 2002, the journey he 

had anticipated began in a way 

he had not expected. Now, the 

12-year Veteran of the US Marine Corps—who had trained more than 400 

recruits as a drill instructor and earned distinction as the first Warrant Officer 

to complete the grueling Marine Corps Martial Arts Instructor–Trainer 

Program—faced his greatest test: overcoming his own mortality. 

The sound of the artificial ventilator that kept his now paralyzed body 

breathing brought him to consciousness on February 23, 2002 at Scripps 

Memorial Hospital in San Diego. His C5/C6 cervical vertebrae had been 

fractured from the rollover. The broken pieces had to be surgically removed 

to relieve pressure on his spinal cord, and a titanium cage was placed around 

his spine to hold it together. Within days, he had completely lost function in 

his legs, arms, and bodily systems. 

Shortly after transferring to the San Diego VA Medical Center to begin 

rehabilitation, Gillums began a 4-month journey where major setbacks and 

incremental progress would typify the course of rehabilitation. It would take 

numerous bouts of passing out due to hypotension whenever his nurses sat 

him up before he could even imagine getting into a wheelchair, much less 

push one. His first bout with autonomic dysreflexia, an extremely painful 

residual effect of spinal cord injury, brought new meaning to the definition of 
292 H Pr o m o t i n g Su c cess f u l I n teg r at i o n

pain tolerance. Simple tasks 

like eating independently 

called for Herculean 

endurance and mental 

energy beyond that he 

had once marshaled to 

complete ten 54-hour, 

48-mile crucible exercises 

during his 2-year tour as a 

drill instructor. 

Reintegrating back into 

his world meant adapting 

to his new normal, and 

he did. Soon, the matto-wheelchair transfers 

got easier for him. Using 

his spasticity to dress while he lay on his back became second nature. 

Maneuvering his wheelchair eventually required more motivation than pain 

as he got stronger. These successes would condition him for greater tests of his 

will where living, not just surviving, was the end game. 

For Gillums, living meant finding the will to push beyond the embryonic 

protection of the VA Medical Center and back out into a world full of 

challenges. It pushed him to win two Gold Medals at the National Veterans 

Wheelchair Games and ski the Black Diamond slopes in Aspen, Colorado. It 

pushed him across the stage at the University of San Diego, where he earned 

a graduate degree in business. It pushed him down the aisle at the St. Regis 

Hotel where he married his wife, Tammie. 

Sherman’s will now pushes him in his tireless advocacy for Veterans with 

severe disabilities across the country, in national media, and on Capitol Hill. 

Most importantly, it pushes Chief Warrant Officer Gillums to the bedsides 

of the many recovering Warriors whose paths to spinal cord injury would go 

through freeways, battlefields, and training bases. He hopes that all of them 

will see his life as a case study in resilience worth emulating.
Despite the fact that the current unemployment rate for 

Veterans has dropped, those with catastrophic disabilities are still 

six to eight times more likely to remain unemployed 

despite having a desire to work. 

This reality is linked to a number of factors, starting with low

 self-expectations on the Veteran’s part. But employers 

have contributed as well, by submitting to stigmas and misperceptions 

about drawbacks of hiring “less than perfect” Veterans. 

H H H

Al Kovack Jr.

President, Paralyzed Veterans of America

Congressional Testimony

May 20, 2015

C h a p ter Twelve

Education and Employment

MARY R. GOLDBERG, PhD*; ANNE E. BARRY, MS, CRC†; 

MARIA MILLEVILLE, MEd‡; MICHELLE L. SPORNER, PhD, CRC§; 

RON DRACH¥; ALLEN LEWIS, PhD, CRC ¶; and

BRIAN BILSKI, BS#

*

Education and Outreach Coordinator, Rehabilitation Research and Development 

Service, US Department of Veterans Affairs, 6425 Penn Avenue, Pittsburgh, 

Pennsylvania 15206

†

Rehabilitation Counselor, Office of Vocational Rehabilitation, 531 Penn Avenue, 

Pittsburgh, Pennsylvania 15222

‡

Principal, Up Next LLC, 1200 Richmond Street, Pittsburgh, Pennsylvania 15218 

§

Assistant Professor, Department of Rehabilitation Science and Technology, 

University of Pittsburgh, 5044 Forbes Tower, Pittsburgh, Pennsylvania 15260

¥

Sergeant (Retired), US Army; President, Drach Consulting, 7600 River Falls Drive, 

Potomac, Maryland 20854; formerly, Director, Government and Legislative Affairs, 

Department of Labor, Washington, DC

¶

Dean and Professor, State University of New York Downstate Medical Center, College of Health Related Professions, 450 Clarkson Avenue, Brooklyn, New York 11203

#

President, Veteran Integration Solutions, 17529 Deer Isle Circle, Winter Garden, 

Florida 34787; formerly, Colonel (Retired), US Marine Corps; Consultant/Economic 

Liaison, US Department of Veterans Affairs, Jacksonville, Florida 
296 H Promoting Successful Integration

INTRODUCTION

How do today’s Service Members and Veterans receive benefits to 

obtain an appropriate education to pursue their career goals? 

Do programs exist to support Service Members and Veterans’ 

training and job seeking efforts? How can supporters and facilitators of 

Service Members and Veterans’ transitional success assist in these efforts? 

To address the current state of Service Members and Veterans’ education 

and employment, it is helpful to understand the history of Veterans’ benefits 

and what programs have been created over time to address education and 

employment issues. This chapter will provide an overview of the following 

three issues: (1) employment and career opportunities, (2) benefits of 

volunteering and being active, and (3) vocational training and education. 

Special emphasis on programs and initiatives for those with primary 

disabilities emerging from current conflicts, posttraumatic stress disorder 

(PTSD), and traumatic brain injury (TBI) will also be examined.

BACKGROUND

T h e Hi st o ry o f Veter a n s ’ Ed u c at i o n

In Abraham Lincoln’s second inaugural address, he charged the US government with the responsibility “to care for him who shall have borne the battle 

and for his widow, and his orphan.” The year of Lincoln’s address was 1865, 

but the history of the care for the country’s Military Veterans dates many 

years prior. The laws, initiatives, and programs dedicated to the Military 

Servicemen and women have a rich and complex evolution—adapting, transforming, and conforming to the current social and military landscape of the 

nation. Following World War I, the foundational legislation for educational 

and vocational training for Veterans surfaced. The legislative responses that 

provided educational benefits to Veterans emerged following military involvement in war and conflict. These legislations were reformed and reflected the 

Veteran population’s needs at that time. 

In 1918, the Soldier’s Rehabilitation Act was passed, thus broadening 

the scope of care offered to Veterans by the government. The Vocational 

Rehabilitation Act established the Federal Board for Vocational Education, 

an independent agency. In the years to follow, the Disabled Veterans’ Rehabilitation Act of 1943 was passed, focusing on job training for Veterans with 

disabilities. In 1944, the Servicemen’s Readjustment Act was signed into 
Education and Employment H 297

effect by President Franklin D Roosevelt in response to the needs created by 

World War II.

The Servicemen’s Readjustment Act, also known as “the GI Bill of 

Rights,” included three key provisions for Service Members and Veterans: 

1. up to 4 years of benefits for education or training; 

2. home, farm, or small business loans with no down payment; and

3. unemployment compensation of $20/week for up to 1 year. 

The educational benefits allocated payment of up to $500 for tuition and 

funding for books, student fees, and supplies. Additionally, those who were 

eligible received a monthly allowance. Total participation in the premier GI 

Bill was approximately half of eligible Veterans. 

The Korean War called for adjustment and accommodations for Service 

Members and Veterans. The 1952 Veterans’ Readjustment Assistance Act 

(or Korean GI Bill) redefined the allocations and benefits. Unemployment 

compensation, insurance, job training, and home loans still existed, and were 

similar to the previous GI Bill. However, the educational benefits were more 

limited, restricting education benefits to a maximum of 36 months as opposed 

to the previously allotted 48 months. Instead of payment directly for tuition, 

Veterans received monthly subsistence checks that could be used for tuition. 

At the termination of these benefits in 1956, 7.8 million Veterans were receiving educational training, and 5.9 million were guaranteed home loans, totaling approximately 50 billion dollars. 

In 1966, Congress passed the Veterans’ Readjustment Benefits Act (or 

Vietnam GI Bill). The 1966 GI Bill reinstated educational benefits, providing 

10 months of education for every 1 month of military service. The Vietnam 

GI Bill was received with unprecedented success. Participation during the 

years following the Vietnam War was 76%, whereas participation for the 

Korean GI Bill was 43.4%. Once again, the educational assistance offered 

to Veterans continued to evolve in the post-Vietnam era with the passage of 

the Veterans Educational Assistance Program (VEAP) Act of 1977. VEAP 

emerged following the transition in the military from the draft to voluntary 

service. The provisional option was made by VEAP that Servicemen could 

pay into their educational fund, with their dollars matched 2:1 with federal 

dollars up to $2,700. 

In the late 1960s, there was a shortage in military recruitment, and the 

government addressed this problem by increasing educational benefits in 

the hope of attracting more recruits. The Veterans Education Assistance Act 

of 1984 (or the Montgomery GI Bill) was passed. The Montgomery GI Bill 
298 H Promoting Successful Integration

provided $300/month for 36 months to eligible Veterans. Eligibility included 

those who served 3 years active duty or 2 years active duty and 4 years in the 

Reserves. It was later expanded to include those who committed to 6 years in 

the Reserves. 

America’s involvement in the Persian Gulf ushered in new amendments 

to the GI Bill for Veterans. In March 1991, the Supplemental Authorization 

and Personnel Benefits Act increased the monthly allowance for Veterans 

receiving educational benefits. About 10 years later, the United States would 

find itself involved the Global War on Terrorism after the September 11, 2001 

terrorist attacks. This war, like others in American history, would challenge 

the existing legislation and call for the evolution of educational benefits that 

would come in the form of the Post-9/11 GI Bill: the Veterans Educational 

Assistance Act of 2008.1,2

Veter a n s Ed u c at i o n T o d ay: Ed u c at i o n , Rete n t i o n , 

Gr a d u at i o n , a n d Em p l o y me n t

The Post-9/11 GI Bill was one of the most significant pieces of legislation in 

terms of educational benefits since the conception of the first GI Bill in 1944. 

Increased benefits offered to Veterans include full tuition and fee coverage 

for in-state public undergraduate institutions. Out-of-state choices, private 

institutions, and graduate schooling are also available for coverage if an 

agreement is made by the institution and the Department of Veterans Affairs 

(VA) to match funds to cover costs.3 Today, estimates of those using the Post9/11 GI Bill are approximately 760,000 Service Members and Veterans. This 

number is only expected to increase because there are now approximately 2 

million Veterans who will be returning home as a result of the winding down 

of American involvement in the Middle East. In a recent study conducted by 

the Iraq and Afghanistan Veterans of America organization and Prudential 

Financial, Inc, the majority of Veterans reported education as a priority; 44% 

reported themselves as full- or part-time students.4,5 The US Bureau of Labor 

Statistics (BLS) reported in 2010 that 45.9% of Veterans who have served 

since September 2001 have some college education and that 23.4% have 

received a Bachelor’s degree, leaving only 30.7% of Veterans without any 

form of postsecondary education. 

Currently, the Post-9/11 GI Bill is just 6 years old. Due to its infancy, 

there is little data available about its current standing and long-term success. 

Student Veteran retention in postsecondary education is an important area 

with an unfortunate lack of data. Although reliable and complete data are not 

available, reports are inconsistent and unreliable.6 However, this situation is 

being remedied. In 2010, a press release by the Student Veterans of America 
Education and Employment H 299

(SVA) announced a collaborative effort between the VA, SVA, and National 

Student Clearinghouse to track the success of student Veterans to include 

retention, graduation, and employment outcomes. Additionally, President 

Obama signed an executive order in April 2012 that mandated documentation of outcomes and the rate of graduation among student Veterans. In 

2013, the BLS reported that unemployment rates for Veterans with postsecondary education credentials are lower than those without these credentials 

(Figure 12-1).7 However, in the same report, an ironic trend emerged showing 

that, although the use of the Post-9/11 GI Bill is increasing, so is the unemployment rate of Post-9/11 Veterans. Currently, the unemployment rate for 

male Veterans is 4.5%, 5.4% for female Veterans, and 5.8% for their nonVeteran counterparts. Veterans under the age of 24 years have the highest 

unemployment rate at 13%, which is a highly unfavorable comparison to 

their non-Veteran peers.7 Syracuse University’s Institute for Veterans and 

Military Families (IVMF) published a comprehensive Veteran employment 

situation report in March 2013 that provides a full picture of the Veteran 

employment landscape. 

Leg i sl at i ve Ba c k i n g

In addition to the various GI Bills and described provisions, there are additional federal laws, policies, and programs that affect enrollment, retention, 

and employment of Veterans. The Transition Assistance Program (TAP) was 

created and established as a pilot program in 1990 to offer in-person assistance in the form of a 3-day workshop for Service Members coming off 

deployment orders and retiring from the military. Within TAP, the DepartFi g u re 12-1. Unemployment Rate (Total Annual Average Percentage). 

DATA SOURCE: BUREAU OF LABOR STATISTICS.

Veterans of Iraq and Civilians Veterans 18–24 Civilians 18–24

Afghanistan Wars 

2008 2009 2010 2011 2008 2009 2010 2011 2008 2009 2010 2011 2008 2009 2010 2011

7.3

10.2

11.5 12.1

5.2

8.6 9.4 8.7

17.7

20.9

18.9

30.2

12.3

16.9 16.4 16.1
300 H Promoting Successful Integration

ment of Defense (DoD) offers preseparation counseling; the Department of 

Labor (DOL) offers briefings regarding employment and reemployment rights 

as well as job placement trainings, and the VA offers services and education to 

Veterans with disabilities. In 2011, Congress passed the VOW Act (Veterans 

Opportunity to Work and Hire Heroes Act of 2011), which mandates that all 

separating Service Members attend TAP, and that the Department of Labor 

redesign its portion, the employment workshop.8

In 1994, the Uniformed Services Employment and Reemployment Rights 

Act took effect, and it outlines protections to Veterans and members of the 

National Guard and Reserves in the way of civilian job rights and employee 

benefits. The Service Members Civil Relief Act (SCRA) modernized the 

Soldiers’ and Sailors’ Civil Relief Act of 1940.8 In 2003, the Service Members 

Civil Relief Act offered protection in matters involving rental agreements, 

security deposits, prepaid rent and insurance, and tax payments for Reservists 

who were called to active duty. 

The Higher Education Relief Opportunities for Students Act of 2003 

provides protection against adverse implications of Federal student aid to 

Service Members and Veterans. It includes special provisions for these students during times of war or national emergency.8

 There is also the Veterans 

Opportunity to Work Act established in 2007 that expanded training and 

educational opportunities to Veterans, as well as included incentives for employers to hire Veterans. Similar programs to this include the Yellow Ribbon 

Reintegration Program, VA for Vets, and Hire Heroes USA. Degree-granting 

institutions of higher learning participating in the Yellow Ribbon Program 

agree to make additional funds available for Veterans’ education programs 

without an additional charge to their GI Bill entitlement. VA for Vets helps 

Veterans and transitioning Military Service Members find federal or nonprofit 

careers, whereas Hire Heroes USA is dedicated to creating job opportunities 

for Veterans and their spouses through military transition training and corporate partnerships.

EMPLOYMENT AND CAREER OPPORTUNITIES

The GI Bill has trained and provided employment opportunities to 450,000 

engineers, 238,000 teachers, 91,000 scientists, 67,000 doctors, 22,000 dentists, and millions of other Veterans in the workforce. Despite the fact that 

69.3% of today’s Veterans have a Bachelor’s degree or some college education, the unemployment rate for Veterans is on the rise and shows a disparity 

between Veterans and non-Veterans.9 The troops serving in America’s Global 
Education and Employment H 301

War on Terrorism are coming home, and the longest wartime chapter in 

America’s history is drawing to an end. As a result, there will be potentially 

hundreds of thousands of Veterans seeking employment and hoping to carve 

out a new life and vocational identity. Thus, there are many federal initiatives 

and resources for Veterans pursuing employment. 

A supplemental note required when discussing Veterans’ employment is 

that of the disabled Veterans seeking entrance into or already in the workforce. Reports provide numbers ranging from 47,000 to 75,000 Servicemen 

returning home with service-connected disabilities.10,11 Moreover, at any given 

time, there are approximately 200,000 Veterans with disabilities who are 

trying to find a job.12 Twenty-five percent of Veterans making up this population are diagnosed with “invisible wounds.” These disabilities can include 

impaired hearing, degenerative vision, traumatic brain injuries, and PTSD.10

All war-related disabilities require cognizant consideration, respect, and sensitivity from potential employers. In more complicated cases, education and 

patience may be required as well. 

In addition to the Veterans Opportunity to Work program and Hire 

Heroes USA, there are other noteworthy federal initiatives. In 2011, President Barack Obama signed the American Jobs Act that granted tax credit to 

businesses that hired unemployed Veterans. An extension of this Act is the 

Wounded Warrior tax credit provided to those who employ Veterans with 

service-connected disabilities. Additionally, several organizations and Internet 

resources exist to aid the job search process for Veterans, as well as for potential employers of Veterans: 

• Feds Hire Vets,

• Job Accommodation Network, 

• Employer Assistance and Resource Network, 

• National Resource Directory, and

• AbleForces.org. 

A more comprehensive review of helpful resources can be found in Table 

12-111 and in Chapter 14 (Overview of Military and Veteran Resources).

In 2012, IVMF published “The Business Case for Hiring a Veteran: Beyond 

the Clichés.”13 This paper identified the strengths, skills, and assets that 

today’s Veterans possess that make them optimal candidates for employers. 

Common themes that showed up in the IVMF brief were the strong work 

ethic, sense of mission, leadership, and high levels of trust that are commonly 

found among Veteran populations. Veterans typically have a strong sense of 

self-efficacy, a high need for achievement, and the ability to make effective 
302 H Promoting Successful Integration

Ta b le 12-1. Summary of Low-Intensity Programs*

Program Name Services Types of Assistance

AbilityOne Provides employment opportunitites for people 

who are blind or who have other severe 

disabilities

http://www.abilityone.org

Link to opportunities, job 

placement, and matching

Able Forces Provides employment opportunities and 

community-based job preparation training 

to returning Service Members suffering from 

severe physical disabilities and psychological 

disorders

http://www.ableforces.org

Link to opportunities, job 

placement, and matching

Air Force Wounded 

Warrior HART 

Program

Assists wounded Airmen with employment 

placement or employment counseling

http://www.af.mil/News/ArticleDisplay/

tabid/223/Article/131091/palace-harthelps-injured-airmen.aspx

Link to opportunities and 

job preparation

America's Heroes at 

Work

Provides information and toolkits to employers 

hiring Veterans with TBI and PTSD

http://www.dol.gov/vets/ahaw

Link to resources for 

employers

DoDVets Provides general career information for 

Veterans with disabilities who are looking for 

opportunities at the Department of Defense; 

includes federal employment information, 

Q&As for Veterans and managers, internships, 

and education and training programs

http://www.godefense.com/veterans

Link to opportunities

EARN Provides information for employers seeking to 

recruit and hire employees with disabilities

http://www.askearn.org

Link to resources for 

employers

Entrepreneurship 

Bootcamp

Offers experiential training in entrepreneurship 

and small business management to Soldiers, 

Sailors, Airmen, and Marines with disabilities

http://bv.vets.syr.edu

Job preparation

Feds Hire Vets Provides training information and resources 

for federal agencies looking to hire Service 

Members and Veterans

http://www.fedshirevets.gov

Link to resources for 

employers

Hire Heroes USA Provides links to career opportunities 

nationwide for returning Service Members, 

specifically those who have been wounded 

or with any level of disability

http://www.hireheroesusa.org

Link to opportunities, job 

placement, and matching
Education and Employment H 303

JAN Provides employers with informational assistance on workplace accommodations and the 

Americans with Disabilities Act

http://www.askjan.org

Link to resources for 

employers

National Resource 

Directory

Provides access to services and resources that 

support employment

http://www.nationalresourcedirectory.gov

Link to opportunities

VETS Provides information and resources about 

employment opportunities and employment 

rights for individuals with disabilities

http://www.dol.gov/vets

Link to opportunities

VetSuccess Offers services such as helping build jobseeking skills, resume development, and 

assistance finding and keeping a job

http://benefits.va.gov/benefits

Link to opportunities, job 

preparation, job placement, and matching

Work Support Provides links to reports, manuals, and 

resources to accommodate employees with 

disabilities

http://www.worksupport.com

Link to resources for 

employers

Warrior Care

and Transition

Matches injured Warriors with case managers 

to build personalized work plans and provide 

job skills training

http://www.wtc.army.mil

Job preparation

Wounded Warrior 

Project

Offers higher education programs, information technology training, and employment 

assistance services (an extensive employment 

database is currently under development)

http://www.woundedwarriorproject.org

Link to opportunities, job 

placement, and matching

DoD: Department of Defense; EARN: Employer Assistance and Resource Network; HART: Helping 

Airmen Recover Together; JAN: Job Accommodation Network; PTSD: posttraumatic stress disorder; 

Q&As: questions and answers; TBI: traumatic brain injury; Vets: Veterans; VETS: Veterans’ Employment 

and Training Service

*This table provides resources found on the Internet. Due to the nature of online resources, these 

Web addresses are subject to change without notice. We suggest using a search engine to find any 

missing resources.

Data source: Reproduced with permission and minor changes from Osilla K, Van Busum K. Labor Force 

Reentry: Issues for Injured Service Members and Veterans. Santa Monica, CA: RAND National Defense 

Research Institute; 2012.
304 H Promoting Successful Integration

decisions in dynamic situations. They are generally comfortable with autonomy and uncertainty, but remain resilient, mission focused, and driven toward 

successful outcomes. Their experience provides team-building skills, as well 

as a commitment to organizational structure and leadership. The majority of 

Veterans will have had cross-cultural experiences with a rich diversity of work 

settings and a developed sense of cultural sensitivity.

Furthermore, Veterans have and can leverage their advanced technical 

training. Their experiences will have often exposed them to accelerated training in highly progressive technology. Several of these skills will adeptly transfer 

advantageously to the fields of science, technology, engineering, and math.9

Veter a n s Ad m i n i st r at i o n V o c at i o n a l

Re h a b i l i tat i o n a n d Em p l o y me n t

The history of employment services dates back to 1918 with the Vocational 

Rehabilitation Act. Throughout the century, the basic services outlined in the 

1918 Act were renamed and structurally reorganized until they finally landed 

under Chapter 31 in Title 38 of the Code of Federal Regulations. Chapter 

31 is the Vocational Rehabilitation and Employment (VR&E) Program, the 

mission of which is to prepare, train, attain, and maintain suitable employment for Veterans with a service-connected disability of at least 20%. If the 

goal of employment is not attainable for a Veteran with a severe disability, 

then VR&E benefits include identifying realistic living situations, distinguishing rehabilitation and resources to reach that end, and meeting the goal of 

independent living. 

Once a Veteran has received his/her disability rating status and is deemed 

eligible for Chapter 31 benefits, the Veteran will be able to initiate these 

services at any point within 12 years of his/her initial eligibility. A Veteran is 

then entitled to a maximum of 48 months of services, and services include 

the assignment of a vocational rehabilitation counselor. The counselor and 

Veteran will work together to establish a rehabilitation plan. In this plan, 

skills, strengths, aptitudes, and interests will be identified. The counselor and 

Veteran will explore the job market and investigate wage information, demands of the job, and relevant training requirements.14 Chapter 31 is part of 

the VA branch known as the Veterans Benefits Administration. The Veterans 

Health Administration is a sister branch of the Veterans Benefits Administration and houses a separate vocational rehabilitation service for Veterans 

regardless of disability rating. The program includes the same collaboration 

and goal setting with a counselor. It offers three primary vocational assistance 

programs: (1) compensated work therapy, (2) incentive work therapy, and 

(3) supported employment. Studies have shown and supported the efficacy of 
Education and Employment H 305

these programs. Veterans who engage in vocational services are more likely 

to find and maintain competitive employment, earn higher wages, work more 

days, and have more vocational opportunities than those who do not receive 

these services.10,15,16

EXPLORING NEW OPPORTUNITIES

As previously described, transitioning Service Members tend to possess overall skill sets that show tremendous benefits in the civilian workforce. Some 

attributes that they bring to an employer are often referred to as soft skills, 

and they include the following: 

• commitment and loyalty,

• dedication and focus,

• “get-the-job-done” attitude,

• unsurpassed experience working under pressure,

• experience in conflict resolution,

• multicultural experience,

• security issues on an international scale, and 

• ability to work individually or as part of a team.

Often, however, transitioning Service Members have difficulty translating 

their military experience into civilian language and terminology. Therefore, 

they also have trouble getting their resumes to the “top of the pile.” Because 

of certain stigma attached to military service, they are sometimes reluctant or 

unsure about exposing their military history. 

Likewise, many Veterans experience difficulty assimilating back into 

society. The stigma especially impacts those who are living with PTSD and/or 

TBI. These injuries may generally be invisible and are frequently referred to as 

the signature injuries of Iraq and Afghanistan. As many as one in five Veterans of the Iraq and Afghanistan wars has dealt with depression or stress disorder. Estimates range up to 300,000 with PTSD. Additionally, 19% report 

they might have experienced a TBI, usually as the result of a roadside bomb. 

In June 2010, when the Society for Human Resource Management surveyed 

its members, 46% said they believed PTSD and other mental health issues 

posed a hiring challenge. Only 22% said the same about combat-related 

physical disabilities. Although media attention has helped make the diagnoses 

and treatment of PTSD and TBI government priorities, Veterans believe that it 

has also contributed to the stigma associated with these wounds.
306 H Promoting Successful Integration

In an attempt to address the stigma and other issues faced by Veterans 

with PTSD and TBI, DOL—through a collaborative effort between their 

Office of Disability Employment Policy and the Veterans’ Employment and 

Training Service—established America’s Heroes at Work (http://www.dol.

gov/vets/ahaw/). This initiative was designed to educate employers and others 

about issues related to employment that might impact Veterans with PTSD 

and TBI. DOL recognized they could not do it alone, and reached out to and 

received support from the DoD and the VA, as well as from the private sector. 

DOL established an employment pilot for Veterans with PTSD and TBI, and 

several employers came forward. From that pilot program, DOL learned that

• the most responsive employers show strong, visible commitment from 

top-level decision makers; 

• individualized workplace flexibility is the key to success and has applicability to the entire workforce;

• work experience, internship, and mentorship opportunities are extremely 

beneficial to both employers and Veterans; 

• TBI/PTSD-related stigma exists among many employers, including those 

employers used to hiring Veterans; and 

• employers are typically unaware of the resources that exist to help them 

provide appropriate workplace accommodations. 

Pr i vate Sec t o r I n i t i at i ves

President Obama had asked the private sector to hire 100,000 Veterans/

returning Service Members by 2015. The 100,000 Jobs Mission was launched 

with the goal of hiring 100,000 transitioning Service Members and Military 

Veterans by 2020. Eleven corporations have joined this mission. Even prior to 

the President’s request, many employers initiated specific outreach efforts to 

hire not only returning Service Members, but also specifically Wounded Warriors, including those living with PTSD and/or TBI.

Northrop Grumman Corporation (Falls Church, VA) established 

Operation IMPACT (Injured Military Pursuing Assisted Career Transition), 

which is focused on Wounded Warriors living with PTSD and/or TBI. British 

Aerospace (Farnborough, UK) and Marconi Electronic Systems (Chelsmford, 

UK) have programs for hiring Veterans with PTSD and/or TBI. In addition, 

Computer Sciences Corporation (Falls Church, VA) developed a program for 

hiring Veterans, military spouses, spouses of severely wounded and injured 

Veterans, and caregivers.

JPMorgan Chase & Co (New York, NY) has developed and is executing 

a holistic Veteran’s strategy. Two key elements include a commitment of $7.5 
Education and Employment H 307

million to (1) provide seed funding for the creation and (2) launch a “first-ofits-kind” Institute for Veterans and Military Families at Syracuse University, 

as well as the 100,000 Jobs Mission.

The US Chamber of Commerce created a private sector National Veterans Employment Advisory Council, which will be comprised of 25 of America’s largest employers, representing every major industry and sector. They also 

initiated a series of nationwide job fairs to assist job-seeking Veterans.

Feder a l Sec t o r I n i t i at i ves

On November 9, 2009, President Obama issued Executive Order 13518 

(Veterans Employment Initiative) calling on federal government agencies to 

increase their efforts to employ Veterans in the federal workforce. To assist 

this effort, the Office of Personnel Management established Feds Hire Vets 

(http://www.usajobs.gov/). This site contains valuable information for job 

seekers (Veterans) and hiring officials. 

Veterans can access federal jobs in several ways, but typically they apply 

through USAJOBS (https://www.usajobs.gov/). By applying through this 

portal, eligible Veterans may receive 5 or 10 points added to their passing 

score of any test or numerical rating. This does not guarantee a job, but does 

benefit the applicant.

The Veterans Recruitment Appointment allows federal agencies to 

appoint an otherwise qualified and eligible Veteran to any position up to 

GS-11 or the equivalent without competing with other applicants (see 38 

USC § 4214; 5 CFR Part 307). The VA or any military service branch may 

also appoint qualified and eligible Veterans who have a disability rating of 

30% or more (see 5 USC § 3112; 5 CFR 316.302; 5 CFR 316.402; and 

5 CFR 315.707).

The Veterans Employment Opportunity Act (VEOA) of 1998 as amended allows Veterans to apply to announcements that are only open to so-called 

“status” candidates, which means “current competitive service employees” 

(Veterans’ preference does not apply). VEOA was enacted in recognition that 

Veterans should have all the rights and benefits in employment accorded to 

other federal employees. To be eligible for a VEOA appointment, a Veteran 

must have been granted an honorable or general discharge and must be either 

preference eligible as defined in Title 5 USC § 2108(3) or be a Veteran who 

substantially completed three or more years of active service. [For additional 

information, see the Office of Personnel Management’s section on qualifying 

service (http://www.opm.gov/policy-data-oversight/veterans-services/

vetguide/) (PL 105-339, October 31, 1998; 5 USC § 3304f; 5 CFR 315.611; 

and 5 CFR 335.106).]
308 H Promoting Successful Integration

Veterans with disabilities who participate in the VA’s VR&E program 

may be eligible for an appointment with a federal agency in a position for 

which they have been trained through VR&E (see 5 USC, § 3112; 5 CFR 

316.302; 5 CFR 316.402; 5 CFR 315.707; and 5 CFR 315.604). Veterans in 

the VR&E program may also gain valuable experience through the Non-Paid 

Work Experience where they may be placed in an internship-type program in 

a job that is compatible with their training objective (eg, an accounting major 

can be placed in an accounting-related job, etc). These jobs can be in any 

federal, state, or local government agency. They will continue receiving their 

VR&E stipend, but will not be paid by the agency. VR&E also administers 

the Coming Home to Work program that assists eligible Service Members 

who are pending medical separation. These Service Members may be placed 

in the Non-Paid Work Experience and still retain their active duty pay.

DoD operates a similar internship program for wounded, ill, and injured 

transitioning Service Members called Operation Warfighter (OWF). OWF is 

a nonpaid internship program within the federal government for returning 

Service Members while still on active duty in accordance with DoD Instruction 1000.17.17 The objective of OWF is to place recovering Service Members 

in a supportive work environment to assist their rehabilitation and to potentially increase career readiness. Originally, OWF opportunities were available 

only in the Washington, DC, area, but have since been expanded to other 

geographic areas that have a significant federal employment presence and are 

near a military treatment facility. Currently, DoD is planning on opening these 

opportunities to the private sector. Although DoD has refrained from calling 

OWF an internship program, it allows transitioning wounded, ill, and injured 

Service Members an opportunity to work at these federal agencies performing 

meaningful work that garners them valuable civilian work experience. It was 

never intended to be a placement program, but many of the agencies have 

employed these Service Members upon discharge. Most, if not all, Veterans in 

this program are eligible for the Veterans’ Recruitment Appointment.

One of the most common and frequent problems reported by transitioning Service Members and employers is that their resumes are often replete 

with military language that civilian employers (public and private) cannot 

understand. There are several sites for translation of military skills into the 

private sector (see section on Private Sector), and one has been developed 

for the federal sector. The Crosswalk from Military to Federal Civilian Jobs 

program of the state of Maryland (http://www.dllr.state.md.us/mil2fedjobs/) 

assists the transitioning Service Member with the ability to write a resume 

that uses language accessible to federal managers and hiring officials.
Education and Employment H 309

EDUCATION AND VOCATIONAL TRAINING

One consequence, albeit generally a positive consequence, of exploring new 

opportunities is the realization that additional skills are required. The American economy has increasingly required a more highly skilled workforce in 

recent years, making education instrumental to the Veteran’s successful transition to civilian life. For individuals transitioning out of the military, vocational 

counseling is a critical component in the adjustment to the nonmilitary, civilian workforce. By participating in the broader vocational counseling process, 

Veterans may discover alternative interests, as well as transferable skills and 

abilities. Through this process, Veterans may identify alternative education 

opportunities they previously would not have considered.

