From Combat to Classroom

Jennifer Romesser, PsyD, Darlene Head, Danica Richins, LCSW, Jason E. Molesky, and Dallas B. Griffiths

This training guide represents a partnership between the George E. Wahlen Department of Veteran Affairs Medical Center, the Brain Injury Association of Utah and many state and community agencies and organizations that serve Veterans. This partnership includes a multi-disciplinary group of professionals with medical, mental health, legal, academic and employment expertise. In particular, the development of this guide has included close collaboration with the Salt Lake Community College Veterans Services Center, a nationally recognized model that has helped tens of thousands of Veterans achieve academic success over the last half-century.

PURPOSE

Hundreds of thousands of servicemembers have been deployed to serve in Operation Iraqi Freedom (OIF) and Operation Enduring Freedom (OEF), Operation New Dawn (OND), and Operation Odyssey Dawn (OOD), and many more may be deployed and return home in the coming years. Many of these servicemembers and Veterans will choose to access their military education benefits and begin the next phase of their lives at postsecondary institutions. Some will continue to serve as Reservists or National Guards men/ women and balance this with the responsibilities of returning to school. For the purpose of this manual, we will refer to all Service men/women and Veterans attending college as student-Veterans.

College campuses may soon see an influx of military servicemembers seeking an undergraduate education. According to the American Council on Education (2008), campuses across the country are on the cusp of serving more than 2 million military veterans. While many may be Veterans of OEF/OIF/ OND/OOD, there are also other era Veterans (i.e., Veterans discharged before 9/11/2001) that are enrolled and will be enrolling in universities and colleges across the nation. Many campuses have seen a dramatic increase in the registration of student-Veterans returning from Iraq and Afghanistan and the numbers are expected to increase as military personnel transition to civilian life. Colleges and universities located near VA Polytrauma Centers have also seen a significant increase in students with disabilities according to interviews with staff (Church, 2009). Educational Institutions may also be working with military family members, as military education benefits can be transferred to dependents under certain circumstances. Benefits are sometimes granted to the spouse and children of servicemembers who have been killed in the line of duty or who are rated 100% disabled and unable to work according to the Veterans Benefits Administration (VBA). Student-Veterans face particular adjustment issues not typical of the general student population and you play a crucial role in the effort to achieve their academic goals. With the proper preparation, you will find your work with student-Veterans to be unique and very rewarding. This training guide will help equip you with the knowledge and resources you will need to embrace working with student-Veterans with confidence and respect.

GENERAL INFORMATION ABOUT VETERANS AND SERVICEMEMBERS

WHO ARE VETERANS AND SERVICEMEMBERS?

The United States Armed Forces consist of the Army, Navy, Marine Corps, Air Force, and Coast Guard. You can refer to members of any of the branches as “soldiers” or “service men/women,” but each branch also has its own name for its members (i.e., soldier, sailor, marine, air man/woman, respectively). You may also hear other distinctions such as “Reserve,” “National Guard,” or “Active Duty.” Simply put, “Active Duty” means the person is serving the military full-time, whereas “Reserve” and “National Guard” mean he/she is serving part-time usually while holding other civilian responsibilities (e.g., jobs, school).

WHO IS AN OEF/OIF/OND/OOD VETERAN?

OEF/OIF/OND/OOD servicemembers and Veterans are the men and women who have served in our United States Armed Forces during the United States Global War on Terrorism (GWOT), 2001-2009, and continuing Overseas Contingency Operations. The majority of deployments have been to Iraq and Afghanistan, although many servicemembers have also been deployed to adjacent areas such as Kuwait. Nearly one-third of the servicemembers involved in these conflicts have been deployed two or more times. Deployments typically last from three to fifteen months, partially depending on the branch of service and goal of the mission. Jobs and duties performed by each servicemember are so varied it is simply impossible to list them all here. Some jobs may require going into life-threatening combat zones and others may require staying on base providing supportive duties. Thus, depending on the locale of their deployment and the nature of a servicemembers duties, they may have been exposed to combat or other traumatic situations. Servicemembers not exposed directly to combat may have experienced other high-stress situations and hardships as a result of their deployment. It is important to note though, that to those serving in the military, deployments are not only categorized as hardships but many speak of the positive and meaningful experiences they had while deployed.

OTHER-ERA VETERANS

While this guide speaks directly about OEF/OIF/OND/OOD Veterans in some parts, it is important to note that there are many other-era Veterans who are attending colleges and universities. Much of the information provided in this guide applies to all student-Veterans regardless of when and where they served.

FEMALE VETERANS

Women make up approximately 20% of the military population and serve in many important roles. It is important to note that while women are officially barred from front-line combat duty, they do serve in active combat zones and may have been exposed to combat as well as other types of trauma, including military sexual trauma (MST). The information presented in this guide is applicable to Veterans of all genders.

