Using Peer Support Groups to Enhance Community Integration of Veterans in Transition

Abstract

Peer support groups, also known as “self-help groups,” provide a unique tool for helping veterans working through the military-to-civilian transition to achieve higher levels of social support and community integration. The number and variety of community-based peer support groups has grown to the point that there are now more visits to these groups each year than to mental health professionals. The focus of these groups on the provision of social support, the number and variety of groups, the lack of cost, and their availability in the community make them a natural transition tool for building community-based social support. A growing literature suggests that these groups are associated with measurable improvements in social support, clinical symptoms, self-efficacy and coping. For clinical populations, the combination of peer support groups and clinical care results in better outcomes than either alone. Given this evidence, we suggest clinical services use active referral strategies to help veterans engage in peer support groups as a means of improving community reintegration and clinical outcomes. Finally, suggestions for identifying appropriate peer support groups and assisting with active referrals are provided.

Full text

Using Peer Support Groups to Enhance Community Integration of Veterans
in Transition
Charles E. Drebing, Erin Reilly, Kevin T. Henze, Megan Kelly, Anthony Russo, John Smolinsky,
Jay Gorman, and Walter E. Penk
Bedford VA Medical Center, Bedford, Massachusetts
Peer support groups, also known as “self-help groups,” provide a unique tool for helping veterans
working through the military-to-civilian transition to achieve higher levels of social support and
community integration. The number and variety of community-based peer support groups has grown to
the point that there are now more visits to these groups each year than to mental health professionals. The
focus of these groups on the provision of social support, the number and variety of groups, the lack of
cost, and their availability in the community make them a natural transition tool for building community-
based social support. A growing literature suggests that these groups are associated with measurable
improvements in social support, clinical symptoms, self-efficacy and coping. For clinical populations, the
combination of peer support groups and clinical care results in better outcomes than either alone. Given
this evidence, we suggest clinical services use active referral strategies to help veterans engage in peer
support groups as a means of improving community reintegration and clinical outcomes. Finally,
suggestions for identifying appropriate peer support groups and assisting with active referrals are
provided.
Keywords: social support, community integration, veterans, military, self-help groups
Social support is possibly the key factor underlying successful
community integration. Defined as the real or perceived availabil-
ity of social resources (Cohen, Gottlieb, & Underwood, 2001),
social support is integral to successful functioning in most of the
dimensions of community integration, including relationships with
a spouse/significant other, parental functioning, friendships, work,
education, spiritual/religious functioning, leisure, domestic life,
and civic life (Resnik et al., 2012). High levels of social support
are consistently associated with broad health outcomes including
enhanced physical health (Uchino, 2004), mental health (Lakey &
Orehek, 2011), and health care utilization (DiMatteo, 2004;Gul-
liver, Griffiths, & Christensen, 2010). Finally, lower levels of
social support are associated with increased risk of mortality, even
when corrected for background variables, with an effect size that
is as large or larger than known health risks such as tobacco use,
alcohol consumption, obesity, and exercise (Holt-Lunstad, Smith,
& Layton, 2010).
Military personnel transitioning to civilian life are vulnerable to
a decline in social support. As part of postdeployment transitions,
they are typically exchanging social networks—leaving one group
of relationships and facing the need to develop or reestablish
another group (Hopewell & Horton, 2012). The change in social
networks is more dramatic because it reflects a transition between
two cultures, with different norms and expectations for interper-
sonal connection (Hall, 2011). Military culture typically involves
membership in tightly connected and interdependent groups that
emphasize conformity and mutual support (Ainspan & Penk, 2008;
Junger, 2016). In contrast, Western civilian culture emphasizes
individuality, independence and choice. Military culture explicitly
exerts external pressure on individuals to connect and work to-
gether in service of “the mission,” whereas civilian culture typi-
cally exerts relatively limited pressure for this type of connection
(Hall, 2011). For many veterans, the transition to civilian life also
corresponds with the transition into adulthood. Service members
often leave the civilian community at the end of adolescence to
serve in the military, doing work outside of the experience of many
in the original community. When service members return to their
civilian communities, the transition to adult life has been made
more complex by the time away and their experience in military
roles and within a military subculture that most civilians do not
understand.
Many veterans return with medical and/or mental health prob-
lems that are also associated with higher risk for reduced social
support. For example, up to 16% may meet criteria for PTSD
(Gates et al., 2012), which is associated with significant difficulties
across a broad range of relationships (Cohen, Zerach, & Solomon,
2011;Laffaye, Cavella, Drescher, & Rosen, 2008;Solomon, De-
kel, & Zerach, 2008). PTSD symptoms such as irritability, feelings
of detachment from others, and avoidance of social situations are
associated with the erosion of positive relationships and a decline
in social support over time (King, Taft, King, Hammond, & Stone,
Charles E. Drebing, Erin Reilly, Kevin T. Henze, Megan Kelly, Anthony
Russo, John Smolinsky, Jay Gorman, and Walter E. Penk, The Social and
Community Reintegration Research Program, Bedford VA Medical Cen-
ter, Bedford, Massachusetts.
This project was supported by the VA Rehabilitation Research and
Development Research Enhancement Award Program (1 I50 RX001873-
01). The information provided in this study does not represent the views of
the Department of Veterans Affairs or the United States government.