On average, individuals with college degrees earn $15,000 to $20,000 

more than high school graduates and are more likely to pass on this higher 

socioeconomic status to their children. Higher earning individuals rate their 

quality of life as higher than those making lower wages. These individual 

benefits translate into social benefits. Higher enrollment and graduation of 

Veterans from colleges and universities and participation in vocational training programs ensure that more qualified professionals will be prepared to 

enter the modern workforce and contribute to our Nation’s economy.

Although research on Veterans’ education is just beginning to emerge, 

it is already known that Veterans have difficulty transitioning to a college 

environment for various reasons, including the following: having the inability 

to relate to traditional students, having service-connected disabilities, being a 

target of antiwar sentiments, and encountering the insensitivity of faculty. In 

addition, 

• Only 22% of colleges with services for Veterans and active duty Service 

Members provide comprehensive transition programs that link those 

services together. 

• Only 33% of higher education institutions offer special programs for 

Veterans with disabilities.18

• Only 23% offer special services and programs for Veterans with invisible 

disabilities (eg, TBI and PTSD).18 Invisible disabilities can translate into 

poor academic performance and lead to student Veterans dropping out of 

school. Only 2 of 5 colleges provide training for faculty and staff working with this population.19

With support from the President, DoD, the VA, DOL, and the Department 

of Education, stakeholders in Veterans’ education have worked together to 
310 H Promoting Successful Integration

identify strategies and to establish clear guidelines that colleges and universities should follow to best serve Veterans. These support structures should 

also help them reach their academic and career goals while attending to their 

rehabilitation needs and recognizing their status as nontraditional students. 

The outcome of their efforts is depicted in the 8 Keys to Success: 

1. create a culture of trust and connectedness across the campus community 

to promote well-being and success for Veterans;

2. ensure consistent and sustained support from campus leadership;

3. implement an early alert system to ensure that all Veterans receive 

academic, career, and financial advice before challenges become 

overwhelming;

4. coordinate and centralize campus efforts for all Veterans, together with 

the creation of a designated space (even if limited in size);

5. collaborate with local communities and organizations, including government agencies, to align and coordinate various services for Veterans;

6. use a uniform set of data tools to collect and track information on 

Veterans, including demographics, retention, and degree completion;

7. provide comprehensive professional development for faculty and staff on 

issues and challenges unique to Veterans; and

8. develop systems that ensure sustainability of effective practices for 

Veterans.20

Currently, more than 250 higher educational institutions have adopted the 

8 Keys to Success,20 and the number of colleges expected to adopt the keys 

continues to grow. When choosing a college, a Service Member is encouraged 

to check whether that institution of choice has adopted the 8 Keys to Success.

Although more institutions are making their campuses Veteran-friendly 

by raising awareness of Veterans’ issues on campus and centralizing services 

for Veterans, a few offer comprehensive transition programs that do not 

only direct Veterans to resources available outside of the institution, but also 

provide those services in-house, thus expediting the transition process. Such 

intensive training programs are available at the academic and vocational 

levels, and can accommodate Veterans and Service Members with various 

interests and career aspirations. 

Ex per ie n t i a l Lea r n i n g f o r Veter a n s i n Ass i st i ve

Tec h n o l o g y a n d E n g i n eer i n g

The ELeVATE (Experiential Learning for Veterans in Assistive Technology 

and Engineering) program at the University of Pittsburgh is an evidence-based 
Education and Employment H 311

comprehensive transition program for Veterans interested in pursuing a career 

in the fields of engineering and technology. ELeVATE is based on a threephased approach, with each phase consisting of various interventions:

• phase 1: corresponds to the first 10 weeks of the program, and focuses on 

the acquisition of skills necessary to succeed in a demanding and unfamiliar academic environment; 

• phase 2: ELeVATE students apply to and transition to college as they 

continue to work on their research projects; and 

• phase 3: students remain connected to the program by mentoring new 

ELeVATE students while working on their college degree. 

Community reintegration, academic preparation, professional development, and vocational rehabilitation are essential components of ELeVATE. 

Prior to joining ELeVATE, each Veteran is assigned to a mentoring team 

comprised of a faculty member, a graduate student, and a Veteran community 

mentor who has successfully reintegrated into civilian society. To ensure that 

the ELeVATE staff and mentors can provide the necessary support to program participants, regular training sessions are conducted by a rehabilitation 

counseling professional in which they learn about common injuries, prevailing 

conditions (eg, TBI and PTSD), and how those conditions affect the Veteran’s 

experience in college. As a result, the ELeVATE program’s staff members are 

knowledgeable about how to coach a student Veteran to best negotiate the 

rehabilitation process while pursuing higher education or vocational training.

Making the experience meaningful is part of the success of academic 

transition programs. Participation in rehabilitation science and technology 

research allows ELeVATE students to engage in technical disciplines while 

working on projects that can change the lives of people with disabilities 

(including Veterans and Service Members). 

In addition to the research project, ELeVATE students participate in 

additional lectures and workshops, such as Technologies for Competitive 

Adaptive Sports, Introduction to Machining Skills, Research Methods, and 

Oral Presentation Skills. Additional activities include networking events with 

local employers and field trips to organizations of interest. Each activity 

presents ELeVATE students with the opportunities to network with professionals in science, technology, engineering, and math, and to explore different 

career options. 

Vocational counseling is an essential component of ELeVATE. Students 

have comprehensive rehabilitation plans based on their functional and neuropsychological needs, as well as interests, aptitude, and career goals. The 
312 H Promoting Successful Integration

plan sets out objectives that must be met at specific time points to achieve 

more distant goals. As the participants develop a better understanding of their 

strengths and limitations through the course of the program, they work with 

the rehabilitation counselor to incorporate their new awareness into their 

revised rehabilitation plans. Each ELeVATE student meets individually with 

the rehabilitation counselor at least three times during the 10-week period. 

Group sessions attended by the students and all ELeVATE staff members are 

held weekly. The purpose of those sessions is to address any transition-related 

questions the students might have. The sessions also give the students an 

opportunity to share their thoughts about their academic experience in a supportive environment. 

During educational or vocational counseling, focus should be placed on 

the strengths of the individual as well as on the challenges they may face or 

could potentially face. For Veterans with disabilities, an important component 

of the vocational counseling is to help identify potential strategies an individual could use to promote success in the classroom and on the job. They could 

include personalized compensatory strategies or workplace accommodations, 

such as taking frequent breaks, working in a quiet space, or using assistive 

technology. The Job Accommodation Network is a resource that individuals 

can use to get tips and tricks to promote employment while working around 

some of the challenges associated with TBI and PTSD. 

E n t rep re n eu rs h i p B o o t c a m p f o r Veter a n s

IVMF at Syracuse University has been a leader in providing education opportunities for transitioning Service Members and Veterans, supporting their 

families, and working with individuals and institutions to facilitate the successful transition of Veterans into civilian society. The IVMF offers numerous transition tracks for Service Members, Veterans, and their families, thus 

responding to the unique needs of their program participants. 

The IVMF’s Entrepreneurship Bootcamp for Veterans (EBV) is a unique 

program for Veterans with service-connected disabilities who wish to start 

their own businesses. The program utilizes a three-phase approach, where 

each phase corresponds to development of specific knowledge and skills 

necessary for a Veteran’s success as a new entrepreneur: 

• phase 1: participants develop their business concepts while engaging 

in online training provided by entrepreneurship faculty and graduate 

students at one of the EBV universities;

• phase 2: a 9-day residency at an EBV university, where Veterans 

participate in entrepreneurship workshops; and
Education and Employment H 313

• phase 3: participants continue to receive support from the EBV faculty 

and partnering institutions. 

In addition to providing Veterans with disabilities with knowledge and 

practical skills for starting a successful business, the program helps them 

establish support networks, further helping them prosper in their new role 

as entrepreneurs. 

The EBV program was recognized by the Secretary of the Army as a 

“National Best Practice” in 2009 and was featured in Inc. magazine as being 

among the top 10 entrepreneurship programs in the nation. The success of 

EBV led to the development of more entrepreneurship programs targeting 

women Veterans, families of Veterans, Reservists and members of the Guard, 

and active duty Service Members at the earliest stages of the transition process. 

V o c at i o n a l Tr a i n i n g Pr o g r a ms

According to DOL’s Occupational Outlook Handbook,

21 many professions 

that require vocational training, especially those in the technology domain, 

will be in high demand and will be compensated for at a high rate in just a 

decade. Several colleges have established programs to accommodate Veterans 

and Service Members who are interested in manufacturing careers. Typically, 

such programs include training in an academic environment followed by an 

on-the-job component that can serve as a springboard to employment or 

further education.

For example, with support from DOL, 12 state and community colleges 

in Florida have been part of the Florida TRADE (Transforming Resources for 

Accelerated Degrees and Employment) program, designed to assist Veterans (among other groups) by providing them with accelerated training (3–6 

months) that can lead to internships and employment in manufacturing. The 

network of employers working with the TRADE colleges is broad, and various certifications are available based on the participants’ interests. Vocational 

training received through the TRADE network can be converted into credits 

and counted toward an Associate’s degree. However, programs like TRADE 

are not designed specifically for Veterans and might not be right for those 

Veterans who need more coaching in compensatory strategies as they transition to college and employment. Therefore, it is important for transitioning 

Service Members and their support networks to be familiar with comprehensive transition programs designed specifically for Veterans with and without 

disabilities.

Although the need for comprehensive vocational training transition 

programs for Veterans remains high, only a few institutions currently offer 
314 H Promoting Successful Integration

such programs. The Advancing Inclusive Manufacturing (AIM) program at 

the University of Pittsburgh is designed specifically to aid in the transition of 

rehabilitating Wounded Warriors and rehabilitating Veterans to machining 

careers. Over a 12-week period, AIM students learn basic machining principles and practices as they cycle through fundamental areas of fabrication, 

including carpentry, welding, prototyping, and electronics. Upon completion of the program, AIM students can independently design, develop, and 

evaluate their own product using established design principles. AIM program 

training activities include computer-aided design concepts, rapid prototyping, 

tubing, bending, and machining and milling. 

In addition to technical training, the AIM curriculum includes vocational 

training sessions in which Veterans work on goal setting and career planning. 

The curriculum is enhanced with workshops on disability support and various 

areas of assistive technology, including mobility, communication, computer 

access, and prosthetics and orthotics. AIM training takes place at the Human Engineering Research Laboratories, the VA Center for Wheelchairs and 

Associated Rehabilitation Technology. The laboratories’ training facilities 

were designed specifically to accommodate a range of physical and cognitive disabilities. After successful completion of the program, AIM trainees are 

prepared to sit for the National Institute for Metalworking Skills Level 1 Exam 

and are matched with an employer in the area for on-the job-training experience at local companies, where potential full-time employment can be secured. 

Tr a n s i t i o n Pr o g r a ms

The SVA (which provides undergraduate Veterans with resources, support, 

and advocacy) and Kognito Interactive (New York, NY), a developer of roleplaying health training simulations) together created evidence-based training 

modules22 that allow faculty, staff, and peers to practice how to best provide 

support to student Veterans when they encounter challenges associated with 

transitioning to campus and civilian life in general. Training covers a range 

of topics, including academic challenges, time management, cultural differences, and managing classroom discussions on topics that Veterans might 

find difficult. This training also presents the viewer with real-life scenarios 

and provides immediate feedback via an emotionally responsive avatar to 

help the trainee learn effective communication skills specific to the student 

Veterans’ needs. As more institutions adopt this or other training tools, more 

will be known about the effectiveness of virtual versus live, in-person training 

modules. Thus, virtual reality training modules can be a valuable resource at 

institutions with limited access to rehabilitation counseling professionals. 
Education and Employment H 315

The number of colleges partnering with the DoD’s Defense Activity for 

Non-Traditional Education Support initiatives, the VA’s VetSuccess On Campus, and the VA’s Veterans Integration to Academic Leadership programs—

designed to aid in the transition process—continues to grow, thus ensuring 

that more Veterans have knowledge of and access to the resources available to 

them through the VA. 

VOLUNTEERING

Education and employment are key strategies in helping Veterans to achieve 

an optimal quality of life and return to being productive civilian citizens. 

However, these strategies do not function in a vacuum, and their value can be 

magnified when combined with volunteering. There is a relationship between 

military service and volunteering. Military service renders one more likely to 

volunteer because it socializes individuals with a concept of civic responsibility from which volunteering is a natural outgrowth.23 Formal volunteer programs that target Veterans have been shown to be successful. For example, 

Veterans with disabilities who have volunteered for The Mission Continues 

program have reported enhanced educational and career development.24

Seven of 10 Veterans participating in this program continued their education, 

8 of 10 were successful in transferring military competencies into civilian employment, and 9 of 10 were able to develop professional networks to benefit 

future career development.24

Volunteering can augment the education strategy by offering an immediate complement to didactic learning by bridging theory learned in the classroom with actual practice in an authentic context. Furthermore, volunteering 

provides “in vivo” exposure to real-world work even before the Veteran 

is able to gain such exposure on a paid and gainful basis (ie, in a real job). 

Ultimately, volunteering represents experiential learning and jump-starts the 

process of building social capital (ie, developing an effective social network). 

The combination of meaningful employment and a well-developed personal 

and/or professional network can pave the way for the Veteran to achieve an 

enviable quality of life. 

Volunteering is experiential learning because it occurs within the milieu 

of a real-work setting. Experiential learning aligns well with adult learning 

theory (ie, andragogy). The concept of andragogy was developed by Malcolm 

Knowles.25 In contrast to pedagogy that addresses teaching of children, andragogy assumes that adult learners
316 H Promoting Successful Integration

• have life experience that stimulates learning, 

• are self-directed in learning, 

• are ready to learn based on advanced social roles and development, and 

• can apply learning immediately. 

The life experience of adults is a key ingredient that, when combined with the 

learning task, can result in a teachable moment. Robert Havighurst popularized the teachable moment concept in the 1950s.26 The experiential learning 

that occurs through volunteering inherently links to the adult learning theory 

and the concept of the teachable moment. This attribute, combined with the 

volitional aspect of volunteering (ie, the fact that volunteering is freely chosen 

by the Veteran), means that it has the potential to be an efficacious approach 

for enhancing the community reintegration of Veterans. 

Beyond the experiential learning involved in volunteering is the need for 

the Veteran to build an effective network of individuals who provide social 

and professional support (ie, social capital). Such a network can provide 

strategic guidance, connection, and entry into situations that can boost the 

Veteran’s development. Often, Veterans do not take full advantage of networking opportunities because of either faulty understanding of its power 

or lack of practice, thus leaving networking skills underdeveloped.27 The 

positive impact of both volunteering and networking on the key outcomes of 

education, employment, and quality of life can render the Veteran optimally 

prepared for a successful postmilitary lifestyle (Figure 12-2). Such a lifestyle is 

characterized by the Veteran who is 

Fi g u re 12-2. The Veteran Opportunity Cycle. 

Volunteering

[”in vivo” and experiential learning]

EMPLOYMENT

[outcome 2]

Networking

[social capital]

EDUCATION

[outcome 1]

IMPROVED QUALITY OF LIFE

[outcome 3]

Optimal community integration

Full participation
Education and Employment H 317

• empowered and self-determining; 

• prepared professionally through specific education, and volunteer and 

employment experiences; 

• self-sufficient; 

• able to participate in all desirable life pursuits; and 

• in possession of a well-developed amount of social capital for personal, 

social, and professional purposes. 

Therefore, from a holistic perspective, volunteering helps the Veteran to fully 

seize a commensurate share of the American dream as a civilian. 

SUMMARY

This chapter provides an assortment of opportunities for Veterans to consider 

as they are transitioning to the civilian world. This transition often requires 

the acquisition of new skills that may be obtained through a community college or university, by volunteering, or through a private or federal sector work 

training program, and financed through a variety of disability and/or military benefits. Collaborations between educators, counselors, administrators, 

employers, and human resources personnel may provide the optimal level 

of support required for educational and employment retention. A multitude 

of research opportunities, many aimed at best practice development, exist to 

continue to better understand and meet the needs of this population. As more 

transparent data emerge, additional federal and private programs may be 

created to address the Veterans’ most pertinent needs. This not only benefits 

Veterans and their future education and employment pathways, but also highneed employment areas, including (but not limited to) the science, technology, 

engineering, and math sectors. 
318 H Promoting Successful Integration

Refere n ces

1. Stanley M. College education and the midcentury GI bills. Q J Econ.

2003;118(2):671–708.

2. Department of Veterans Affairs. VA history in brief. http://www.va.gov/opa/

publications/archives/docs/history_in_brief.pdf. Accessed June 23, 2015.

3. O’Herrin E. Enhancing Veteran success in higher education. Peer Rev. 

2011;13(1):15–18.

4. Institute for Veterans and Military Families. The business case for hiring a Veteran: beyond the cliches. http://nvti.ucdenver.edu/resources/resourceLibrary/pdfs/

Syracuse%20Business%20Case%20to%20Hire%20a%20Vet.pdf. Accessed 

February 2, 2015.

5. Prudential Financial, Inc., Afghanistan and Iraq Veterans’ of America. Veterans 

employment challenges: perceptions and experiences of transitioning from military to civilian life. http://www.prudential.com/documents/public/Veterans

EmploymentChallenges.pdf. Accessed February 2, 2015.

6. Sander L. As GI bill expands, so do calls for tracking Veterans’ academic success. 

Chron High Educ. 2012;59(17):3.

7. Bureau of Labor Statistics. Employment Situation of Veterans—2015. Washington, DC: US Department of Labor; March 22, 2016. News Release USDL-16-

0611.

8. Veterans Opportunity to Work Act to Hire Heroes Act of 2011. The VOW Act. 

Washington, DC: House Committee on Veterans’ Affairs; November 21, 2011. 

9. Mitcham M. Academic Recognition of Military Experience in STEM Education.

Washington, DC: American Council on Education; 2013.

10. Twamley EW, Baker DG, Norman SB, Pittman JE, Lohr JB, Resnick SG. Veterans 

Health Administration vocational services for Operation Iraqi Freedom/Operation Enduring Freedom Veterans with mental health conditions. J Rehabil Res 

Dev. 2013;50(5):663–670. 

11. Osilla K, Van Busum K. Labor Force Reentry: Issues for Injured Service Members 

and Veterans. Santa Monica, CA: RAND National Defense Research Institute; 

2012.

12. Ruh D, Spicer P, Vaughan K. Helping Veterans with disabilities transition to 

employment. J Postsecond Educ Disabil. 2009;22(1):67–75.

13. Institute for Veterans and Military Families. The Business Case for Hiring a 

Veteran: Beyond the Clichés. Syracuse, NY: 2012.

14. Crane B, Scott C, Davis C. Veterans’ Benefits: The Vocational Rehabilitation and 

Employment Program (RL34627). Washington, DC: Congressional Research 

Service; 2008.

15. Frain MP, Malachy B, Bethel M. A roadmap for rehabilitation counseling to serve 

military Veterans with disabilities. J Rehabil. 2010;76(1):13–21.

16. Burnett-Zeigler I, Valenstein M, Ilgen M, Blow AJ, Gorman LA, Zivin K. Civilian 

employment among recently returning Afghanistan and Iraq National Guard 
Education and Employment H 319

Veterans. Mil Med. 2011;176(6):639–646.

17. Cooper RA, Pasquina P, Drach R, eds. Warrior Transition Leader: Medical 

Rehabilitation Handbook. Washington, DC: Borden Institute; 2011.

18. Cook BJ, Kim Y. From Soldier to Student: Easing the Transition of Service 

Members on Campus. Washington, DC: American Council on Education; 2009.

19. Redden E. Campus as vet-friendly zones. http://www.insidehighered.com/

news/2009/06/05/veterans. Accessed February 2, 2015.

20. Baker S. 8 Keys to Success: Supporting Veterans, military and military families on 

campus. http://www.whitehouse.gov/blog/2013/08/13/8-keys-success-supportingveterans-military-and-military-families-campus. Accessed February 2, 2015. 

21. Department of Labor. Occupational Outlook Handbook. http://www.bls.gov/

ooh/. Accessed February 2, 2015. 

22. Kognito Web Site. Creating a supportive campus for student veterans. http://

www.kognito.com/products/voc/. Accessed February 2, 2015. 

23. Nesbit R, Reingold DA. Soldiers to citizens: the link between military service and 

volunteering. Public Admin Rev. 2011;Jan/Feb:67–76.

24. Matthieu MM, Smith ID, McBride AM, Morrow-Howell N. The Mission Continues: Engaging Post-9/11. Disabled Military Veterans in Civic Service (Research 

Brief). St. Louis, MO: Center for Social Development, the George Warren Brown 

School of Social Work, Washington University; 2011: 1–3. CSD Publication no. 

11–25. 

25. Knowles MS. The Modern Practice of Adult Education, Revised and Updated.

Chicago, IL: Follett; 1980.

26. Lewis PH, Lewis AN, Williams FD. Cultural competency in public administration programs. In: Norman-Major KA, Gooden ST, eds. Cultural Competency 

for Public Administrators. New York, NY: M. E. Sharpe; 2012: 244–264.

27. Faulkner ML, Nierenberg A, Abrams M. Networking for Veterans: A Guidebook 

for a Successful Military Transition into the Civilian Workforce. Boston, MA: 

Pearson Learning Solutions; 2013.

Bi b l i o g r a p h y

Lincoln A. Second Inaugural Address, March 4, 1865. Washington, DC: The 

Abraham Lincoln Papers at the Library of Congress, 1837–1897.
320 H Promoting Successful Integration

Ser gea n t D. J o s h u a

Ma r i n o enlisted in the US 

Army in May 2001 and attended 

Advanced Individual Training 

at Fort Gordon, Georgia, for 

the Military Occupational 

Specialty of 25S (31S), Satellite 

Communications Systems 

Operator/Maintainer. Marino 

quickly advanced to the position 

of Team Chief at his first duty 

station in the Republic of Korea. 

After 3 years, he successfully 

transferred his skill set to Fort 

Riley, Kansas, where he was 

instrumental in standing up the 4th Brigade Combat Team of the 1st Infantry 

Division. During his deployment to Iraq in 2007–2008, Sergeant Marino 

was wounded by several mortar blasts in an indirect fire attack, sustaining 

a traumatic brain injury and multiple concussions. Upon return to garrison, 

Sergeant Marino continued to train soldiers despite his condition. However, 

as he worsened, it was determined by a medical evaluation board that he was 

no longer fit for duty. Thus, he was separated from the Army in 2009.
Education and Employment H 321

Josh moved back to his 

hometown of Pittsburgh, 

Pennsylvania, and started 

classes at the University 

of Pittsburgh using the 

Chapter 33 Post-9/11 

GI Bill. Throughout the 

following semesters, 

Josh utilized the many 

community supports 

and accommodations 

made available to him 

to effectively transition 

into a career that suited 

his talents. A dedicated 

team of professionals 

within the VA Pittsburgh 

Healthcare System 

offered treatment for 

physical maladies, 

as well as counseling 

to advance his social 

and professional 

reintegration. In working 

with the Vocational 

Rehabilitation 

Department, Josh was guided through the process of furthering his education 

and career. Working to better the quality of life of other Veterans was always 

his primary goal, with the belief that healing the wounded required not only 

intellectual know-how, but also a strong sense of empathy that only another 

Veteran could provide.

After 3 years, he graduated with a BS degree in Social Sciences. He was 

selected to participate in the Experiential Learning for Veterans in Assistive 

Technology and Engineering (ELeVATE) program at the Human Engineering 

Research Laboratories (HERL). Alongside other Veterans in an environment 

that championed the camaraderie present between former and current 
322 H Promoting Successful Integration

members of the Armed Forces, Josh 

was able to experience the inner 

workings of research studies in 

assistive technology and rehabilitation, 

coordinate on a professional article 

and symposium presentation,

and participate in professional 

development sessions designed to 

advance his career and reintegration. 

He excelled in the program—which 

solidified his intent to pursue graduate school for certification as a 

Rehabilitation Counselor—with the goal of providing care and understanding 

to other Veterans when they need it most. 

Josh regularly volunteers with Three Rivers Adaptive Sports (TRAS) and 

numerous annual marathons within the Pittsburgh area. He is currently 

acting as a peer mentor for program participants at HERL. His most ardent 

supporters throughout have been his mother, father, and extended family, but 

especially his wife of 5 years, Dr Rebecca Marino.
It is a moral obligation to our Soldiers and their

 families that they have a place to heal and transition back 

to the force and/or transition out.

H H H

Brigadier General Darryl Williams

Commander, US Army Warrior Transition Command

July 11, 2012

C h a p ter T h i rtee n

Accessible Homes, Communities,

and Transportation

CAROL PEREDO LOPEZ, AIA*; LAVINIA FICI PASQUINA, MS†; 

AMANDA McALPINE, NCIDQ, LEED AP‡; PATRICK RAKSZAWASKI, 

RA§; STEVE BUCHA, AET¥; and PAUL F. PASQUINA, MD¶

*

Accessibility Design Review Manager, Washington Metropolitan Area Transit Authority, 600 5th Street, NW, Washington, DC 20001

†

Associate Professor of Architecture and Director of Digital Media, The Catholic 

University of America, 620 Michigan Ave, NE, Washington, DC 20064

‡

Interior Designer, AE Works Ltd., 6587 Hamilton Avenue, Pittsburgh, Pennsylvania 

15206

§

Project Architect, AE Works Ltd., 6587 Hamilton Avenue, Pittsburgh, Pennsylvania 

15206

¥

Architectural Designer, AE Works Ltd., 6587 Hamilton Avenue, Pittsburgh, Pennsylvania 15206

¶

Colonel (Retired), Medical Corps, US Army; Chief, Department of Orthopaedics and 

Rehabilitation, Walter Reed National Military Medical Center, 4494 North Palmer 

Road, Bethesda, Maryland 20889
326 H Promoting Successful Integration

INTRODUCTION

One of the most important goals in achieving successful reintegration after combat-related wounds, injuries, or illnesses may be returning home. Unfortunately, for many injured Service Members 

and families, their homes were defined by their duty station. For those who 

medically separate (ETS or Expiration of Term of Service) or retire from 

the military, one of the first steps to successful return to the community is 

to decide where to reside. Selecting the right location and community may 

be challenging and is often influenced by multiple factors, such as 

• Where have you previously lived that you enjoyed the most?

• Where do you have the most access to healthy relationships (including 

family and friends)?

• What vocational opportunities exist in that community?

• What are the options for current or future children in terms of public and 

private schools?

• What are the local laws regarding state and local income and property 

taxes for military and disabled Veterans? 

The answers to these questions require significant thought; research online 

or with counselors; and conversations with friends, family, and trusted colleagues who have already successfully made this transition. Although there 

are significant stresses associated with these decisions, one must recognize 

that moving is always an option. Because military Service Members are often 

accustomed to moving, they should not be fearful of this in the future. They 

should recognize that many families even in the civilian sector frequently 

relocate based on many of the same factors. To keep relocation as an option 

in the future, however, sound financial decisions are critical. Committing to a 

high mortgage rate before first testing a community may put individuals and 

families at significant financial risk; therefore, one may consider renting prior 

to committing to purchasing a house.

In addition to previous considerations, those individuals with physical, 

emotional, and psychological injuries after military service must also carefully assess issues surrounding accessibility, transportation, and independence. 

This is especially true for individuals with physical or cognitive impairments 

related to injuries such as amputation, traumatic brain injury, vision or 

hearing impairment, and paralysis. In addition, those Service Members with 

significant extremity trauma are at a higher risk of developing issues such as 

posttraumatic arthritis, overuse injuries, or increased cardiovascular disease 
Access ible Homes , Communities , and Transportation H 327

with aging. Despite these challenges, it is important to remember that even 

with their physical, cognitive, or psychological impairments, their ultimate 

disability is often more reflective of the context of their living environment 

rather than their ability to walk, see, or hear. Today’s advances in adaptive techniques and assistive technology can frequently support substantial 

independent living even when severe impairments exist, and can substantially 

decrease disability when these technologies are properly incorporated into the 

individual’s living environment. Furthermore, smart home technologies have 

universal appeal to individuals with and without disabilities, thus making 

these homes more accessible and affordable as technology advances.1–3 This 

chapter provides an in-depth discussion of home, community, and transportation considerations for those with physical, cognitive, and psychological 

impairments.

ACCESSIBLE HOMES

At the top of the list when selecting a home are usually issues such as 

• location, 

• number of bedrooms, 

• closet and living spaces, 

• bathrooms and kitchens, and

• outdoor settings. 

However, when accessibility becomes a priority, there are many additional 

elements that need to be considered. Residential architects report in the 

2014 AIA (American Institute of Architects) Home Design Trends Survey 

that one of the most significant trends in home layouts is improving accessibility. Street-level entries, ramps, broader halls, and open floor plans are all 

increasing in demand.4 Wider hallways and fewer steps have been reported as 

increasing in popularity by almost two-thirds of respondents, whereas 55% 

of respondents report that increased accessibility into and out of the home 

by using ramps and on-grade entrances is also becoming more popular. With 

open layouts and improved accessibility trending, accessible housing options 

are becoming increasingly available.

Selec t i n g a Ho me

When looking for a home, there are many points to consider and many questions to ask. Although new home design is now trending toward more open, 
328 H Promoting Successful Integration

flexible spaces, there are also many older homes on the market with great 

features that can provide the required accessibility. To help you find your new 

home, the following sections detail important features to look for in a community, outside the home, with the interior home design and floor layouts, 

various building systems, and more.

Community

Community is a very important consideration when selecting a home. Nearby 

services and amenities, as well as landscaping and lighting, all contribute to 

creating a feeling of home and belonging while increasing convenience. When 

considering the neighborhood where a home is located, take time to explore 

and understand how the location fits into your lifestyle. 

The following questions help to identify important key features when 

examining prospective neighborhoods:

• What services, activities, and amenities are nearby?

Close proximity to a grocery store, pharmacy, post office, hardware 

store, bank, healthcare, and other services can minimize traveling distance, thus quickly increasing convenience. In urban areas, these services 

may be able to be accessed without use of a vehicle. 

• Is it easy to travel on the surrounding streets and sidewalks?

Although most communities have gone through substantial transformation since the Americans with Disabilities Act (ADA)5

 was enacted, the 

level of accessibility required will vary depending on individual needs. 

When looking to relocate, it is important to consider specific items. For 

example, paths should be examined for level sidewalks, manageable 

curbs, and functional ramps, as well as lighting on streets. 

• What is the feel of the neighborhood? 

In addition to seeing what services and amenities are nearby, it is also a 

good idea to research and ask around about noise and traffic, as well as 

local/community activities. Is the area noisy at night? Are there regular 

neighborhood gatherings? Is the community active in supporting social 

and environmental interests and groups?

Outside the Home

Beyond the community, there are important features outside the home to take 

a closer look at, such as parking and how many steps it takes to get to the 

front door. These elements might not seem as important as what is inside the 

home, but these features can greatly impact day-to-day activities. Availability 

of a yard, deck, patio, or front porch can also provide more livable space to 
Access ible Homes , Communities , and Transportation H 329

host barbecues and other gatherings. Not only is accessibility becoming more 

attractive to homebuyers, so is their access to outdoor space.6

The following questions can help to identify important key outdoor 

features: 

• What type of parking is available?

If you have a vehicle, it is important to examine any driveways, carports, 

or garages for level surfaces and availability/maneuverability of space. If 

there is no on-site parking option, look for nearby street parking while 

considering the volume of traffic and other events that take place in the 

area that could impact availability.

• How do I get into the house?

Sidewalks, steps, paths, and lighting are main outdoor landscape elements that should be carefully considered. The number of steps, levelness 

of paths, and amount of lighting can assist in supporting safe and secure 

home access.

• Does the outdoor space require a lot of maintenance?

Decks, green space, flowers, and trees can help create a personal outdoor 

oasis, and are also an extension of your home and livable space. Maintenance of these outdoor spaces is important, including the need for lawn 

services, snow removal, or leaf removal.

These issues are explored in greater depth in the section on Outdoor Spaces.

Interior Home Design and Floor Layout

Inside the home, carefully consider how individual rooms are accessed. Doors 

and stairs are interior elements to inspect carefully. Specifically, the number 

of stairs, positioning of handrails, stair treads, adequate lighting, and door 

handles and locks that impact home mobility and privacy. 

Visibility and Comfort

Visibility and comfort are important considerations in creating both a welcoming and accessible home environment. Home systems include windows, air 

conditioning, heating, plumbing, and electrical work. If building a new home, 

custom systems can be easily included during construction. If buying an existing home, some compromises may be needed. However, it is fairly simple to 

incorporate certain elements to help with visibility and enhance comfort. 

The following questions can help to identify important key features in 

home systems: 
330 H Promoting Successful Integration

• Visibility and Power: Are outlets, switches, and lights easily accessible?