MILITARY CULTURE AND THE STRENGTHS OF THE VETERAN

While much of this guide focuses on the challenges of the post-deployment and post-military service periods, it is also very important when working with this population to consider the strengths that many student-Veterans embody. Common strengths include determination, a strong work ethic, patriotism, commitment, dedication, honor, willingness to sacrifice and loyalty. These strengths are often magnified in situations where the student-Veteran feels respected and acknowledged. Many of these qualities translate into important and valuable civilian skills (e.g., leadership, strong teamwork and excellent communication). In college/university settings, these strengths often manifest as high motivation with a strong sense of purpose, punctuality, dependability, and diligence, making the student-Veterans strong candidates for academic success.

When recruits enter the military, they are immersed in a world where the institutional value of the group is supreme to that of the individual. Recruits swear allegiance to something larger than themselves; they fight for something more than themselves; they are fighting for their comrades, their unit, and ultimately, their homes and families (DND, 1984). Transitioning back to civilian society can be difficult for some servicemembers due to the many differences between the military structure and the civilian world. It is important to understand these differences when working with our returning servicemen and women.

ETHNIC/DIVERSITY ISSUES

Currently the ethnic makeup of the U.S. Armed Forces is similar to the ethnic makeup of the general U.S. population. National Guard and Reserve units are more likely to reflect the ethnic make-up of the particular state. Because of the nature of warfare the military puts emphasis on structure, hierarchy and rank. The group culture of the military places less emphasis on group differences such as race, socio-economical status and education compared to the civilian world. With that being said, some soldiers have experienced discrimination and prejudice. This has been especially true for gay and lesbian individuals. Although there has recently been a change in the homosexuality “ban” within the military, it is important to understand that this does not necessarily constitute a change in military culture or attitude.

EDUCATION BENEFITS

Members of the Army, Navy, Air Force, Marine Corps, Coast Guard and Reserve and National Guard may be entitled to up to 36 months of educational benefits under the Montgomery GI Bill (MGIB). Benefits vary based on type of service, years served and when and where the student-Veterans served. Benefits may also be available for dependent(s) of Veterans if transferred, due to severe disability or death of the servicemember as a result of their service.

Education benefits can only be used at institutions with VA approved programs, apprenticeship or on-the job training programs. Classes taken must be required for graduation or program completion at the institution the student-Veteran is enrolled to be eligible. MGIB and other educational benefits available today for Veterans and their dependents are:

30 MGIB
Active duty G.I., servicemember paid $1,200.00 to qualify
(Benefits for veterans)

Ch 31 VA Rehab
Veterans with 20% disability rating or greater
(Benefits for veterans)

Ch 33- Veterans
Service after 9/11
(Benefits for veterans)

Ch 33 TEB
Transfer of Education Benefits to spouse/dependents
(Benefits for veterans)

Ch 33 FRY
Available for dependents of a parent killed in the line of duty
(Benefits for spouses and independents of veterans)

Yellow Ribbon Program
Ch 33-100% eligible – jointly paid between school and VA
(Benefits for spouses and independents of veterans)

Ch 35
For spouse/children, parent 100% disabled or killed in the line of duty
(Benefits for spouses and independents of veterans)

Ch 1606
Reserve and National Guard–not serving any Active Duty Ch 1607 Reserve and National Guard–Active Duty Support – OEF/OIF
(Benefits for veterans)

Parent School/Secondary
Seeking Degree at Parent school-guest at another school
(Benefits for veterans)

MYCAA
A DOD program to assist the spouse of a deployed soldier
(Benefits for spouses and independents of veterans)

Examples of additional benefits available to student-Veterans in the State of Utah are:

In addition to the MGI education benefit provided because of military service, the National Guard or Reserve Units, or the individual state, may offer other sources of funding. Your school’s Certifying Official or State VA Office can offer information about additional benefits available in your area. (DVA handbook 2010)

VOCATIONAL REHABILITATION

Administered by Veterans Benefits Administration (VBA), the Vocational Rehabilitation program’s primary function is to help individuals who have service-connected disabilities become suitably employed, maintain employment or achieve independence in daily living. Vocational Rehabilitation requires at minimum a 20% service connection disability for a military related physical or mental health condition (“service connection” means that the VBA has determined that a disability resulted from military service; the percentage reflects severity). Veterans use their vocational rehabilitation benefits to pay for tuition and fees and may be given an allowance for course supplies (e.g., computers, calculator, paper, cognitive prosthetics, books) and a living allowance Unlike the GI Bill, student-Veterans using their Vocational Rehabilitation benefits to return to school are assigned a VBA Vocational Rehabilitation counselor that provides support throughout their academic career as needed. It can be useful for college/university advisors to communicate with these counselors. This can be facilitated by the Veteran/servicemember signing a release of information (ROI).