Correspondence concerning this article should be addressed to Charles
E. Drebing, The Social and Community Reintegration Research Program
(116A), Bedford VA Medical Center, 200 Springs Road, Bedford, MA
01730. E-mail: Charles.Drebing@VA.gov
Psychological Services In the public domain
2018, Vol. 15, No. 2, 135–145 http://dx.doi.org/10.1037/ser0000178
135

2006). Research also documents elevated rates of depression,
anxiety, and anger among transitioning veterans that can contribute
to interpersonal problems and erosion of social support (Stice,
Rohde, Gau, & Ochner, 2011). In a survey of post-9/11 combat
veterans returning to the community (Sayer et al., 2010), 45%
reported difficulty reestablishing civilian friendships, 44% re-
ported difficulty making friends, and 28% reported difficulty in
maintaining friendships from the military. Similar strains were
seen within family supports, with 42% reporting difficulty get-
ting along with their spouse/partner, 29% having difficulty
getting along with their children, and 34% having difficulty
getting along with other family members. A full 56% report
difficulty confiding in or sharing personal thoughts and feelings
with others, although another 49% report difficulty feeling that
they “belong” in civilian life.
Part of the challenge with postdeployment reintegration in-
volves emerging norms in the communities veterans are reentering.
In his landmark book, Bowling Alone, Robert Putnam (2000)
reviews a wide range of evidence regarding trends in reduced
community engagement within Western culture over the past 50
years. From joining community organizations, volunteering, vot-
ing, or simply knowing one’s neighbors, there is evidence of a
steady decline in community engagement. These trends suggest
that returning veterans are likely to find fewer partners in the
community looking to engage with them, thus reducing their
potential to find social support. It also suggests that the social
norms and associated expectations of engagement reflect reduced
expectations that veterans should seek social support or that com-
munity members will reach out to veterans.
There are encouraging data on veterans’ potential for social
engagement. In comparison to their civilian counterparts, veterans
are generally more likely to trust and talk with their neighbors, to
participate and serve as leaders in civic organizations, and to be
politically engaged (Tivald & Kawashima-Ginsberg, 2015). They
are more likely to endorse cultural values that encourage engage-
ment and service. It is possible that this was true before their
military service, which was part of their decision to serve. It is also
possible that their military service activates or strengthens a nat-
ural instinct to belong and affiliate with purpose-driven groups
(Junger, 2016), resulting in increased potential for community
engagement and community service postdeployment. Either way,
this relative strength creates important advantages when it comes
to social support intervention.
Social Support Interventions and the Benefits of Peer
Support Groups
A range of intervention strategies have been developed for
at-risk populations that can inform social reintegration strategies
with veterans in transition (Cattan, White, Bond, & Learmouth,
2005;Rook, 1984). A number of interventions simply provide or
replace one to one social support, including supported socialization
(Davidson et al., 2004;Fisk & Frey, 2002), volunteer visitors
(Mulligan & Bennett, 1978), and peer phone support (Heller,
Thompson, Trueba, Hogg, and Vlachos-Weber, 1991) programs.
Educational interventions have also been developed, from simple
didactics teaching people about the importance of social support to
more extensive training in social skills (Cattan et al., 2005;Rook,
1984). There have also been efforts at “indirect social network
building,” referring to interventions that involve people in specific
activities that often result in new social connections, while inten-
tionally not appearing social in focus (Hagan, Manketelow, Taylor,
& Mallett, 2014;Pilisuk & Minkler, 1980). From this perspective,
interventions like supported employment, supported education,
and supported volunteerism place people in activities in which
supportive social relationships often develop. Finally, there have
been efforts to change the environments in which people live in a
way that encourages support (Rook, 1984).
Most of these interventions require significant investment in
professional support and require significant time for social support
to grow. In contrast, a relatively cost-effective and widely acces-
sible approach with good empirical evidence of improvement in
social support, is the strategic use of peer support groups (Drebing,
2016). “Peer support groups,” also referred to as “self-help
groups” or “mutual aid” or “mutual help” groups, refer to collec-
tions of people who gather together to talk about shared problems
or experiences and to provide informal support to each other. The
focus of the group may be a common clinical condition (such as
addiction, diabetes, or depression), a life problem (a trauma, loss
of child, or bankruptcy), or a personal circumstance or challenge
(veterans groups, those trying to lose weight, or people looking to
advance their career). Support usually comes in the form of emo-
tional support, information, or guidance based on shared personal
experience. Some groups may have additional agendas, such as
advocacy or community service, but all have mutual support as a
central activity. Peer support groups are a subgroup of “support
groups,” which may or may not have a clinician as a facilitator.
Peer support groups can take many forms (Kelly & Yeterian,
2012). For example, although most meet in-person, a growing
number use a conference call or Web based format. Some groups
are open to drop-in attendance, indicating that anyone who is
seeking peer support can attend any meeting. Others are closed,
with attendance limited to a specific set of people who are iden-
tified as members. Although many are fairly small in size (5–15
attendees), some are quite large or have no size limits. Group
facilitation may be provided by a well-trained Certified Peer
Specialist, or by a volunteer group member who has limited or no
formal training. Meeting format can also vary. Some groups have
a fairly set routine, whereas others have more unstructured meet-
ings. Typical participation in some groups is just a few meetings,
although other groups have members who attend for years. The
flexibility of peer support group formats helps meet the varied
needs and expectations of attendees, and allows for support
through the method that best suits their interests.