The positioning of outlets and light switches is important because the 

height and location can greatly impact use. Motion sensors and lamps 

can also enhance the ease of operating and providing ambiance while 

adding character to living spaces. To support numerous electrical 

devices—including security and automation systems, multiple computers, and peripheral electronics (as well as charging stations for motorized 

wheelchairs or electric prostheses)—proper grounding and outlet locations are necessary.

• Windows and Blinds: How do they open?

The type of window, casement or double hung, impacts reach and level 

of effort to open and close it. Although casement windows can often be 

opened while seated, double hung windows require a higher reach. Similarly, longer cords and rods make blinds and window coverings easier to 

use, especially from a wheelchair or short prostheses.

• Air Conditioning/Heating: How is the temperature of the home 

controlled? 

There are a variety of air conditioning/heating systems used in homes. 

Forced air, radiators, and electric are the most common types. These 

different systems not only vary in how they adjust temperatures, but also 

range in utility costs. If you are thinking of buying an existing home, consider asking for information on past utility usage and costs. Temperature 

regulation can be particularly challenging for individuals with conditions 

such as brain injury, spinal cord injury, and multiple sclerosis; therefore, 

independent room cooling or heating systems may be necessary, depending on how many individuals will be occupying the home. Newer technologies, available now through companies like Nest Labs (Palo Alto, 

CA), provide “learning thermostats” that can be programmed to meet an 

individual user’s needs.7

• Plumbing: How is water temperature adjusted?

Typical homes use a storage tank hot water heater. If large amounts of 

hot water are used at once, it will take time to replenish the hot water 

supply just as it may take time for warm water to reach the faucet when 

it is initially turned on. In contrast, instantaneous water heaters (or tankless water heaters) heat the water directly at the fixture, but are typically 

less energy efficient. It is especially important to check that plumbing has 

insulation, particularly at sinks where the hot water supply is exposed.8

Home Layout: Kitchen, Bathroom, and Bedroom 

Normally, the kitchen, bathroom, and bedroom are the most used rooms. 

Looking for key features and asking a few important questions can help you 
Access ible Homes , Communities , and Transportation H 331

better understand what is best for your personal needs, as well as enhance 

your living environment substantially.

The following questions can help to examine important key features in 

these rooms:

• Navigating the Kitchen: Are key appliances and cabinets positioned for 

easy access? 

There are many different types of kitchen layouts that offer a range 

of features to support easy access. It is important to consider how the 

kitchen is used currently, compared with the layout wanted. For instance, 

people who cook a lot should examine whether the kitchen has enough 

counter space. Are key appliances (eg, microwaves, sinks, ovens, etc) 

easily reached? Do cabinets offer enough reachable storage?

• Bathroom: What fixtures and layout options enhance accessibility?

The location of toilets, showers, and tubs can impact accessibility, especially for those individuals with limited mobility. Mirrors and grab bars 

are key features to look for, but also items that can be added or adjusted 

to meet individual needs. Availability of open, clear floor space is also 

something important to take into account. When using the bathroom, is 

there enough space to move about?

• Bedrooms: What design features can make your bedroom not only more 

accessible, but also more comfortable?

To provide a relaxing, enjoyable space, some key features to consider in 

a bedroom include the following items that help make the use of lighting, 

power, and home systems more convenient: positioning of light switches 

near beds and nightstands, easily reachable storage/closet space, remote 

control operation of ceiling fans and other home systems, etc.

Miscellaneous Items for Consideration 

Small details can help everyone get around the house more easily and make 

day-to-day activities simpler. The following questions address a few additional items to consider when buying a home:

• Does the flooring support safe travel throughout the house? 

Do the floors, carpets, or tiles impair wheelchair or prosthetic mobility? For individuals with frequent headaches, which light and noise may 

aggravate, are there accessible locations within the home that can be 

darkened and sound minimized? For individuals with cognitive problems, 

does an open floor layout support orientation and wayfinding, and also 

incorporate appropriate privacy?
332 H Promoting Successful Integration

• Where is the laundry room located?

If possible, laundry machines should be located on a main living level. 

Side-loading machines are more easily accessible for those individuals 

in wheelchairs. 

• Is there adequate security?

Doorbells, door latches, peepholes, and security systems that monitor 

intrusion, fire, and carbon monoxide are important features that can be 

adjusted to support a safe, secure, and more accessible home. Many of 

the security devices that are now available can stream images directly to 

a tablet or smartphone. In addition, devices such as the Kwikset Kevo 

Smart Lock (Lakeforest, CA) allow individuals to control door locks with 

Bluetooth technology.9

Ide n t i f y i n g Eleme n ts o f t h e Ho me T h at Need

Im p r o veme n t Based o n S pec i f i c Needs

A common misperception is that “accessible design” only applies to individuals who are wheelchair users. In fact, many individuals benefit from modifications to their home environments to not only improve their independence, 

but also to improve overall quality of life, whether from a physical, sensory, 

cognitive, or psychological impairment.10,11

Hearing Impairment 

Simple design considerations can help those with hearing impairments. In a 

compartmentalized home with many different rooms, people tend to rely on 

speech to get the attention of others. This can be challenging in a situation 

where there are one or more people living in the home who are deaf.12 In 

comparison, in an open floor plan, people can more easily see one another, 

making communication easier. Also, incorporating lighting and bright colors 

can make signing appear more clear. When it comes to finishes, matte paint 

helps to reduce glare while supporting visual clarity.

Visual Impairment 

For those with visual impairments, contrasting floor textures and colors can 

help with wayfinding or room-to-room travel, alerting one to room transitions. In addition to texture and color, lighting can play a big role in helping 

to distinguish important areas and features in a home. For example, entrances 

and halls with bright, overhead lighting make it easier to find keys and open 

doors.12 Glow-in-the-dark tape is another option that can be placed along 

baseboards or stairwells to provide guidance in low levels of light. Along long 

corridors, a chair rail can be added for tactile guidance. This is a more subtle 

addition than a handrail.
Access ible Homes , Communities , and Transportation H 333

For those with limited mobility and/or eyesight impairments, existing 

outlets or light switches in hallways can be replaced with a combination night 

light/control that turns the light portion on when it is dark. Light switches for 

ceiling-mounted lighting fixtures and fans can be replaced with motion sensor 

switches that also have remote control or manual override controls. Doorbells, fire alarm systems, and carbon monoxide detectors with light-based 

alerts can also help enhance safety and awareness of surroundings.

For easy use, lamps should be plugged into outlets with switch control. 

Different light bulb and lamp color temperatures (warm vs cool light) are 

also available. Lamp color is measured by the Kelvin scale. Lamps within the 

3,000 to 3,500 K range (warm) produce a calm, welcoming, and relaxing 

atmosphere. Lamps with shades should also be used to prevent direct glare. 

Advanced technologies now allow options for controlling lighting with a 

smartphone. They also have options for programming different rooms with 

different lighting features to change automatically throughout the day, such 

as the Philips Hue Connected Bulbs (Philips Lighting, B.V., Amsterdam, The 

Netherlands).13 

Allergies, Breathing Difficulties, or Temperature Sensitivities

If allergies or temperature sensitivities exist, it is important to consider how 

the temperature of the home is controlled. As described previously, there are a 

variety of air conditioning/heating systems used in homes. Forced air, radiators, and electric are the most common. Forced air systems allow for faster 

adjustments in temperature. However, forced air may cause unwanted breezes 

or drafts and circulate dust in the home. In contrast, radiators provide slow 

and steady heat without moving air, but temperature adjustments usually 

take longer. Most homes have one thermostat for the entire structure. If more 

acute control is required, through-the-wall or window cooling units can be 

added, as well as space heaters. Ceiling fans can improve comfort by blowing 

downward during the summer to provide a cooling effect or blowing upward 

during the winter to draw room air up and force warm air down. This is 

especially effective for rooms with high ceilings.

Spinal Cord Injury Care

Individuals with a spinal cord injury or disorder will most likely require an 

assistive device for mobility, such as a manual or powered wheelchair. During 

the transition between inpatient rehabilitation and home discharge, most 

rehabilitation centers have a simulated home environment that allows the 

individual to engage in therapy directed at ensuring independence and safety 

at home. Therefore, the more the simulated environment can replicate the 

patient’s home, the better the rehabilitation team can prepare the individual. 
334 H Promoting Successful Integration

An example of a simulated environment is depicted in Figure 13-1. Important 

features of the space include

• a minimum diameter of approximately 51⁄2 feet in each space to provide 

enough clear space to move around, 

• grab bars where appropriate in the bathroom for ease of movement, 

• placement of the washer and dryer on the main living level, and 

• positioning of appliances close to one another to facilitate ease of use.14 

The following sections discuss improving wheelchair accessibility in the home. 

Further details are available in the VA Handbook for Design.

15 

Fi g u re 13-1. Simulated Living Transition Environment. 

MIN: minimum; A.F.F.: above finish floor
Access ible Homes , Communities , and Transportation H 335

Ma k i n g a Bat h r o o m

Ac cess i b le

A bathroom tends to be the 

most important room in a 

house, yet it also tends to be 

the smallest. Because of this 

issue, many people overlook 

just how much they use this 

room and focus on making 

do with something underwhelming. With the right attention to layout, positioning 

of doors, and the style of key 

features (eg, toilets, showers/

tubs, sinks, etc), a bathroom 

can become accessible, 

and be transformed into a 

personal spa. Ultimately, this 

room can not only enhance 

personal hygiene, but also provide comfort and relaxation. Touchless faucets, 

heated tile floors, and sliding pocket doors are just a few features that do not 

require a full bathroom renovation.

Small upgrades (eg, doors and layout, clear floor space, etc) can help 

make a bathroom not only accessible, but also more comfortable. All included heights and reach ranges listed below are based on ADA standards, but 

should be tailored to individual needs.

Doors

Access is the first important feature to consider. Doorways at least 32 to 

36 inches wide are recommended to make it easy to get in and out of the 

bathroom. At least 18 inches of clear space should be provided parallel to 

the doorway on the latch side of the door to help make it easier to access the 

bathroom. As shown in Figure 13-2,5 the door should swing out of the bathroom space to make sure it is easy to exit the room.

Layout, Clear Floor Space

To accommodate easy movement within the bathroom and access to key 

bathroom spaces, a 5-foot-diameter turning radius is recommended, as well 

as a clear floor space (see Figure 13-2). Enhancing easy turning also improves 

visibility within the space, which also can be enhanced by placement of adFi g u re 13-2. Example of Bathroom Layout. 
336 H Promoting Successful Integration

ditional mirrors. When adding or repositioning mirrors, pay attention to the 

height and position to best meet individual needs. Tilting mirrors can also 

provide better visibility. 

Toilets

The height and position of a toilet and nearby grab bars are very important 

in bathroom design and upgrades. ADA toilet seats are recommended to be 

between 17 and 19 inches above the floor. However, for people who have 

trouble sitting down, or getting up once seated, a thicker toilet seat can 

increase the height of the toilet. Horizontal and vertical grab bars can also be 

added near the toilet. Typical dimensions and positioning of these items are 

noted in Figure 13-3. However, depending on individual needs and preferences, these heights may require adjusting.

Clear space around the toilet ensures that appropriate space is available 

to move around in. A clear floor space of at least 60 inches perpendicular 

to the side wall and 59 inches perpendicular from the rear wall should be 

provided. The toilet should be located approximately 18 inches off of the 

adjacent wall. If a wall is not available, the toilet should be located 16 inches 

off the centerline of the floor with a centered mounted grab bar.5

Bathroom Sinks

Careful sink positioning is critical to allow ease of use. Wall-mounted shallow 

sinks allow more space under the basin, thus improving wheelchair access. 

If the sink is not in a vanity cabinet, all exposed piping must be insulated to 

Fi g u re 13-3. Positioning of Toilets and Grab Bar. 

A B

MAX: maximum; A: Toilet positioning; B: grab bar positioning
Access ible Homes , Communities , and Transportation H 337

prevent injury and scalding, if the user comes into contact with the piping. 

Counters can also be wall-mounted or have minimal structural supports 

under the counter to further allow wheelchair access. Lever faucets are also 

easier to operate than knobs. Suggested clearances and positioning are noted 

in Figure 13-4.5

Showers

There are many types of showers and different configurations to meet individual needs. Transfer-type and roll-in showers are usually the best options 

for accessible bathrooms. All shower floors should be of a nonslip material to 

help prevent slips and falls. Flexible hose and handheld showers are also easy 

upgrades to help with limited mobility.

Transfer-type showers are generally smaller, but at a minimum should be 

at least 36 inches wide x 36 inches deep (Figure 13-5).5 Adequate clear floor 

Fi g u re 13-4. Suggested Sink and Vanity Dimensions. 

MAX: maximum; MIN: minimum

A: Suggested sink dimensions (upper)

B: Suggested vanity dimensions

C: Suggested sink dimensions (lower)

A B

C
338 H Promoting Successful Integration

space should be provided outside of the shower to help with getting in and 

out and moving around the bathroom. In transfer-type showers, a fold-up 

shower seat is recommended for ease of use and comfort. The seat should be 

mounted 17 to 19 inches above the floor, but should be adjusted based on 

individual needs. The height and positioning of grab bars in showers are also 

especially important and should be adjusted to meet personal preference. A 

horizontal grab bar is best positioned across the control wall and side wall 

to a point of 18 inches from the control wall. An 18-inch vertical grab bar 

should also be provided 4 inches from the edge of the shower entrance and 

above the horizontal grab bar.

Roll-in type showers are best characterized by the lack of any threshold 

between the shower and the bathroom floor (Figure 13-6). Usually, these 

Fi g u re 13-5. Transfer-type Showers. 

MAX: maximum

A–C: Shower dimensions

A

B C
Access ible Homes , Communities , and Transportation H 339

showers are at least 60 inches wide x 36 inches deep. A 36-inch-wide minimum opening can be provided at one end of the compartment if an enclosed 

shower is desired. For added comfort and to support limited mobility, a foldup shower seat is an option. If a seat is provided, horizontal grab bars are 

only needed on the control and opposite side walls.

Bathtubs

With the right positioning and features, bathtubs are also an option in an 

accessible bathroom. Maximally, tubs should be 17 to 19 inches above the 

floor. Grab bars are especially important when using tubs. Key heights and 

positions of grab bars are described later, but should be adjusted based on 

personal needs and preference.

Horizontal grab bars should be installed along the side wall at 33 to 36 

inches above the finish floor. The end of the grab bar should be 12 inches 

maximum from the control wall and 15 inches from rear wall. Grab bars 

should be installed on the side wall 8 to 10 inches maximum above the rim 

of the bathtub. A 24-inch horizontal grab bar should be installed on the control wall at the front edge of the bathtub.

Vertical grab bars of 18 inches should be installed 4 inches from the front 

edge of the bathtub and 4 inches above the horizontal grab bar (Figure 13-7). 

Fi g u re 13-6. Roll-in Showers. 

MAX: maximum; TYP: typical

A: Roll-in shower floor plan; B: roll-in shower dimensions

A B
340 H Promoting Successful Integration

Ac cess i b le Ki t c h e n s

The kitchen’s central role in the home as a place to prepare meals, eat, gather, 

and entertain should be seriously considered in terms of increasing accessibility. When designing a new or renovating an existing kitchen, the first consideration should be the layout of space.

12,15 Several different types of kitchen 

layouts can include the following: 

• U-shaped kitchen: With more counter space than a traditional kitchen layout, this kitchen is more convenient for several people (Figure 13-8A).8,12

• L-shaped kitchen: This type of kitchen provides several work surfaces for 

people to work with enough space around them. This is the most ideal 

layout, but, often, the amount of square footage required for this layout is 

less readily available (see Figure 13-8B).8,12

• Galley-style kitchen: This layout can fit into a smaller space. Although 

it provides more entry and exit points to the space, its use is often limiting for individuals using wheelchairs who will have less turning space 

and typically only a side approach to counters and appliances (see 

Figure 13-8C).8,12

Once the optimal layout has been determined, consideration should be 

then given to countertop, cabinet, and appliance choices; layout; and 

configuration. Leaving empty space under countertops around the sink or 

cooking area is valuable for wheelchair accessibility. 

Fi g u re 13-7. Bathtubs and Grab Bars. 

MAX: maximum; A: Bathtub dimensions (top); B: bathtub dimensions (side)

A B
Access ible Homes , Communities , and Transportation H 341

Fi g u re 13-8. Accessible Kitchens. 

MIN: minimum

A: U-shaped kitchen

B: L-shaped kitchen

C: Galley-style kitchen

A

Appliances: Safety 

and ease of use should 

be the priority when 

thinking about kitchen 

layout and the appliances that are placed in 

it. Appliances that offer 

both visual and sound 

alerts, as well as glarefree and nonreflective 

controls, are recommended. In addition, 

appliances with automatic shut-off and other 

programmable features 

are generally more accessible to all household 

members.

In terms of a 

kitchen layout, the 

availability of natural 

light and views to the 

outdoors are primary 

considerations that can 

significantly improve 

the environment of 

the space. Window 

height should always

be considered. Outdoor 

views can dramatically 

enhance the ambiance in 

the kitchen and provide 

access to natural light, 

which can help boost 

someone’s mood, be a 

B

C
342 H Promoting Successful Integration

part of controlling depression, and just make a person feel better. In addition, 

lower countertops and sinks are easier for someone in a wheelchair or those 

with limited mobility to use. When choosing sinks, the depth needs to be 

considered for ease of reaching. A depth of no more than 5 inches should be 

considered, and there should be at least 2 to 3 inches of countertop in front of 

the sink to provide arm support.15 For easy use, controls for the sink should 

have paddle or lever faucets rather than knobs. Hands-free or touch-activated 

faucets are other options for many users.5 Finally, it would be ideal for the 

sink and dishwasher to be side by side for ease of use. Although this is a good 

starting point and rule of thumb, no two people are alike, so these reach 

ranges and heights may need to be adjusted for each individual.

Refrigerators: Cabinetry is now able to accommodate larger appliances, such as dishwashers and refrigerators. Many times, this design not 

only creates a seamless concept, but also creates more accessible appliances, 

specifically for wheelchair users. For example, side-by-side refrigerators with 

pull-out shelves create flexibility, and pull-out freezers provide more shelving 

that requires less reach. Microwaves may also be built into the casework at a 

lower height for ease of accessibility and reach range. 

Ovens and Stoves: As previously described, safety and ease of use should 

be the priority, especially when selecting ovens and stoves. Choosing a 

cooktop without open flame, such as an induction cooktop, would add the 

benefit of safety, as well as energy efficiency. Additional features to be aware 

of when choosing a safe oven or stove are automatic shut-off and cool touch 

features.15 Similar to reach ranges of sinks, placement of controls need the 

same consideration. The controls should be located along the front or side of 

the unit for both ease and safety. One does not need to reach across the hot 

surface to properly use the appliance.8 Finally, cooktops and ovens do not 

need to be a one-unit appliance. Purchasing and designing cooktops and ovens separately may work best for the space so the cooking surface has a clear 

area below it (similar to accessible sinks). Models also exist that are height 

adjustable and have buttons for up/down movement.16

Storage: Aside from how the storage is designed, ample storage is able to 

minimize the need for multiple shopping trips, making it easier on a person 

with limited mobility. Storage is able to be easily retrofitted into existing 

kitchens or into standard cabinets. Adjustable shelving, revolving trays, and 

pull-out/pull-down shelves are able to improve access to stored items. Deep 

shelves and high, wall-mounted cabinets should be avoided. The standard 

maximum depth of cabinets is considered to be 25 inches, but, based on personal preference, this may need to be adjusted. Toe spaces under the cabinets 

should be 9 inches high and 6 inches deep to support closer access points to 

cabinets and storage.5
Access ible Homes , Communities , and Transportation H 343

Assistive Technology: As introduced in Chapter 3 (The Promise of the 

Future: Assistive Technology, Transportation, and Emerging Technologies), the 

Cueing Kitchen2 and KitchenBot are the emerging assistive technologies that 

will bring additional assistance in the coming years. The Cueing Kitchen is an 

intelligent coaching system that can guide people with cognitive impairments 

through steps to prepare a meal independently. The KitchenBot is an integrated 

robotic kitchen manipulator designed to aid people with upper extremity impairments with common kitchen tasks, such as meal preparation and cleanup. 

Ha l lways , Sta i rs , a n d D o o rs

Inside the home, it is important to assess access to all rooms. An open floor 

plan minimizes hallways and narrow routes; however, this is not always 

possible in existing homes. An ideal hallway width is 4 feet, but many homes 

have much more narrow hallways.12 With access being a high priority, the 

minimum width should be 3 feet 8 inches. For dead-end passageways (without space to turn around at the end), an open space of approximately 5 feet in 

diameter should be created to allow enough turning radius to accommodate 

wheelchair use. In addition, flooring surfaces should be low-pile dense carpeting or nonslip wood or tile, with consistency between hallways and rooms. 

If there are stairs inside the home, it is best to install handrails on both 

side walls (if possible). Handrails should be sturdy and have no disruptions in 

continuity (ie, brackets should not interfere with the continuous grasping of 

the handrail). Stairs are typically 11 inches deep and have a vertical height of 

7 inches. Most codes dictate that risers, the vertical height between the steps, 

must be solid to prevent slips through the back of the steps. Proper lighting is 

also important in stairwells. A lower amount of light may be adequate if there 

is a high enough contrast between the edges of the tread and the risers. The 

goal is to make the edges of the steps visible, which enhances accurate placement of feet on the steps and hands on the railings.

Proper selection of doors also enhances access to the home, as well as 

to each room. Residential doors are usually 32 inches wide, but older homes 

may have more narrow openings. Optimally, doors should be at least 36 

inches wide to improve access. They should be mounted to open out when 

exiting small spaces, such as bathrooms. Although residential doors do not 

typically have automatic closers on them, many storm doors do. These should 

be adjusted to close slowly. Doors that swing in should have between 18 

to 24 inches of clear space on the side of the door with the handle to make 

it easier to exit the room.5,8 Switching hardware from knobs to levers can 

greatly enhance ease of grasp and use. 
344 H Promoting Successful Integration

Fl o o rs

Color and texture are important considerations for flooring. Flooring should 

be slip-resistant, but smooth to make it easier to walk on or maneuver a 

wheelchair across. Some examples of slip-resistant materials include low-pile 

carpet, hardwood, laminate, linoleum, rubber, matte and textured ceramics, and cork.12 By incorporating contrasting colors, walls, floors, and door 

thresholds are able to help with wayfinding, especially for individuals with 

vision impairment. They can be even more enhanced with textural contrast. 

Glare can be disturbing and intolerable for some individuals; therefore, lowmatte and low-gloss paint finishes are also recommended. For individuals 

with vision impairments, materials that enhance echoed sound (eg, hardwood, marble, ceramic, and laminate) can help augment awareness of the 

space and surroundings. In contrast, for those with hearing impairments, it is 

important to silence noise. Thus, using flooring such as carpet, cork, or rubber can best support their needs.12

Wa l ls

Smooth finishes are recommended to avoid abrasions if they are bumped into. 

As with flooring, the use of contrasting colors can help identify architectural 

components, such as the wall and floor, wall and ceiling, wall and door, door 

handles, wall switches, and wall outlets. Textural contrast is also helpful in 

identifying primary routes and functional areas. 

Bed r o o ms

In a home with multiple bedrooms, when choosing which bedroom would 

be best (in addition to size), consider the proximity to the bathroom or egress 

from the home in an event of an emergency. Also, consider window height 

and the views to the outdoors for enhanced ambiance.

A space of at least 13 feet x 14 feet is recommended for a bedroom.17

This amount of space allows for enough clear space even with standard 

furniture. Open space of about 5 feet on each side of the bed is recommended 

if possible.1 To increase convenience, important items such as clothing and 

storage for medical equipment should be positioned nearby for easy access. 

Bedroom furniture should be placed to allow easy, unobstructed pathways 

and reaches for drawers and handles. Legs on furniture have both an aesthetic 

and functional purpose; they make the room look bigger while also allowing 

a wheelchair user to approach more closely. Open shelving may also make 

storing and access to clothes easier.17
Access ible Homes , Communities , and Transportation H 345

In addition to furniture placement, the placement of electrical outlets 

and controls is just as important. The use of three-way switches, for example, 

gives the individual the freedom to operate lights and other features from 

both the entry area and by the bed area without excessive moving around.17

By considering placement of the outlets and controls, advanced technology 

can be incorporated with ease. For example, if a lift is needed, a ceilingmounted outlet will provide power without long extension cords or the need 

to hardwire the electrical system. Because safety is always the top priority, 

a switch next to the bed can be connected to a communication system that 

alerts of falls or other care needs.17

Ou t d o o r S pa ces

As described previously, there are important features outside of the home to 

consider, such as available parking and how many steps are needed to enter 

the home. These elements might not seem as important as the general interior 

of the home, but they may have a significant impact on day-to-day activities 

and quality of life. Ideally, yard and outdoor spaces should be extensions 

of the home, thus providing—if desired—more enjoyable living spaces with 

plants, comfortable seating, and recreation or cooking amenities. Accessibility 

to both interior and exterior spaces is fundamental to an accessible home. 

Parking

If there is a driveway, check for a level surface and make sure that there is 

plenty of width to get in and out of a vehicle. A carport or garage offers 

protection from the elements. If there is no on-site parking option, look for 

nearby street parking and consider the volume of traffic and other events that 

take place in the area that could impact availability.

Access to the Main Entry

Sidewalks, steps, paths, and lighting are main outdoor landscape elements 

that should be reviewed carefully. Ideally, the number of steps to the front 

door should be minimized, and either handrails or a ramp may need to be 

installed to improve home accessibility. Exterior wood stairs should have 

treads for additional slip resistance. Ample light at entrances, along with 

markings at any changes in level, helps support safe and secure home access. 

Any concrete pads or pathways leading to the home should be level. Typically, a 1⁄2-inch difference in height is the maximum a wheelchair can get over 

without assistance.5,8 Concrete should also be slightly sloped to allow rain to 

run off without puddling, which in wintertime would form ice. 
346 H Promoting Successful Integration

ACCESSIBLE COMMUNITIES AND TRANSPORTATION

When choosing a community to live in, proximity to work, family, healthcare, 

and friends is a major factor to consider. Careful analysis of specific elements 

can help determine whether the community meets a person’s accessibility 

needs. Ideally, a community should be universally accessible; many communities have gone through substantial transformation since the ADA was enacted 

in 1990. The level of accessibility within a community, however, may vary 

depending on the individual’s needs. Therefore, when looking to relocate or 

assess the accessibility of a community, it is helpful to consider the following 

questions:

• Is the community pedestrian-friendly? A “walkable” community is generally more accessible for those who use mobility aids (eg, wheelchairs 

or prosthetics), as well as for those who are blind or who have limited 

vision. A pedestrian-friendly community has sidewalks, curb cuts, clearly 

marked crosswalks, and pedestrian signals at busy intersections. Safe 

pedestrian connections to grocery stores, banks, post offices, parks, and 

playgrounds make a community more attractive to walking options, 

so that individuals rely less on vehicular transportation. Communities 

with transportation nodes (eg, bus stops or train stations) are inherently 

pedestrian-friendly and are also generally more accessible.

• Are recreation facilities accessible? Accessible fields can be used and 

enjoyed by all individuals with disabilities. Paths without steps or steep 

slopes provide access to those who rely on wheeled devices and those 

who use prosthetic limbs. Clearly accessible signs in large fonts, raised 

lettering, and Braille—along with barrier-free paths—make facilities more 

accessible for individuals who are blind. Many community pools have 

lifts to improve access. Some pools have transfer areas where the ledge of 

the pool is raised 18 inches on the deck side of the pool to ease individual 

access from a wheelchair. In many community fitness centers, exercise 

equipment is relatively versatile and has features to allow use by individuals with a variety of disabilities. 

• Are community gardens accessible? Gardens are popular and can be 

established in community parks and sometimes on rooftops. Making 

an existing community garden accessible to a person who cannot bend 

down to reach the ground surface can be as simple as installing raised 

planters (ie, where the planter surface is 18 inches above the surrounding ground area). This can be accomplished by using prefabricated raised 
Access ible Homes , Communities , and Transportation H 347

containers or by building them on site. Accessible gardens can provide 

fresh produce, are therapeutic and calming, and can foster community 

involvement. 

• Are grocery stores accessible? Shopping for food is a routine. Locating an 

accessible grocery store or a store that delivers food should be considered. 

Since the ADA was passed 20 years ago, most grocery stores are accessible. Stores generally have wide aisles to support two-way traffic, which 

greatly enhances wheelchair mobility. However, shelving height may 

still be a problem for people of short stature or those individuals using a 

wheelchair. Store employees are generally available to help shoppers with 

disabilities and should be called on as needed. Online shopping is also 

widely available for most goods and services, and home delivery services 

greatly enhance access. Software programs, such as the JAWS (Job Access 

With Speech) screen reader, are very helpful for individuals who are blind. 

Ac cess i b le Pu b l i c Tr a n s p o rtat i o n

A community with nodes of public transportation can greatly enhance 

independence. Since the ADA became law, all public transportation systems 

are required to be accessible. Detailed information regarding the accessibility of the public transportation system is generally available within the local 

transportation authority’s website. For example, the Washington Metropolitan Area Transit Authority (www.wmata.com) has an accessibility tab on its 

website that leads to information about all services—including fixed rail, bus 

services, and the Paratransit Service (called “MetroAccess”)—that provide 

door-to-door aid for qualified individuals. Individuals must reserve rides at 

least 24 hours before their desired pick-up time. To qualify for this service, 

customers must present an application signed by a physician certifying that 

they are not able to use bus and rail services independently. Individuals who 

qualify are eligible for a MetroAccess Identification Card. Some customers 

can use fixed-route buses and trains; however, for some trips, they need to 

supplement their transportation needs with door-to-door service. Reduced 

fare rates are also generally available for daily users.

City subway/public transportation systems should be fully accessible. 

Stations should have elevator entrances, accessible fare vending machines, and 

fare gates. Train platforms should be equipped with safety features—including detectable warning tiles, lighting and audio, and visual information—for 

those with hearing or vision impairments. Public buses should be able to 

lower the floor or deploy a ramp to ease access. Many public transportation 

systems offer free travel training for customers who need orientation on the 
348 H Promoting Successful Integration

system. Travel trainers provide customers with disabilities-specific information on how they can best use the bus and rail systems. Real-time subway, 

train, or bus information should also be available online and accessible from 

a smartphone or tablet. These should also be compatible with a screen reader. 

Applications such as NextBus may also be helpful to customers using public 

transportation. This GPS (Global Positioning System)-enabled application 

for mobile devices recognizes the location of the nearest stop and informs the 

user when the bus will arrive. 

Ta x i Serv i ces

Generally, a standard taxi is accessible to people who are blind, deaf, or have 

cognitive disabilities. Taxi services must provide rides to customers with service 

animals without adding an additional fee. Unfortunately, there may not be a 

wide choice of taxi services for people who use wheelchairs or scooters, because the ADA does not require taxi services to purchase or lease wheelchairaccessible automobiles. However, because of public pressure, there has been 

an increase of wheelchair-accessible taxis in large metropolitan areas. For taxis 

that are accessible, no additional fare should be added for the services.

Dr i v i n g, Bu y i n g, o r Ad a p t i n g a Ca r

Technological advances have given people with disabilities greater opportunities for driving independently using adaptive equipment. Depending on the 

use of adaptive devices, however, certain restrictions may be placed on the 

license. Although an individual cannot be denied the opportunity to apply 

for a license due to a disability, there are safety reasons why some drivers 

have been denied the opportunity to drive a car or have restrictions placed on 

their license. For example, a person could be denied a license to drive a car 

with a manual transmission if that person needs to use manual controls for 

depressing a clutch, braking, and acceleration because it may not be possible 

to have one hand on the wheel at all times. Before investing in a modification 

for a vehicle, careful research about the possibility to sustain a driver’s license 

should be considered.

Information pertaining to adaptation of motor vehicles for individuals with disabilities can be found at the National Resource Directory.18 In 

addition, the Department of Veterans Affairs (VA) offers a one-time grant of 

a maximum of $20,114.34 toward the purchase of an accessible automobile. The VA will also pay for adaptive equipment for a vehicle, as well as its 

maintenance and replacement multiple times during the Veteran’s or Service 

Member’s life. To be eligible for these grants, the Service Member or Veteran 

must have one of the following disabilities: 
Access ible Homes , Communities , and Transportation H 349

• loss or permanent loss of use of one or both feet,

• loss or permanent loss of use of one or both hands, or 

• severe burn injury. 

More information regarding eligibility for a VA vehicle grant or for application forms19 may be found at http://benefits.va.gov/BENEFITS/factsheets/

serviceconnected/Auto.pdf. Additional information on applying for a VA 

grant can be obtained at http://www.vba.va.gov/pubs/forms/VBA-21-4502-

ARE.pdf. 