USDEPARTMENT OF VETERANS AFFAIRS — BENEFITS AVAILABLE TO VETERANS

HEALTHCARE BENEFITS

A person who served on active duty and was discharged or released under conditions other than dishonorable, may qualify for VA healthcare benefits through the Veterans Health Administration (VHA) and receive healthcare at a VA Medical Center. Reservists and National Guard members may also qualify for VA healthcare benefits if they were called to active duty (other than for training only) by a federal order, and have completed the full period for which they were called up or ordered to active duty. For questions about eligibility and healthcare benefits, it is suggested that Veterans call their local VA Medical Center and ask to speak to a representative in the Enrollment Office.

OTHER BENEFITS

The Veterans Benefits Administration (VBA), also called the VA Regional Office, is responsible for administering the Department of Veterans Affairs programs that provide financial and other forms of assistance to Veterans, their dependents, and survivors. Major benefits include service-connected disability compensation, Veterans’ pensions, survivors’ benefits, vocational rehabilitation, educational assistance, home loan guarantees, and life insurance coverage.

The National Cemetery Administration (NCA) operates 125 national cemeteries in the United States and territories, together with oversight/management of 33 soldiers’ lots, confederate cemeteries, and monument sites. The mission of NCA is to honor Veterans with a final resting place and commemorate their service to our Nation.

Post-Deployment Issues

The experience of a single or sometimes multiple deployments can create unique challenges for servicemembers and their families. Higher rates of marital discord and divorce have been observed among servicemembers. Some of the common post-deployment concerns are discussed below; however, it is important to note that there is no ‘typical’ readjustment pattern following a deployment. Factors such as the nature of the deployment , family functioning, and financial circumstances (among many other issues) can significantly impact the readjustment trajectory.

MARITAL AND FAMILY ISSUES

After being separated for sometimes more than a year, military families face the challenges of quickly adapting to new parenting, spousal, and occupational responsibilities. During a deployment, servicemembers often miss their families and may count down the days until they are able to return home and reunite with them. They may have high expectations that they will quickly pick up where they left off. However, after a honeymoon period, the realities of readjusting and stresses of creating a new ‘normal’ can become apparent. Servicemembers may return home to significant changes. For example, important household decisions may have been made in their absence. New family routines or traditions began, or young children may not remember them, be slow to warm up to them or cling to them.

On the other hand, the veteran’s family may also report that the veteran has changed during his or her absence. The servicemember may have experienced combat-related events that profoundly impacted their perspective. Also, after becoming accustomed to military culture and deployment-related stressors, servicemembers may find it challenging to manage some family dilemmas. For example, the common parenting practice of having to make a request repeatedly or coping with an inconsolable crying baby requires readopting a civilian skill set that they may not have utilized in some time.

Under ideal conditions the readjustment process can take several months for families to reach a new equilibrium. The emergence of deployment-related conditions like Traumatic Brain Injury (TBI) and Posttraumatic Stress Disorder (PTSD) can further prolong this process. Collectively, these issues can impact the servicemember’s and/or his or her spouse’s function in the academic environment. Having reasonable expectations for this transition period as well as collaboratively negotiating new roles within the family are important steps in readjusting after deployment. There is help available for military families. Individual, family and child therapy is available to assist in the readjustment process and improving their relationships. The appendix of this guide includes a list of resources available to assist you in referring student-Veterans to federal, state and community agencies that can assist them in their adjustment process.

FINANCIAL ISSUES

Veterans may return from their time serving with concerns about earning enough money to support themselves and their families. Their military pay may have changed, and veterans may need to seek alternative ways to support their families. In some cases, work positions that were intended to be held while they were away have been filled. The process of applying for and receiving disability or academic benefits can be slow, causing increased financial stress. Also, mental health issues such as PTSD, TBI, depression or sleep problems can undermine a veteran’s ability to maintain a regular school or work schedule or perform at their best capacity.

SCHOOL AND WORK BALANCE

Creating balance between work and school can be a challenge, especially if they have never attended a post-secondary institution. Student-Veterans may not realize the amount of time they need to invest in studying and may set themselves up for academic difficulties by committing to more work-hours than what is realistic. Some student-Veterans, for example, are surprised to hear that they are required to study three hours per credit hour (i.e., one hour in class and two hours on their own), which makes the 12-credit load almost a full-time job. Further, some types of psychological distress can affect concentration, which will further increase the time required to accomplish school work. It may be difficult for veterans to acknowledge and ask for help when struggling.