Taken together, peer support groups represent a surprisingly
large and growing community-based social support resource for
veterans. Almost 20 years ago, Kessler and colleagues documented
a steady increase in general peer group participation, with 10 –20%
of the U.S. population reporting that they had participated in a peer
support group at some time in their lives, and 5–10% having
participated in the past year (Kessler, Mickelson, & Zhao, 1997).
All evidence suggests that participation rates have grown since.
This popularity cannot be attributed to marketing, as these groups
generally have little publicity of any kind. Instead, it is most likely
due a number of key advantages (Drebing, 2016). First, peer
support groups are available in most communities, at times and
locations organized around participants’ schedules. Second, peer
support groups are usually free to participants. Third, peer support
136 DREBING ET AL.

groups are focused primarily on the provision of social support.
Although many people get social support indirectly through en-
gagement in social roles like work or community activity, peer
support groups meet primarily and explicitly to provide support.
To begin receiving support, participants typically need only show
up and begin to interact with other attendees. That is in contrast
with most of the previously noted intervention strategies (educa-
tions, skills development, changing environment) or naturalistic
strategies that require the development of relationships over time.
If we consider common barriers that many people face in building
social support (e.g., social anxiety, limited social skills, limited
environments), peer support groups present relatively few barriers
to access and so are more likely to be successful with these
populations. Finally, there is a remarkable variety in the focus and
format of peer support groups available now in many communities.
Within the larger networks of peer support groups, there is also a
growing variation in population targets, with groups differentiated
by gender, age, sexual orientation, marital status, veteran status.
Evidence Regarding Effectiveness
Although there is a growing literature documenting the out-
comes of peer support groups, it is important to note that it has
important limitations. There has been a longer history of research
interest in peer support groups that target substance use disorders,
and so the number of studies evaluating Alcoholics Anonymous
(AA) and Narcotics Anonymous (NA) is greater than the number
of studies evaluating other types of groups. There are common
themes in outcome across different types of groups, but very few
studies that include different types of groups. There has also been
a great deal of variety in design, with many studies comparing
self-selected populations of people attending or not attending a
peer support group, or attending in combination with clinical
treatment. There are a growing number of randomized trials,
though these are difficult to conduct given the nature of the
intervention (Humphreys et al., 2004).
If social support is a primary goal of a referral to peer support
groups, it is reassuring that studies generally find that participation
in peer support groups with different areas of focus, is associated
with enhanced social support (Davidson et al., 1999;Humphreys et
al., 2004). Examinations of broader outcomes across different
types of groups suggest that participation is often associated with
improvements in outcomes such as self-efficacy and coping, en-
ergy, self-care and treatment compliance, and communication with
clinical providers (Barlow, Turner, & Wright, 2000;Griffiths et
al., 2005;Kennedy et al., 2007;Long, Jahnle, Richardson, Loew-
enstein, and Volpp, 2012;Pfeiffer, Heisler, Piette, Rogers, &
Valenstein, 2011;Schulz et al., 2008).
If we look at studies that focus on the targeted outcome of
specific types of groups (e.g., drug abstinence after participation in
Narcotics Anonymous), the data are also encouraging. A number
of studies have found a positive correlation between participation
in AA and subsequent abstinence from alcohol, and participation
of NA and abstinence from illegal drugs (Humphreys, 2004). A
number of studies have compared people who participate in clin-
ical programs that emphasize adjunct 12-step meeting attendance
versus those that do not. In this type of comparison abstinence
rates at follow-up are significantly better for programs that em-
phasize participation in peer support groups, and at the same time,
those who participated in the groups were using less formal care at
the time of follow-up (Humphreys & Moos, 1996,2001). Ran-
domized trials also find positive associations between assignment
to clinical treatment and AA participation and abstinence from
alcohol as far as 10-years post assignment (Pagano, White, Kelly,
Stout, & Tonigan, 2013). Finally, meta-analytic reviews also sup-
port the efficacy of treatment and AA compared to treatment alone
(Forcehimes & Tonigan, 2008;Tonigan, Toscova, & Miller,
1996).
Of the studies that evaluated peers support groups focused on
mental health variables, results in terms of improvement in the
targeted mental health variable are less consistent. In one study
examining the impact of peer support groups for adults with a
serious mental illness, the improvements in psychological func-
tioning were found for those in the peer support group condition
(Roberts et al., 1999), although other studies with this population
have found less consistent evidence of benefit (Magura et al.,
2002). Studies of groups for adults with mood or anxiety disorders
found a similar pattern of results. In a randomized study (Bright,
Baker, & Neimeyer, 1999) comparing group therapy and peer
support groups for adults with depression, the clinical outcomes of
the two groups were equivalent, with participants in both groups
improving. Similarly, in a study of veterans with at least one
psychiatric diagnosis, participants randomly assigned to a
recovery-oriented peer support group (Vet-to-Vet) had similar
outcomes to those in a clinician-led recovery group (Eisen at al.,
2012). Several studies with less rigorous designs found that par-
ticipation was correlated with positive outcomes, but were less
able to say that participation is the cause of the positive outcome
(Houston, Cooper, & Ford, 2002;Powell, Yeaton, Hill, & Silk,
2001).