SUMMARY

Injuries or illnesses, particularly those affecting Wounded Warriors and 

Veterans, may cause significant physical, cognitive, and emotional impairments. The resulting disability from these impairments, however, is largely 

influenced by one’s environment. Modern technologies now support numerous adaptive solutions to enhance functional independence for individuals 

who have a variety of severe impairments. Numerous resources are currently 

available at the local, state, and federal levels to help support individuals with 

disabilities. Tailoring one’s home and community to be more accessible helps 

socialization and promotes successful family and community participation, 

which is fundamental to long-term health and quality of life. Success begins 

with being aware of one’s deficits and working with dedicated professionals 

to implement solutions, whether that be building a new home, modifying an 

existing home, relocating to another community, or just being familiar with 

and accessing resources that already exist within the community. 

No te

The information presented in this chapter is based on the current knowledge of the authors and is provided for general information purposes only. Because individual needs 

vary, we advise readers to consult appropriate professional resources to decide what is 

safe and appropriate for their specific needs. Any action taken based on the information presented in this chapter is the responsibility of the user.
350 H Promoting Successful Integration

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com/c-p/046677426354/hue-personal-wireless-lighting. Accessed November 6, 

2015.

14. Department of Veterans Affairs, Office of Construction & Facilities Management. Design Guide—June 2008: Spinal Cord Injury/ Disorders Center. US 

Department of Veterans Affairs website. http://www.cfm.va.gov/til/dGuide/

dgSCIDC01.pdf. Accessed December 24, 2015.

15. Veterans Benefits Administration. VA Handbook for Design: Specially Adapted 

Housing for Wheelchair Users. Washington, DC: VBA; August 2009. Pamphlet 

26-13. 
Access ible Homes , Communities , and Transportation H 351

16. Freedom Lift Systems. Cabinet and Shelving Lifts. Freedom Lift Systems website. https://freedomliftsystems.com/Adjustable-Height-Counter-Lifts. Accessed 

November 7, 2015.

17. Schwab C. Around the House: Bedroom Addition Provides In-Home Healing. October 2011. http://www.aia.org/aiaucmp/groups/aia/documents/pdf/

aiab103880.pdf. Accessed November 20, 2015.

18. National Resource Directory. NRD website. https://m.nrd.gov/transportation_

and_travel/vehicle_modifications_and_adaptive_equipment. Accessed December 

14, 2015.

19. US Department of Veterans Affairs. VA Benefits Fact Sheets. VA website. 

htttp://benefits.va.gov/BENEFITS/factsheets/serviceconnected/Auto.pdf. 

Accessed November 14, 2015.
352 H Promoting Successful Integration

Gu n n ery Ser gea n t

Ja mes M. J o sep h was born 

in Pittsburgh, Pennsylvania on 

May 7, 1961. He enlisted in the 

Marine Corps on May 8, 1979 

and attended boot camp at the 

Marine Corps Recruit Depot in 

San Diego, California. From 1979 

to 1983, he served in the Marine 

Corps Infantry as a Mortarman. 

Subsequently, Joseph completed 

schooling for a lateral move, thus 

becoming a Small Missile Systems 

Electro-Optical Repairman. In 

December 1990, he was ordered 

to Direct Support Group 2, 1st FSSG (Force Service Support Group) Saudi 

Arabia, where he was assigned as the Electro-Optical Repair Chief and served 

as a Breach Guide during Operation Desert Storm. 

During the fall of 1994, Joseph was diagnosed with diabetes mellitus. This 

information was kept confidential and only the Commanding Officers/

First Sergeants of his subsequent units were advised of his health problem. 

In February 1996, he returned to Okinawa, Japan, for the third time and 

served as the Fire Control Repair Chief of Ordnance Maintenance Company, 

Maintenance Battalion, 3rd FSSG. In August 1999, Joseph was assigned to 

the Marine Corps Detachment at Aberdeen Proving Ground. He served as an 

Electro-Optical Instructor and as the Senior Marine Instructor. 

 

After becoming insulin-dependent, Gunnery Sergeant Joseph retired 

from the Active Marine Corps Forces in 2001. Following retirement, he 

worked as a Machine Technician for the Dialysis Clinic, Inc (Pittsburgh, 

Pennsylvania). The challenges of working constant shift schedules led 

Joseph to the Vocational, Rehabilitation, and Education counselors at the 

Department of Veterans Affairs (VA). Upon qualifying for the Chapter 31 

Vocational and Rehabilitation Program, he attended Point Park University 

and earned a BS degree in Information Technology.
Access ible Homes , Communities , and Transportation H 353

While attending school full time, Joseph was also employed as an 

Administrative Clerk/Information Technology Specialist at the Human 

Engineering Research Laboratories, Department of Veterans Affairs. After 

completing the internal VA job application process, he changed career 

paths and became an Information Security Officer for the Veterans Benefits 

Administration in Pittsburgh. Eventually, he became the Facility Chief 

Information Officer at the Office of Information and Technology for the 

same organization. As increasing job responsibilities and 24/7/365 on-call 

status proved to be incompatible with the time requirements needed to deal 

with taxing, daily diabetic routines, Joseph retired in December 2012.
354 H Promoting Successful Integration

Finding retirement unfulfilling, Joseph returned to the Human Engineering 

Research Laboratories and was enrolled in the Advancing Inclusive 

Manufacturing (AIM) Program. After graduating from AIM, he was 

encouraged by the program’s director to consider changing careers and 

return to school. 

James Joseph is currently a second-year graduate student at the School 

of Health and Rehabilitation Sciences at the University of Pittsburgh. He 

is pursuing an MS degree in Clinical Rehabilitation and Mental Health 

Counseling. He is also a member of the American Legion and the Disabled 

American Veterans.
The delivery of high-quality, accessible healthcare services

 as the foundation of a ready force—

and the life-saving care in the deployed environment is 

a force multiplier.

H H H

Honorable Jonathan Woodson, MD

Assistant Secretary of Defense Health Affairs

Director, TRICARE Management Activity

October 9, 2015

C h a p ter F o u rtee n

Overview of Military and 

Veteran Resources 

RORY A. COOPER, PhD*

*

Director and Senior Career Scientist, Human Engineering Research Laboratories, 

Rehabilitation Research and Development Service, US Department of Veterans 

Affairs, 6425 Penn Avenue, Pittsburgh, Pennsylvania 15206, and Distinguished 

Professor and FISA Foundation–Paralyzed Veterans of America Chair, Department 

of Rehabilitation Science and Technology, University of Pittsburgh, 6425 Penn 

Avenue, Suite 400, Pittsburgh, Pennsylvania 15206

INTRODUCTION

After over a decade of being at war, there has been growth in the 

number and size of government programs to assist wounded, injured, 

and ill Service Members, Veterans, and their families. In addition, 

there have been various government agencies and offices (Exhibit 14-1) that 

have attempted to meet their needs with varying degrees of success. Some 

programs have also been created that promise to have a profound effect on 

the Veteran population (eg, the Post-9/11 GI Bill). A significant challenge that 

remains is the difficulty in identifying the various programs, sorting through 

the eligibility requirements, and surmounting the application processes.

Physical and mental health are personal to each of us and require a 

proactive approach to maintain or improve well-being. This requires people 

to participate in regular physical activity, good nutrition, and quality sleep. 

Service Members are accustomed to having a mission and a unit that has 

an assigned purpose, goal, and specific objectives. Postmilitary life will be 

most successful if Veterans also set goals and develop long-range objectives. 
358 H Promoting Successful Integration

Ex h i b i t 14-1. Web Sites to Assist With Health, Reintegration, and Resilience 

National Resource Directory nrd.gov

Army Medicine armymedicine.mil

TRICARE tricare.mil

MyHealtheVet www.myhealth.va.gov

National Veterans Wheelchair Games wheelchairgames.org

National Disabled Veterans wintersportsclinic.org

Winter Sports Clinic

National Disabled Veterans va.gov/opa/speceven/ssc/

Summer Sports Clinic

Dietary Guidelines for Americans www.cnpp.usda.gov/dietary-guidelines

US Department of Agriculture Dietary choosemyplate.gov/tools-supertracker

Guidelines for Americans SuperTracker 

American College of Sports Medicine acsm.org/public-information/position-stands

Position Stands

Comprehensive Soldier and csf2.army.mil/

Family Fitness program

Navy and Marine Corps www.med.navy.mil/sites/nmcphc

Public Health Center

Vet Centers www.vetcenter.va.gov

Association of the United States Army ausa.org/family

Soldier For Life program soldierforlife.army.mil

Marine For Life program www.usmc-mccs.org/services/career/

marine-for-life-network

VA eBenefits www.ebenefits.va.gov

Veterans’ Employment and Training Service dol.gov/vets/programs

Hero2Hired h2h.jobs

Hiring Our Heroes uschamberfoundation.org/hiring-our-heroes

Small Business Administration— sba.gov/offices/headquarters/vbd/resources/4930

Resources for Veterans 

Office of Personnel Management— opm.gov/policy-data-oversight/veterans-services/

Veterans Services vet-guide

Web sites are listed in the order that they appear in the chapter. This exhibit and chapter provide 

resources found on the Internet. Due to the nature of online resources, these Web addresses 

are subject to change without notice. We suggest using a search engine to find any missing 

resources.
Overview of Military and Veteran Resources H 359

Military service ingrains in Veterans the need to pay attention to detail, to 

look for anything and everything that is wrong or out of place, and to correct 

it immediately. In the civilian world, this may not always be appreciated and 

may be viewed by colleagues as criticism.

The first stop for Service Members, Veterans, and their families who are 

seeking resources should be the National Resource Directory (nrd.gov). The 

National Resource Directory was established to be an authoritative source of 

information for wounded, injured, and ill Military and Veteran Service Members, their families, and the people who care for them. These individuals use a 

wide range of benefits and resources available to them from

• federal, state, and local governments; 

• not-for-profit organizations; and

• corporate America. 

A collaboration of the Department of Defense, the Department of Labor, 

and the Department of Veterans Affairs (VA), the National Resource Directory is found as a free online tool that provides access to more than 10,000 

resources at the national, state, and local levels. 

With the market penetration of smartphones, access to information is 

literally at the fingertips of users. Smartphone applications include an increasing number of health-related information programs. These applications can 

be helpful and have been used successfully to assist people in making positive changes in their lives. There are a growing number of devices that assist 

with maintaining health and fitness that communicate with or complement 

smartphones.

HEALTH-RELATED RESOURCES

There are a number of sponsored resources from the Department of Defense 

and the VA to help promote a healthy lifestyle. The US Army offers several 

programs. Information can be found at the Army Medicine Web site (army

medicine.mil). This site includes some participatory challenges for individuals, 

families, and friends. Army Medicine encourages soldiers and their families to 

• take 10,000 steps per day for at least 30 days,

• eat 8 servings of fruits and vegetables over 8 days, and

• sleep 8 hours per day for at least 8 days in sequence.
360 H Promoting Successful Integration

TRICARE (tricare.mil) offers information on health and wellness. This 

site provides information about the location of military treatment facilities and wellness centers. TRICARE provides information on what benefits 

are covered, contact information for doctors, cost estimates, steps to take 

when there are changes in life events, and health and wellness information. 

TRICARE also offers information on health and wellness, as well as on the 

following:

• alcohol awareness,

• tobacco cessation,

• preventative services,

• getting fit, and

• healthy partners.

The VA offers information and programs to help promote the health and 

well-being of Veterans. The primary online pathway for helping Veterans to 

manage their health is via MyHealtheVet (www.myhealth.va.gov). This online 

resource enables Veterans to manage their medical priorities through an online 

prescription refill service, personal health journal, and links to federal and VA 

benefits. In addition, the VA also provides various health support services to 

help Veterans maintain physical and mental wellness (Exhibit 14-2).

For Veterans with disabilities, the VA offers a number of national events 

to promote participation in healthy sports and recreation activities. Among 

these are the National Veterans Wheelchair Games (wheelchairgames.org), the 

National Disabled Veterans Winter Sports Clinic (wintersportsclinic.org), and 

the National Disabled Veterans Summer Sports Clinic (va.gov/opa/speceven/

ssc). 

The US Department of Agriculture and the US Department of Health 

and Human Services prepare and distribute Dietary Guidelines for Americans 

(www.cnpp.usda.gov/dietary-guidelines) every 5 years. These guidelines provide advice about consuming fewer calories, making informed food choices, 

and being physically active to attain and maintain a healthy weight, reduce 

the risk of chronic disease, and promote overall health. The US Department 

of Agriculture offers the “supertracker” (choosemyplate.gov/tools-super

tracker) to help people follow a healthy diet plan. The supertracker provides 

examples of daily food plans, suggestions on tracking calories, information on 

how to best allocate calories, and tips on how to interpret food labels. A very 

useful aspect of this tool is an explanation of empty calories and solid fats.
Overview of Military and Veteran Resources H 361

The American College of Sports Medicine (acsm.org/public-information/

position-stands) provides time and intensity recommendations for cardiorespiratory, resistance, neuromotor, and flexibility exercises.1

 Their guidelines offer 

guidance on improving and maintaining health, strength, endurance, flexibility, 

coordination, and agility. The American College of Sports Medicine recommends a minimum of 150 minutes of weekly exercise, which may be obtained 

by exercising longer on days when time is available or breaking workouts into 

several increments of 10 minutes or more throughout a day.

Ex h i b i t 14-2. MyHealtheVet

MyHealtheVet helps to maintain physical and mental wellness through the following:

• support for blind and low-vision Veterans and their families;

• support and services for those who care for Veterans;

• attention to the spiritual health needs of Veterans;

• short-stay and long-stay nursing home care for Veterans who are medically and mentally stable;

• a vocational rehabilitation program that endeavors to match and support work to ready 

Veterans for competitive jobs;

• advocating for health promotion, disease prevention, and health education for our Nation’s 

Veterans;

• geriatric and extended care services for Veterans, including noninstitutional and institutional 

options;

• a variety of resources, programs, and benefits offered by the VA to assist Veterans who are 

homeless;

• maintenance and improvement of the health and well-being of Veterans through excellence in 

healthcare, social services, education, and research;

• remaining a Center of Excellence for research and education on the prevention, understanding, 

and treatment of posttraumatic stress disorder;

• a source of prosthetic and orthotic services, sensory aids, medical equipment, and support 

services for Veterans;

• improvement of access to and quality of care for Veterans living in rural areas;

• resources and tools to help smokers quit;

• treatments addressing all types of problems related to substance use, from unhealthy use of 

alcohol to life-threatening addictions;

• the Veterans Crisis Line (dial 1-800-273-8255 and press 1), a toll-free, confidential resource that 

connects Veterans in crisis and their families and friends with qualified, caring VA responders;

• the MOVE! Weight Management Program, which helps Veterans to lose weight, keep it off, and 

improve their health; and

• implementation of positive changes in the provision of care for all female Veterans.
362 H Promoting Successful Integration

RESILIENCE-RELATED RESOURCES

Serving in the military may present challenges to the people serving and their 

families, especially during deployment or mobilization. Service in the Armed 

Forces requires working long hours in the face of difficult and sometimes lifethreatening issues that may place severe pressures on the people serving, as 

well as their families. Operational and wartime missions can have physiological and psychological effects on how Service Members, Military Civilians, 

and their families think, feel, and act. Therefore, the military provides tools 

and resources to help people become more resilient. 

The US Army offers the Comprehensive Soldier and Family Fitness 

program (csf2.army.mil) that is designed to build resilience and enhance the 

performance of Soldiers, their families, and Army civilians. This program also 

provides hands-on training and self-development tools to members of the 

Army to help them cope with adversity, perform better in stressful situations, 

and thrive in all aspects of life. It also offers an online self-assessment and 

self-development tool (known as ArmyFit) for Soldiers, family members, 

and Army civilians that includes videos, information, and links to people or 

organizations. Similarly, the Navy and Marine Corps provide both in-person 

and online services to members of the Armed Forces and their families 

through the Navy and Marine Corps Public Health Center (www.med.navy.

mil/sites/nmcphc). 

Service Members can become more resilient by working on several key 

factors: 

• incorporating role flexibility into their toolkit to encourage being able 

to function in multiple roles; 

• practicing active coping strategies;

• maintaining communication/contact with friends and family during 

deployment;

• setting realistic expectations; and 

• building strong, supportive, and healthy relationships.

REUNION AND REINTEGRATION RESOURCES

Reunion and reintegration after deployment are not always easy. A broad 

range of counseling, outreach, and referral services for Veterans and their families may be needed. Services may include individual and group counseling (eg, 
Overview of Military and Veteran Resources H 363

in areas such as posttraumatic stress disorder), alcohol and drug assessment, 

and suicide prevention referrals. Readjusting to a “new normal” is a transition involving some level of stress. After a deployment, and especially if there 

is also a prolonged hospitalization or recovery, everything at home will not 

be the same. People change with time, and members of the Armed Forces are 

affected by each deployment. Reintegration is a process of adjustment to a new 

normal that can last from days to years, depending on the circumstances. If a 

Service Member returns with a major disability, such as a limb amputation, 

adjustment and reintegration can be extensive. Deployment—especially when 

severe wounds, injury, or illness result—can strengthen or strain relationships. 

Patience and flexibility can improve chances for successful reintegration.

The VA provides Vet Centers (www.vetcenter.va.gov) to welcome home 

war Veterans by providing readjustment counseling in a caring manner. Vet 

Centers assist Veterans and their families with a successful postwar adjustment in or near the communities where they live. The Association of the 

United States Army (ausa.org/family) has produced a set of materials to help 

Service Members and families with successful reintegration and with building strong families. The Association provides a list of expectations to help 

promote successful reintegration (Exhibit 14-3).

Some people find it hard to talk about deployment activities. Everyone 

develops their own coping strategies. However, it may be helpful to talk with 

a trusted friend, family member, or healthcare professional. It is acceptable 

Ex h i b i t 14-3. Association of the United States Army

To promote successful reintegration, the Association of the United States Army provides the 

following list of expectations:

• expect to have mixed emotions about being home,

• expect to see changes in your partner,

• expect you and your family members to need reassurance as you readjust,

• expect the spouse/parent who remained home to want to help with family maintenance,

• expect your partner to remember the promises made while you were separated,

• expect your partner to need some romance and pampering,

• expect your partner to feel a mix of anger and resentment if she/he had a difficult time 

while you were gone,

• expect you and your partner to experience some physical and emotional fatigue after the 

initial reunion,

• expect adjustments to take from several weeks to several months, and

• expect to feel some sadness or depression.
364 H Promoting Successful Integration

and may be desirable to talk about deployment and disability experiences. 

Appropriate sharing with family and friends can be a powerful source of support and help with reintegration and readjustment. Sharing with other people 

may be a helpful coping strategy that is often recommended by physicians 

and psychologists.

Service Members, when undergoing reintegration, may demonstrate one 

or more of the following: low frustration tolerance, anger management issues, 

difficulties in coping and self-regulation, hypervigilance, social withdrawal, 

and higher risk for alcohol and other substance abuse. Service Members had a 

concrete purpose in their units, but they may lose this sense of purpose upon 

reentry into a civilian community.

The Army and Marine Corps have programs to help Soldiers and Marines with successful reintegration into civilian life, including the Soldier For 

Life (soldierforlife.army.mil) and the Marine For Life (www.usmc-mccs.org/

services/career/marine-for-life-network) programs. These programs provide 

links wherein Veterans can turn for information on 

• benefits, education, and career opportunities; 

• fitness and health;

• family services;

• mental health services;

• suicide prevention; 

• posttraumatic stress disorder; and 

• traumatic brain injury. 

These resources and connections can help Soldiers and Marines obtain the 

necessary training and qualifications and make the needed connections to be 

successful in their efforts to reintegrate into civilian life. Veterans embody the 

traits that employers seek—they have years of outstanding training and are 

disciplined leaders, loyal team members, and hard workers. The Soldiers For 

Life and Marines For Life programs provide Veterans with the tools to be 

successful members of their communities by using the resources and training from the Army or Marine Corps, while readily having access to the wide 

network of civilian entities that will support them.

BENEFIT RESOURCES

A challenge that many Veterans face, and that may ultimately cause them 

hardship, is not immediately accepting that they have earned the benefits 
Overview of Military and Veteran Resources H 365

offered to them by the military and the VA. It is often in the nature of Military Service Members and Veterans to be modest and self-sufficient. Veterans 

must accept that they have earned the benefits that they receive, and come 

to accept that there is nothing wrong with applying for and receiving them. 

Many of the procedures for securing Veterans benefits are complex and can 

be confusing, even for those who know them well. Many Veterans benefits 

have deadlines for applying. In some cases—including some kinds of insurance, education, and other important benefits—once the deadlines expire, 

there is no recourse. Do not try to apply for benefits on your own, especially 

those from the VA. There are Veterans service organizations that provide 

excellent assistance at no cost.

Military service is a hazardous profession, not only when serving in hostile regions that can impact your body and mind, but also during training and 

when exposed to the materials and substances with which Service Members 

come into contact with that can impact health, often long into the future. 

Therefore, it is important to enroll in the VA as soon as you are eligible. VA 

service connection is often the gateway to VA healthcare, even if only needed 

in the future. If the VA grants service connection, even at a 0% rating, the 

Veteran will have the condition recorded and may be eligible for increased 

compensation if the service-connected condition worsens over time.

The VA provides an online gateway to benefits information known as 

eBenefits (www.ebenefits.va.gov) that every Veteran should review, in addition to contacting a credentialed service officer at one of the national Veteran 

service organizations. The eBenefits Web site provides links and information 

to apply for benefits, to learn about and apply for the post-9/11 GI Bill, to 

extend TRICARE benefits, and to sign up for MyHealtheVet. VA benefits 

cover a broad range of domains that include 

• healthcare, 

• life insurance, 

• education, 

• employment, 

• self-employment, 

• compensation, 

• burial, and 

• assistance for qualified dependents. 

The VA offers a home loan guaranty program to help individuals obtain 

a home loan at favorable interest rates and terms, often with no or very little 

down payment. Some states also have a state-level Veteran-specific home loan 
366 H Promoting Successful Integration

program, including Alaska, California, Oregon, Texas, and Wisconsin. Many 

state housing agencies also offer home loan assistance and other housing 

programs that Veterans may qualify for, even though they are not Veteranspecific. Many of the VA benefit programs have deadlines or time limits; 

therefore, it is best to start early and exercise due diligence.

Most states and US territories provide benefits, programs, and services to 

Active Duty, Reserve, and National Guard Military Service Members; Veterans; and dependents. All 50 states—as well as Washington, DC, Puerto Rico, 

American Samoa, Guam, the Northern Mariana Islands, and the US Virgin 

Islands—have services for Veterans operating at the local level that offer a 

complex array of benefits, programs, and resources that may supplement or 

complement those provided by the federal government or that are specific to 

a certain state or territory. Reserve and National Guard members or Veterans 

who may not qualify for federal Veterans benefits may still qualify for state or 

territory programs.

EMPLOYMENT RESOURCES

Military experiences help to shape Veterans for a lifetime. Much of military 

life is about teamwork and unified efforts to achieve a common mission 

or objective. A high level of cooperation and selfless service often becomes 

ingrained in Veterans. It is important to understand that much of society is 

based on competition and not on cooperation. The level of competitiveness 

experienced in postmilitary life may feel unfamiliar or even oppressive. 

The Department of Defense, the VA, and the Department of Labor offer 

employment assistance programs for Veterans and employers who would like 

to hire them. The Department of Labor’s Veterans’ Employment and Training Service (dol.gov/vets/programs) offers employment and training services 

to eligible Veterans through a noncompetitive Jobs for Veterans State Grants 

program. In this program, funds are allocated to State Workforce Agencies 

in direct proportion to the number of Veterans seeking employment within 

their state. The Uniformed Services Employment and Reemployment Rights 

Act protects civilian job rights and benefits for Veterans and members of 

Reserve components. The Uniformed Services Employment and Reemployment Rights Act also provides enforcement mechanisms, and includes federal 

government employees and those employees eligible to receive Department 

of Labor assistance in processing claims. Under the Vietnam Era Veterans’ 

Readjustment Assistance Act of 1974, federal contractors and subcontractors must track and report annually to the Department of Labor the number 
Overview of Military and Veteran Resources H 367

of employees in their workforces who belong to the categories of Veterans 

covered under the affirmative action provisions of the Vietnam Era Veterans’ 

Readjustment Assistance Act.

Hero2Hired (H2H; h2h.jobs) is a Department of Defense program that 

provides Reserve Component Service Members with a tool to connect to and 

find jobs with military-friendly companies. H2H offers career exploration 

tools, military-to-civilian skills translations, education and training resources, 

and a mobile app. If Reserve Component Service Members are unsure about 

what they want to do, H2H offers a short skills and interests survey to help 

determine career types that may fit the Service Member’s background.

The US Chamber of Commerce offers a Hiring Our Heroes (HOH; 

uschamberfoundation.org/hiring-our-heroes) program. HOH is a nationwide initiative to help Veterans, transitioning Service Members, and military 

spouses find employment opportunities. HOH works through the network 

of state and local chambers and strategic partners from the public, private, 

and nonprofit sectors. HOH deploys two overriding strategies: (1) grassroots 

engagement and (2) public–private partnerships.

The Small Business Administration–Resources for Veterans (sba.gov/ 

offices/headquarters/vbd/resources/4930) offers a number of opportunities 

for Veterans. The Small Business Administration has 16 resource centers 

around the country that provide services (exclusively for Veterans), such as 

mentoring, training, business preparation, and more. Veterans may qualify for 

government contracting to grow a small business. Service-Disabled VeteranOwned Small Businesses may be able to become a part of the Service-Disabled Veteran-Owned Small Business Concern program. This procurement 

program provides that federal contracting officers may restrict competition 

to the Service-Disabled Veteran-Owned Small Business Concern and award a 

sole-source or set aside a contract wherein specific criteria are met. 

The Office of Personnel Management–Veterans Services (opm.gov/policydata-oversight/veterans-services/vet-guide) handles programs that provide 

some degree of preference for qualified Veterans in appointments to federal 

jobs. The US Congress has enacted laws to prevent Veterans seeking federal 

employment from being penalized for their time in military service. Veterans’ 

preference recognizes the economic loss suffered by citizens who have served 

their country in the Armed Forces, restores Veterans to a favorable competitive position for government employment, and acknowledges the larger 

obligation owed to disabled Veterans. 

Veterans’ preference is codified in various provisions of Title 5, United 

States Code. Veterans who are disabled or who served on active duty in the 
368 H Promoting Successful Integration

Armed Forces during certain specified time periods or in military campaigns 

are entitled to preference in hiring and also in retention during reductions in 

force. In addition to receiving preference in competitive appointments, Veterans may be considered for special noncompetitive appointments for which 

only they are eligible.

SUMMARY

There are thousands of organizations, programs, resources, and Web sites 

to assist with health, reintegration, and resilience. Only a small fraction of 

them are covered within this chapter. However, those selected are among the 

most used and have been based on the latest clinical and scientific evidence. 

More information and continuous updates are also available through the 

Defense Health Agency’s programs, presentations, seminars, and Web-based 

resources.2

Refere n ces

1. Garber CE, Blissmer B, Deschenes MR, et al. Quantity and quality of exercise for 

developing and maintaining cardiorespiratory, musculoskeletal, and neuromotor 

fitness in apparently healthy adults: guidance for prescribing exercise. Med Sci 

Sports Exerc. 2011;4:1334–1359.

2. Joint Chiefs of Staff Web site. Sea of Goodwill: Matching the Donor to Need—

White Paper. http://www.jcs.mil/Portals/36/Documents/WarriorFamilySupport/

SOGW_donor_to_need.pdf. Accessed July 7, 2015.
Overview of Military and Veteran Resources H 369

Mi ke Sav i c k i grew up in 

Franklin, Massachusetts, as 

the eldest of three children. 

He attended Franklin High 

School and was a member of 

the varsity soccer, basketball, 

and track teams. In school, he 

also discovered creative writing 

and science. Mike attended 

Tufts University in Medford, 

Massachusetts, and earned 

a BA in political science and 

international relations. During his 

4 years there, he was a member 

of the Zeta Psi fraternity, and 

played varsity soccer, club rugby, and volleyball. At the same time, Mike 

also completed a 4-year Navy ROTC (Reserve Officers’ Training Corps) 

scholarship program at Massachusetts Institute of Technology in nearby 

Cambridge. He also ran two Boston Athletic Association Boston Marathons 

because, well, there are just some things in college one has to do.

In November 1990, while training to become a US Navy F-14 fighter 

pilot, Mike Savicki sustained a severe spinal cord injury after diving into 

the waters off Pensacola Beach, Florida. In an instant, the then 22-yearold went from being a fit, active, promising Naval officer—commissioned 

as the top flight candidate in the nation’s number one ROTC college 

graduating class—to an individual with a severe spinal cord injury who 

was challenged with learning to live life again using a wheelchair. As the 

United States sent its soldiers and sailors to the Persian Gulf, Mike was 

transferred from a Florida hospital’s intensive care unit to the Veterans 

Affairs Hospital in West Roxbury, Massachusetts.

After completing 7 months of rehabilitation in a Veterans Affairs spinal 

cord injury unit, Savicki relocated from his family home in Massachusetts 

to attend graduate school at Duke University in North Carolina. Along 

the way, as he regained his independence, earned an MBA, and delivered 
370 H Promoting Successful Integration

the commencement address, Savicki became involved in wheelchair sports. 

Competitions took him across the United States and around the globe to 

various countries, including Australia, New Zealand, and Vietnam.

Now, over half his life later, Savicki continues to pursue his passion. 

Not only is he an 18-time finisher (and 5-time division winner) of the 

prestigious Boston Athletic Association Boston Marathon (making him the 

only person to have completed the marathon on foot and subsequently in a 

wheelchair), he has also earned more than 85 Gold Medals in the National 

Wheelchair Veterans Games (the nation’s largest annual sporting event 

for athletes with disabilities). A triathlete since 1999, Savicki became the 

first quadriplegic to finish the 70.3-mile Beach to Battleship Half Ironman 

Triathlon in his home state of North Carolina in 2009. He also played 

quad rugby—a Paralympic sport more popularly known as Murderball—

for 13 years and spent 3 years as a high-performance program member 

competing for a spot on the Athens 2004 Paralympic team.
Overview of Military and Veteran Resources H 371

Mike’s success extends well beyond 

athletics. After receiving his MBA, 

he accepted a full-time job as a 

Management Consultant at Public 

Consulting Group, Inc, in Charlotte, 

North Carolina. From there, he landed 

a job as Deputy Director of World 

T.E.A.M. Sports, a nonprofit for people 

with and without disabilities. In his free 

time, he began freelance writing and 

has since profiled a broad spectrum of 

professional athletes, political figures, 

and comedians.

Savicki is currently the Founder and Chief of Scratching Post Communications, which offers creative communications services, consulting, and 

public relations for businesses and individuals. He is the recipient of the 

Tufts University Distinguished Alumni Award and the National Veterans 
372 H Promoting Successful Integration

Wheelchair Games’ Spirit of the Games 

Award. For 4 years, he has served as 

spokesperson for National Mobility 

Awareness Month.

Mike Savicki was married in 2010. He 

and his wife, Sarah, welcomed a baby 

girl into their lives shortly thereafter.

Overcoming adversity, marathons, 

triathlons, degrees, companies, teams, 

books, magazines, speeches, advocacy 

efforts in DC, and fighter jets? “That’s 

nothing,” he says. The real challenge? Keeping up with a toddler whose life 

is unfolding each and every day.
We don’t differentiate between the combat wounded or just

plain sick — people who may have fallen off a ladder or who 

have cancer. We’re going to take care of you until you

 transition back to duty or return to civilian life.

H H H

Colonel Willard Buhl

Commander, US Marine Corps

Wounded Warrior Regiment

February 26, 2014

C h a p ter Fi f tee n

The Role of Service

Organizations and Volunteers 

S. ELAINE EITLER, MEd, IAST,* and WILLIAM M. LAKE, BS†

*

Assistive/Special Education Technologist/Education Specialist, Curriculum and Instruction Information Technology, George Mason University, 4400 University Drive, 

Fairfax, Virginia 22030 

†

Colonel (Retired), US Marine Corps; Rehabilitation Counseling Graduate Student, 

School of Allied Health Professions, Rehabilitation Counseling, Virginia Commonwealth University, 821 West Franklin Street, Richmond, Virginia 23284; formerly, 

Director, Marine For Life Injured Support Program, Headquarters, US Marine Corps

INTRODUCTION

The World Health Organization defines quality of life as “the 

perception by individuals of their position in life, in the context of 

the culture and value systems in which they live and in relation to 

their goals, expectations, standards and concerns.”1(p1) Inevitably, perceptions 

may change as individuals transition from military service and reintegrate 

into civilian communities. Admiral Michael Mullen, former Chairman of 

the Joint Chiefs of Staff, has said that improving reintegration for Veterans 

and Service Members is the goal toward which we all strive.2 Embarking on 

a “new normal” is a challenge some individuals find exhilarating. Others 

find the process daunting and feel that it creates an overwhelming sense of 

vulnerability. 