DRIVING CONCERNS

When veterans return from deployment, the significance of driving a vehicle may have changed dramatically from their pre-deployment experiences. Civilian driving differs significantly from combat driving (e.g., not stopping at stop signs, constantly scanning and watching other vehicles, avoiding potholes where bombs may be hidden, and driving erratically to be purposely unpredictable). For this reason, many returning combat veterans report that operating a vehicle or being a passenger can be highly stressful. The perception of being unsafe or feeling threatened can contribute to incidents of road rage and dangerous driving. Student-veterans may feel particularly wound up or agitated for minutes to hours after driving to school, which may affect their concentration and participation in class.

Treatment is available to assist Veterans in accomplishing this transition safely and to reduce the risk of harm and legal involvement. The appendix of this guide includes a list of resources available to assist you in referring Veterans and servicemembers to federal, state and community agencies that can help them in their adjustment process.

MISSING CLASSES FOR MEDICAL APPOINTMENTS

It is helpful to encourage student-Veterans to schedule medical appointments at times less likely to affect class attendance. However, they may have scheduled their appointment six months before they enrolled in school. Sometimes there is little or no flexibility with possible appointment times. For example, in certain clinics at VA Medical Centers, Veterans are automatically scheduled into the next available appointment slot and some clinics are only available one ½ day a week. While a Veteran always has the option to cancel and reschedule an appointment, doing so may significantly lengthen the time before they can be seen. It is recommended that colleges and universities be flexible in regards to Veterans needing to attend medical appointments. If proof of a medical appointment is needed, Veterans can ask their provider for a brief statement on VA letterhead.

MILITARY LEAVE AND RE-DEPLOYMENT

Those still active in the National Guard/Reserves may be called up at any time for training, drill or active duty service. At minimum they are required to attend training one weekend per month and extended training for two weeks to a month at some time during the year. Some military members may also be required to attend an extended training in preparation for future deployment. National Guard and Reserve members may be given activation orders for a few months down the road or receive orders to report in a matter of days. They must get their affairs in order before they leave, such as their will, power of attorney, etc.

Student-Veterans care about their classes but they must leave when they are told to go. Please be flexible whenever possible to assist them to complete their classes or to withdraw from their classes without penalty.

Mental Health and Medical Issues

PTSD, DEPRESSION AND SUBSTANCE ABUSE

POSTTRAUMATIC STRESS DISORDER (PTSD)

PTSD is an anxiety disorder that can develop after the experience of or witnessing a traumatic event (e.g., military combat, natural disasters, terrorist incidents, serious accidents or physical or sexual assault as an adult or in childhood) (APA, 2000). Most survivors of trauma will experience an initial anxiety reaction but return to healthy equilibrium given a little time. Some people, however, will have stress reactions that do not go away on their own or may even get worse with time. These individuals may develop PTSD. Research suggests that approximately 15% of OEF/OIF soldiers returning from deployment have combat-related PTSD (Hoge, et al., 2008). This percentage may be higher in soldiers whose military occupations were at higher risk for trauma.

Three types of challenges/symptoms are present with PTSD. “Re-experiencing” symptoms (reliving of the traumatic event) may be triggered by something that reminds the person of the trauma and takes them away from being fully engaged in the here-and-now. For example, a Veteran may hear a car backfire, which triggers the trauma of gunshots, which in turn can shift thinking to a memory of being in gunfire accompanied by a strong emotional reaction of distress, anxiety and fear. The second cluster of symptoms is referred to as avoidant symptoms (APA, 2000). Because memories of the traumatic event are powerful and painful, individuals with PTSD may take active steps to avoid situations or activities that remind them of the trauma (e.g., watching war movies). It is not uncommon for student-Veterans to avoid crowded places on campus such as the student bookstore during the first week of class. Being surrounded by people triggers the reaction of elevated alertness and anxiety which was a much needed response in the combat zone. Similarly, some student-Veterans struggle attending lectures in classrooms where escape would be difficult. Avoidance of traumatic memories may also manifest as numbing of emotions or memories. These individuals may appear detached or unaffected, or they may isolate them-selves from others.

The third cluster of symptoms is referred to as hyper-arousal symptoms (APA, 2000). People with PTSD often feel constantly alert which can cause sleeping difficulties, outbursts of anger or irritability and concentration problems. Feeling constantly “on guard,” they are compelled to survey their environment for escape routes, possible danger points and unfriendly/dangerous looking stimuli. Engaging in such a task is quite cognitively taxing and can hamper their ability to attend to more salient stimuli (e.g., lecture material, or conversation with an academic advisor). Proximity to others is also a common concern. For example, many Veterans prefer having people in their line of sight rather than behind them. Some classrooms may be more anxiety-provoking than others. Auditoriums with stadium seating, rooms with bolted chairs, or rooms with only one exit, may be particularly challenging. In such cases, you may encourage the student to contact the school’s disability support services for accommodations.