Several studies evaluating groups focused on medical conditions
found participation associated with positive results in a number of
outcomes related to illness management. In a study of patients with
cardiovascular disease participating in a cardiac rehabilitation pro-
gram that included peer support group attendance, improvements
in blood pressure, health behaviors and scores on a measure of
health-related quality of life were all correlated with the degree of
peer support group attendance (Schulz et al., 2008). In a random-
ized study of patients with arthritis, the group assigned to a peer
support group intervention that included peer-education was sig-
nificantly better than the control group on measures of health
self-efficacy, symptom management, exercise, and depression
(Barlow et al., 2000). Finally, in a randomized trial focusing on
patients with a range of “chronic” medical conditions such as
diabetes, cardiovascular disease, respiratory disease or arthritis,
participants were assigned to a peer-led “self-management” sup-
port group with a wait-list control group. Those who attended at
least half of the meetings in the peer support group were signifi-
cantly better than the control group in terms of health self-efficacy,
self-management behaviors and depression (Griffiths et al., 2005).
A few studies have compared formal clinical care directly to
peer support groups, results documenting to the efficacy of both, as
well as the potential for added value through their combination.
For example, most people who attend AA or other clinically
focused peer support groups, also receive formal care for the issue
they are seeking help with (Kessler et al., 1997). In a few studies
that compared peer support group and participation in clinical care,
the size of the benefit of participation in peer support groups for
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PEER SUPPORT GROUPS

mental health problems was similar to the size of benefit resulting
from formal care for alcohol use (Bright et al., 1999;Marmar,
Horowitz, Weiss, Wilner, & Kaltreider, 1988). Participation in
both clinical care and peer support groups at the same time is
associated with better outcomes than participation in clinical pro-
grams alone (Kelly, Stout, Magill, Tonigan, & Pagano, 2010;
Pagano et al., 2013;Timko, Sutkowi, Cronkite, Makin-Byrd, &
Moos, 2011;Walitzer, Dermen, & Barrick, 2009).
Specific Strategies for Integrating Peer Support
Groups With Formal Treatment
From a clinician’s perspective, there are key situations in which
participation in peer support groups can help enhance clinical
outcomes for veterans in transition (Drebing, 2016).
Veterans Who Need to Expand or Replace Current
Social Support
Given the strong relationship between social support and phys-
ical and mental health outcomes, clinicians should be routinely
watching for and addressing low levels of social support. For
veterans identified with low levels of support, referral to peer
support groups may be one of the easiest interventions available to
address that need. Some types of social supports can have a
negative influence, such as friends or family who support sub-
stance abuse. Again, peer support groups can be ideal for those
veterans who may need support as they replace existing negative
social relationships (Kelly, Stout, Magill, & Tonigan, 2011).
Veterans Who Need Help Transitioning to Natural
Community Supports
Some veterans are in transition to new communities, or specif-
ically from the military to civilian communities. These transitions
often take time and are stressful, particularly for those with mental
health concerns. Other veterans who have participated in signifi-
cant mental health treatment may develop dependence on treat-
ment and treatment providers, and may have difficulty in transi-
tioning out of treatment (Drebing, 2017). Participation in peer
support groups during treatment can help reduce the loss of sup-
port at the time of clinical treatment termination, and can help
veterans transition to reliance on naturally existing support in their
target community.
Veterans Who Need Pragmatic Information About an
Illness, Treatment, and Recovery From That Illness
Although clinicians can provide basic education about an illness
and the corresponding treatment, clients often benefit from edu-
cation about the personal experience of an illness, treatment and
recovery from fellow clients. Peer support groups are often a
valuable source of such information, provided by members who
are further along in the course of the illness or in recovery
(Drebing, 2017). Exposure to group members who are in recovery
can provide concrete evidence for hope in clients who feel dis-
couraged about their chances of recovery.
Veterans Who Need a Place to Provide
Prosocial Behavior
Peer support groups are a place to both receive and provide peer
support. Some clients need access to opportunities to provide
support to others, and peer support groups represent a setting with
many of these opportunities (Pagano, Post, & Johnson, 2011).
Veterans often comment on the value of peer support as an
opportunity to “help another Vet” and may be particularly moti-
vated by opportunities to support other Veterans.
Clinical programs that provide an active referral of their clients to
peer-support groups have better clinical outcomes than those that
provide simple referral information (Sisson & Mallams, 1981;Timko,
DeBenedetti, & Billow, 2006;Walitzer et al., 2009). The term “active
referral” includes several groups of strategies including: (a) Raising
the topic with clients and verbally encouraging participation; (b)
Providing written information about specific peer support groups (i.e.,
location, directions, time); (c) Arranging for a current peer support
group member to meet or call a client to talk about the group; (d)
Asking for a verbal or written commitment from the client to attend
a meeting; (e) Reviewing and/or practicing common behaviors
needed during attendance at peer support groups; and (f) Following up
after a referral by asking about attendance and encouraging continued
participation. Table 1 includes specific examples of strategies found to
be associated with higher participation rates.
Types of Commonly Available Groups Organized by
Group Focus
Most available groups can be organized around broad categories of
focus. This is not to say that the focus identified by the group is the
only or the primary benefit, or reason to refer. In many cases, broader
social support is the most important benefit for a participant, and the
clinical focus is secondary. In this way, referral of a veteran to any
peer support group that they qualify for, may be a successful strategy
for increasing community engagement and social support regardless
of whether they have an urgent need related to the specific focus of the
group (e.g., addiction, medical health, life challenges).
Table 2 provides a listing of organizations that support or at
least offer national or international directories for self-help groups
organized around the central themes.