Berglass and Harrell3 note that, “As a veteran grows increasingly comfortable with life after military service and achieves better social and personal 
376 H Promoting Successful Integration

relationships, health and satisfaction of material needs, and purpose in life, 

he or she may become increasingly well.”3(p1) Facilitating a successful reintegration requires resilience. Traits of resilience—such as courage, patience, 

self-efficacy, and self-control—allow persons to achieve success in the face of 

adversity. With each success, quality of life is enhanced.

The impact of reintegration expands beyond individual needs. When 

dealing with the many physical and cognitive challenges associated with new 

disabilities, individuals need assistance from support networks that share their 

core beliefs. These networks must confirm to the individual that no matter 

how much has changed, their needs and potential remain important, and the 

possibility for a bright future lies ahead. 

A holistic reintegration plan can heighten the likelihood of positive 

outcomes. Inclusive plans place emphasis on the individual’s physical and cognitive health, material needs (eg, housing, financial, legal, spiritual, etc), and 

sense of purpose. The plan also focuses on the stakeholders in the individual’s 

rehabilitation (ie, family, friends, and social networks). Having a dialogue 

about expectations during the reintegration plan is vital to fulfilling the individual’s needs in the key areas of social and human capital (Figure 15-1).

VOLUNTEERISM

Statistics released by the Bureau of Labor Statistics in February 2013 reported 

that 64.5 million Americans were involved in a volunteer activity. Motivation 

to participate in volunteerism is as varied as the millions of individuals who 

engage in connecting with a cause. Clary et al4 described the Volunteer Functions Inventory (VFI) motives, which are widely regarded as the most credible 

measures of volunteer motivation. The VFI explores six decision-making, 

functional factors related to volunteerism by measuring 30 motivations to 

engage in unpaid helping activities.4 As designated by Clary et al, the VFI 

motives are as follows:

1. protective—a way of protecting the ego from the difficulties of life;

2. values—a way to express one’s altruistic and humanitarian values;

3. career—a way to improve career prospects;

4. social—a way to develop and strengthen social ties;

5. understanding—a way to gain knowledge, skills, and abilities; and 

6. enhancement—a way to help the ego grow and develop.
The Role of Service Organizations and Volunteers H 377

Fi g u re 15-1. Holistic Reintegration.

SENSE OF PURPOSE

[employment, education, membership,

influence. . .]

MATERIAL NEEDS

[housing, financial, legal . . .]

RELATIONSHIPS

[family, friends, social networks . . .]

HEALTH

[physical, mental, spiritual . . .]

Whether engaged in volunteer activities or receiving assistance, persons 

must determine how to pair personal motivation with expectations and 

goals. Utilizing motivation inventory tools, such as the VFI, allows organizations and volunteers to match motivational needs to an array of volunteer 

tasks, thus increasing the likelihood of a more positive volunteer experience. 

Expanding horizons can be a means of positively impacting quality of life for 

oneself and others. However, in the quest for success, mistakes will be made. 

Dale Carnegie said that, “The successful man will profit from his mistakes 

and try again in a different way.”5(p1) In essence, mistakes or missteps should 

not be roadblocks to achieving desired outcomes. Sharing successes and failures will help others to develop their own unique coping strategies and lead to 

improved personal volunteer outcomes.

SOCIAL AND HUMAN CAPITAL

Though modernized, the terms social capital and human capital are not new 

concepts. In 1865, Alexis de Tocqueville coined the phrase “habits of the 

heart,” which described caring for one another’s well-being as a means to feel 

socially connected and useful.6 Studies conducted on the impact of social capital on quality of life were summarized by academic Robert Putnam who defined social capital as “the collective value of all social networks and the inclinations that arise from these networks to do things for each other.”7 Putnam 
378 H Promoting Successful Integration

concluded that such connectedness is necessary for the safety and security of 

individuals and communities. In addition to Putnam’s formal definition, social 

capital has been described as professional contacts, networks, employment 

leads, and social relationships. The works of Tocqueville, Putnam, and others 

support the age-old notion that people not only want to be needed, but also 

need to be needed.

Theodore Schultz coined the phrase “human capital” in the 1960s. 

Human capital encompasses intangible concepts, such as ability, skill level, 

knowledge, leadership, and work experience. Many individuals believe that 

investing in these concepts by training and educating individuals improves 

human capacity and the quality of production output. 

In a 2010 report by Copeland and Sutherland, “No single agency or 

organization has the manpower, resources, or intellectual capital to provide 

a lifetime of care and support to our military families.”8(p7) The adage “there 

is strength in numbers” can be appropriately applied to the reintegration 

process. Currently, Veterans and Service Members benefit from popular 

support of American citizens to ease the strain that their service has on their 

well-being. The Sea of Goodwill report places emphasis on the “capacity of 

greatness” that lies within our military personnel, their families, and the societies they reintegrate into and how this symbiotic relationship between each 

of these groups can benefit each of them. The report also focuses on ways to 

empower Veterans and Service Members by providing opportunities through 

education, employment, and healthcare and by connecting them with the 

services that will support their specific needs. Stakeholders involved in reintegrating Veterans and Service Members into society are often driven by a wide 

variety of motivations, including patriotism, social awareness, and sometimes 

personal financial benefit. The stakeholders involved in an individual’s rehabilitation need to constantly measure the effectiveness of resources and make 

adjustments in the best interest of each individual Veteran. 

 

CONSIDERATIONS FOR SELECTING A TRANSITION 

SERVICE PROVIDER

When selecting from the multitude of service providers, consideration should 

be given to the following questions:

• Does the provider identify with the breadth of needs?

• Does the provider understand that needs are unique to a particular 

individual (ie, one size does not fit all)?
The Role of Service Organizations and Volunteers H 379

• Is the provider aware that needs may be defined by generational 

perceptions/attitudes?

• Does the provider have the ability to change with the times, evaluate 

outcomes, and learn from mistakes?

• Is the provider well informed and have an evidence-based action plan?

• Does the provider have connectivity and collaborate with other 

organizations?

• Does the provider have a concise understanding of military culture?

• Is the provider a catalyst for advocacy?

• Does the provider help individuals understand how their proficiencies 

align with their needs?

• Does the provider offer incentives for reintegration? 

Reintegration is a long-term prospect, not a one-time event. A commitment to 

prioritizing short- and long-term goals will require compromise and tolerance. Advocating for the rehabilitating individual will require stakeholders to 

be assertive and persistent. A determined course of action needs to be logical 

and organized. Developing coordinated, seamless, evidence-based approaches 

and setting common goals for a reintegration strategy will benefit all decisionmakers. The benefits of developing a coordinated approach may include, but 

not be limited to:

• reducing duplicative efforts,

• promoting connectedness,

• alleviating feelings of being overwhelmed and confused,

• empowering stakeholders with ownership of ideas,

Ta b le 15-1. Typical Scenarios of Service Delivery

RURAL URBAN

Roving providers Facility-based providers

Referral-based services Self-sustained/in-house services

Nonprofit transport Public transportation

Services provided via phone and social networking Services provided person-to-person

Services available through local for-profit and 

not-for-profit chapters

Services provided in local, state, and 

federal government centers

Telemedicine and telerehabilitation delivery utilized Medicine and rehabilitation delivery 

person-to-person
380 H Promoting Successful Integration

• decreasing stressors,

• increasing communication and cooperation,

• allowing more efficient allocation of resources,

• avoiding influences from unnecessary bureaucracy, and 

• helping to identify barriers.

The acronym FOB may be helpful in assembling a plan. As described in the 

Warrior Transition Leader handbook,9 F = Forward thinking, O = looking for 

Opportunities, and B = Building a new life.

Each transition is unique to individual circumstances. Not all programs 

will be beneficial or comprehensive in meeting an individual’s needs. For 

example, leveraging sustained service of care will require familiarity with the 

location in which the individual resides, since the availability of resources, 

areas of expertise travel time, and delivery of services and/or resources in urban areas may differ from that of rural settings (Table 15-1). Diversity will be 

necessary to enhance the likelihood of desired outcomes. The ideal program 

will help individuals think about the future, find opportunities, and begin the 

journey of building their new reality. 

VOLUNTEER PROGRAMS

No one is useless in this world who lightens the burdens of another.

Charles Dickens

Having a sense of purpose often results in improved self-respect and elevated 

levels of pride. Sense of purpose may be associated with work or activities, 

such as gainful employment, unpaid labor, or volunteerism. A Veteran’s sense 

of purpose may be different than an active Service Member’s. The change of 

roles inherent in transitioning from active duty to Veteran status may challenge Veterans’ perceptions of themselves or create confusion as to their value 

to society. Participation in volunteer activities can enrich social and human 

capital, thus elevating the sense of purpose.

The advantages and benefits of engaging in volunteerism as a provider 

of services or assistance will vary for all participants. Volunteer assistance can 

provide encouragement to individuals who may have experienced helplessness. 

Productivity within a community is empowering and can be therapeutic. Service can positively impact learned behaviors and skill sets. Volunteering may 

spark rediscovery of a passion or discovery of new competencies and interests. 
The Role of Service Organizations and Volunteers H 381

In 2012, Secretary of Labor Hilda L. Solis10 remarked that volunteerism 

cannot replace formal job training and is not a replacement for compensated employment. Yet, in a competitive job market, volunteerism might give 

individuals a leg up on the competition by improving one’s social and human 

capital.10 

WHAT HUMAN OR SOCIAL CAPTIAL DO YOU BRING TO THE TABLE?

Anecdotal evidence asserts a symbiotic relationship in which volunteerism can 

lead to employment and employment can lead to volunteerism (Figure 15-2). 

Findings from the 2013 study by Spera et al11 conclude that individuals who 

have volunteer experience have 27% better odds of securing employment. 

This study also found that persons without a high school diploma, but who 

have volunteer experience, have a 51% greater chance of obtaining employment. Data from this study suggest that education and volunteerism impact 

social and human capital. This research provides reasonable justification that 

involvement in social/volunteer activities and education can improve quality 

of life.9

In contrast, passivity can be an agent for feelings of loneliness, anxiety, 

disassociation, and powerlessness. Passivity can lead individuals to engage in 

behaviors detrimental to their well-being and quality of life, such as eating 

Fi g u re 15-2. A Symbiotic Relationship: Volunteerism–Human Capital–

Social Capital.
382 H Promoting Successful Integration

and sleeping disorders, substance abuse, emotional distress, and deliberate 

self-harm. Sustained apathy frequently leads to a person’s mental and physical health spiraling out of control, and has the potential of creating instability 

and roadblocks to successful reintegration. 

Volunteerism allows for an active social life and opportunities to learn 

new concepts and skills. When a decision has been made to opt in to the 

arena of volunteerism, it is important for participants to prepare themselves 

for their mission. Outreach efforts are not a one-size-fits-all proposition. Reintegrating Veterans and Service Members will bring different life experiences to 

the table. Stakeholders need to develop a genuine understanding of the challenges that Service Members faced while on active duty. Care providers also 

need to have working knowledge, beyond generalities, of the population they 

wish to serve. Understanding the lingo or common language prior to volunteering is a valuable asset in building rapport. Likewise, knowing that others 

understand the journey from military to civilian life is comforting to those 

embarking on the process. Although age-appropriate connections may stimulate mutual trust between providers and receivers, others will find fulfillment 

in working across generations. Interacting with those who have had similar 

life experiences will help individuals create social bonds and build meaningful friendships. Providers and volunteers should respect comfort levels. They 

should play to strengths and leverage risk taking. 

Terra Zvara, a former Red Cross Volunteer, noted that contributions 

should provide guidance, not handholding (T. Zvara, personal communication, June 2013). Zvara cautioned caregivers not to underestimate individuals 

needing assistance. She warned that one’s limitations or shortcomings should 

not be a barrier to volunteerism because everyone has skill sets and natural 

abilities that can make a difference. Barbara van Dahlen12 confirmed this notion, and stated that Service Members diagnosed and undiagnosed with medical needs (eg, posttraumatic stress disorder, traumatic brain injury, and spinal 

cord injury) can be affected by their experiences while serving; however, their 

service-related diagnoses should not preclude success at their endeavors.10

Recipients of help may need nurturing to overcome the stigma associated with asking for aid. Reluctance to seek assistance is a common behavior 

among those who have served. Reticence may indicate that the individual has 

not acquired strategies that support behaviors necessary to manage significant 

life changes. Persons navigating reintegration will profit from associating with 

role models who demonstrate these skills and have the ability to instill them 

in others. This is especially true for Veterans who have transitioned from 

highly structured military environments to civilian routines. 
The Role of Service Organizations and Volunteers H 383

Experienced volunteer and former Wounded Warrior assistive technology 

advisor Emily Davis reported that recipients of assistance frequently shared 

expressions of appreciation for being supported by volunteers who had life 

experiences and opinions independent of military service (E. Davis, personal 

communication, June 2013). She noted that Veterans and Service Members 

often expressed that their relationships with civilians provided an autonomous safe haven where they could speak openly and take risks that they may 

not have felt comfortable doing in front of their military comrades.

COMPASSION FATIGUE

The role of a volunteer is not always auspicious. In this realm of support, the 

occurrence of burnout is common. It is not unusual for volunteers to feel isolated from their regular social networks. Relationships with certain individuals may be physically and/or emotionally challenging. Often persons needing 

assistance with the reintegration process have visible and invisible wounds 

that impact volunteer collaboration. The relationship between provider and 

recipient can stimulate stressors detrimental to the caregiver’s well-being, and 

these empathetic responses may result in symptoms of physical or mental 

distress in a volunteer. Many times, these signs go unnoticed, even by those 

closest to the person. 

Time committed to volunteer work should not be regarded as burdensome. When providing aid is perceived as onerous, the caregiver usually 

becomes ineffective. When stakeholders recognize and validate compassion 

fatigue, volunteers may be better equipped to mitigate effects to their interpersonal relationships and well-being. Knowing the warning signals may help to 

prevent this type of exhaustion. 

According to Susanne Babbel,13 caregivers suffering from compassion 

fatigue may find themselves:

• feeling disassociated,

• feeling angry,

• having anxiety,

• experiencing sleep disturbances and having nightmares, and

• feeling powerless.

 

To combat compassion fatigue or burnout, caregivers should share successes and acknowledge failures. Instead of complaining, caregivers should 

have meaningful communications daily with good listeners. Caregivers need 
384 H Promoting Successful Integration

to come to terms with fears and anger. They should balance time volunteering with time spent on personal interests/hobbies. Scheduling quiet alone time 

may help volunteers recalibrate the effectiveness of their efforts. Maintaining a healthy diet and a regular exercise regime may also help minimize the 

phenomenon of compassion fatigue. 

DIVERSITY OF VOLUNTEER PROGRAMS

Camaraderie is revered in the service. This mutual respect for colleagues has 

led many to become involved in assisting with reintegration. An abundance of 

volunteer programs are available for the Veteran or Service Member during 

and after reintegration. Selecting a program will depend on physical location, 

physical abilities, and personal preferences. Networking with others is a 

viable means of connecting with an organization. 

In this chapter, we have divided organizations into three entities: 

(1) Military and Veteran organizations, (2) umbrella organizations, and 

(3) wraparound programs. The goals of organizations are typically outlined 

in their history or mission statement. The goals of some organizations are 

wide-ranging, whereas others are genre-specific. 

Mi l i ta ry a n d Veter a n Or g a n i z at i o n s

Preparing for and actively navigating the reintegration process takes perseverance. This is particularly true when the Service Members begin to establish a 

record of benefits they are afforded as compensation for their time in service. 

Throughout the transition period, both the reintegrating individuals and their 

stakeholders will rely heavily on government and volunteer organizations.

Ta b le 15-2. Web Site Resources

WEB SITE WEB ADDRESS

Blue Star Families bluestarfam.org

Corporation for National and Community Service volunteeringinamerica.gov/national

Give an Hour giveanhour.org

Independent Sector independentsector.org

The National Resource Directory nrd.gov

Wounded Warrior Project woundedwarriorproject.org
The Role of Service Organizations and Volunteers H 385

Service Members moving from active duty to Veteran status will participate in the Transition Assistance Program (TAP). TAP attendance is required 

for all separating Service Members. Its main focus is on the individual leaving 

service. The TAP experience provides professional and moral support to colleagues as they move from the military community to the Veteran or civilian 

community. TAP educates participants on a wide variety of topics and assists 

in the compilation of a paperwork trail associated with separation. TAP also 

provides guidance in helping individuals identify a civilian career path and 

teaches skills associated with building a professional resume. TAP also assists 

in the application for Veteran benefits. In the past, TAP has been criticized as 

not being effective; however, TAP has undergone a major overhaul and is a 

valuable part of departing military service.

Many organizations are connected with every branch of the military, and 

many others are connected to one specific military branch. Some organizations are more visible than others, but all seek a better quality of life for those 

who are serving or have served our nation, including those with both seen 

and unseen injuries. These organizations have an intimate understanding 

of Veteran concerns. Personal mentors, peer support groups, and programs 

focused on athletics and hobbies are also available to facilitate connectedness 

with other Veterans. Participation in any of these programs as either a volunteer or a recipient of services may help to restore and boost one’s confidence 

and resilience. 

As noted in the previous chapter, an important resource for both active 

duty and Veteran Service Members is the National Resource Directory (see 

http://www.nrd.gov/). This directory provides a cornucopia of resources dedicated to successful reintegration of troops and their families (Table 15-2).

One hurdle that transitioning individuals face is how to translate 

their highly specialized military skill sets to the civilian sector. Often, this 

translation is complicated by physical and/or cognitive injuries acquired 

while serving. There are numerous organizations focused on matching skill 

sets to needs. Usually, these organizations are well versed in service-related 

injuries and the needs of individuals living with these disabilities. The process 

can be intimidating, but Veterans have found relief when accessing available 

programs. As part of the transition, individuals may benefit from educating 

themselves about the spectrum of not-for-profit organizations whose missions 

share passions similar to their own, and other groups that provide service to 

ease the anxiety generated by change. Stakeholders must diligently examine 

each organization to determine if the match will fit the criteria they have set 

for improving their quality of life (Exhibit 15-1).
386 H Promoting Successful Integration

Um b rel l a Or g a n i z at i o n s

For the purpose of this chapter, umbrella organizations are defined as entities 

that pool resources to provide expertise and coordinate activities or actions. 

These differ from the aforementioned groups in that they have no specific 

military ties. Yet, many of these groups have a storied history in delivering 

services to Service Members and Veterans. 

Veterans may have sustained injuries that make it difficult to achieve their 

goals or partake in desired activities. Such constraints may be related to a VetEx h i b i t 15-1. Examples of Organizations Involved in Bettering Quality of Life 

for Service Members and Their Caregivers

The American Legion

The focus of the American Legion is active duty Service Members, Veterans, and communities. The American Legion is dedicated to promoting patriotism and strengthening 

communities through mentor programs and sponsorships. 

For more information, visit legion.org/heroes 

Disabled American Veterans 

As a Veterans Rights advocate, the Disabled American Veterans provides assistance and 

outreach to Veterans with disabilities and their families. 

For more information, visit dav.org

The Mission Continues

Bringing Veterans and civilians together, the guiding principles of The Mission Continues 

are “work hard, trust, learn and grow, respect, and have fun.” 

For more information, visit missioncontinues.org

Paralyzed Veterans of America

The Paralyzed Veterans of America has spent decades advocating for Veterans and 

empowering Veterans with injuries to realize a life of independence.

For more information, visit pva.org

Team Rubicon

The members of Team Rubicon are focused on utilizing the skills of Veterans to respond to 

the needs of communities devastated by disasters. 

For more information, visit teamrubiconusa.org

United Service Organizations

The United Service Organizations is dedicated to lifting the spirits of Service Members 

worldwide. This organization provides a tangible way for Americans to thank those who 

protect their freedoms.

For more information, visit uso.org
The Role of Service Organizations and Volunteers H 387

eran’s environment, status/position, or health. Some umbrella organizations 

provide a wide range of services specific to rejuvenating personal interests. 

Others are designed to teach new skills (Exhibit 15-2).

Wr a pa r o u n d Pr o g r a ms

Wraparound programs are typically community-based collaborations that 

provide services to individuals and their families in a specific geographical 

area. Traditionally, these programs embrace persons in need and provide 

nonjudgmental and unconditional care. Services provided are as varied as the 

multiple agencies involved in developing customized plans and creative soluEx h i b i t 15-2. Examples of Organizations With a Rich History of 

Volunteer Activity

Easter Seals

For more than 100 years, Easter Seals has assisted individuals and individuals with 

disabilities and special needs and their families. Easter Seals’ emphasis is on medical 

rehabilitation, employment and training, child services, adult and senior services, and 

recreation. 

For more information, visit easterseals.com

Paralympics, US Olympic Committee

Based in Colorado Springs, the mission of the US Olympic and Paralympic Committees 

is to support athletic endeavors by providing assistance with funding, insurance, tuition 

grants, and career services. 

For more information, visit teamusa.org

The Peace Corps

The Peace Corps’ goals focus mainly on training and promoting an international understanding of Americans.

For more information, visit peacecorps.gov

Red Cross

The main focus areas of the American Red Cross are to administer disaster relief; support 

American military families; provide lifesaving blood, health, and safety services; and supply international services. Their network’s mission is to prevent and alleviate suffering and 

hardship. 

For more information, visit redcross.org

Teach for America

Teach for America provides training and career development to potential leaders who will 

invest in providing education for underserved communities.

For more information, visit teachforamerica.org
388 H Promoting Successful Integration

tions to support those in need. In general, these agencies tend to have a more 

intimate relationship with clients. Frequently, these programs are discovered 

through personal interactions that stakeholders have within their communities (ie, school systems, places of worship, civic associations, etc). This type 

of networking may create opportunities that may not be realized in working 

with larger service organizations.

Some examples of wraparound programs include the following:

• community outreach,

• civic organizations,

• philanthropic organizations,

• business organizations,

• faith-based organizations,

• family assistance providers,

• internships,

• mentorships,

• social media forums,

• peer-to-peer outreach, and

• advocacy groups.

SUMMARY

Al Condeluci—author, consultant, and CEO of Community Living and Support Services of Pittsburgh—described the structure of a bridge merging “two 

important notions, the simplicity of connecting two points and the complexity of the engineering necessary to make the connection.”14 In Condeluci’s 

bridge metaphor, he implores persons on one side of a river (ie, point A) 

trying to reach the other side (ie, point B) to “seek out help from an engineer 

as to how we might mitigate or get rid of the river so we can pass to point 

B safely.”14(p2) It is not a provider or volunteer’s responsibility to change the 

world; commitment should be based on realizing a desired quality of life. As 

Condeluci so eloquently states, “The river is not a problem, but a reality to be 

addressed based on the strength and stability of the shorelines where we plan 

to anchor the bridge.”14(p2) Whether acting as the recipient of assistance or as 

the volunteer who delivers support, one should be the agent of change, the 

engineer of strength, and the creator of stability.
The Role of Service Organizations and Volunteers H 389

Refere n ces

1. World Health Organization. WHOQOL: measuring quality of life. WHO Web 

site. http://www.who.int/healthinfo/survey/whoqol-qualityoflife/en/. Accessed July 

24, 2015.

2. Belanger M, Magoon M, Weepie N, et al. The path to healthy homecomings. 

http://www.boozallen.com/content/dam/boozallen/media/file/Path_To_Healthy_

Homecomings.pdf. Accessed February 2, 2015.

3. Berglass N, Harrell MC. Well after service: Veteran reintegration and American 

communities. http://www.cnas.org/sites/default/files/publications-pdf/CNAS_

WellAfterService_BerglassHarrell.pdf. Accessed February 2, 2015. 

4. Clary E, Snyder M, Ridge RD, et al. Understanding and assessing the motivations 

of volunteers: a functional approach. J Pers Social Psychol. 1998;74:1516–1530.

5. Carnegie D. The motivational speakers hall of fame. GetMotivation Web site. 

http://getmotivation.com/dale-carnegie-hof.html. Accessed July 2013.

6. Tocqueville A, Bender T, eds. Democracy in America. New York, NY: McGrawHill Companies; 1981.

7. Putnam RD. Bowling Alone: The Collapse and Revival of American Community. 

New York, NY: Simon & Schuster; 2000: 19.

8. Copeland JW, Sutherland DW. Sea of goodwill: matching the donor to the need. 

http://usarmy.vo.llnwd.net/e2/rv5_downloads/features/soldierforlife/White_PaperSea_of_Goodwill_17MAY2010.pdf. Accessed September 2013.

9. Cooper RA, Pasquina PF, Drach R, eds. Warrior Transition Leader: Medical 

Rehabilitation Handbook. Washington, DC: Department of the Army, Office of 

The Surgeon General, Borden Institute; 2011.

10. Solis HL. Remarks for the Honorable Hilda L. Solis: White House Conference on 

Expanding Opportunity Through Volunteering. http://www.dol.gov/_sec/media/

speeches/20120419_WH.htm. Accessed July 14, 2013.

11. Spera C, Ghertner R, Nerino A, DiTommaso A. Volunteering as a pathway to 

employment: does volunteering increase odds of finding a job for the out of 

work? http://www.nationalservice.gov/ impact-our-nation/research-and-reports/

volunteering-pathway-employment-report. Accessed August 2013. 

12. Van Dahlen B. The value of Veterans’ service back home. Time. June 2013. 

13. Babbel S. Bodily symptoms of empathy. Psychology Today. July 2012.

14. Condeluci A. Cultural Shifting: Community Leadership and Change. St Augustine, FL: Training Resources Network; 2002.
390 H Promoting Successful Integration

Gu n n ery Ser gea n t

Mat t h ew Ha n n a n served 

for 15 years active duty in the US 

Marine Corps from September 

18, 1995 to October 30, 2010. 

He was medically separated after 

an injury he sustained in Fallujah, 

Iraq, on January 21, 2007. He 

served his entire career as an 

Intelligence Analyst/Intelligence 

Chief. Matthew was directly 

involved in Combat Operations 

in Tirana, Albania, and the Al 

Anbar Province of Iraq. He also 

participated with humanitarian 

operations in the Mediterranean Sea, with tsunami relief efforts in 2005, and 

with operations in the Caribbean Sea in 1996. 

While in the Marine Corps, Gunnery Sergeant Hannan was stationed with 

various operational forces that include (but are not limited to) Joint Special 

Operations Command, US Forces in Korea, 2nd Marine Aircraft Wing, 2nd 

Marine Division, Marine Forces South, Joint Interagency Task Force South, 

and III Marine Expeditionary Force. 
The Role of Service Organizations and Volunteers H 391

After his medical separation, he participated in an internship that was 

offered through the Veterans Affairs Vocational Rehabilitation Clinic with 

the Human Engineering Research Laboratories (HERL) in the ELeVATE 

Program (Experiential Learning for Veterans in Assistive Technology and 

Engineering). Matthew is currently working on his undergraduate degree 

in Public Service (Nonprofit Management). He has plans to apply to the 

Master’s degree program in Rehabilitative Counseling at the University of 

Pittsburgh, while working as a research assistant at HERL. 

Hannan is an active member in the Veterans of Foreign Wars (VFW) Post 

92, Disabled American Veterans, American Legion Post 868, and the Marine 

Corps League Post 827. He also volunteers as an Assistant Team Leader for 

Semper Fi Odyssey, acts as a peer mentor for the Wounded Warrior Project, 

is a Student Ambassador and Veteran Advisor to the College of General 

Studies, and is a youth mentor and wrestling coach with the Shadyside Boys 

& Girls Club of Western Pennsylvania. Matthew is currently the President of 

Pitt Vets, which is the Student Veterans of America Chapter at the University 

of Pittsburgh.
392 H Promoting Successful Integration
The quality of our men and women in uniform 

directly contributes to our roles as the world’s 

pre-eminent fighting force.

H H H

Honorable Jessica Wright

Under Secretary of Defense for Personnel and Readiness

March 25, 2014

C h a p ter Si x tee n

Culture and Reintegration

of Veterans 

ALLEN LEWIS, PhD, CRC*; SETH MESSINGER, PhD†; 

TWYLLA KIRCHEN, PhD, OTR/L‡; JEANNE WENOS, Ped§; and

SHELLY BROWN, MEd¥

*

Dean and Professor, State University of New York Downstate Medical Center, 

College of Health Related Professions, 450 Clarkson Avenue, Brooklyn, 

New York 11203

†

Research Director, Center for Rehabilitation Sciences Research, Department of 

Rehabilitation, Uniformed Services University of the Health Sciences, 4301 Jones 

Bridge Road, Bethesda, Maryland 20814

‡

Director, Occupational Therapy Program, College of Health and Behavioral Studies, 

Department of Health Sciences, James Madison University, 800 South Main Street, 

Harrisonburg, Virginia 22807

§

Assistant Professor, Occupational Therapy Program, College of Health and 

Behavioral Studies, Department of Health Sciences, James Madison University, 

800 South Main Street, Harrisonburg, Virginia 22807

¥

Doctoral Candidate, Graduate School of Education, Duquesne University, 

600 Forbes Avenue, Pittsburgh, Pennsylvania 15282
396 H Promoting Successful Integration

INTRODUCTION

This chapter addresses the role that culture plays in the reintegration of 

Veterans to civilian life in the United States. It addresses the concept 

of culture, pluralism in the United States, and the many cultural 

dimensions in today’s military. The role of culture for individuals entering and 

exiting the military, unique considerations regarding women in the military, 

barriers to Military Family reintegration, along with strategies to address the 

barriers are also examined. The chapter concludes with a discussion of the role 

of culture in promoting Service Member reidentification as a healthy civilian.

THE CONCEPT OF CULTURE

A useful way to approach the concept of culture, particularly in this chapter, 

is to think of it as a set of enduring constructions that provide a framework 

for perception and meaning among people who share a world, however 

loosely or narrowly defined. Culture can be described as a series of “scapes” 

that link people across space and time, even if they are quite distant from one 

another.1 An example is the broadly shared dispositions, habits, and values 

of investment bankers or electronic music devotees across the globe. Military 

Service Members are another example. There is a wide range in technology 

and skill among uniformed Service Members from different nations, but there 

is a sense that individuals who are Service Members share certain beliefs and 

skills that have drawn them into their career.2 Simply watching documentaries, such as Restrepo (a 2010 film about an American Army unit) and Armadillo (a 2010 film about a Danish Army unit), bears this out. 

This concept of culture is also a process. Culture as a set of ideas and 

dispositions is unevenly distributed across a society or group.3,4 For instance, 

people draw on sets of shared meanings, but do not always invest them with 

the same significance. Furthermore, they may share sets of shared meanings 

and also have several that overlap with entirely separate communities.5 The 

concept of culture has typically been used to explain commonalities in societies. However, in the last couple of decades, researchers have become intrigued 

about the way that culture can highlight differences within communities.3,6,7 

PLURALISM IN THE UNITED STATES

The United States, which has always been pluralistic or culturally diverse, is 

becoming demonstratively more so. Some estimates place the white popula-
Culture and Reintegration of Veterans H 397

tion slipping into the minority position within the next several decades.8,9

However, it is easy to overstate this process in part because the notions of 

race, ethnicity, and color in the United States have historically been very fluid. 

In the 19th century, many categories of people who are now included within 

the white category were seen in starkly different terms.10,11 US immigration continues to be a major source of diversity, with rapid increases among 

individuals from Asia and Latin America accounting for the majority of new 

citizens. Along with ethnic, racial, and religious diversity, there is increasing acknowledgment of sexual and gender diversity in the United States. In 

terms of the military, the most significant change reflecting this diversity has 

been the end of the “don’t ask, don’t tell” (DADT) era in 2013 that officially 

opened the military to recruits regardless of sexual orientation. 

THE MANY FACES OF CULTURE IN TODAY’S MILITARY 

When demographic information about active duty US military personnel is 

available, it is usually broken down into two categories: (1) enlisted personnel and (2) officers. Although divisions among the service branches and 

other qualifiers are often noted, it is the division between the officers and 

the enlisted personnel that permeates almost every demographic data point. 

A distinction is made, however, when measuring educational achievement 

within the military. For reference, there are approximately 1,196,897 enlisted 

Service Members and 232,139 officers within the entirety of US Department 

of Defense (DoD) personnel.12

Ra ce a n d Et h n i c i t y

Although the military exhibits some diversity, whites make up approximately 

74.6% of the entire active duty force and minorities make up 25.4%, of 

which 17.8% are black.12 These proportions, though not equivalent, do trend 

with race and ethnicity rates among the civilian population and have a similar 

distribution within both the enlisted and officer realms.12 Combat fatalities are also proportional to these rates.13 It appears that whereas minorities 

do tend to be underrepresented, the distribution mirrors that of the civilian 

population in both raw numbers and placement of different races among duty 

stations, rank, and responsibility.

Ge n der 

Female Service Members are significantly underrepresented in the US military. 

The service-wide enlisted female percentage is 14%, with the Air Force having the highest percentage of women at 19.9% and the Marine Corps having 
398 H Promoting Successful Integration

the lowest percentage at 6.2%.12 Among officers, the service-wide percentage 

is 15.3%, slightly better than the percentage among the enlisted population.12 Again, the Air Force has the highest representation of female officers at 

18.3% and the Marine Corps has the lowest representation of female officers 

at 5.8%.12 Since 1980, approximately 5% of active duty military fatalities 

have been women.13 Until recently, women were not allowed to deploy to 

frontline combat roles. Thus, this may explain their underrepresentation 

in the military. This thinking may account for the difference in recruitment 

numbers of women among branches, as well as the disproportionate representation of women in officer roles. The lack of combat roles for women is 

almost certainly responsible for the disproportionately low incidence of active 

duty fatalities.