PTSD is a serious but treatable disorder. If left untreated, however, PTSD can lead to significant problems in day-to-day functioning, both for Veterans and their families. There are multiple treatment options available to effectively deal with PTSD. The appendix of this guide includes a list of resources available to assist you in referring your student-Veterans to additional organizations and agencies that can assist Veterans with PTSD.

MILITARY SEXUAL TRAUMA

In both civilian and military settings, servicemembers can experience a range of unwanted sexual behaviors that they may find distressing. These experiences happen to both women and men. “Military sexual trauma,” or MST, is the term used by the Department of Veterans Affairs to refer to experiences of sexual assault or repeated, threatening acts of sexual harassment. Military sexual trauma can result in physical and emotional difficulties. There is help available for servicemembers and Veterans who have experienced MST. Every VA facility has an MST Coordinator who serves as a contact person for MST-related issues, who can help Veterans find and access VA MST services and programs. In the appendix of this guide a list of resources is available to assist you in referring your student-Veterans to organizations and agencies that can assist Veterans who have experienced MST.

DEPRESSION

Depression is different from normal human unhappiness. Depression is a deep, prolonged and painful sadness that does not respond to attempts to help a person “cheer up.” It includes a loss of interest in things one was previously interested in, such as family, hobbies, friends and work. Other symptoms of depression include diminished self-worth, irritability, problems with sleep and appetite, decreased motivation, decreased libido, slowed thinking, and difficulties in concentration (APA, 2000). Suicidal ideation is a serious aspect of depression. If you suspect one of your student-Veterans is having suicidal thoughts, you are encouraged to ask him/her about it, consult with your campus mental health resources, and/or refer the student-Veteran to a mental health professional.

SUBSTANCE ABUSE

PTSD, pain and depression are risk factors for developing substance abuse (Bray, et al., 2010). Overwhelmed by insomnia and nightmares, flashbacks, and a host of family, school or work–related problems, some individuals may turn to alcohol or other substances, both prescribed and illegal, to manage sleep irregularities and cope with anxiety related to memories of trauma. Using substances can have significant social, emotional, cognitive and academic consequences, both short term and long term. In the appendix of this guide is information on evaluation and treatment services for alcohol and substance abuse concerns.

Traumatic Brain Injury

TBI is the result of injury to the brain brought upon by some external physical force (e.g., a fall, motor vehicle accident, blow to the head, or a blast). TBI can result in a range of physical, cognitive, emotional and behavioral symptoms. Moderate and severe traumatic brain injuries (those injuries characterized by a loss of consciousness for more than thirty minutes) can impact many different areas of functioning depending on the extent and location of the damage to the brain.

PHYSICAL CONCERNS

Following a TBI, individuals sometimes develop physical problems such as muscle weakness or paralysis, balance issues, dizziness and gait disturbance, problems with swallowing, headaches and changes in sensory experience. Sleep difficulties and fatigue may also occur after a TBI which can intensify other symptoms.

COGNITIVE ISSUES

Individuals can experience cognitive deficits of varying severity after a TBI, including difficulties with learning and memory, attention and concentration problems, slowed speed of thinking, changes in the ability to understand language and express oneself and problems with organizing, planning, reasoning and abstract thinking. Sometimes the individual may not be aware that he/she suffers from these difficulties.

EMOTIONAL ISSUES

Problems with emotional functioning can also occur following a TBI. Some individuals suffer from symptoms of depression, anxiety, mood liability (unpredictable and intense mood swings), emotionality, irritability, tearfulness or difficulty feeling and expressing emotion.

BEHAVIORAL CONCERNS

Behavioral disturbances can also accompany TBI. Some may become uninhibited, impulsive or aggressive; others may not read social cues appropriately or understand subtle non-verbal behaviors of others. They may also experience changes in personality and temperament which may magnify personality traits and idiosyncrasies. Any of these symptoms may result in difficulties in social, academic and occupational functioning. Most individuals with a history of traumatic brain injury who experience ongoing difficulties will need academic support and could benefit from the services provided by their institution’s Disability Resource Center.

MILD TBI

mild traumatic brain injury (mTBI) is a less severe form of brain injury commonly referred to as a concussion. Recent studies have suggested that about 10-20% of deployed soldiers have sustained a probable concussion during their deployment (Hoge, et al., 2008). Civilian research studies suggest that in the majority of cases (upwards of 97%), post-concussive symptoms resolve in 1-3 months (McCrea, 2008; Mittenberg et al., 1996). Individuals that have suffered multiple concussions or have co-occurring mental health issues may be at risk for more persistent symptoms (Hoge, et al., 2008).