(a) Substance Use. For many people, peer support groups
have been such a key element in their recovery from
misuse of drugs and alcohol that when people hear the term
self-help or peer support group, they often think of 12-step
groups like AA. There are more self-help groups for
substance-related conditions than any other type of group,
and these groups are available to a larger portion of the
world.
(b) Behavioral Addictions and Other Troubling Behaviors.
There is a growing number of peer support organizations
focusing on troubling behaviors that some would call
compulsive or addictive behaviors. Although some qualify
as a mental illness, we have listed these groups under this
heading because of their similarities.
(c) Other Mental Illness. There is a large and growing array
of peer support groups for adults dealing with mental
health conditions other than substance use disorders and
behavioral addictions. Some are organized around a spe-
138 DREBING ET AL.

cific disorder or combination of disorders, and others are
organized around the theme of recovery or some aspect of
recovery.
(d) Other Medical Conditions. Peer support groups for med-
ical conditions are now common, but relative to groups
focusing on addiction, fewer are organized by national or
international organizations. Support groups focusing on
medical illness are more commonly associated with local
organizations or health care providers, and so are more
integrated with professional care. This can make them
somewhat difficult to locate through national listings of
groups and locations. Clinicians may need to search online
for local listings by medical condition, or talk with local
medical providers.
(e) Disabilities. There is a wide range of support groups for
adults with disabilities and family members of children
with disabilities. Again, a greater portion of these groups
are organized at a local level. Local chapters of some
national organizations function as peer support groups, but
many also involve advocacy as part of their mission.
(f) Other Life Challenges. There has been a remarkable
growth in the number and range of peer support groups that
have developed around broader life challenges, such as
being impacted by suicide, or trying to address unemploy-
ment. Again, many of these groups are local, and may
require some initial research to find.
Groups With a Specific Focus on Veterans and
Military Personnel
Though many of the above-referenced groups can be excellent
referrals for veterans transitioning to civilian life, there are also
many veteran-specific peer support groups. Relatively common
veteran support groups include:
VA peer support groups. The Veterans Healthcare Admin-
istration (VHA) is the largest provider of health care to veterans,
and employs more than 1,000 Certified Peer Specialists, many of
whom lead peer support groups (Chinman, Salzer, & O’Brien-
Mazza, 2012;Resnick & Rosenheck, 2008). The VHA also part-
ners with other organizations that provide peer support groups as
part of VHA programming. These include organizations focused
on veterans, like Vet 2 Vet U.S.A., and organizations that focus on
specific clinical conditions, like AA or the National Alliance on
Mental Illness (NAMI). VA-based peer support groups have some
distinct advantages including: (a) There is a wide variety in focus
and format across the groups available at 150 ⫹VA medical
Table 1
Evidence-Based Active Peer Support Group Referral Practices
Strategy Empirical support
(1) Raise the topic with clients and verbally encourage participation. 1
Instruct Client to attend at least a target number of meetings per week.
Ask Client to set a personal goal to attend a target number of meetings. 1, 2
Mention goal of “90 meetings in 90 days.” 1
Encourage Client to obtain a sponsor. 2
(2) Provide written information about specific peer support groups.
Provide the Client with a list of meetings, with times, locations and directions to those meeting (by foot, car, and public
transportation). 2, 3
Provide the Client with handout about 12-step/self-help groups that include summary information on philosophy, structure and
terminology. 2, 3
Provide the Client with key reading material, such as The Big Book for AA. 1
Provide Client with a list of local meetings preferred by other clients.
Provide the Client with a list of common concerns of other clients about attending meetings. 2
Provide the Client with a handout about obtaining a sponsor 3
Provide the Client with a list of currently available local sponsors. 2, 3
(3) Arrange for a current peer support group member to meet or call a Client.
During a meeting with the Client, phone conference a group member to arrange for them to meet the Client before a meeting. 3, 4
During a clinical session with the Client, phone a group member and have them introduce themselves and agree to meet at
the meeting. 2, 4
During a clinical session with the Client, phone a group member and have them arrange to provide a ride to the Client to the
meeting. Have the group member call to remind the Client about the group, the night before the meeting. 3, 4
(4) Ask for a verbal or written commitment from the patient to attend a meeting.
Ask the Client to make a verbal or written commitment for meeting their goal of attending Xmeetings. 1, 2
Ask the Client to document attendance or reason for nonattendance in a journal. 1, 2
Review the journal comments with the Client during a subsequent meeting. 2
Ask the Client to have the Peer Support Group secretary document their attendance. 2
(5) Review and/or practice common behaviors needed during attendance at peer support groups.
In the clinical setting, create practice sessions/ simulations to expose the Client to the group format and common behaviors. 3
In the clinical setting, have the Client participate in a practice group meeting or simulation. 3
(6) Follow up after a referral by asking about attendance and encourage continued participation
Raise the topic of Client’s experience—if they did not attend, recommend attendance or ask for a commitment to attend. 2, 3, 4
Raise topic of the Client’s experience in subsequent meetings. 2
Raise the topic of “Getting Active” in support groups (e.g., speaking out in meetings, getting support from others, seeking a
sponsor). 1
Note. The four referenced studies evaluated combinations of the practices listed in this table, finding that these combinations were associated with higher
participation rates. 1 ⫽Walitzer et al. (2009);2⫽Timko et al. (2006);3⫽Timko et al. (2011);4⫽Sisson & Mallams (1981).