Sex u a l Or ie n tat i o n

Under DADT, gay and lesbian Service Members could be separated from 

service if they revealed their sexual orientation while in the military. Because 

of this practice, there was a disincentive for homosexual Service Members to 

reveal themselves. Therefore, this population remained unrecorded in any demographic data that the DoD released, which obscures their representation in 

the military.14 However, with the recent repeal of DADT, we can reasonably 

expect the issue to be studied more thoroughly in the future.

Rel i g i o us /S p i r i t u a l Af f i l i at i o n

Information regarding religious and spiritual affiliation within the military 

was reported by the Military Leadership Diversity Commission.15 In that 

report, data from the Religious Identification and Practices Survey (RIPS) 

revealed greater religious diversity within the ranks of military personnel 

younger than age 40 years, compared with Military Personnel older than 

age 40 years. The current military also reports greater religious diversity 

than previous generations, including those from the “Greatest Generation” 

who served during World War II.16 Religiosity in the military was studied 

in the context of diversity by the Defense Equal Opportunity Management 

Institute (DEOMI). Faith groups were identified by DEOMI, the Defense 

Manpower Data Center, the American Religious Identification Survey, and 

the Pew Research Center’s Religious Landscape Survey as Protestant (variety 

of denominations), Catholic, Orthodox, other Christian, and Jewish (roughly 

75%).17 Also included was a smaller percentage of Muslim, Pagan, Eastern, 

Humanist, and other less common affiliations. Depending on the source used, 

12% (as reported by the Pew Research Center) to 25% (as reported by RIPS) 

were identified as having no religious affiliation. 
Culture and Reintegration of Veterans H 399

Religious beliefs are thought to be central to a person’s worldview and 

are influential to choices that individuals make in life, including the shaping 

of values that influence one’s judgment.18 Because of the diverse expression of 

religiosity in the military, clinicians working with individuals in the military 

must be mindful of the contributions of individual belief systems to patterns 

of thinking.19 Resilience or the lack of it may manifest from healthy and 

unhealthy beliefs regarding religiosity and spirituality.19 One study measured 

intrinsic religiosity of Military Veterans using a three-item questionnaire 

of perceptions of a strong sense of God’s presence, the importance of one’s 

religion linked to its provision for meaning to life, and the vital importance 

of having a relationship with God. Veterans, likewise, reported having an 

internal sense of allegiance to their personal religious beliefs.20 

The military reports its struggle to holistically embrace human diversity 

while maintaining standards of excellence surrounding 

• character,

• obedience, 

• unit cohesion, 

• esprit de corps, and 

• mission readiness 

for which matters of religion and spirituality pose a particular challenge.15

Issues of harassment within the military surrounding the expression of one’s 

religious beliefs have been reported.19 However, the spiritual element is 

designated as one of four dimensions of a Service Member’s well-being that 

comprise mission readiness21:

1. assessment of emotional, social, family, and spiritual fitness;

2. universal resiliency training;

3. individualized training; and

4. training of master resilience trainers.

Part of the Army’s Comprehensive Soldier and Family Fitness program includes a relatively new component—spiritual fitness—added to the approach 

for maintaining holistic health and wellness.21 The pendulum appears to be 

swinging back to the rediscovery of spiritual practices of healing, substantiated by reports of patients desiring prayer time with their physician; experiencing deep satisfaction with spiritual means of reframing injury or illness; 

and seeking alternative therapies that address the mind and spirit, in addition 

to treating physical ailments of the body.22 
400 H Promoting Successful Integration

S o c i a l Ec o n o m i c Stat us 

Socioeconomic status (SES) among Service Members is difficult to determine 

because many of its usual factors are not recorded by the DoD, and the SES 

indicators that are recorded tend to hold less meaning than similar measures 

used to compare groups in the civilian population. This occurs because the 

use of these tools between Service Members in the same branch does not yield 

much variation in quality of life. Factors such as homogenized healthcare and 

the enforcement of uniform lifestyle standards that are regulated by individual 

commands in keeping with the standards of that branch are contributory 

components. Comparisons among branches encounter similar problems 

because each military branch has to adhere to basic military-wide standards. 

Factors that are recorded can be useful when comparing the SES of Service 

Members to that of their civilian counterparts. For example, 92.5% of Service 

Members among all military branches have a high school diploma or above, 

and 89.3% of Service Members have a BA/BS or above.12 The only outlier 

in this sample is the Coast Guard, which decreases the service-wide BA/BS 

attainment average to 53.4%.12 With the exception of the Coast Guard at the 

college level, military educational achievements at these levels are significantly 

higher than those of the civilian population.23

Cu lt u re a n d t h e Mi l i ta ry Fa m i ly

The Military Family may consist of the Service Member, his or her spouse, 

children, and, at times, extended family members (eg, parents, other relatives, 

etc). Kirchen and Hersch24 conducted a qualitative study that examined the 

lived experiences of World War II, Korean War, and Vietnam Veterans who 

had recently transitioned to a long-term care facility. One of the most salient 

themes that emerged from analysis of the phenomenological data was the 

importance of the Military Family. Participants in the study identified strong, 

supportive families as being the most important factor in their ability to cope 

with frequent deployments and other stressors associated with military life.24

Fitness for duty is a term used to describe a Service Member’s physical and 

mental health in relation to his or her ability to deploy or perform duties 

stateside. There is a direct correlation between the strength of the family 

support system and a Service Member’s ability to perform his or her duties as assigned.25 Wang et al26 examined the association between military 

divorce with mental, behavioral, and physical health outcomes. They found 

that compared to those who remained married, recently divorced individuals 

were significantly more likely to screen positive for new-onset posttraumatic 

stress disorder, depression, smoking initiation, binge drinking, alcohol-related 

problems, and moderate weight gain.26
Culture and Reintegration of Veterans H 401

There are numerous factors that affect the sustainability of the Military 

Family unit. However, the stress of being able to kill, avoiding being killed, 

caring for the wounded, and witnessing death and injury are all part of 

military service. Additional military occupational stressors include frequent 

relocation, separation from family, and being constantly available. Although 

other occupations may have similar stressors, the stressors identified here are 

salient features of military service.27 It is not surprising that divorce rates for 

military couples from October 1, 2006 to October 1, 2007 were approximately 25,000 failed marriages of 755,000 married active duty troops.17

As such, military leaders recognize the importance of keeping Service 

Members healthy and deployable through fostering strong and committed 

Military Families.

CULTURE AND THE MILITARY: THE PARADOX

One of the main cultural processes associated with the military (aside from its 

power as a tool for social mobility both geographically and through SES) is 

that it is a machine for producing specific kinds of uniformity. The raw material of this uniformity is the diverse social landscape of the United States. 

E n ter i n g t h e Mi l i ta ry a n d t h e R o le o f Cu lt u re

One way to understand the process of entering the military is to see it as a 

ritual of initiation. Victor Turner28 introduced a model of the ritual process 

that was drawn from his work with an African people known as the Ndembu. Basically, Turner argued that rituals occur in three stages: (1) separation, 

(2) transition, and (3) reincorporation. A problem with this work is that it 

can be infinitely recursive (thus every transfer of duty station can serve as an 

initiation ritual). Nonetheless, when considering the significant moments of 

military life, this three-part approach is quite useful.28

The first stage of the ritual process, separation, can be seen vividly in the 

entry into military service at the basic training level. Participants in an ongoing study at Walter Reed Army Medical Center described how going to their 

basic training locations had some features of a pilgrimage. These individuals 

went to a common airport or other facility on their own. Often, they would 

meet up with guides at USO (United Service Organization) offices in airports 

(that provide a public welcome and hospitality space for Service Members) 

and then be sent on their way. When they finally arrived at their in-processing 

location, they experienced a sharp breach with the lives they were leaving. 

For example, 
402 H Promoting Successful Integration

• they had to get rid of their clothes,

• they had to have their hair shorn, and 

• they had to be moved through a whole series of events designed to strip 

them of their individuality (eg, receiving uniform clothing, being yelled at 

as a group, moving rapidly through medical examinations, etc).29 

Turner referred to the second stage of the ritual process (transition) as 

liminality, or a time out of time. For example, features that would have differentiated military recruits prior to entry are erased. This is seen in the physical 

experiences previously described, but also in other ways. For instance, race, 

ethnicity, and, to some extent, gender are erased as instructors herd, exhort, 

and berate recruits through a wildly varied series of physical and mental 

exercises. Individuals described experiencing routine lack of sleep, eating 

unpalatable food, and being constantly reminded that they were separated 

from their familiar lives. (This is reinforced by quite literally cutting off 

recruits from friends and family for the duration of their basic training.) 

Furthermore, instructors deliberately seek to sow doubt about families of 

the recruits, especially friends, in an effort to coerce recruits into seeing their 

comrades and other Military Service Members as their “true” families.30

Although all of this may bear strong similarities to examples of negative conditioning, there is also a positive conditioning aspect of this training. 

Throughout basic training, differences that might have stratified recruits in 

their home environments are dissolved in favor of membership in the wider 

service branch. Recruits experience changes in their bodies, cognitions, and 

capacities. They become stronger and more fit, able to excel at a wide variety 

of mechanical and physical skills, and perceive risks and dangers in their 

environment that they might have been unaware of in their former lives. The 

recruits have the experience of camaraderie, as well as an enhanced sense of 

personal prestige and status at having succeeded in being welcomed (at the 

end of training) into a very highly regarded institution. 

Reincorporation, or the third stage of the ritual process, has recruits 

becoming fully accredited members of their service branch in a public ceremony that welcomes parents and friends to the military installation where 

they trained. Here, newly minted Soldiers, Sailors, Airmen, and Marines are 

able to give their loved ones a tour, show off their new bodies in their crisp 

uniforms, and, perhaps more importantly, give a demonstration of their new 

bearing as Service Members. These experiences are reproduced, though with 

likely diminished intensity, as Service Members move on to advanced training 

and are then assigned from one unit to another.
Culture and Reintegration of Veterans H 403

Service Members have often pointed out that individuals who have not 

experienced deployment or combat are relatively ill-treated compared to 

other members of the unit. This has the effect, perhaps intended, of encouraging these inexperienced Service Members to eagerly await their upcoming 

deployment. 

Ex i t i n g t h e Mi l i ta ry a n d t h e R o le o f Cu lt u re 

Military service offers a very durable platform for identity among Service 

Members. The durability of this identity is visible in material culture. Clothing, hats, bumper stickers, and license plates can all be tools with which to 

share the military component of one’s biography. More subtly, though more 

importantly, military training becomes integrated into an individual’s embodied sense of being in the world after Service Members leave the military 

and reintegrate into civilian society.29,31 Military training and combat exposure may both act as barriers to social reintegration.32,33 This problem has 

emerged, to some extent, as a stigma (given the number of suicides among 

Veterans and active duty personnel, and the sensationalizing of crimes committed by Veterans) that may follow Veterans as they negotiate their pathway 

to civilian life. 

Veterans of Vietnam, Iraq, and Afghanistan have all shared the burden 

of being viewed with some suspicion by the public. This is in part motivated 

by accounts of poor social reintegration through criminal or suicidal behavior 

by some Veterans.34 Currently, the question of social reintegration is nationally prominent and is accompanied by accounts of antisocial behavior by 

individual Veterans. For example, a Navy Veteran allegedly perpetrated a 

mass shooting at the Navy Yard in Washington, DC. This alleged shooter 

had never deployed to a combat theater, but this fact may be obscured simply 

because he was a Veteran. 

Paradoxically, Veterans may also struggle with the ways that they are 

positively valued in public life. Veterans are often held up as models of civic 

participation. In addition, they are also often referred to as heroes. This intense 

measure of public approval can be constraining for Veterans who may be 

struggling with reintegration challenges or who simply want to return anonymously to civilian life. It can be a challenge to live normally in a community or 

even attend sporting or other public events. Frequently, it can be difficult being 

called on when a master of ceremonies asks all Veterans to raise their hands 

or stand up to receive public ovations. One Veteran discussed the uncomfortable situation of being offered money as a token of gratitude for his military 

service.2 After attempting to gently refuse a proffered $20 bill, the well-wisher 
404 H Promoting Successful Integration

lightly tossed the bill into the open window of the Veteran’s car, necessitating 

him to crawl around on the floor to find it later. Although this may seem like a 

rare circumstance, it is nonetheless indicative of some of the potential challenges faced by Service Members who become a kind of condensed symbol for 

civilians rather than fully accepted as realized human beings. 

UNIQUE CONSIDERATIONS OF WOMEN AND REINTEGRATION

Hi st o r i c a l Pers pec t i ve

Women have served in every war and conflict in United States history, from 

undercover spies in the Revolutionary War to combat pilots in Afghanistan.35

The first formal recognition of women in the military occurred in 1901 with 

the establishment of the US Army Nurse Corps.35 The inception of an allvolunteer force in 1973 initiated a dramatic increase of women entering the 

armed forces. Several historic junctures in US military policy changed the face 

of women Service Members and expanded opportunities for advancement 

and combat roles, including:

• 1901 Congress creates the Army Nurse Corps. Participants had no 

official military rank, received unequal pay, and were not eligible 

for retirement.

• 1941 The Women’s Army Auxiliary Corps was conceived by the 

US Congress and received full military status in 1943.

• 1951 The Defense Advisory Committee on Women in the services 

was established.

• 1967 Public Law 90-130 eased restrictions contained in the 

Women’s Armed Services Integration Act, which was passed 

19 years earlier, in 1948.

• 1973 The US military becomes all-volunteer. 

• 1990s Access increases for opportunities in combat zones. 

• 2011 The Department of Veterans Affairs (VA) and the DoD 

collaborate on the VA Task Force for Women.

T h e Fa ce o f T o d ay’ s Wo me n Veter a n s

Women represent 8% of Veterans, with the largest percentage (more than 

50%) having served in conflicts since 1990.35 Black women comprised the 

largest minority of women Veterans at 19%, compared to the overall US 

population of 12% black women. Conversely, women Veterans from Puerto 

Rico represented 8% of the women’s Veteran population.35 Further, the 
Culture and Reintegration of Veterans H 405

average age of women Veterans in 2009 was 48 years, 2 years older than 

the average age of the general population of US women. The percentage of 

women Veterans with children under the age of 17 was 39%, slightly higher 

than the population of US women with children in the same age range.35

P o st dep l o y me n t I ssues Im pa c t i n g Wo me n

The postdeployment experience of women Veterans is similar to the psychological trauma of men Veterans, with an additional layer of trauma for 

women who identify as an underrepresented minority. Postdeployment issues 

can include homelessness, military sexual assault, and posttraumatic stress 

disorder (PTSD).

Homelessness

According to the 2013 Annual Homeless Assessment Report36 to Congress, 

8% of the Veteran homeless population are women. The overall rate of 

chronically homeless Veterans has declined, yet 8% represents approximately 

4,400 women Veterans without a consistent home.36

Military Sexual Assault

Men and women Service Members can be impacted by sexual trauma, yet 

women face additional barriers and challenges when reporting incidents and 

receiving support.37 Approximately 20% to 40% of women Veterans report 

incidents of military sexual assault.38

Posttraumatic Stress Disorder 

Research has shown a high percentage of Veterans with PTSD, including 

women. In women, a significant amount of comorbidity exists between PTSD 

and depression, often compounded by military sexual assault.39 The purpose 

of the study was to identify barriers to care for women Veterans with PTSD. 

An interesting finding was determined: 27% of women Veterans did not seek 

treatment because of a lack of awareness of eligibility or available services.39

The study by Lehavot et al39 concluded that future outreach and education efforts should target women Veterans. Additionally, the study identified 

that women Veterans had greater access to the Internet and computer usage, 

thus suggesting that telehealth and computer-based resources may represent 

an alternative option for care and support.39

Rec o m me n d at i o n s 

Several factors contribute to effective return to civilian life following deployment, particularly as it applies to children and youth in Military Families.40
406 H Promoting Successful Integration

The concept of seamless communities refers to the need for caregivers, service 

providers, and community entities to recognize the unique structure of military life, including language, norms, and customs.40 Additionally, an understanding of the policies that govern access to and usage of resources further 

supports the concept of seamless communities.40 As the leading provider of 

medical and behavioral health services for Veterans, the VA is cognizant of 

the need for unique services to address the needs of women Veterans. Thus, 

the VA has developed comprehensive, gender-specific programs and facilities 

for women Veterans. 

The following initiatives for women Veterans support services for 

physical and mental health; educational opportunities; and procurement of 

adequate, safe housing.

Homelessness

• Supportive Services for Veteran Families 

https://www.va.gov/homeless/for_women_veterans.asp

• Housing Choice Vouchers 

 https://www.va.gov/homeless/hud-vash.asp

General Health

• Center for Women Veterans 

https://www.va.gov/womenvet

• Women Veterans Health Care 

www.womenshealth.va.gov

Military Sexual Trauma and PTSD 

• Military Sexual Trauma 

www.mentalhealth.va.gov/msthome.asp

• PTSD: National Center for Posttraumatic Stress Disorder (NCPTSD) 

www.ptsd.va.gov

REINTEGRATION BARRIERS AND STRATEGIES

There are several notable barriers and strategies to overcome the problems 

associated with reintegration of military families (Table 16-1). A strong case 

has been made for embedding family-based care for military and Veteran 

families in the community.41 This is especially true for family separation from 

the military, but it will require many civilian resources (including those of the 

VA) to answer the call. In addition, the family unit is more likely to experi-
Culture and Reintegration of Veterans H 407

ence high reintegration stress in the presence of PTSD-related symptoms and 

when the Service Member’s mental health is low.42 Stress factors associated 

with reintegration most often reported by the Service Member or his or her 

spouse include the following:

• limited access to medical care, 

• financial constraints, 

• ability to locate employment for the Service Member and/or the spouse, 

• management of chronic medical conditions sustained by the Service 

Member while on active duty, and 

• social isolation within a community that may not understand 

military culture.

Ta b le 16-1. Barriers/Strategies for Military Family Reintegration

BARRIERS STRATEGIES/RECOMMENDATIONS

Limited access to medical care • Consider residing in a location that is within driving 

distance to a major military hospital or VA medical center

Financial constraints • Identify states that do not tax military retirement—

Service Members who retire from the military

• Consider transferring GI Bill benefits to college-age 

children

• Use VA housing benefits to finance a home

Locating employment • Know that the Service Member and his or her spouse 

may be eligible to use the GI Bill to obtain a degree or 

an additional degree

• Be aware that hiring preferences exist for Service Members and some spouses within the federal government 

service employment system

Existing medical conditions 

(psychological/physical)

• Ensure that all medical conditions are revealed prior to 

separation from the military

• Receive ongoing care and support of all conditions and 

advocate for additional support from the VA for any 

service-related conditions that surface postseparation

Social isolation • Remain in contact with military-related friends through 

social media, phone, e-mail, and/or visits

• Connect with other military-affiliated families in the community

• Participate in community-based activities through church, 

school, or work

 VA: US Department of Veterans Affairs
408 H Promoting Successful Integration

THE ROLE OF CULTURE IN PROMOTING 

SOLDIER REIDENTIFICATION AS A HEALTHY CIVILIAN

Resilience (the ability to bounce back from or be insulated from adversity), 

social capital (viable social networks), and reintegration (resuming civilian life 

in a complete and healthy manner) are important and interwoven concepts 

in the lives of Service Members attempting to successfully reenter civilian 

society. Reentry requires successful reidentification from a Service Member to 

a healthy Veteran/civilian member of American society and consists of three 

dimensions:

1. the role of culture in becoming a Service Member, 

2. the natural and multiple stressors that occur as one moves from the role 

of Service Member to Veteran, and 

3. the role of culture in facilitating a smooth transition back to civilian life. 

This three-dimension experience is one wherein culture plays a pivotal role in 

assisting the former Service Member to become successfully reidentified as a 

healthy civilian.

The process of becoming a Service Member, especially in the early stages 

of basic training, arguably is intended to mute the cultural identities of individuals who have entered the military and amplify the culture of becoming 

and being a Service Member. Thus, the prime objective of a Service Member 

is to become a well-trained fighting machine in which personal autonomy 

and unique manifestations of personality and self-concept are not allowed to 

interfere with receiving orders and executing the primary mission of successful combat. Therefore, when an individual enters the military and begins to 

assume the identity of a Service Member—thus replacing his or her former 

cultural orientation as a unique individual (a civilian) with that of a Service 

Member—this is an intentional process. 

When a Service Member has completed the active duty mission and resumes life as a Veteran/civilian, there are several stressors that typically present 

themselves as barriers to the process of successfully transitioning back to nonmilitary life, such as medical issues, financial challenges, psychological/emotional adjustments, and social concerns. There is typically a multiplier effect 

among these countervailing demands/stressors as depicted in Figure 16-1. The 

problem is that the magnitude of these combined demands and stressors can 

have a synergistic negative effect on the Service Member attempting reentry 

into society. To successfully navigate these multiple demands, the Service Member must embrace a cultural identity that can match the demands. Sometimes, 
Culture and Reintegration of Veterans H 409

the former identity as a Service Member can manage the demands effectively, 

and sometimes the Veteran needs to embrace a new cultural identity to match 

the multiple demands of this new environment. Keep in mind that formerly the 

military provided a homogenous milieu that addressed medical care, financial 

remuneration, psychological and emotional self-concept, as well as social capital needs, and all within the self-contained military installation community.

In Figure 16-1, the soldier is being encroached on by four competing 

stressors: (1) medical issues, (2) social concerns, (3) psychological/emotional 

adjustments, and (4) financial challenges. Essentially, the identity of being 

a combat Service Member (ie, old identity) does not help when successfully 

navigating the demands of the new civilian context. The solution is for the 

Service Member to engage in a systematic and intentional process of reidentification to regain a multifaceted cultural identity that will successfully match 

the dimensions of American society. As this happens, the individual’s resilience improves, as does the social capital, and, ultimately, the reintegration 

process will be well underway. 

At the core of the reidentification process is the whole-person model by 

Wegscheider-Cruse.43 She proposes a six-dimensional whole-person concept 

in the context of helping individuals in their recovery from alcoholism to 

successfully reenter a life of sustained sobriety. We are not comparing recovery from alcoholism to the reintegration process for a Veteran. However, the 

Wegscheider-Cruse model has been applied to the population of persons with 

alcoholism. Thinking more generally about this whole-person model and the 

process of adjusting to civilian life, the model offers concrete dimensions for 

consideration. The six dimensions of this model are 

Fi g u re 16-1. Multiple Demands on Soldiers Attempting to Reenter 

American Society.

Medical Issues

SOLDIER WITH

OLD IDENTITY

Financial Challenges

Psychological/Emotional

Adjustments Social Concerns
410 H Promoting Successful Integration

1. physical, 

2. mental, 

3. emotional, 

4. social, 

5. spiritual, and 

6. volitional. 

Much like what Wegscheider-Cruse proposed for persons recovering from 

alcoholism (in the context of reintegrating Veterans), still the goal would be to 

have each returning Service Member commit to an explicit process of identifying at least one asset in each of the six dimensions and then devote constant 

attention to a regime of personal development in those areas. The asset in 

each dimension would serve as a positive foundation on which to build out 

and continue to develop. As development transpires, the Service Member 

evolves toward a new cultural orientation in all six dimensions.43

Over time, this process of building assets, growing cultural identity, 

and accomplishing personal development in each of the six dimensions will 

lead the Service Member to a new identity as a civilian. Thus, the civilian 

endeavors to function to full personal potential physically, mentally, emotionally, socially, spiritually, and volitionally. As this occurs, the individual will 

automatically become more resilient from having assets and a new identity 

in each of the six dimensions that serve as natural insulation to adversity. 

With the person developing a social dimension, the construction of social 

capital will also be underway. Work on the whole person in each of the six 

dimensions will lead to a new identity as a former Service Member. Thus, 

this Veteran/civilian is now on his or her way to developing a new and full 

cultural existence. The Service Member’s work in each of the six dimensions 

of the whole person becomes a new identity. Therefore, a beginning cultural 

orientation (eg, values, beliefs, preferences, and worldview) assists the individual in becoming fully functional in American society, with a stronger sense 

of reintegration, resiliency, and growing social capital. 

SUMMARY

In this chapter, we discussed the role of culture in the reintegration of Veterans. Adequately addressing the full scope of a broad concept such as culture 

in one chapter is a tall order. Nevertheless, we have attempted to do so, and 

in so doing have touched on many important aspects of culture in the United 

States and how those aspects intersect with the experience of being a Veteran 
Culture and Reintegration of Veterans H 411

while attempting to successfully reenter civilian society. We have defined the 

concept of culture, discussed the overarching role that culture plays in the 

pluralistic US landscape, and introduced the salient dimensions of culture that 

must be considered when working with Veterans. The chapter concludes with 

a recommended process that can assist the Veteran in effectively reentering 

civilian society through identification of a holistic set of personal assets that 

form the basis for developing a new civilian cultural identity.

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414 H Promoting Successful Integration

Pet t y Of f i cer 3r d Cl ass

Al K o va c h , in 1983, was a 

heavily recruited high school AllAmerican swimmer who chose 

Indiana University for its decadeslong reputation as a swimming 

powerhouse. Legendary swim 

coach Dr James E. Counsilman 

instilled character traits associated 

with Olympic-class athletes, 

such as resilience, teamwork, 

selflessness, and patriotism. 

Possessing such characteristics 

might explain why Kovach joined the Navy in 1988 and volunteered for 

what is recognized by experts as the toughest military training in the world: 

Basic Underwater Demolition/SEAL training (also known as BUD/S). 

Kovach pushed through the physical, mental, and emotional challenges of 

BUD/S and, following graduation, was assigned to SEAL Team 5 located in 

Coronado, California. However, his career was cut short in 1991 while on a 

combat training exercise. Kovach broke his neck in a parachuting accident 

that resulted in permanent paralysis from his chest down. 
Culture and Reintegration of Veterans H 415

While hospitalized, Kovach 

received a visit from the Paralyzed 

Veterans of America (PVA), an 

organization that helped him secure 

the VA benefits he earned as a result 

of his military service. Benefits also 

included a housing grant to make 

his home wheelchair accessible, a 

vehicle that was adapted with hand 

controls, and access to a lifetime 

of quality healthcare.

Kovach’s first employment position 

following his paralysis was as 

PVA’s Government Relations 

Director in San Diego, California. 

The Americans with Disabilities 

Act was passed in 1990 and gave 

a voice to 45 million people. It 

was an exciting time to be in 

Kovach’s position. However, after 

much contemplation, he chose to go back to his athletic roots and began 

competing in races. 

His first competition was in 1994, and he won four Gold Medals at the 

National Veterans Wheelchair Games. Kovach went on to become a 

member of the 1996 US Paralympic Team and subsequently won multiple 

national titles and set many records on the track.

Kovach quickly transitioned from the track to the road. Not only did he 

win prestigious races—including the Los Angeles Marathon in 1996 and 

1997—but he also expanded his repertoire to include hand-cycling and 

triathlons. He claimed victories in places as far from home as Australia. 

With a “been there, done that” attitude, Kovach looked for a greater 

challenge. Thus, in 1998, he completed a 3,700-mile triathlon that began 

in Los Angeles and ended 65 days later in New York City. In recognition 
416 H Promoting Successful Integration

for his athletic accomplishments, Kovach was honored by the San Diego 

Hall of Champions as the Disabled Athlete of the Year in 1999. 

Multiple injuries have sidelined Kovach’s ability to continue competing 

in triathlons and marathons, but his need for speed endures in many 

incarnations. He now competes in motorsports and continues to be 

instrumental in creating adaptive sports programs for children with 

disabilities. 

Kovach recently played a role in putting together a team of paralyzed 

Veterans, SCUBA professionals, and medical researchers to conduct a pilot 

study to explore the neurological, psychological, and pulmonary effects 

of SCUBA on people with spinal cord injury and disease (SCI/D). The 

remarkable results were documented in a film titled Sea of Change.

In recent years, Kovach has chosen to repurpose his skills and abilities, thus 

turning his attention to supporting his fellow paralyzed Veterans. In 2014, 

Kovach was elected National President of PVA. As the face and voice of 

20,000 Veterans with SCI/D, Kovach has an enormous responsibility that 

he does not take lightly. After all, it took PVA 70 years to create its stellar 

reputation as the premier Veterans service organization that is the sole 

advocate in the realm of healthcare, benefits, research, and civil rights for 

Veterans with SCI/D. Using the traits and skills learned from his days as a 

Navy SEAL, Kovach is now leading PVA on a trajectory for success.
There is nothing more gratifying than to care for 

these wounded, ill, and injured heroes.

H H H

Lieutenant General Eric Schoomaker

Commander, US Army Medical Command

US Army Surgeon General

Congressional Testimony

April 21, 2010

C h a p ter Seve n tee n

Summary 

RORY A. COOPER, PhD*

*

Director and Senior Career Scientist, Human Engineering Research Laboratories, Rehabilitation Research and Development Service, US Department of Veterans Affairs, 

6425 Penn Avenue, Pittsburgh, Pennsylvania 15206, and Distinguished Professor and 

FISA Foundation–Paralyzed Veterans of America Chair, Department of Rehabilitation Science and Technology, University of Pittsburgh, 6425 Penn Avenue, Suite 400, 

Pittsburgh, Pennsylvania 15206

INTRODUCTION

We must also remember that conflict is a human endeavor, 

ultimately won or lost in the human domain. 

The Army operates in the human domain which is the

most important factor in a complex environment.

General Raymond T. Odierno

US Army, Chief of Staff

(2011–2015)

There is an understanding gap between American society and the 

population serving within the military and Veterans. Less than 1% 

of Americans are serving in uniform, and about 6% of the American 

population are Military Veterans. This creates challenges for Service Members 

and Veterans when reintegrating. Although most people are supportive of 

Service Members and Veterans, they often do not know how best to assist 
420 H Promoting Successful Integration

or translate military experience into successful civilian careers. This makes it 

important for Service Members and Veterans to be resilient and to assist each 

other with successful reintegration.

RESILIENCE

Planning and effort are required to instill the resilience needed for successful reintegration. Building resilience for successful reintegration, either back 

into the military service or the civilian community as a successful Veteran, is 

a multidimensional process. Personal resilience is essential for successful reintegration. Resilience is multidimensional and consists of physical, cognitive, 

social, and spiritual factors.

Too much stress of any kind can negatively impact a person’s resiliency, 

health, memory, attention, and creativity. Some of the best ways to beat stress 

include exercising, eating right, getting adequate sleep, having social support 

through family and friends, and maintaining an optimistic outlook. Resilient 

people take care of themselves so that they can attack the challenges that face 

them. Building physical resilience through exercise and a healthy diet can have 

a positive impact on other components of resilience, especially the physical and 

mental elements. For example, exercise can improve brain function. Exercise 

has been shown to improve attention, processing speed, executive functions 

(eg, planning and organizing), memory, creativity, and flexibility in thinking. 

Only 20 to 35 minutes of aerobic exercise per day can have a positive effect. 

Maintaining a balanced diet and promoting a healthy body weight not only 

benefits resilience, but also slows cognitive declines associated with aging.

REINTEGRATION

Self-awareness is key to building resilience and to successful reintegration. 

Self-awareness links the complex interplay between leadership, readiness, 

fitness, and human performance. There are multiple aspects of successful 

reintegration, including:

• physical and mental health;

• connectedness through positive and supportive relationships with family 

and/or friends;

• financial stability; and 

• a sense of making meaningful contributions to home, work, or society. 
Summary H 421

The support of organizations, family/friends, and members of the broader 

community—whether military or civilian—can play a large role in successful reintegration. Service Members and Veterans must recognize that they do 

not need to face the challenges of reintegration on their own, and should rely 

on their training and experiences to reach out to and connect with trusted 

individuals and organizations that will help them to succeed. 

Many military and Veterans service organizations (VSOs) provide valuable assistance, with a wide array of programs to assist Service Members 

and Veterans with reintegration. Most organizations do not charge for their 

services. There are a number of VSOs that offer a variety of services and 

programming. Some Veterans are active in multiple organizations, and some 

Veterans are not interested in any. In any case, it is worthwhile to contact 

different VSOs and learn about them. These organizations can help Veterans 

connect to other Veterans, provide recreation and service activities, and assist 

with employment. This can help with reintegration and also provide a social 

network to strengthen resistance.

Many employers and colleges provide Veterans with assistance in successful reintegration. Veteran-friendly employers and colleges have offices that 

provide assistance with applying for positions or enrolling in college. Often, 

civilian employers have little experience with the military or Veterans and are 

unsure of how to translate military experiences into civilian job requirements. 

There are services to help Veterans create civilian-style resumes. However, 

greater success in securing employment is likely when the company has a 

Veterans employment specialist within the human resources department or 

has Veterans on the team with hiring authority.