It is very important for Veterans with a history of concussions to be evaluated by a medical professional with expertise in the area of mTBI. The VA Health Care System is equipped to evaluate and treat all OEF/OIF/OND/OOD Veterans with possible mTBI. If you have a student-Veteran who is concerned about possible brain injury, refer them to their local VA. In the appendix of this guide a list of resources is available to assist you in referring your student-Veterans to additional organizations and agencies trained to assist Veterans with traumatic brain injury concerns.

Sensory Difficulties

Changes in hearing can occur in individuals who have been exposed to hazardous levels of noise, such as weapons fire and blasts. TBI can also be a risk factor for changes in hearing. In some cases there may be increased sensitivity to everyday sounds. This can be problematic in a classroom or large group setting; it makes it difficult to tune out extraneous noise and may affect concentration and focus.

Tinnitus (ringing, buzzing, humming sounds in the head) is another common problem experienced by returning Veterans and can be distracting in the academic setting, affecting concentration and attention.

In many cases effective treatment or rehabilitation strategies are available. Individuals with auditory difficulties may benefit from discussing their concerns with their primary care provider, who can refer them to the appropriate specialty provider. Evaluation and treatment of auditory concerns is available in the community as well as through the VA Medical Center.

The visual system has components throughout the brain that can be affected by TBI. TBI can result in difficulty with ocular accommodation, which involves sustaining focus on particular aspects of the environment for example during reading. Light sensitivity may also be an issue and some student-Veterans may choose to wear sunglasses or hats indoors as a way to compensate for this. It is important for professors and staff members to accommodate this adaptive behavior whenever possible.

Fortunately, there are many vision therapies, environmental accommodations and task modifications that can be helpful in addressing visual difficulties. Student-Veterans with visual concerns should contact their primary care physicians for a referral to the appropriate medical professional for further evaluation. They should also consult the college Disability Resource Center for classroom accommodations.

Cognitive Issues

Cognitive problems can occur as a result of numerous medical and mental health conditions (Iverson, 2005). Cognitive dysfunction is common in individuals with TBI, sleep disorders, depression, anxiety, PTSD, substance abuse, and chronic pain. Examples of common cognitive difficulties include: difficulty with concentration and focus, problems with learning and recalling new information, slower speed of thinking, difficulty with planning, reasoning and organization, problems with abstract reasoning, and changes in language abilities. These types of difficulties have the potential to negatively impact academic functioning. Academic accommodations may facilitate academic success for students with cognitive difficulties. Student-Veterans with concerns about cognitive issues should consult with their primary care physician either in the community or at the VA Medical Center. They should also be encouraged to contact their institution’s Disability Resource Center for information about possible accommodations.

TIPS FOR WORKING WITH VETERANS WITH COGNITIVE IMPAIRMENTS

Regardless of the cause of the difficulty, the following tips may be helpful when working with an individual with cognitive problems.
Individuals with memory problems may benefit from repetition to help with new learning and memory. Repeat information and instructions often.
Individuals with memory problems or processing difficulties may benefit from information that is displayed visually.
In addition to verbal instruction, visual modeling/materials can be helpful. Ask the individual to write down important facts – names, dates, instructions and assignments, etc.
Follow-up calls or meetings may be necessary to ensure the individual understood/retained the information and was able to follow through.
Some individuals may have difficulty following multi-step instructions due to the complexity. Break things down into one or two simple steps at a time.
Some individuals have slowed processing speed meaning they need more time to comprehend what others say and organize and formulate their own verbal or behavioral response. Be sensitive to the rate of your speech or response time.
Expect a delay in the person’s verbal and/or behavioral responses.
As much as possible, avoid noisy/distracting environments that may make it more difficult for the individual to focus.
Some individuals need hearing aids after brain injury. You do not need to speak more loudly or get closer than usual. The hearing aids amplify sounds well. If you are uncertain as to whether you can be heard clearly, just ask.
After TBI some people have difficulty with visual organization and path-finding. Buildings and campuses can be very confusing to those who are unfamiliar with them. Escorting students to their destination and giving clear, simple directions are very important.
Fatigue is a common issue after TBI. Asking individuals how they are feeling and whether they want a break may be helpful. Scheduling brief breaks (i.e., the last 5-10 minutes of every hour) will help if they are hesitant to verbalize their fatigue.
Frustration and irritability is common after TBI. Allow breaks and align expectations accordingly.

Sleep Problems and Chronic Pain

Veterans often report that sleep during deployment is quite disturbed. For some, problems with sleep onset and maintenance persist when they return home (Capaldi et al., 2011).

Some individuals may feel increased anxiety and vulnerability at night. Oftentimes, missions were conducted under the cover of darkness, which trains the soldier’s body to view darkness as dangerous. Some missions allowed for very little or no opportunity to sleep and when it was available it may have been very different when compared to a typical civilian sleep schedule (Wesenten and Balkin, 2010). These patterns can be difficult to undo.