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Table 2
A Sampling of Organizations With National or International Directories of Peer Support Groups
SUBSTANCE USE DISORDERS
Alcoholics Anonymous (AA)
Al-Anon
Alateen
Cocaine Anonymous (CA)
Crystal Meth Anonymous (CMA)
Dual Recovery Anonymous
Families Anonymous
Life Ring Secular Recovery (LRSR)
Marijuana Anonymous (MA)
Moderation Management (MM)
Narcotics Anonymous (NA)
Nar-Anon
Nicotine Anonymous
Secular Organization for Sobriety (SOS)
SMART Recovery
Women for Sobriety (WFS)
BEHAVIORAL ADDICTIONS
Anorexics and Bulimics Anonymous (ABA)
Bettors Anonymous
Debtors Anonymous (DA)
Eating Disorders Anonymous
Gamblers Anonymous (GA)
National Association for Shoplifting Prevention
National Eating Disorders Association
Overeaters Anonymous (OA)
Sex Addicts Anonymous (SAA)
Sexual Compulsives Anonymous (SCA)
Sex and Love Addicts Anonymous (SLAA)
Sexaholics Anonymous (SA)
Sexual Recovery Anonymous (SRA)
Workaholics Anonymous (WA)
MEDICAL CONDITIONS—CANCER
American Childhood Cancer Association
National Cancer Institute
Lung Cancer Alliance
Cancer.net
American Childhood Cancer Association
MEDICAL CONDITIONS—DEMENTIAL AND
OTHER NEUROLOGICAL DISORDERS
Alzheimer’s Disease and Related Dementias
Attention Deficit Disorder (ADD/ADHD)
Autism and Asperger’s Syndrome
Learning Disabilities Association of America
Learndisability.meetup.com
National Multiple Sclerosis Society
MEDICAL CONDITIONS—HEART DISEASE
Mended Hearts
WomenHeart
MEDICAL CONDITIONS—RESPIRATORY ILLNESS
COPD & Emphysema
Lung Cancer Alliance
OTHER MEDICAL CONDITION
Defeat Diabetes Foundation
Herpes, Hepatitis, HIV
DISABILITIES
Hearingloss.org
Ears for Eyes
VisionAware.org
Wheel of Life
SpinalCord.org
OTHER COMMON MENTAL HEALTH CONDITIONS
Anxiety and Depression Assoc. of America (ADAA)
Attention Deficit Disorder Association
Depression Bipolar Support Alliance (DBSA)
Depressed Anonymous (DA)
Dialectical Behavior Therapy (DBT) Peer Support Groups
Dual Recovery Anonymous
Emotions Anonymous (EA)
Gift From Within
International Obsessive Compulsive Foundation
National Alliance on Mental Illness (NAMI)
Postpartum Progress
Postpartum Support International
Recovery International/The Abraham Low Institute (RI/TALI)
Schizophrenics Anonymous (SA)
Wellness Recovery Action Plan (WRAP) Support Groups
Anxiety and Depression Assoc. of America (ADAA)
Attention Deficit Disorder Association
BROADER LIFE CHALLENGES—PEOPLE AFFECTED BY SUICIDE
American Association of Suicidology (AAS)
American Foundation for Suicide Prevention
BROADER LIFE CHALLENGES—PEOPLE AFFECTED BY LGBTQ
STIGMA
Parents Family Friends Allies United with LGBTQ People (PFLAG)
Transgender American Veterans Association
BROADER LIFE CHALLENGES—PEOPLE AFFECTED BY LOSS AND
BEREAVEMENT
Compassionate Friends
Mended Hearts
Tragedy Assistance Program for Survivors
BROADER LIFE CHALLENGES—PARENTING
Parents Anonymous
Because I Love You
Multiples of America (Parents of Twins etc.)
Attachment Parenting International (API)
Parents Without Partners
Resolve (That National Infertility Association)
BROADER LIFE CHALLENGES—UNEMPLOYMENT
Dept. of Labor: Career One Source (American Job Centers)
JobHunt.org
Neighbors Helping Neighbors
140 DREBING ET AL.

centers; (b) Many of the groups are led by Certified Peer Special-
ists, who have more formal training that many community-based
peer support group leaders (Harrington, Dahoney, Gregory,
O’Brien-Mazza, & Sweeney, 2011); and (c) Groups are often
better integrated with formal health care than community-based
groups. They vary in focus, with specific groups for women
veterans, and veterans of different eras, experiences and clinical
concerns. They may be integrated into specific VA clinical ser-
vices, such as the peer support groups for veterans enrolled in VA
Psychosocial Rehabilitation and Recovery Programs, or veterans
enrolled in PTSD treatment. In some settings, VA peer support
groups may also include family members and friends (Gregory,
2008). The main disadvantage of VA peer support groups is that
most are not in the community, and so can be less effective in
encouraging full community engagement and integration.
Veteran service organization groups. Many national Vet-
eran Service Organizations such as the Disabled American Veter-
ans (DAV; https://www.dav.org/membership/local-chapters/) that
provide varying forms of service and advocacy to veterans, also
provide social support within their programming. Some have be-
come more active in developing explicit peer support groups, and
using these to help veterans connect to other veterans and to the
organization.
Support groups for female veterans. Besides general VA
support groups targeting women, there are local community-based
support groups for female veterans. Army Women United (http://
www.armywomen.org/) supports a network of groups for female
veterans that combine social support with service and advocacy.