There are likewise many colleges and universities with small student 

populations who are Veterans, and these organizations may not be aware of 

the knowledge gained through military schools and hands-on experiences. 

This may place Veterans at a disadvantage for admissions and for receiving 

course credit for prior experience and training. Veteran-friendly colleges and 

universities typically have an office of Veterans services and may have a chapter of the Student Veterans of America. Some of the services that are particularly beneficial include the following:

• transition assistance programs (eg, access to Veterans benefits, math, and 

writing skills building, study habits, campus resources), 

• counseling and tutoring services, 

• Veterans scholarships,

• summer internships with research laboratories and/or industry, and 

• placement assistance. 
422 H Promoting Successful Integration

Community colleges are often a good starting point, especially because they 

may be close to home, offer lower costs, and provide greater flexibility. If the 

goal is to pursue a 4-year degree or advanced degree, it is important to select 

a community college with matriculation agreements to 4-year colleges.

Employment with or without a college degree can lead to a fulfilling career 

and greater financial security. However, financial security also requires planning and commitment. Creating and following a budget requires discipline. 

As a tool, a budget can help to prepare for

• unforeseen circumstances, 

• long-term goals (eg, purchasing a home, paying for children’s college), 

• short-term goals (eg, planning for a vacation, purchasing/replacing an 

appliance), and

• balancing necessary expenditures (eg, food, housing, utilities, transportation) and discretionary spending (eg, entertainment, dining out). 

Managing life balance is important to achieving success and happiness at 

work, at home, and in the community.

It is important to find healthy and healing pursuits (eg, art, travel, sports, 

etc). Life is more pleasant when it includes activities that an individual enjoys, and it is even more so when these lead to improved physical and mental 

health. People have many preferences about the types of activities that they 

enjoy. Those activities that include families and friends are often more enjoyable and encourage people to participate for many years. It is important to 

incorporate healthy pursuits, especially physical activity, into our daily routines. Regular aerobic exercise, especially when involved in an activity that one 

enjoys, can have significant influence on a person’s physical and mental health.

SOCIAL NETWORKS

It is difficult to live in isolation, and the lack of a strong social support system 

can lead to depression and poor health. People who have strong social networks tend to be happier, healthier, and have greater satisfaction with work, 

home life, and their role with family, friends, and the community. A strong 

social network does not necessarily equate to a large social network. A strong 

and supportive relationship with a few close friends and/or family members 

can be very effective.

A strong social network is an important component of resiliency. Having 

people who can be relied on to assist in times of challenges or even during a 
Summary H 423

crisis can provide individuals with the confidence to take healthy risks (eg, 

form new relationships, seek a promotion or a better job, buy a house, or 

attend college). Close friends and family, especially those with shared experiences and values, who live positive lifestyles, are important to help address 

problems, answer questions, and make improvements in one’s self, relationships, and community. Social networks are also key to finding a satisfying 

career after serving in the military. Most people learn of and attain career 

positions and skills through their networks of friends who make connections 

that lead to appropriate positions that provide opportunities for professional 

growth. Personal connections can help to overcome the hurdles often faced 

by Veterans. People who have not served in the military or who may not be 

familiar with military service may have difficulty interpreting the Veteran’s 

skills and how these skills match to key elements of a position. A Veteran in 

the organization may be able to help with this issue.

CONNECTION AND SUPPORT

For Service Members or Veterans with disabilities, it is important to remain 

connected with a specialized team of medical professionals and to participate in regular check-ups. The standard recommendation is annually once a 

person is living within his/her home community. The Department of Veterans 

Affairs (VA) maintains a number of specialty clinics and clinical care teams 

to serve Veterans with limb amputations, spinal cord injuries, polytrauma, 

posttraumatic stress disorder, vision loss, hearing impairments, etc. The VA is 

a proponent for the concept that “rehabilitation is a life-long process.” Some 

military treatment facilities also support this premise. It is important to enroll 

for VA care if and when eligible. Physical, cognitive, and sensory impairments 

are seldom static, and changes over time may be compensated for through 

advances in technology, new medications, and periodic reinforcement of 

therapeutic interventions (eg, counseling, physical therapy, and occupational 

therapy). At the very least, Service Members and Veterans with disabilities 

who use assistive devices should remain in contact with their clinical team to 

remain aware of advances in technology that may help to improve function, 

comfort, and performance.

Veterans have a long tradition of being engaged in their communities 

and providing support for worthy causes. In many cases, Veterans are pillars 

of their communities and apply the skills and experiences that they gained 

while serving in the military to improve their communities as Veterans. Being 

engaged in their communities is an obligation that Veterans should accept to 
424 H Promoting Successful Integration

contribute toward supporting the needs of Veterans who are less capable of 

advocating for themselves, to contribute to the understanding of the general 

public of military service, and to help build inclusive communities where 

everyone is valued and respected. Veterans of each generation have worked 

to improve the lives of their successors. The concept of “paying it forward” is 

important within the Veteran community and helps to ensure that challenges 

faced by one generation are reduced for subsequent generations.

SUCCESSFUL REINTEGRATION AND RESILIENCY

Successful reintegration and resilience are multifactorial. Ultimately, each 

Service Member and Veteran must set and assess their personal goals. However, some metrics are generally accepted as measures of progress:

• employment (either paid or volunteer); 

• stable, healthy relationships with others; 

• frank assessment of oneself and accurate interpretation of 

perceptions of others; 

• physical and mental health; 

• spiritual centering; 

• ability to withstand change and adversity; and 

• making positive contributions.

Building resilience and successfully reintegrating into society may be challenging, especially when not connected to other mutually supportive people 

with common interests and values. In a notable number of cases, Service 

Members and Veterans view their lives as being better posttrauma. The concept of posttraumatic growth relates to having an adversity-building character 

and forging a physically and mentally stronger Service Member or Veteran. 

A significant number of Service Members and Veterans with severe injuries, 

such as limb amputations or paralysis due to spinal cord injuries, often find 

new and rewarding outlets for their talents and discover strengths that they 

were previously unaware that they had. There are numerous examples, some 

illustrated in this book, wherein Service Members and Veterans translated 

adversity into advantage, and transformed their lives and those of their communities through sports, education, entertainment, and employment. 
Summary H 425

Sta f f Ass i sta n t t o t h e

Sec reta ry o f t h e Ar m y, 

US Ar m y Ca p ta i n

(Ret i red) Mat t h ew A. 

Stat o n was born in Madison 

Heights, Virginia, and enlisted 

in the Virginia National Guard 

as a Simultaneous Membership 

Program (SMP) cadet with the 

29th Infantry Regiment in 1998 

while attending Virginia Military 

Institute for one year. Following 

graduation, he enlisted as an 

infantryman (11B) in the US Army. Matthew was stationed in Vicenza, 

Italy, with the 1st Battalion, 508th Infantry Airborne Combat Team before 

deciding it was time to pursue a different path in the military. After serving 

3 years of active duty, Matt attended Officer Candidate School and was 

commissioned in September 2002. 

Staton traveled to Fort Carson, Colorado, for his first duty assignment after 

becoming a Second Lieutenant. He deployed to Iraq in July 2003 as the Rifle 

Platoon Leader of Charlie Company, 1st Battalion, 8th Infantry Regiment. 

During his deployment, Matt was exposed to multiple IEDs (improvised 
426 H Promoting Successful Integration

explosive devices), resulting 

in a mild traumatic brain 

injury, as well as sustaining 

a gunshot wound to the leg. 

He continued to serve and 

recover in multiple roles with 

the 1-8th Infantry, culminating 

in commanding the battalion’s 

rear detachment while the 

unit deployed back to Iraq 

(2005–2006).

In August 2007, Staton returned to Virginia after completing the Army’s 

Physical Disability Evaluation System and being medically retired from 

the Army. In September 2007, Matthew began his current service as a 

Department of the Army civilian and as a direct Advisor/Staff Member to the 

Secretary of the Army for Ill, Injured, and Combat Wounded Soldiers. 

In the years following Matthew’s deployment, he and his family learned 

to cope with the impact of mild traumatic brain injury and posttraumatic 
Summary H 427

stress disorder, two invisible 

injuries of war along with 

the physical injuries he 

sustained from combat. 

He has since become 

a Professional Alpine 

Disabled Ski Instructor, a 

Professional Association of 

Diving Instructor (PADI), 

and a Handicapped SCUBA 

Association buddy for 

individuals with disabilities. 

He also holds a PADI 

Master Scuba Diver rating. 

Matthew currently volunteers with multiple organizations that support 

people with disabilities. He is married to Jennifer Staton, has a 10-year-old 

daughter Samantha, and lives in Fredericksburg, Virginia.

Matthew Staton’s decorations include the Superior Civilian Service Award, 

Army Staff Badge, Combat Infantryman Badge, Expert Infantryman 

Badge, US Airborne Wings, Tunisia Airborne Wings, Hungarian Airborne 

Wings, Bronze Star Medal with Valor, Bronze Star Medal, Purple Heart, 

four Army Commendation Medals, five Army Achievement Medals, Army 

Good Conduct Medal, Army Reserve Components Achievement Medal, 

Iraq Campaign Medal, Global War on Terrorism Expeditionary Medal, 

Global War on Terrorism Service Medal, NCO (noncommissioned officer) 

Professional Development Ribbon, Army Service Ribbon, two Overseas 

Service Ribbons, and the NATO (North Atlantic Treaty Organization) 

Medal (Kosovo).

 

Acknowledgments

Ma n y pe o p le p r o v i ded g u i d a n ce, a d v i ce, a n d ass i sta n ce in 

the conceptualization and preparation of this book. The tremendous dedication, selfless service, and commitment to excellence exhibited by the men 

and women in the Armed Services, Military Veterans, and their families have 

provided inspiration. 

The following people deserve to be recognized for their contributions, 

motivation, inspiration, guidance, or leadership: Honorable Jessica Wright, 

Honorable Lynda Davis, Honorable John McHugh, GEN Joseph Dunford, 

GEN(Ret) James Amos, GEN(Ret) Michael Haige, LTG(Ret) Eric Schoomaker, LTG Patricia Horoho, LTG Gary Cheek, VADM Matthew Nathan, 

MG Darryl Williams, Mr. Thomas Webb, COL Chris Toner, COL Danny 

Dudek, Col. Willy Buhl, COL (Ret) John Mayer, COL (Ret) Gregory Boyle, 

SgtMaj(Ret) Joseph VanFonda, CSM Ly Lac, BG Novell V. Coots, MG John 

Gronski, SMA(Ret) Ken Preston, SMA(Ret) Jack Tilley, SMA(Ret) Raymond 

Chandler, SgtMaj Ronald Green, CAPT William B. Adams, Dr. Alice Aiken, GySgt(Ret) James Joseph, GySgt(Ret) Matt Hannan, CSM(Ret) Althea 

Dixon, MG(Ret) Anthony Cucolo III, COL(Ret) Barbara Springer, CSM(Ret) 

Benjamin Scott, BG Patrick Sargent, Maj.(Ret) Brian Bilski, COL Christopher Boyle, Mark Campbell, Casey Fisher, COL David Bair, COL Frank 

Frazier, COL Matthew St. Laurent, COL Colin Greene, Dan Pulz, LTC David 

Rozelle, CSM David Davenport Sr., Debbie M. Paxton, LtGen(Ret) Doug 

Robb, Ellyn Dunford, CSM Eugene B. Chance, GEN Frank Grass, GEN(Ret) 

Frederick Franks, MAJ George Smolinski, COL(Ret) Greg Gadson, COL 

Craig Trebilcock, Honorable Jack Farley, Honorable James D. Rodriguez, 

COL(Ret) Jim Ficke, Jim Marszalek, BG John Cho, Col.(Ret) John Hugya, 

Karen Guenther, Dr. Ken Lee, Lonnie Moore, CAPT Louis Tripoli, LtCol 

Joseph Allena, LtCol Leland Suttee, LTG Michael Tucker, MajGen Michael 

Lehnert, CSM(Ret) Malcolm D. Parrish, CSM(Ret) Mark Dennis, Matthew 

Staton, CSM Matthew Brady, Megan Andros, SgtMaj Michael T. Mack, 

LTC(Ret) Mike Richardson, MSgt Benjamin Fender, Lt. Nathan Bastien, 

RADM(Ret) Clarke Orzalli, LTC Paula Smith, SgtMaj(Ret) John Ploskonka, 
430 H Acknowledgments

RADM Joan Hunter, MG(Ret) Richard Stone, BG(Ret) Rick Gibbs, Rocky 

Bleier, Ron Drach, Seamus Ahern, SgtMaj(Ret) Karlton Kent, Dr. Stephanie 

Belanger, Stephen Tomlin, MajGen T. S. Jones, Tammy Peppe, Tracey 

Koehlmoos, COL(Ret) John Shero, COL(Ret) Chuck Scoville, CSM(Ret) 

Jesu Febo-Colon, Cpl(Ret) Artem Lazukin, CSM(Ret) Bob Gallagher, 

COL(Ret) Timothy Karcher, Ken Ductor, William R. Cole, and SgtMaj 

Michael P. Barrett.

All of the authors, editors, and the team at the Borden Institute have 

earned the most heartfelt “thank you” from the editors, Dr. Cooper, 

Dr. Pasquina, and D. A. Etter.

Furthermore, all the Service Members and Veterans who contributed 

their stories to this book deserve special recognition because they serve as 

examples to all of us that adversity can be transformed into positive growth 

and lead to a “new normal” that can be rewarding and fulfilling. 
Acronyms and Abbreviations 

ABS acrylonitrile butadiene styrene

ACE Ask, Care, Escort

ACV actual cash value

ADA Americans with Disabilities Act

ADAPT After Deployment: Adaptive Parenting Tools

ADL activities of daily living

ADRC Aging and Disability Resource Centers

AIA American Institute of Architects

AIM Advancing Inclusive Manufacturing

APA American Psychiatric Association

AT assistive technology

ATM automated teller machine

BG Brigadier General

BLS US Bureau of Labor Statistics

BUD/S Basic Underwater Demolition/SEAL training

CAF Challenged Athletes Foundation

CAPT Captain

CAREN Computer-Assisted Rehabilitation Environment

CART Communication Access Realtime Translation

CBT cognitive behavioral therapy

CD Certificate of Deposit

CHAMP Consortium for Health and Military Performance

CIL Center for Independent Living

CO Commanding Officer

COL/Col. Colonel

Cpl Corporal

CRSC Combat-Related Special Compensation

CSM Company Sergeant Major

CT coping training

d depth

DADT don’t ask, don’t tell

DCUs desert camouflage uniform

DEOMI Defense Equal Opportunity Management Institute
432 H Acronyms and Abbreviations

DoD Department of Defense/US Department of Defense

DOL US Department of Labor

EBV Entrepreneurship Bootcamp for Veterans

ELeVATE Experiential Learning for Veterans in Assistive 

Technology and Engineering

EPW electrical powered wheelchair

ETS Expiration of Term of Service

FMLA Family Medical Leave Act

FSB Forward Support Battalion

FSSG Force Service Support Group

GEN General

GPS Global Positioning System

GySgt Gunnery Sergeant

H2H Hero2Hired

HERL Human Engineering Research Laboratories

HOH Hiring Our Heroes

IAHP International Association of Hygienic Physicians

iARM intelligent Assistive Robotic Manipulator

ICF International Classification of Functioning, Disability, and Health

IED improvised explosive device

IMES implantable myoelectric sensor

IMPACT Injured Military Pursuing Assisted Career Transition

IRA Individual Retirement Account

ISO International Organization for Standardization

IUD intrauterine device

IVMF Institute for Veterans and Military Families

JAWS Jobs Access With Speech

Lt. Lieutenant

LTC/LtCol Lieutenant Colonel

LTG/LtGen Lieutenant General

MAJ/Maj. Major

MajGen Major General

MA2R*INES3 Mission, Accountability and Attitude, Responsibility, 

Integrity, Nourish, Energy, and Synergy/Strive/SMEAC

MBA master’s degree in business administration

MeBot Mobility Enhancement Robotic wheelchair

MEDCOM medical communications

MEPS Military Entrance Processing Station

mFLC Military and Family Life Counselor
Acronyms and Abbreviations H 433

MG Major General; medial gastrocnemius

MHS Military Health System

MSgt Master Sergeant

NAMI National Association for Mental Illness

NATO North Atlantic Treaty Organization

NCIL National Center for Independent Living

NCO noncommissioned officer

NDVWSC National Disabled Veterans Winter Sports Clinic

NVWG National Veterans Wheelchair Games

OEF Operation Enduring Freedom

OIF Operation Iraqi Freedom

OT occupational therapist

OWF Operation Warfighter

PADI Professional Association of Diving Instructors

PerMMA Personal Mobility and Manipulation Appliance

PFC Private First Class

POW prisoner of war

PSF power seating function

PT physical therapy; physical training

PTSD posttraumatic stress disorder

PV2 Private Second Class

PVA Paralyzed Veterans of America

PVC polyvinyl chloride

QRMC Quadrennial Review of Military Compensation

RADM Rear Admiral

RAND RAND Corporation

RESNA Rehabilitation Engineering and Assistive Technology 

Society of North America

RIPS Religious Identification and Practices Survey

ROTC Reserve Officers’ Training Corp

RTD return to duty

SAH Specially Adapted Housing

SCAADL Special Compensation for Assistance with 

Activities of Daily Living

SCI spinal cord injury

SCI/D spinal cord injury and disease

SCUBA Self-Contained Underwater Breathing Apparatus

SEG stable exercise group

SES socioeconomic status

SFL-TAP Soldier for Life-Transition Assistance Program

SGLI Servicemembers Group Life Insurance
434 H Acronyms and Abbreviations

SGT Sergeant

SgtMaj Sergeant Major

SMA Sergeant Major of the Army

SMART specific, measurable, attainable, realistic, and time-bound (goals)

SMEAC Situation, Mission, Execution, Administration, 

and Communication

SS Schutzstaffel

SUV sports utility vehicle

SVA Student Veterans of America

TA tibialis anterior

TAP Transition Assistance Program

TBI traumatic brain injury

3D three-dimensional

TRADE Transforming Resources for Accelerated Degrees and Employment

TRAS Three Rivers Adaptive Sports

USA United States of America

USABA US Association of Blind Athletes

USMC US Marine Corps

USO United Service Organization

VA Department of Veterans Affairs/US Department of Veterans Affairs

VADM Vice Admiral

VAULT Value, Accept, Understand, Love, and Trust

VE virtual environment

VEAP Veterans Educational Assistance Program

VEOA Veterans Employment Opportunity Act

VFI Volunteer Functions Inventory

VFW Veterans of Foreign Wars

VGLI Veterans Group Life Insurance

Voc Rehab Vocational Rehabilitation and Employment

VR virtual reality

VR&E Vocational Rehabilitation and Employment

VREG virtual reality exercise group

VRET virtual reality exposure therapy

VSC Virtual Seating Coach

VSO Veterans Service Organization

w width

WASUSA Wheelchair Ambulatory Sports, USA

WHO World Health Organization

WTC Warrior Transition Command

WTL Warrior Transition Leader

WTU Warrior Transition Unit

WWP Wounded Warrior Project
Suggested Reading List

Aiken AB, Belanger AH, eds. Beyond the Line: Military and Veteran Health Research.

Kingston, Ontario, Canada: McGill-Queen’s University Press; 2013.

Aiken AB, Belanger AH, eds. Shaping the Future: Military and Veteran Health Research. Kingston, Ontario, Canada: Canadian Institute for Military and Veteran 

Health Research, Canadian Defense Academy Press; 2011.

Ainspan ND, Penk WE, eds. When the Warrior Returns: Making the Transition at 

Home. Annapolis, MD: Naval Institute Press; 2012. 

Anderson B, Mack D. No Turning Back. New York, NY: Berkeley Publishing Group; 

2011.

Armstrong K, Best S, Domenici P. Courage After Fire: Coping Strategies for Troops 

Returning from Iraq and Afghanistan and Their Families. Berkeley, CA: Ulysses 

Press; 2006.

Cifu DX, Lew HL. Handbook of Polytrauma Care and Rehabilitation. New York, 

NY: Demos Medical; 2014.

Cleland M, Raines B. Heart of the Patriot: How I Found the Courage to Survive 

Vietnam, Walter Reed, and Karl Rove. New York, NY: Simon & Schuster Paperbacks; 2009.

Cody V. Your Soldier, Your Army. Arlington, VA: The Institute of Land Warfare, Association of the US Army; 2005.

Condeluci A. The Essence of Independence. Rock Hill, NY: Irwin Siegel Agency, Inc.; 

2000.

Cucolo G. Dog Tags: The History, Personal Stories, Cultural Impact, and Future of 

Military Identification. Cleveland, GA: Allen House Publishing; 2011.

Daugherty SJ, ed. Profile of the U.S. Army: A Reference Handbook. Arlington, VA: 

The Association of the United States Army; 2014.

Downs DA, Ilia Murtazashvili I. Arms and the University: Military Presence and the 

Civic Education of Non-Military Students. Cambridge, MA: Cambridge University Press; 2012.
436 H Suggested Reading Li st

Finkel D. Thank You for Your Service. New York, NY: Random House Publishing; 

2013. 

Future Warfare Division, Army Capabilities Integration Center. Army Innovation: 

First Principles and Supporting Essays, Unified Quest—Win in a Complex 

World. Fort Eustis, VA: US Army Training and Doctrine Command; 2015.

Headquarters, Department of the Army. Leadership Development. Washington, DC: 

DOA; 2015. Field Manual FM 6-22.

Institute for Veterans and Military Families, Syracuse University. Guide to Leading 

Policies, Practices & Resources. New York, NY: Syracuse University; 2012.

Klein SD, Kemp JD, eds. What Adults with Disabilities Wish All Parents Knew: Reflections from a Different Journey. New York, NY: McGraw-Hill Books; 2004.

Lincoln A. Second Inaugural Address, March 4, 1865. Washington, DC: The Abraham Lincoln Papers at the Library of Congress, 1837–1897.

Linker B. War’s Waste: Rehabilitation in World War I America. Chicago, IL: The 

University of Chicago Press; 2011.

Lynch R, Dagostino M. Adapt or Die: Leadership Principles from an American General. Grand Rapids, MI: Baker Books; 2013.

Magnuson PB. Ring the Night Bell: The Autobiography of a Surgeon. Boston, MA: 

Little, Brown and Company; 1960.

Nathan D, Ainspan ND, Penk WE, eds. Returning Wars’ Wounded, Injured, and Ill: 

A Reference Handbook. Westport, CT: Praeger Security International; 2008.

Office of Warrior Care Policy. Caregiver Resource Directory. Alexandria, VA: The Office of Warrior Care Policy; 2015.

Phillips JW, Falcone P. Boots and Loafers: Finding Your True North. Seattle, WA: 

CreateSpace Independent Publishing Platform; 2014.

Poorman C, ed. The Next Step: The Rehabilitation Journey After Lower Limb Amputation. Washington, DC: US Department of Veterans Affairs; 2012.

Rigsby S, Glatzer J. UnThinkable. Carol Stream, IL: Tyndale House Publishers, Inc.; 

2009. 

Rozelle D. Back in Action: An American Soldier’s Story of Courage, Faith and Fortitude. Washington, DC: Regnery Publishing; 2005.

US Armed Forces. The Noncommissioned Officer and Petty Officer: Backbone of the 

Armed Forces. Washington, DC: National Defense University Press; 2014.

US Army Medical Command. The Performance Triad Guide. Washington, DC: Army 

Medicine; 2015.
Index

AbilityOne, 302

Able Forces, 301, 302

Accessibility

communities, 328, 346–347

Cueing Kitchen, 65–66

housing, 254–255, 326–345

transportation, 347–349

ACE framework, 93–94

Acronyms, 431–434

ADA. See Americans with Disabilities Act

ADAPT program. See After Deployment: 

Adaptive Parenting Tools program

Adaptive driving, 46–47, 268, 348–349

Adaptive sports

benefits for successful reintegration, 204–206

creating inclusive activities, 209–210

history in rehabilitation and reintegration, 

201–203

importance in rehabilitation and reintegration, 

200–201, 203–204

maintaining healthy habits over a lifetime, 

206–208

organizations providing opportunities, 210–213

providing opportunities, 209–210

Adaptive Sports Program, 269

ADRCs. See Aging and Disability Resource Centers

Advance Sports Club Finder, 211

Advancing Inclusive Manufacturing, 314

After Deployment: Adaptive Parenting Tools 

program, 150, 160, 163

Aging and Disability Resource Centers, 255

Aid and Attendance and Housebound Pension 

Benefits, 268

AIM. See Advancing Inclusive Manufacturing

Air Force Aid Society, 288

Air Force Wounded Warrior HART Program, 302

Allergies

housing considerations, 333

Allyn, General Daniel B., 107

Alms-giving, 123–124, 131

Altruistic behavior, 121–122, 131

American Art Therapy Association, 129, 132

American Board for Certification in Orthotics, 

Prosthetics, & Pedorthics, 53, 54

American College of Sports Medicine

Position Stands, 358, 361

American Jobs Act, 301

American Legion, 386

American Psychiatric Association, 86

Americans with Disabilities Act, 208, 346

America’s Heroes at Work, 302, 306

Amos, General James F., 197

Amputation

lower extremity amputation types, 58–59

upper extremity amputation levels, 54–56

Anderson, Mike, 29

Ankles

artificial foot/ankle systems, 57–58

Antidepressants

effect on sexual functioning, 186

Anxiety disorders

role of family and friends in care and 

rehabilitation, 152–155

APA. See American Psychiatric Association

Arendt, Hannah, 119

Army Emergency Relief, 288

Army Medicine, 358

Army Reserve

reintegration of personnel, 11

ArmyFit, 362

Army’s Ready and Resilient Campaign, 8, 95

Artistic expression, 129, 132

Ask, Care, Escort framework, 93–94

Assistive technology

adaptive driving, 46–47

cognitive assistive technologies, 48–52

computer access, 47

emerging technologies, 64–72

feature matching, 50–52

importance of, 42

mobility, 43–47

orthotics, 52–53

power wheelchairs, 45

prosthetics, 53–61

seating, 43–47

super lightweight manual wheelchairs, 45–46

three-dimensional printing, 62–63

ultralight manual wheelchairs, 43–45
438 H Index

Association of Assistive Technology, 255

Association of Assistive Technology Act 

Programs, 51

Association of the United States Army, 358, 363

AT. See assistive technology

Athletic trainers, 30

Attachment

definition, 140–141

styles of, 141

Attendant care, 254

Auto insurance, 279

Automobiles

adaptive driving, 46–47, 348–349

allowance and training for adaptive 

equipment, 268, 348–349

Avanafil, 181

Back-end load funds, 278

Bathrooms

accessibility, 330–331, 335–340

bathtubs, 339–340

doors, 335

grab bar positioning, 336, 340

layout of, 330–331, 335–336

showers, 337–339

sinks, 336–337

toilets, 336–337

Bedrooms

electrical outlet placement, 345

furniture placement, 344–345

layout of, 330–331

space requirements, 344

Behavior problems

resource websites, 162–163

Behavioral health. See also Mental health

facilitating help, 157–159

Benefits

resources, 364–366

Berg, Retired Marine Corps Sergeant Baren, 

195–196

Biopsychosocial model of disability, 245

Birth control, 183–185

Birth control patch, 184

Birth control pills, 184

Blanton, Staff Sergeant Amber, 235–236

BlazeSports America, 213

Blue Star Families, 384

Body-powered prosthetic devices, 54

Brain Injury Association of America, 255

Breathing difficulties

housing considerations, 333

British Aerospace, 306

Budgets, 271–274

Buhl, Colonel Willard, 373

Bureau of Vocational Rehabilitation, 255

Captioning, 51

Caregivers

considerations for, 285–286

expenses, 285–286

financial support, 286–287

job support, 286–287

support resources, 161, 287–288

CAREN system, 31, 61, 226–227, 229

CART, 51

CBT. See Cognitive behavioral therapy

Center for Assistive Technology, 43–45

Center for Independent Living, 255

Center for the Intrepid, 53

Center for the Study of Traumatic Stress, 162

Centers for Medicare & Medicaid Services, 287

Challenged Athletes Foundation, 213

Children

family relationships and resiliency, 146–149

reactions to parent’s deployment, 143–144

resource websites, 163

strengthening parenting practices, 149–152

Cialis, 181

CIL. See Center for Independent Living

Cleland, Max, 10

Clinical Practice Guidelines, 85

Coaching into Care, 162

Cognitive assistive technologies, 48–52

Cognitive behavioral therapy, 92

Collectivism, 122

Combat-Related Special Compensation, 267

Coming Home Project, 163–164

Coming Home to Work program, 308

Communication

facilitating help for mental health issues, 

157–159

sexual health and, 189–192

Communication Access Realtime Translation, 51

Communities

accessible communities, 328, 346–347

resources, 253–256

returning to, 249–253

social capital and, 248–249

support services, 253–256

Compassion fatigue, 383–384

Complete-enclosure sockets, 56

Comprehensive Assistance for Family Caregivers, 

286–287

Comprehensive Soldier and Family Fitness 

program, 7, 94–95, 358, 362

Computer access, 47

Computer Assisted Rehabilitation Environment, 

31, 61, 226–227, 229

Computer Sciences Corporation, 306

Concentrative meditation, 117–118

Concussion Coach, 164

Condoms, 185

Connection

definition, 111–112
Index H 439

Contemplative meditation, 118

Contingency funds, 264

Contraception, 183–184

Cooking

Cueing Kitchen, 65–66

KitchenBot, 69, 70

Corporation for National and Community 

Services, 384

Counseling interventions

barriers to accessing services, 96

positive psychology, 94–96

posttraumatic stress disorder, 91–93

suicide prevention, 93–94

traumatic brain injuries, 93

Crisis Hotline, 162, 361

Crosswalk from Military to Federal 

Civilian Jobs, 308

Crouse, Private Second Class Greg, 258–260

CRSC. See Combat-Related Special Compensation

Cueing Kitchen, 65–66

Culture

community and, 248, 251–252

concept of, 396

ethnic diversity, 397

gender diversity, 397–398

Military Family, 400–401

pluralism, 396–397

racial diversity, 397

reintegration and, 396–411

religious affiliations, 398–399

role in military, 401–404

role in promoting soldier reidentification, 

408–410

sexual orientation, 398

socioeconomic status, 400

spiritual affiliations, 398–399

Cybersickness, 223

DADT. See Don’t Ask, Don’t Tell

Debt payment, 274–276

Defense Activity for Non-Traditional Education 

Support, 315

Defense and Veterans Brain Injury Center, 161, 164

Defense Centers of Excellence for Psychological 

Health and Traumatic Brain Injury, 90

Defense Centers of Excellence Outreach Center, 164

Defense Equal Opportunity Management 

Institute, 398

Dempsey, General Martin E., 21

DEOMI. See Defense Equal Opportunity 

Management Institute

Deployment Health Clinical Center, 160

Depressive disorders

role of family and friends in care and 

rehabilitation, 152–155

sexual health and, 185–187

Diabetes mellitus

use of virtual reality in therapy, 230

Diaphragms, 184

Diet

Dietary Guidelines for Americans, 358

Dietary Guidelines for Americans SuperTracker, 358

food costs, 273

grocery store accessibility, 347

Dietary Guidelines for Americans, 358, 360

Dietary Guidelines for Americans 

SuperTracker, 358, 360

Disabilities

biopsychosocial model, 245

community resources, 253–256

definition, 5

discrimination and devaluation of people with 

disabilities, 240–241

importance of connection and support, 423–424

inclusion and, 242

interdependence paradigm, 246

medical model, 242–245

self-determination and, 246–247

sexual health and, 175–176, 188–189

support services, 253–256

Disability ratings, 84

Disabled American Veterans, 203, 386

Disabled Sports USA, 212

Disabled Veterans’ Rehabilitation Act, 296

DoDVets, 302

Domitrovich, Private First Class Steve, 103–106

Don’t Ask, Don’t Tell, 397, 398

Driving, adaptive, 46–47, 268, 348–349

Driving rehabilitation

use of virtual reality, 228

Dunford, General Joseph F., Jr., 219

EARN, 301, 302

Easter Seals, 387

eBenefits, 266, 365

EBV. See Entrepreneurship Bootcamp for Veterans

Education and Employment Initiative, 161

Education and training

8 Keys to Success, 310

Experiential Learning for Veterans in Assistive 

Technology and Engineering, 310–312

guidelines for colleges and universities, 309–310

history of veterans’ education, 296–298

legislative backing, 299–300

Montgomery GI Bill, 269, 297–298

Post 9/11 GI Bill, 269, 298–299

resources, 161

8 Keys to Success, 310

Elbow disarticulation prosthetic devices, 55

Electrical powered wheelchairs, 67–68, 229

ELeVATE. See Experiential Learning for Veterans in 

Assistive Technology and Engineering

Elizabeth Dole Foundation, 284

Emergency funds, 264

Emergency savings, 276

Emerging technologies, 64–72
440 H Index

Employer Assistance and Resource 

Network, 301, 303

Employer-sponsored plans, 277

Employment

federal sector initiatives, 307–308

legislative backing, 299–301

low-intensity programs, 302–303

new opportunities, 305–308

private sector initiatives, 306–307

resources, 161, 366–368

unemployment rates, 299, 300

Vocational Rehabilitation and Employment 

program, 269

Entrepreneurship Bootcamp for Veterans, 302, 

312–313

Environment

definition, 5

EPW. See Electrical powered wheelchairs

Erectile dysfunction, 180–183

Ethnic diversity, 397

Exercise

maintaining healthy habits, 206–208

Exercise physiologists, 30

Experiential Learning for Veterans in Assistive 

Technology and Engineering, 310–312

Exposure therapy, 93, 222, 224–226

Externally powered prosthetic devices, 54

Fair Housing Act, 241

Families

attachment relationships, 141–142

children’s reactions to deployment, 143–144

deployed spouse or parent reactions to 

deployment, 144–145

family relationships and resiliency, 146–149

importance in reintegration, 139–164, 421

negotiating relationships throughout deployment 

cycle, 140–145

nondeployed spouse or parent reactions to 

deployment, 142–143

reintegration resources, 159–164

role in mental and behavioral health, 152–159

strategies for improving relationships and 

reintegration, 146–159

strengthening parenting, 149–152

Family Medical Leave Act, 286

Family Readiness Group, 160

Farley, John J., III, 76–78

Fasting, 126–127, 131

Feature matching, 50–52

Federal Benefits for Veterans, Dependents and 

Survivors, 268

Federal Board for Vocational Education, 296

Feds Hire Vets, 301, 302, 307

Feet

artificial foot/ankle systems, 57–58

Financial management

caregiver challenges and assistance, 284–288

conducting a current financial assessment, 

269–274

emergency savings, 276

financial counseling support, 288–289

financial stability research, 270

following traumatic injury or illness, 265–266

insurance, 279–284

investing for retirement, 277–279

military transition planning, 264–265

paying down debts, 274–276

preparing a budget, 271–274

transition assistance, 267–269

FMLA. See Family Medical Leave Act

Food

costs, 273

Dietary Guidelines for Americans, 358

Dietary Guidelines for Americans 

SuperTracker, 358

grocery store accessibility, 347

Fox, Terry, 10

Friends

importance in reintegration, 421

role in mental and behavioral health, 152–159

Front-end load funds, 278

Gaming-based technology, 223–224

Gandhi, Mahatma, 113

Gardens, 346–347

Gender diversity, 397–398

Genital wounds, 176

GI Bill, 269, 297–299

GI Bill of Rights, 297

Gillums, Chief Warrant Officer 2, 

Sherman, Jr., 291–292

Give an Hour, 384

Global Assessment Tool, 95

Grab bars, 336, 340

Grass, General Frank J., 137

Groceries

food costs, 273

store accessibility, 347

Group-based exposure therapy, 93

Group life insurance, 283

Guttman, Sir Ludwig, 202

Gventer, Lieutenant Colonel Steven E., 18–20

Hannan, Gunnery Sergeant Matthew, 390–392

Health-related resources, 359–361

Healthcare

budgeting costs, 274

Healthcare information

use of virtual reality, 230–231

Hearing impairment

housing considerations, 332

Helping Airmen Recover Together, 302

Hemicorporectomy, 60
Index H 441

Hemipelvectomy, 59

HERL. See Human Engineering Research 

Laboratories

Hero2Hired, 358, 367

Higher Education Relief Opportunities for Students 

Act, 300

Hip disarticulation, 59

Hire Heroes USA, 300, 302, 358, 367

HISA. See Home Improvement and Structural 

Alterations program

Holistic reintegration plan, 376, 377

Home Improvement and Structural Alterations 

program, 268

Homelessness, 405, 406

Homeowners insurance

actual cash value coverage, 281

contents coverage, 280

deductibles, 281

dwelling amount, 280

liability coverage, 280

replacement cost coverage, 281

Hormonal implants, 184

Hotline, 162

Housebound Pension Benefits, 268

Housing

access to main entry, 329, 345

accessible housing, 254–255, 326–345

allergy considerations, 333

bathroom accessibility, 330–331, 335–340

bedrooms, 330–331, 344–345

breathing difficulty considerations, 333

budgeting costs, 272

comfort, 329–330

considerations outside the home, 328–329

doors, 343

floor layout, 329

flooring, 331, 344

grants for disabled veterans, 267–268

hallways, 343

hearing impairment considerations, 332

home layout, 330–331

interior design, 329

kitchens, 65–66, 69, 70, 330–331, 340–343

laundry rooms, 332

outdoor spaces, 329, 345

parking, 329, 345

security, 332

selecting a community, 328

selecting a home, 327–328

simulated living transition environment, 334

Special Housing Adaptation, 268

Specially Adapted Housing, 267

spinal cord injury considerations, 333–334

stairs, 343

temperature sensitivity considerations, 333

visibility, 329–330

visual impairment considerations, 332–333

walls, 344

Human capital, 377–378, 381–383

Human Engineering Research Laboratories, 31

Humeral amputation, 55–56

Hunter, Howard W., 115

Hybrid powered prosthetic devices, 54

Hydraulic ankle, 57

Hydraulic knee, 58

IAHP. See International Association of Hygienic 

Physicians

iARM, 68–69

ICF. See International Classification of Functioning, 

Disability, and Health

IDEO. See Intrepid Dynamic Exoskeleton Orthotic

IMES. See Implantable myoelectric sensor 

robotic arm

Impairments

definition, 5

Implantable myoelectric sensor robotic arm, 72

Inclusion

definition, 242

Independent Sector, 384

Individual Retirement Accounts, 277

Institute for Veterans and Military Families, 299, 

301, 307, 312–313

Insurance

auto insurance, 279

budgeting costs, 274

homeowners insurance, 280–281

life insurance, 282–284

renters insurance, 281

Integration. See also Reintegration

framework for, 11–13

goals of, 6

purpose of handbook, 4–6

structure of book, 6–7

Intelligent Assistive Robotic Manipulator, 68–69

Intelligent coaching, 64–68

Interdependence paradigm, 246

Internal Revenue Service, 277

International Association of Hygienic Physicians, 

126–127

International Classification of Functioning, 

Disability, and Health, 5, 245

International Olympic Committee, 202–203

International Paralympics Committee, 202

Intimacy

sexual health and, 173–177

InTransition, 162

Intrauterine devices, 183–184

Intrepid Dynamic Exoskeleton Orthotic, 53

Investments, retirement, 277–279

IRAs. See Individual Retirement Accounts

IUDs, 183–184

IVMF. See Institute for Veterans and Military 

Families

JACO Robotic Manipulator, 68–70
442 H Index

JAN, 303

JAWS. See Job Access With Speech

Job Access With Speech, 347

Job Accommodation Network, 301, 303

Jobs for Veterans State Grants, 366

Joseph, Gunnery Sergeant James M., 352–354

Journaling, 119–121, 130

JPMorgan Chase & Co., 306–307

Kacer, Retired Staff Sergeant Michael, 36–38

Kamson, Sergeant Miles, 135–136

Kansas State University, 270

Kitchens

appliances, 341–342

assistive technology, 65–66, 69, 70, 343

Cueing Kitchen, 65–66

KitchenBot, 69, 70

layout of, 330–331, 340–241

storage, 342

Knee disarticulation, 59

Knees, prosthetic, 58

Koenig, Dr. Harold, 112

Kognito Interactive, 314

Korean GI Bill, 297

Kovach, Petty Officer 3rd Class Al, 414–416

Kovack, Al, Jr., 293

Language pathologists/therapists, 28

Leavenworth Order, 12

Levitra, 181

Life insurance

converting to Veterans Group Life 

Insurance, 283

final expenses, 282

group life insurance, 283

income, 282

individually owned life insurance, 283–284

liabilities, 282

Life Insurance

budgeting costs, 274

Lincoln, Abraham, 296

Love and Logic, 163

Lower limb orthotic devices, 52

MacDonald, Robert, 261

Marconi Electronic Systems, 306

Marine For Life program, 358, 364

MA2R*INES3, 12–13

Marino, Sergeant D. Joshua, 320–322

Maxwell, Lieutenant Colonel Tim, 168–170

Meal preparation

Cueing Kitchen, 65–66

KitchenBot, 69, 70

Meaning

definition, 111

MeBot, 67, 68, 229

Medicaid, 287

Medical model of disability, 242–245

Medical paradigm, 243–245

Medicare, 287

Meditation, 117–118, 130

Mental health

adjusting from Service Member to civilian, 

82–83

anxiety disorders, 152–155

barriers to accessing counseling services, 96

counseling, 91–96

depressive disorders, 152–155, 185–187

facilitating help, 157–159

factors affecting adjustment, 87–88

manifestations of adjustment difficulties, 88

positive psychology, 94–96

posttraumatic stress disorder, 86–87, 88–89, 90, 

145, 152–155, 187

psychosocial adjustment, 82–84

rehabilitation interventions, 91–96, 222, 

224–226

reintegration and, 81–82

resource websites, 162–163

risk factors for adjustment difficulties, 83–84

sexual health and, 185–192

substance abuse, 152–155

suicide, 89–90

supporting adjustment, 90–91

traumatic brain injuries, 85–86, 89, 90, 188–189

Mental health workers, 29

MEPS acronym, 8, 13

Merton, Thomas, 124

MetroAccess, 347

MFLC. See Military and Family Life Counselor

Microprocessor-controlled ankle, 57

Microprocessor knee, 58

Miley, General Mark A., 237

Military and Family Life Counselor, 288

Military Family, 400–401

Military Kids Connect, 163

Military OneSource, 160, 266, 288

Military relief societies, 288

Mindfulness meditation, 118, 162–163

Mobility enhancement, 66–67

Mobility Enhancement RoBot, 67, 68, 229

Mobility rehabilitation

use of virtual reality, 229

Montgomery GI Bill, 269, 297–298

Motor learning concepts, 222

Muenster sockets, 55

Mullen, Admiral Mike, 79

Multiaxis foot, 57

Multidisciplinary Rehabilitation Team

athletic trainers, 30

exercise physiologists, 30

interdisciplinary team, 25

mental health workers, 29

occupational therapists, 27

orthotists, 29

physiatrists, 24–26
Index H 443

physical therapists, 26–27

prosthetists, 29

recreational therapists, 28

rehabilitation engineers, 30–32

rehabilitation nurses, 28–29

social workers, 29

speech and language pathologists/therapists, 28

Mutual funds, 277–278

MyHealtheVet, 358, 360–361

NAMI. See National Association for Mental Illness

National Association for Mental Illness, 256

National Center for Independent Living, 255

National Center for Posttraumatic Stress 

Disorder, 163

National Defense Authorization Act, 287

National Disabled Veterans Winter Sports Clinic, 

203, 205, 358, 360

National Guard

reintegration of personnel, 11

National Guard and Reserve

impact of Iraq and Afghanistan wars on 

relationships, 139–140

National Resource Directory, 160, 266, 301, 303, 

348, 358, 359, 384, 385

National Suicide Prevention Lifeline, 94

National Veterans Employment Advisory 

Council, 307

National Veterans Wheelchair Games, 203, 206, 

358, 360

Navy and Marine Corps

Public Health Center, 358

Navy-Marine Corps Relief Society, 288

NCIL. See National Center for Independent Living

NDVWSC. See National Disabled Veterans Winter 

Sports Clinic

Nerve reimplantation

targeted muscle reinnervation, 71

Neuromuscular rehabilitation

use of virtual reality, 226–227

Neuromuscular Research Laboratory, 30

Nintendo Wii Fit, 227

No-load funds, 278

Non-Paid Work Experience, 308

Northrop Grumman Corporation, 306

Nurses, rehabilitation, 28–29

NVWG. See National Veterans Wheelchair Games

Obama, Barack, 299, 301, 306, 307

Obesity

use of virtual reality in therapy, 230

Occupational therapists, 27

Office of Personnel Management, 307, 358, 367

100,000 Jobs Mission, 306, 307

Operation Enduring Freedom

PTSD rates, 87

resource website, 162

Operation IMPACT, 306

Operation Iraqi Freedom

PTSD rates, 87

resource website, 162

Operation Warfighter, 161, 308

Orthotic and Prosthetic Activities Foundation, 53

Orthotics, 52–53

Orthotists, 29

Osteointegration, 71–72

Outside hinge, 58

OWF. See Operation Warfighter

Pace, General Peter, 39

Paralympics, 202–203, 211, 387

Paralyzed Veterans of America, 203, 211, 386

Paratransit Service, 347

Parents

deployed parent’s reactions to deployment, 

144–145

family relationships and resiliency, 146–149

nondeployed parent’s reactions to 

deployment, 142–143

resource websites, 163

strengthening parenting practices, 149–152

Partial foot amputation, 58–59

Passive prosthetic devices, 54

Peace Corps, 387

Pedestrian-friendly communities, 346

Peer support. See Social capital

Penile implants, 182–183

Penile injections, 181

Permanent life insurance, 283

PerMMA, 27, 70–71

Personal expenses, 274

Personal Mobility and Manipulation 

Appliance, 27, 70–71

Phone app, 64–65

Physiatrists, 24–26

Physical environment

definition, 5

Physical Medicine and Rehabilitation

Multidisciplinary Rehabilitation Team, 24–32

rehabilitation care plan, 33–34

Service Member and family education, 32

vocational rehabilitation, 32

Physical therapists, 26–27

Picasso, Pablo, 129

Plato, 126

Pluralism, 396–397

Policy environment

definition, 5

Polycentric knee joint, 58

Polytrauma/TBI System of Care, 164

Positive psychology, 94–96

Post 9/11 GI Bill, 269, 298–299

Postdeployment retreats, 163–164
444 H Index

Posttraumatic stress disorder

adjustment difficulties, 88–89

counseling and rehabilitation, 91–93

employment initiatives, 305–307

exposure therapy, 93, 222, 224–226

impact on family relations, 145

prevalence rates, 87

role of family and friends in care and 

rehabilitation, 152–155

sexual health and, 187

suicide risk, 90

symptoms of, 86–87, 145

women’s issues, 405

Power seating function, 64–65

Power wheelchairs, 45, 229

Powered ankle, 57

Powered knee, 58

Prayer, 113–115, 130

Priapism, 181

Principlism, 122

Profiles. See Soldier profiles

Prosthetics, 53–61

Prosthetists, 29

PSF. See Power seating function

Psychological health. See Mental health

Psychosocial factors

adjusting from Service Member to civilian, 

82–83

barriers to accessing counseling services, 96

counseling, 91–96

factors affecting adjustment, 87–88

manifestations of adjustment difficulties, 88

positive psychology, 94–96

post-traumatic stress disorder, 86–87, 88–89, 90

psychosocial adjustment, 82–84

rehabilitation interventions, 91–96

reintegration and, 81–82

risk factors for adjustment difficulties, 83–84

service-connected disability ratings, 84

suicide, 89–90

support adjustment, 90–91

traumatic brain injuries, 85–86, 89, 90

PTs. See Physical therapists

PTSD. See Posttraumatic stress disorder

PTSD Coach, 163

Public Health Center, 358

Public transportation, 347–348

QRMC. See Quadrennial Review of Military 

Compensation

Quadrennial Review of Military 

Compensation, 286

Quality of life

definition, 375

organizations for service members and 

caregivers, 386

Quarles, Francis, 117

The Quran, 123

Racial diversity, 397

RAND Corporation, 11, 13–14, 87, 284, 285

Ready and Resilient Campaign, 8, 95

Real Warriors Campaign, 160

Recreational activities

benefits for successful reintegration, 204–206

community facilities, 346

creating inclusive activities, 209–210

importance in rehabilitation and reintegration, 

200–201, 203–204

maintaining healthy habits over a lifetime, 

206–208

organizations providing opportunities, 210–213

providing opportunities, 209–210

therapy services, 269

Recreational therapists, 28

Red Cross, 387

Rehabilitation. See also Physical Medicine and 

Rehabilitation

adaptive sports and, 201–203

importance of sports and recreation, 203–204

inclusion and, 242

use of virtual reality, 222–224, 226–231

Rehabilitation Engineering and Assistive Technology 

Society of North America

website, 51

Rehabilitation engineers, 30–32

Rehabilitation nurses, 28–29

REHAdapt Mounting System, 63

Reincorporation, 402

Reintegration. See also Integration

barriers to, 406–407, 419–420

culture and, 396–411

framework for, 11–13

holistic plan, 376, 377

importance of resiliency, 420, 424

inclusion and, 242

interdependence paradigm, 246

multiple demands of, 409

psychosocial factors, 81–97

resources, 362–364

role of friends and family, 139–164, 421

role of sports and recreation, 200–213

self-awareness and, 420–421

services, 421–422

social capital as model for, 13–14

spirituality and, 110–133

strategies for, 406–407

transition service providers, 378–380

veterans service organizations, 421

whole-person model, 409–410

women’s issues, 404–406

Religious affiliations, 398–399

Renters insurance, 281

Resilience

components of, 8

definition, 7–8, 408
Index H 445

family relationships and, 146–149

framework for building, 8–11

importance for successful reintegration, 420, 424

intervention strategies, 8–9

MEPS acronym, 8, 13

program components, 9

resources, 362

role of friends and family, 139–164

RESNA. See Rehabilitation Engineering and 

Assistive Technology Society of North America

Resources

benefits-related, 364–366

employment-related, 366–368

health-related, 359–361

for military personnel and veterans, 357–368

reintegration, 159–164

resilience-related, 362

reunion and reintegration-related, 362–364

spirituality, 130–133

volunteerism-related, 384–388

Resources for Veterans, 358, 367

Retirement investment, 277–279

Retreats, postdeployment, 163–164

Rigsby, Scott, 10

Risk tolerance, 277

Robb, Lieutenant General Douglas, 171

Robotic arm, implantable myoelectric sensor, 72

Robotic manipulation, 68–71

Robotic wheelchair, 27

Rocker-bottom soles, 59

Roll-in showers, 337–339

Roosevelt, Franklin D., 297

Roth IRAs, 277, 278

Rusk, Dr. Howard, 25

SACH. See Solid-ankle, cushion-heel foot

Sacred writings, 115–116, 130

SAH. See Specially Adapted Housing

Savicki, Mike, 369–372

Savings

costs, 274

emergency savings, 276

SCAADL. See Special Compensation for Assistance 

with Activities of Daily Living

Schoomaker, Lieutenant General Eric, 417

Self-awareness, 420–421

Self-determination, 246–247

Semper Fi Odyssey program, 12

Service Members Civil Relief Act, 300

Service-member’s Group Life Insurance, 282–283

Service opportunities, 121–122, 131

Servicemen’s Readjustment Act, 296–297

Sexual assault, 405, 406

Sexual health

biomedical interventions, 178–180

communication and, 189–192

disability issues, 175–176, 188–189

genital wounds from improvised explosive 

device blasts, 176

intimacy and, 173–177

men’s physical sexual health and 

self-monitoring, 177

psychological health and disability issues, 

185–192

self-monitoring, 177–178

sexual functioning among men, 180–183

sexual functioning among women, 183–185

women’s physical sexual health and selfmonitoring, 177–178

Sexual orientation, 398

SGLI. See Service-member’s Group Life Insurance

SHA. See Special Housing Adaptation

Shoulder disarticulation prosthetic devices, 56

Sick role, 244

Sildenafil, 181

Single-axis foot, 57

Single-axis knee joint, 58

Single-pivot hinge, 58

Sleep disorders, 145

Small Business Administration, 358, 367

SMART goals, 11–12

Smartpen, 47

Smartphones, 48, 51

SMEAC, 12, 13

Social capital

achievement and, 249

building, 249–253

community and, 248–249

definition, 11, 377

description of, 5–6, 240, 377–378

happiness and, 248–249

health and, 248

importance for successful reintegration, 423–424

importance of, 381–383, 408

as model for successful reintegration, 13–14

prosocial behavior and, 249

Social environment

definition, 5

Social networks, 422–423

Social workers, 29

Socioeconomic status, 400

Soldier For Life program, 358, 364

Soldier for Life-Transition Assistance Program, 267

Soldier profiles

Berg, Retired Marine Corps Sergeant Baren, 

195–196

Blanton, Staff Sergeant Amber, 235–236

Crouse, Private Second Class Greg, 258–260

Domitrovich, Private First Class Steve, 103–106

Farley, John J., III, 76–78

Gillums, Chief Warrant Officer 2, Sherman, Jr., 

291–292

Gventer, Lieutenant Colonel Steven E., 18–20

Hannan, Gunnery Sergeant Matthew, 390–392

Joseph, Gunnery Sergeant James M., 352–354
446 H Index

Kacer, Retired Staff Sergeant Michael, 36–38

Kamson, Sergeant Miles, 135–136

Kovach, Petty Officer 3rd Class Al, 414–416

Marino, Sergeant D. Joshua, 320–322

Maxwell, Lieutenant Colonel Tim, 168–170

Savicki, Mike, 369–372

Staton, US Army Captain (Retired) Matthew A., 

425–427

Tresco, Retired Army National Guard Sergeant 

JoAnn, 216–218

Soldier’s Rehabilitation Act, 296

Solid-ankle, cushion-heel foot, 57, 59

Special Compensation for Assistance with 

Activities of Daily Living, 286–287

Special Housing Adaptation, 268

Specially Adapted Housing, 267

Speech and language pathologists/therapists, 28

Speech recognition technology, 51

Spending plans, 271

Spinal cord injuries

housing considerations, 333–334

Spinal orthoses, 52

Spiritual affiliations, 398–399

Spiritual direction, 124–126, 131

Spirituality

alms-giving, 123–124, 131

artistic expression, 129, 132

concepts of, 110–113

definition, 111

development of, 113–132

fasting, 126–127, 131

journaling, 119–121, 130

meditation, 117–118, 130

prayer, 113–115, 130

resources, 130–133

sacred writings, 115–116, 130

service, 121–122, 131

spiritual direction, 124–126, 131

storytelling, 119–121, 130

yoga, 128–129, 131

Split sockets, 55

Sports

benefits for successful reintegration, 204–206

creating inclusive activities, 209–210

history of adaptive sports in rehabilitation and 

reintegration, 201–203

importance in rehabilitation and reintegration, 

200–201, 203–204

maintaining healthy habits over a lifetime, 

206–208

organizations providing opportunities, 210–213

providing opportunities, 209–210

SportsAbilities, 211

Spouses

deployed spouse’s reactions to deployment, 

144–145

nondeployed spouse’s reactions to deployment, 

142–143

Sprint feet, 58

Staton, US Army Captain (Retired) Matthew A., 

425–427

Stendra, 181

Stocks, 277

Storytelling, 119–121, 130

Strengthening Our Military Families initiative, 160

Student Veterans of America, 298–299, 314

Subdermal hormonal implants, 184

Substance abuse

impact on family relations, 145

role of family and friends in care and 

rehabilitation, 152–155

Suicide

prevention, 93–94

rates of, 89–90

risk factors, 90

warning signs, 90

Summer Sports Clinic, 358, 360

Super lightweight manual wheelchairs, 45–46

Supplemental Authorization and Personnel 

Benefits Act, 298

Support services. See also Social capital

accessible housing, 254–255

attendant care, 254

transportation, 254

vocational support, 255–256

SVA. See Student Veterans of America

Symes amputation level, 59

Tadalafil, 181

Talk, Listen, Connect, 163

TAP. See Transition Assistance Program

Targeted muscle reinnervation, 71

Taxi services, 348

Teach for America, 387

Team Rubicon, 386

Team Semper Fi/Semper Fi Fund, 211

Telemedicine. See Virtual reality

Telephone numbers

Crisis Hotline, 162, 361

GI Bill, 269

National Suicide Prevention Lifeline, 94

Veterans Affairs office, 266, 268

Wounded Warrior resources, 266

Temperature sensitivities

housing considerations, 333

Temporary Residence Adaptation, 268

Term life insurance, 283–284

The Mission Continues, 386

Three-dimensional printing, 62–63

TMR. See Targeted muscle reinnervation

TopChair-S, 67–68

TRADE. See Transforming Resources for 

Accelerated Degrees and Employment

Traditional IRAs, 277, 278

Training. See Education and training
Index H 447

Transcendence

definition, 111

Transfemoral amputation, 59

Transfer-type showers, 337–338

Transforming Resources for Accelerated Degrees 

and Employment, 313

Transition Assistance Program, 267, 299–300, 385

Transition planning, 264–269

Transition programs, 314–315

Transition service providers, 378–380

Transportation

accessible transportation, 347–349

adaptive driving, 46–47

budgeting costs, 272–273

public transportation, 347–348

taxi services, 348

transportation services, 254

Transradial amputation prosthetic devices, 55

Transtibial amputation, 59

Trauma-focus group therapy, 93

Traumatic brain injuries

adjustment difficulties, 89

counseling and rehabilitation, 91–93

employment initiatives, 305–307

resource websites, 164

role of family and friends in care and 

rehabilitation, 155–157

sexual health and, 188–189

suicide risk, 90

symptoms of, 85–86

Tresco, Retired Army National Guard Sergeant 

JoAnn, 216–218

TRICARE, 287, 358, 360

Uchtdorf, Dieter Friedrich, 121

Ultralight manual wheelchairs, 43–45

Unemployment rates, 299, 300

Uniformed Services Employment and 

Reemployment Rights Act, 300, 366

United Service Organizations, 386, 401

Upper extremity prosthetic devices, 54

Upper limb orthotic devices, 52

US Army Family Readiness Group, 160

US Army Nurse Corps, 404

US Association of Blind Athletes, 213

US Chamber of Commerce, 307

US Department of Agriculture

Dietary Guidelines for Americans 

SuperTracker, 358

US Department of Defense

military family support website, 160

Special Compensation for Assistance with 

Activities of Daily Living, 286–287

Warrior Games, 203

US Department of Labor

Veterans’ Employment and Training Service, 

303, 358, 366

US Department of Veterans Affairs

Aid and Attendance Benefits, 268

caregiver support program, 161

Comprehensive Assistance for Family 

Caregivers, 286–287

grant for adaptive driving equipment, 268, 

348–349

healthcare enrollment, 266

healthcare resources, 266

Housebound Pension Benefits, 268

Iraq/Afghanistan veteran resources, 162

National Veterans Wheelchair Games, 203

parenting resources, 163

Polytrauma/TBI System of Care, 164

support service resources, 256

telephone number, 266, 268

VA Health Benefits Handbook, 267

Warrior Games, 203

websites, 161, 162, 163, 164, 268

US Marine Corps

SMEAC, 12, 13

US Olympic and Paralympic Committees, 387

US Paralympics, 202–203, 211, 387

USA Paralympic Resource Network, 211

USAJOBS, 307

USO. See United Service Organizations

VA eBenefits, 358

VA for Vets, 300

VA Health Benefits Handbook, 267

Vacuum constrictive devices, 181–182

Vaginal rings, 185

Values

definition, 111

Vardenafil, 181

VAULT, 13

VEAP. See Veterans Educational Assistance Program

VEOA. See Veterans Employment Opportunity Act

Vet Centers, 358, 363

Veterans Administration Adaptive Sports Program, 

211

Veterans Crisis Hotline, 162

Veterans Education Assistance Act, 297–298

Veterans Educational Assistance Act of 2008, 298

Veterans Educational Assistance Program, 297

Veterans’ Employment and Training Service, 303, 

358, 366

Veterans Employment Opportunity Act, 307

Veterans Group Life Insurance, 283

Veterans Integration to Academic Leadership, 314

Veterans Opportunities to Work Act, 300

Veterans Opportunity to Work and Hire Heroes 

Act, 300

Veterans’ Readjustment Assistance Act, 297, 

366–367

Veterans’ Readjustment Benefits Act, 297

Veterans Recruitment Appointment, 307, 308
448 H Index

Veterans service organizations, 421

Veterans Services, 358, 367

VETS, 303

VetSuccess, 303

VetSuccess on Campus, 315

VFI. See Volunteer Functions Inventory

VGLI. See Veterans Group Life Insurance

Viagra, 181

Vietnam GI Bill, 297

Virtual environment, 221–222

Virtual reality

cybersickness, 223

definition, 221

exposure therapy, 222, 224–226

gaming-based technology, 223–224

use in healthcare information and support, 

230–231

use in rehabilitation and physical health, 

222–224, 226–231

Virtual Seating Coach, 64–65

Visual impairment

housing considerations, 332–333

Vocational Rehabilitation Act, 296, 304

Vocational Rehabilitation and Employment 

Program, 269, 304–305, 308

Vocational support, 255–256

Vocational training programs, 313–314

Volunteer Functions Inventory, 376–377

Volunteer programs, 380–381

Volunteerism

benefits of, 315–317

compassion fatigue, 383–384

diversity of programs, 384–388

military and veteran organizations, 384–386

motivation for, 376–377

umbrella organizations, 386–387

wraparound programs, 387–388

VOW Act, 300

VR&E. See Vocational Rehabilitation and 

Employment Program

VSC. See Virtual Seating Coach

VSOs. See Veterans service organizations

Walkable communities, 346

Walter Reed Army Medical Center, 202

Warrior Care and Transition, 303

Warrior Ethos, 19

Warrior Games, 203

Warrior Gateway, 161

Warrior Transition Command system, 49

Warrior Transition Unit, 18–19

Washington Metropolitan Area Transit 

Authority, 347

Websites

AbleForces.org, 301

ACE framework, 93

adaptive sports organizations, 210–213

Air Force Aid Society, 288

American Board for Certification in Orthotics, 

Prosthetics, & Pedorthics, 53

American College of Sports Medicine, 358, 361

American Legion, 386

America’s Heroes at Work, 306

amputation resource, 61

Army Emergency Relief, 288

Association of Assistive Technology Act 

Programs, 51

Association of the United States Army, 358, 363

caregiver support, 161

Centers for Medicare & Medicaid Services, 287

Comprehensive Soldier and Family Fitness 

program, 358, 362

Crosswalk from Military to Federal Civilian 

Jobs, 308

Department of Veterans Affairs, 161, 162, 163, 

164

Dietary Guidelines for Americans, 358, 360

Dietary Guidelines for Americans SuperTracker, 

358, 360

Disabled American Veterans, 386

Easter Seals, 387

eBenefits, 266, 365

education resources, 161

employment resources, 161

Feds Hire Vets, 307

financial stability research, 270

GI Bill, 269

housing grants for disabled veterans, 267–268

job resources, 302–303

Marine For Life program, 358, 364

Military OneSource, 288

The Mission Continues, 386

MyHealtheVet, 358, 360

National Disabled Veterans Winter Sports Clinic, 

358, 360

National Resource Directory, 266, 358, 359, 

384, 385

National Veterans Wheelchair Games, 358, 360

Navy-Marine Corps Relief Society, 288

Office of Personnel Management, 307, 358, 367

Orthotic and Prosthetic Activities Foundation, 

53

Paralyzed Veterans of America, 386

Peace Corps, 387

postdeployment retreats, 163–164

prosthetics resource, 61

Red Cross, 387

Rehabilitation Engineering and Assistive 

Technology Society of North America, 51

REHAdapt North America, 63

reintegration resources, 160–164

resources for military personnel and 

veterans, 358

Small Business Administration, 358, 367

Soldier For Life program, 358, 364
Index H 449

Soldier for Life-Transition Assistance 

Program, 267

spending plans, 271

spirituality resources, 130–132

Summer Sports Clinic, 358, 360

Teach for America, 387

Team Rubicon, 386

traumatic brain injury resources, 164

TRICARE, 287, 360

United Service Organizations, 386

US Olympic and Paralympic Committees, 387

USAJOBS, 307

VA Aid and Attendance and Housebound 

Pension Benefits, 268

VA grant for adaptive equipment, 349

VA Health Benefits Handbook, 267

VA healthcare enrollment, 266

Vet Centers, 358, 363

Veterans’ Employment and Training Service, 

358, 366

volunteerism resources, 383

Washington Metropolitan Area Transit 

Authority, 347

Wounded Warrior Project, 384

Weight-activated stance, 58

Wheelchair & Ambulatory Sports, USA, 212

Wheelchairs

electrical powered wheelchairs, 67–68, 229

MeBot, 67, 68

mobility enhancement, 66–67

PerMMA, 27, 70–71

power, 45

robotic, 27

super lightweight manual, 45–46

TopChair-S, 67–68

ultralight manual, 43–45

Virtual Seating Coach, 64–65

WHO. See World Health Organization

Williams, Brigadier General Darryl, 323

Winter Sports Clinic, 203, 205, 358

Women’s issues, 404–406

Woodson, Honorable Jonathan, MD, 355

Work Support, 303

World Health Organization, 5, 245

Wounded Warrior Project, 212, 266, 288–289, 

303, 384

Wright, Honorable Jessica, 393

Wrist disarticulation prosthetic devices, 55

Writing

sacred writings, 115–116, 130

therapeutic, 119–121

X-frame shoulder sockets, 56

Yellow Ribbon Reintegration Program, 161, 300

Yoga, 128–129, 131