Distressing dreams of military experiences can also interfere with sleep. Often times upon awakening from a nightmare, individuals experience significant anxiety and have difficulty with falling back asleep. Traumatic brain injury can also affect one’s sleep cycle. Regardless of the cause, sleep deprivation enhances a person’s vulnerability to mood disturbances, cognitive difficulties and physical issues.

Therapy and medication can be helpful in improving sleep. In the appendix of this guide a list of resources is available to assist you in referring student-Veterans to treatment if sleep is a concern.

Coping with chronic pain can be physically and emotionally exhausting and can negatively impact mood, sleep and cognitive functioning. Medications used to treat pain, while sometimes helpful, have side effects that can also impact mood, behavior and cognition. Sometimes non-pharmaceutical approaches to treating pain are preferred.

Tips for Colleges and Universities

WORKING WITH COMBAT STUDENT-VETERANS

Rapport is important when working with your student-Veterans which may take time to build and can be facilitated with patience and a caring attitude.
Structure and routine are an essential part of military life. Some post-deployed soldiers may struggle with the lack of routine and structure in their civilian life. Assisting them in creating a schedule ofactivities and goals can often be helpful.
Some Veterans may have the tendency to get angry and irritable very quickly. When you notice irritability suggest a break and do not push. Do not take the irritability personally and try not to be defensive or argumentative.
Veterans and servicemembers have learned valuable skills while serving in the military, including team management, a strong work ethic, attention to detail, confidence, maturity, and teaching skills. Many student-Veterans hope to integrate the knowledge and skills they gained during their military service into their civilian lives and careers. Recognizing these skills and presenting opportunities that allow them to utilize these skills, can benefit the student-Veteran and those around them.
Student-Veterans may be referred to the Dean of Students office or the Behavioral Intervention Teams due to “perceived” threatening or concerning behavior. Some mental health issues can effect an individual’s threshold in emotional regulation. Taking into account your student-Veterans experiences may help determine an appropriate action plan.
It is recommended that you be as collaborative as possible when working with student-Veterans as some may be sensitive to authority figures and resent an authoritative approach. Respect and authority are earned through performance in the military culture, and are not simply the result of a title or an advanced degree.
Avoid religious or political discussions and sharing personal views on military, political or religious issues (e.g., gay and lesbian servicemembers in the military, belief that the war is wrong).
Do not ask about military service in any group environment unless the student-Veteran self-discloses their service. These types of conversations should be conducted in one-on-one settings and done so in a very sensitive manner.

EFFECTIVE COMMUNICATION

Seemingly innocent attempts at communication about military involvement can sometimes be misinterpreted. For example, some Veterans may be sensitive to opinions about war. When working with a transitioning servicemember be conscientious and respectful.

A very general approach is recommended.

What to say

Thank you for Serving.
Thank you for your service to our country.
Welcome back.
Thank their family for the sacrafice they made to preserve the nation's freedom.

Use your professional judgment and always err on the side of caution. If you ask a question, ask a question that solicits direct factual answers:

When did you get back?
What branch of the service are you/were you in?
Where did you serve?
Never pry. If they don’t want to talk, don’t push it. They will initiate a more personal conversation if they trust you and wish to speak about something. Until then, remain polite and professional and open to listening.
Avoid unnecessary curiosity and ask questions only if they seem relevant to assisting the student-Veteran.

What to NOT say

What was going to war like?
What do you think of the war?
Did you see anyone die?
Did you kill anyone?
Did you lose any friends?
How did you get injured?
Are you opposed to the war?
Are you okay (mentally)?
Did you see a lot of dead people?
Are you traumatized?
Are you experiencing PTSD?
Did you see any action?
That must have been hard.
Don’t use military lingo as a way to communicate/connect. For example, don’t say to them “at ease” or “soldier.”
Don’t express excessive praise or thanks to the Veteran. Simplicity is the key.

COMMON CHALLENGES FOR STUDENT VETERANS

Rules for using military benefits are very rigid. The GI Bill only pays for classes that are required for graduation in their declared program.
Veterans have up to 36 months of benefits. When they return from serving they may test into remedial classes or be required to retake classes that use up their benefits.
Many student-Veterans attend school, have a family and hold down a job.
Credits earned for military training often do not transfer toward their academic program of study.
Veterans receive a living stipend based on credit hours enrolled. If their required classes are not available when they register they receive a reduced living stipend which they count on. Early enrollment for student-Veterans easily remedies this issue.