As with many groups tailored to specific veteran populations,
clinicians may initially need to search for local autonomous groups
and then investigate as to their content and quality. Potential
research strategies include web searches, contacting local VA and
Veteran Service Organization offices, and talking to local veteran
advocates.
Support groups for veterans who are students. Many col-
leges and universities have developed formal or informal peer
support groups for their students who are veterans. The national
organization Student Veterans of America is active on 1300 cam-
puses (http://studentveterans.org/chapter/directory), and sponsors
peer support groups for veteran students, among other activities.
There are often local veteran support groups on campuses started
either by the schools or by veterans at the schools. Clinicians may
want to utilize the university website or contact the student affairs
office to see if the university has a chapter of the Student Veterans
of America or other on-campus veteran support groups.
Support groups for veterans by era. There are local and
national organizations that support, or at least provide assistance,
in finding support groups organized by era of service. For exam-
ple, the Iraq and Afghanistan Veterans of America (http://iava.org/
vettogether/) is an advocacy group that facilitates and catalogues a
wide range of social support groups and activities for post-9/11
veterans. These organizations exist for all other eras, though most
involve activities that include peer support as part of other activ-
ities such as advocacy.
Support groups for veterans by shared interest. There is a
wide range of local and national organizations that organize local
groups around a shared interest or activity, and so function as
support groups around that topic. The interest areas range from
sports and hobbies to professional and religious interests. For
example, The Combat Veterans Motorcycle Association (https://
www.combatvet.org/) builds social support among combat vet-
erans interested in riding motorcycles. Team Red-White-and
Blue (https://www.teamrwb.org/chapter-locations) builds sup-
port around shared physical exercise, and The Mission Continues
(https://www.missioncontinues.org/service-platoons/) builds sup-
port through community service. The shared interest or activity
may make it easier for some veterans to engage in this type of
support. The number and variety of interest groups represent a
major advantage to using these groups, but this may require an
initial investment of clinicians’ time for researching local groups.
Support groups for veterans facing specific challenges. A
growing number of support groups are organized around a shared
life or clinical challenge that veterans face. For example, veterans
and family members dealing with bereavement for a loved one
who has died during military service can gain a variety of supports
from Tragedy Assistance Program for Survivors (TAPS; http://
www.taps.org/survivors/caregroups.aspx), a nonprofit organiza-
tion that manages a network of peer-support groups in 15 states, as
well as online support. The Transgender American Veterans As-
sociation (TAVA), (http://transveteran.org/for-veterans/trans-
support-locator/), is an example of a national network of groups
for veterans who are transgendered.
Veteran Coffee Socials—A Novel Approach
While recognizing the value of support groups with a focus on
a shared problem, there is a need for broader, more flexible support
groups for veterans living in a specific community or moving into
that community. Eighteen months ago, as part of the Community
Integration Program (Community Recovery Connections Team or
CRCT) at the Bedford VA Medical Center, we began developing
weekly “Veteran Coffee Socials” as a means of building community-
based peer support groups with no limiting focus besides the desire
to connect veterans in need of community-based social support
(Drebing, 2017). VA Peer Specialists began initiating and facili-
tating weekly Veteran Coffee Socials at local restaurants and
coffee shops in seven towns. The goal of the meetings is broad -
to create an environment that allows veterans to access a wide
variety of formal and informal supports, with a particular focus on
local support and post-9/11 veterans. A secondary goal is to
facilitate the successful movement of veterans leaving VA mental
health treatment and transitioning to community-based peer sup-
port, thus helping improve access to limited mental health treat-
ment resources for new clients. Attendance at the Veteran Coffee
Socials is open and there is little structure besides a facilitator to
start the meetings and to respond to questions. The groups are not
considered to be a clinical intervention and there is no formal
documentation of attendance. There are no fees, and so the primary
financial incentive for the VA is to facilitate flow of clients
successfully transitioning out of treatment and back to community-
based supports, thus improving access for new clients to clinical
services and providers. Veterans who attend decide on the agenda,
which may vary but always includes socializing, exchanging in-
formation about resources, meeting community organization mem-
bers, and connecting around common interests and goals.
This effort started with the development of one group and within
six months had grown to eight groups in eight different commu-
nities. An embedded observer in the groups has been documenting
141
PEER SUPPORT GROUPS

what work was being done. The mean number of attendees has
been 9 per group or 72 veterans per week (Drebing, 2017). Ap-
proximately 50% of participants were post-9/11 veterans and the
remainder were from Vietnam (35%) or post-Vietnam (15%). A
wide range of interactions at meetings were noted including shar-
ing of information, sharing of emotional support, sharing and
organizing physical support, facilitation of local community in-
volvement (e.g., attendance at local 12-step meetings, volunteering
at local events), facilitation of participation in needed clinical care,
facilitation of community advocacy, and development of collab-
orative efforts between organizations. Repeated attendance was
noted both by community-dwelling veterans and veterans transi-
tioning to communities. Observers estimated that approximately
40% of participants were transitioning out, or reducing VA mental
health treatment; 35% were not involved in VA care; and 10%–
15% entered VA care as part of participation. In almost every
group, community organizations that serve veterans began attend-
ing regularly, as did many local officials responsible for veteran
issues. Although a full cost-benefit analysis still needs to be done,
some key advantages of these groups are illustrated in case de-
scriptions below.
Group 1. Each coffee social group is autonomous, with social
support evolving with the interests and needs of the group. A
Veterans Coffee Social started in a local restaurant provides an
example. Starting with the agenda to facilitate social support, the
meeting attendees began to extend the meeting time to allow
members to play chess and checkers after each meeting. It was
observed that attendees who previously had no social connection
to each other apart from the group then began to regularly plan and
engage in shared activities outside the meeting (e.g., bowling,
attending movies, attending community events). Given the number
of post-9/11 veterans, community organizations, such as The Mis-
sion Continues, that seek to enroll veterans from this era, began to
attend to build contacts with those veterans, who then began
attending meetings together. The members of this Coffee Social
began volunteering to prepare and serve meals for homeless fam-
ilies at a local religious organization, building a stronger connec-
tion between participants and the local community.
Group 2. The groups can be developed in communities with
little no organized veteran community resource, and become a
valuable community structure for veterans. In a second example, a
Veterans Coffee Social was started in a community with very few
resources or supports identified for veterans. Given the gap, local
veterans looking for a sense of connection with other veterans in
the area began to join with little outreach or formal publicity,
resulting in the group becoming the key gathering place for vet-
erans living in that community. This group also began to build
connections with other local peer support groups, including local
12-step groups (Alcoholics Anonymous and Narcotics Anony-
mous), thus helping attendees, particularly post-9/11 veterans new
to the community, to connect to a larger network of support. The
depth of the connections became substantial fairly quickly; when
one of the veterans associated with the coffee social passed away,
the other attendees appeared in uniform at the funeral to honor the
deceased and his military service.
Group 3. The degree of autonomy provided to the group
allows these Veteran Coffee Socials to evolve into self-sustaining
groups enabling the initial Peer Specialists to withdraw or reduce
their attendance so that they can develop new groups. In the third
example, the group decided to move the coffee from a restaurant
to the local Veterans Services Office. The willingness of members
to take responsibility for the group, and the integration of a key
local veteran community leader, allowed that particular Veterans
Coffee Social to become self-sustaining. The Peer Specialist who
developed the meeting then withdrew to start a new coffee, and the
meeting has subsequently been facilitated by a post-9/11 veteran
who helped draw in more veterans from his era. In other cases,
community-based organizations that have sent staff to these cof-
fees have subsequently started their own Veteran Coffee Socials in
other towns. This simple, flexible low-cost model of community-
based veteran-focused social support allows for community devel-
opment of peer support resources for veterans transitioning to
target communities.
Recommendations for Increasing Use of Peer
Support Groups
Although knowledge of, and referral to peer support groups
varies by clinical provider, there is convincing evidence that stra-
tegic efforts by health care organizations to encourage active
referral by providers result in significantly higher rates of engage-
ment (Sisson & Mallams, 1981;Timko et al., 2006;Walitzer et al.,
2009). Programs and organizations interested in increasing their
clients’ utilization of community-based peer support groups may
want to start by identifying existing needs for peer support groups
by the veteran population served. With those needs in mind,
programs should then seek to identify existing resources to address
those needs, in terms of local community-based support groups.
Although many national and international organizations have de-
veloped easy-to-use directories of available peer support groups,
there is no single directory of groups focusing on veterans. The
website TexVet (http://www.texvet.com/vetsocial) does this for
the state of Texas, and may be the best example of a large directory
serving the varied needs for support that veterans face. It is worth
noting that there is rapid growth in the number and type of Web
based and telephone-based support groups, which may serve as
resources for virtually any community. The initial empirical evi-
dence suggests that the benefits for these groups is similar to
in-person groups (Houston et al., 2002;Riper et al., 2011). Pro-
grams may want to assess current referral patterns and practices by
local clinicians to identify helpful referral resources and best
practices, as well as gaps in referral practices. Based on the results
of this assessment, programs may want to educate staff about (a)
the benefits of social support and of participation in peer support
groups, (b) results of the needs assessment and survey of local
resources, and (c) effective methods for referring clients. This may
be followed by implementation of routine active referral, along
with ways of monitoring the referral process and outcome. Table
1lists a range of referral practices found to be associated with
higher participation rates.
Clinical organizations may also want to develop or expand
transitional peer support group experiences, including peer support
groups run at the clinical site by program staff, and peer support
groups run by community- support group leaders. Transitional peer
support groups have the advantage of providing clients the expe-
rience of participating in peer support groups within the treatment
setting and increasing familiarity with the format with some com-
munity group members. This initial experience may increase will-
142 DREBING ET AL.

ingness to attend community-based groups, particularly for those
with little experience with support groups or with social anxiety.
Clinical organizations may also want to develop community-based
support groups such as the Veteran Coffee Socials, as a means to
increase access to local community supports. To support these
efforts, organizations may want to ensure they are adequately
staffed with Certified Peer Specialists, who are well suited to lead
and support peer support groups. These staff members have a
unique role in both engaging potential clients in needed care and in
helping clients transitioning out of care to connect with natural
community supports.
Conclusions
Clinical providers serving military personnel and veterans seek-
ing higher levels of community integration need to become more
active in developing and using explicit interventions focusing on
social support. The large and growing network of community-
based peer support groups represents a widely available, inexpen-
sive, and effective means for many veterans to gain social support
and engagement in the community. As their value is often unrec-
ognized by many clinicians, strategic efforts to educate clinical
providers and clients about the benefits of these groups and strat-
egies for referral, will lead to higher participation rates and better
social support and community engagement among veterans.
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Received December 1, 2016
Revision received May 31, 2017
Accepted June 5, 2017 䡲
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