CLASSROOM SUPPORT

In addition to suggestions listed throughout this manual, we encourage you to:

Enhance feelings of comfort in the classroom and in testing setting (e.g., quiet, less crowded). In the case where a medical or mental health disorder is present, the student-Veteran may qualify for academic accommodations or special arrangements, which can be made through your Disability Resource Center.
In your syllabus, include a statement about accommodations for student-Veterans, such as ways for them to make arrangements for medical appointments, training, unexpected leaves of absence, or other needs related to adjustment issues.
Some student-Veterans are sensitive to people being behind them or in very close physical proximity. It may make them more comfortable to let them choose where to sit in the office or classroom setting. Recognize that some individuals will be most comfortable in the back of a classroom near an exit door.
Do not perceive this as disinterest. In fact, this position may enable them to better attend to and integrate new information.
Veterans often have medical appointments scheduled months in advance which may impact course attendance. If their instructor will not work with them, they may get discouraged, possibly fail the class and/or drop out of school. The student-Veteran maybe required to repay the money paid for that class, as a result.
Student-Veterans may have special needs but are often disinclined to seek assistance due to stigma and/ or fear of appearing weak. Encourage them to contact services such as your Disability Resource Center that can help them succeed in school.

CREATING A VETERAN-FRIENDLY CAMPUS

Some of the suggestions below reflect an ideal scenario, but even small changes can make a difference when
serving your student-Veteran population.

Track admissions of Veterans. Knowing the number of attending Veterans is crucial for assessment of
needs and goals. Having this information on file enables you to contact student-Veterans for outreach.
Send a letter from the school’s administration to all new student-Veterans welcoming them to your school.
Create a welcoming Veterans Office. It is ideal to have an office dedicated to serving the needs of student-Veterans. Let them know they are welcome and create a connection that says they are important to the institution. If possible, provide dedicated space on campus where your student-Veterans can study together, socialize, and decompress between classes. This “one-stop shop”
model has proven effective in colleges and universities, and often pays for itself in increased Veterans
admissions and success. If this is initially unfeasible, find some space or events where they can connect
with other student-Veterans.
If you don’t have a center for your students, determine who could serve as a point-person for your student-Veterans to contact and talk to if they have problems. It is important for them to know they have someone they can contact that will assist them if they need it.
Invite members from the Veteran community to your college to meet with your student-Veterans. Many organizations can provide a variety of services such as enrolling students in VA programs and services, provide tutoring support or counseling and are willing to assist the Veterans. Contact your school Certifying official or your State Veterans Office to make the contacts.
Consider deferment of Veterans’ tuition until later in the term. Veterans receive their pay after the term begins, placing a considerable financial stress on the Veteran. Deferring tuition can eliminate this pressure
Create a Veterans Committee. Gather a group of willing employees from different departments (ie:
Registration, Admissions, Disability Resource Center, Student Officer, School Certifying Official, Fi-
nancial Aid, Faculty, Administration, etc) to form a “Veterans Committee” to handle student-Veterans
concerns and offer support.
Encourage and support the creation of a Veterans Club on campus. Seek out student-Veterans with
strong leadership qualities who are interested in creating a club and support them in this endeavor. You
can contact Student Veterans of America (SVA) to assist you in setting up your club (website located in
the appendix of this guide).
Build a website specifically for Veterans. In addition to your institutional requirements for the use
of the GI Bill benefits, feature links to resources and information for students success, links to easily
download relevant government documents and forms, etc.
Provide workshops for your student-Veterans such as Financial Awareness, Study Skills, Stress
Management, etc.
Educate faculty, staff, and administration about student-Veterans issues. Many college and university
personnel are not aware of the challenges and opportunities presented by student-Veterans. A simple
in-service training program, like that offered by the Salt Lake City VA Medical Center and connected
with this training manual, will remedy this lack of awareness and facilitate the academic success of
student-Veterans.
Administer a Veterans’ needs survey. Ask your student-Veterans how satisfied they are with current university/college services, what they think could be done better, and what services they would like
to see offered. They will let you know what they want and don’t want. This also sends the message to
them that the administration is listening.
Determine if your institution could participate in the VA Work-Study Program. You would have VA-funded student-Veterans working on staff to assist other veterans. Veterans serving Veterans can be very powerful in creating important connections.
Serve a birthday cake to the student body for the birthday of each branch of the service and hand out a
flyer with their contributions and interesting facts.
Present your student-Veterans with some special acknowledgement upon graduation. Possibilities
include a Red/White/Blue Veterans Honor cord to wear at graduation, a Veterans coin, etc.
Provide programs on Veterans Day, hold a dinner to honor your student-Veterans, plan an orientation For Veterans only.

RESOURCE GUIDE

HOW TO FIND YOUR LOCAL VA

Check your local phone book and look in the government section in the white pages. You will find a section on the Department of Veterans Affairs. You may go to www.va.gov and search locations at the top of the website. Or call 1-800-827-1000 for information on VA benefits.

REFERRALS AND RESOURCES FOR MEDICAL AND MENTAL HEALTH ISSUES

PTSD: