Peer Outdoor Support Therapy (POST) for Australian Contemporary Veterans: A Review of the Literature

By Kendall Bird In   Issue Volume 22 No. 1 .


Peer outdoor support therapy (POST) is one approach utilised in Canada, the United States and the United Kingdom to address mental illness and distress amongst contemporary veterans. In the current paper several areas of veteran psychological therapeutic treatment are reviewed.

Current standard practice and research studies for therapist-led treatments from Australia are summarised  and critiqued and placed within the literature context examining military and veteran unique needs and challenges to treatment including responsiveness, reluctance and retention.

Research review results regarding peer support interventions and outdoor therapy interventions for non-veteran and contemporary veteran populations are outlined, alongside an overview of known POST programs for veterans.

The implications of the reviewed literature and research are discussed, particularly the need for further research into the role outdoor peer support may play for the Australian veteran population alongside other veteran mental health services.


The unique requirements of military deployment and its impact on mental health have been well established1-4. Given this association and the challenges to treatments with the veteran population, identifying effective approaches for treatment and early intervention to address veteran mental illness through evidence-based research is needed.

The aims in the current paper are to review peer outdoor support therapy (POST) approaches and their use with contemporary returned post-deployed (CRPD) veterans, and to contribute to the debate regarding the role such approaches play alongside the current standard practice in providing effective, culturally-suited treatment. This paper is a review of the literature and includes a research bibliography. The   search methods used are included in Appendix A and the List of Terms in Appendix B.

The effects of deployment, review of current standard practice and research for psychological therapy and the literature regarding veteran reluctance to seek therapy and potential low responsiveness to some treatments are outlined. Current research evidence regarding the effectiveness of peer support, outdoor and POST approaches for non-veteran populations and CRPD veterans experiencing mental illness  are reviewed and discussed.


Effects of Deployment for Contemporary Veterans

Australia’s involvement in Vietnam demonstrated that many veterans experience significant reductions in mental health and wellbeing as a result of combat deployment as well as issues transitioning to post-deployment life1,2. This remains a significant health issue for CRPD veterans, given the known link between military experience and reduced mental health and functioning and increased suicide risk1-4, which is being exposed in the course of  ongoing research. The Australian Department of Veteran’s Affairs (DVA) review of research identified a significant, consistent association between deployment and post-traumatic stress disorder (PTSD), anxiety and depressive disorders, alcohol misuse, suicide post-deployment and relationship conflict3.

Bleier et al.5 surveyed 5,911 current and former Australian Defence Force (ADF) personnel and found that deployment was significantly associated with negative mental health as measured by self-report clinical questionnaires when compared to those who were not deployed. The researchers found that multiple deployments had a cumulative negative effect on mental health (p < 0.01). This link was not found by Hodson et al.6 in their 2010 ADF Mental Health and Wellbeing Study (MHWS), which utilised only current serving personnel and not veterans. More recently, Warren Snowdon, Minister for Defence, Science and Personnel, stated that as of June 2012, 32% of all ADF soldiers medically discharged after deployment to the Middle East were discharged due to mental health conditions directly resulting from deployment7.

Military service alone is associated with higher mental illness rates, regardless of deployment. The 2010 ADF MHWS showed PTSD rates for 24,481 currently serving ADF personnel were almost double that of the non-military Australian population and total mental health disorder rates were significantly higher6. Kaplan and colleagues estimated that the suicide rate for male veterans is double that of the non-veteran population8, thus also indicating a higher vulnerability for those who have left military service. In acknowledgement, transition from service is recognised as a key commitment area within the 2011 ADF Mental Health and Wellbeing Strategy9.

In particular, CRPD veterans experience situations which may result in a higher mental health risk than previously experienced. For example, the heightened use and efficiency of modern improvised explosive devices (IEDs) in civilian centres amongst other challenges not experienced in previous wars require hypervigilance10,11. One study found that a significant increase in errors of memory and attention (scanned before and 4 months after combat deployment) was seen in Dutch military deployed to Afghanistan compared with  those not deployed (22 deployed, 26 in training)12. These deployed personnel also exhibited weaker neurobiological connections and pre-frontal cortex brain tissue damage compared to the non-deployed and these were not related to blast impacts or other causes. Most reduction in functioning was reversed after 1.5 years, except for the connection strength between the midbrain and prefrontal cortex, potentially indicative of ongoing function reduction resulting in a permanent heightened susceptibility to future stress12. ADF re-deployment rates are often more frequent than a minimum of 1.5 years and that recommended by the intergovernmental military alliance North Atlantic Treaty Organisation (NATO). Deployments are also longer than experienced by the ADF previously5, indicating that returning service personnel may not be given the time required for their neurological function to recover.

When mental health issues occur as a result of military experience as outlined above, such military-related stress can be defined as “any persistent psychological difficulty resulting from operational duties” (p. 266)13. This includes the experience of anxiety, depression and PTSD. It is not only the cumulative trauma from deployment but the readjustment process required after returning from deployment which often results in experiences of emotion dissociation, hyper-arousal and vigilance and aggression. Such states are necessary and useful functions within deployment14 and are encouraged within the significant physiological and mental preparation for military service. However they become maladaptive once such skills are no longer requiredand, when maintained long-term, are indicators of PTSD. For many, the autonomic nervous system threat-arousal response is chronically heightened after returning from combat, resulting in cumulative physiological effects of stress or ‘allostatic load’, greatly increasing the risk of physical and mental illness for veterans3,15. Difficult for many to unlearn, such states affect long-term individual and relationship functioning, including affect shut-down to avoid anger and they reduce engagement and therapy success16-18.

Therapist-led Psychological Treatment for Veterans

Current Standard Practice and Treatment Reviews

Individual prolonged-exposure (PE) and trauma-focused cognitive behaviour therapy (CBT) are recommended first-line interventions for both military-induced PTSD and PTSD in Australian non-military populations19-23. Although it is controversial to compare veteran experiences across countries, international studies have been included in the current review given the small number of Australian studies available relating to CRPD veterans.  Rothbaum et al.11 conducted a review of evidence-based treatments for CRPD veterans with PTSD from the United States (U.S.), Iraq and Afghanistan deployments.  The authors concluded that CBT exhibited the greatest empirical support with non-military populations. Warfe et al.24 also reviewed the international literature into individual PE therapy, cognitive therapy and cognitive restructuring for CRPD veterans. Twenty systematic reviews, 34 randomised controlled trials (RCTs) and other non-RCT studies were found which supported the recommendations above; however very few utilised CRPD veteran or current serving military.

Primary Veteran and Military Population Treatment Studies

Twelve studies into therapeutic treatments with CRPD veterans were found and are summarised in Table 1. Please refer to the Table for intervention and population details and main findings. Four were RCTs with two incorporating non-treatment waitlist controls. Four of the longitudinal studies involved either U. S. or Australian veterans returned from Iraq or Afghanistan deployments and Vietnam veterans. Two studies used only Vietnam veterans, while five did not indicate the deployment era. All included predominantly male participants. (refer to pdf for Table 1 )

All of the studies found show reductions in PTSD or improvement in wellbeing. Of the research found, one small-sample RCT showed individual PE therapy was effective for reducing PTSD symptoms for Vietnam veterans from the US, but not in reducing behavioural avoidance or increased sleep25. Group PE therapy has been found in two studies to be associated with reductions in PTSD symptoms and depression and improved functioning in sleep for Vietnam, Gulf War and Iraqi deployed U. S. veterans, with one study showing 36% no longer met PTSD diagnosis criteria26,27. Both studies were small with no control group. Khoo, Dent and Oei’s longitudinal study found that self-reported reductions in PTSD, depression, anxiety, anger, alcohol use, and quality of life were maintained at 12-month post-group CBT treatment for 496 veterans, with only marriage satisfaction not significantly different28. Changes were independent of concurrent individual treatment.

Two studies found U. S. veterans receiving individual cognitive processing therapy (CPT) exhibited reduced PTSD symptoms more rapidly    and decreased avoidance, compared to waitlist controls29. Morland et al. found that group therapy was effective regardless of the mode (face-to-face or via teleconference)30. Blevins, Roca and Spencer noted 63 U. S. veterans who attended an acceptance and commitment therapy (ACT) workshop showed significantly less depression, anxiety and PTSD symptoms and increased relationship satisfaction when compared to control participants31. Providing PE via virtual reality has also been researched.  Reger and Gahm present a case study32 and a U.S. RCT with 19 active military personnel from Iraqi and Afghanistan deployments showed significant reductions in PTSD symptoms for 70% of participants compared to treatment as usual, although no overall group differences were evident33.

Studies which utilised CRPD veteran participants had a small sample size, used a convenience sample and had no control group, increasing the risk of bias and errors. General  limitations also exist given the number of studies where no deployment era was mentioned, or utilised Vietnam veterans only. For example Chard et al. found positive therapeutic change in U. S. veterans from the Iraqi, Afghani and Vietnam conflicts involved in individual PE therapy34. Their study showed younger veterans exhibited a trend toward reduced PTSD post- CPT compared to Vietnam veterans, after accounting for sessions attended and initial PTSD severity, indicating that contemporary veterans may be more responsive to treatment regardless of symptoms severity.

The individual studies show clinical significance supporting the use of individual PE therapy and CPT with veterans. However, while the treatment recommendations are clear, there are limitations as listed above, and they appear based predominantly on empirical research with non-military populations generalised to military and veteran groups. Although supporting the current first-line recommendations for standard practice with veterans, several review authors concluded that research into therapies directly utilising military populations is insufficient. Available trials for their reviews were mostly with Vietnam veterans and limited in sample size, limiting general  application to the CRPD population11,15,22.

Challenges in the treatment of military veterans

Despite empirical support for the treatments outlined above, evidence suggests that many CRPD veterans affected by PTSD may be reluctant to seek treatment and show reduced responsiveness and low retention in individual therapist-led treatments.  Help-seeking may be impaired by attempts to maintain a strong self-view, fear of prejudice in current or future work opportunities, and mistrust factors regarding therapist likeness-to-self, given military cultural group identity13,35,36. In addition, if veterans perceive indifferent or ignorant responses when initially help-seeking this may hinder future help-seeking and treatment responsiveness17,37.

Military culture promotes emotional toughness, strength and camaraderie where mental illness is still seen as malingering or weakness17,19 despite recent awareness efforts, inconsistent with help-seeking behaviour and treatment responsiveness. While necessary for survival in combat, such a culture often means that acknowledging a mental health issue is counter to one’s self-identity15, creating social isolation in dealing with a negative mental health experience16,17. The MHWS showed for example that 48.8% of current serving military personnel who met the criteria for PTSD were not receiving treatment. Of those meeting criteria for a generalised anxiety disorder, 24.4% were not receiving treatment, nor were 85% who meet criteria for an alcohol disorder6.

Creamer and Forbes15 concluded that psychological treatments, although beneficial, appeared less effective for veterans than for non-veteran populations. Creamer et al.19 observed that effect sizes for change for veteran populations are often lower than for non-veteran populations for the same treatment approach. This  review also indicated that the military training and the  requirement to shut-off emotion to be able to complete combat tasks is a key factor in reduced treatment response15.  Arousal mal-adaption is seen in the pairing of stress with anger, and veterans may use numbing and dissociation to avoid anger in civilian life, particularly with loved ones. They argue that veterans with mental illness may show less responsiveness to PE therapies until such arousal pairing is addressed first, thus general CBT and some PE therapy approaches may be ineffective26. In addition, Garcia et al. showed in their study that 68% of 117 U. S. veterans returning from Iraq and Afghanistan terminated treatment before completion38. This highlights the need to consider carefully when using general CBT and PE approaches with this unique group.

Evidence for POST with Non-military Populations

Although autobiographies such as Exit Wounds37 and other public media exposures may slowly change the stigma of mental illness in the Australian military39, the unique experience of CRPD veterans indicates a need to explore the evidence-base for innovative interventions provided outside of the clinical and hospital context, particularly when addressing seeking treatment, retention/engagement and responsiveness.  In particular, peer and outdoor group approaches for treating PTSD and depression may illuminate effective alternative treatment approaches that will engage veterans. 

Peer Support Intervention Evaluation

Peer support is a widely used intervention for mental illness within non-military populations. Table 2 summarises 15 research studies found which measured  peer support approaches with non-military populations, including intervention, population and their main findings. (refer to pdf for Table 2)

In the U.S. 47% of 13,513 substance abuse treatment facilities surveyed in 2009 offered some form of peer-support service40. It is also estimated that more people in the U.S. use self-help groups for substance abuse than any other mental health support combined41. They found that self-help participation was associated with reduced substance use, increased psychosocial functioning, and reduced health care costs.

Hogan, Linden & Najarian conducted a review of 100 studies into social support interventions addressing substance abuse, parenting skills, weight loss and cancer for non-military populations42. They concluded there was some support for the usefulness of social support. However, no studies were rigorous enough to be ranked as clearly efficacious. They noted issues with the study in general,  the lack of control groups and randomisation. However the authors outlined that social support interventions were generally better than no treatment.  Twelve studies showed superior orequal results to alternative treatments, 22 had partial benefits, 17 had no benefits and in 2 studies participants got worse, indicating the importance of matching intervention type to need and with mindfulness of the setup of groups42.

Within the individual studies, evidence supporting the peer approach was seen by Lucksted et al., who conducted a longitudinal study using a peer support intervention for 138 people with mental illness (bipolar, schizophrenia and other diagnoses)43. They found that participation was significantly associated with increased confidence regarding knowledge and management of their illness, less powerlessness, more confidence regarding decision making, and greater connection with others.  Many participants wanted to become involved in advocacy and in the educating others as a result of participation.  Another randomised trial compared standard clinical treatment to treatment plus group intervention involving peer support and citizen training for 114 adults with dual-diagnosis mental health disorders and criminal history.  Although drug use and criminal charges were reduced in both groups, the study showed that peer support was effective for decreased alcohol use beyond standard treatment at 6 months and at 12 months post treatment44. In addition, a study by Sledge et al. showed peer support was associated with significantly reduced re-hospitalisations and number of days in hospital after 9 months of support for patients with psychiatric diagnosis as compared to standard care45. They showed peer support was an effective adjunct to treatment to engage mental health patients with social network preventing relapse.

One study in particular outlined how peer-led approaches can be more effective than professional-led.  Dorgo, Robinson & Bader conducted a randomised control study into peer-support for 131 older adults when an identical fitness program was provided either by peers or by a qualified student46. Although both groups’ fitness improved significantly, peer-led fitness groups showed significantly better outcomes in self-reported physical and mental wellbeing, social functioning, general health, vitality and the ability to carry out physical and emotional roles. They speculated that peer-led interventions may increase adherence to programs, providing positive role modelling and dispelling negative stereotypes about age and ability.

The presence of supportive social relationships alone has been shown to predict better outcomes in therapy for PTSD exposure therapy and cognitive restructuring treatments47. These results strengthen the argument that peer support is valuable in role modelling, health, challenging stigma, and isolation around PTSD experiences.  Such approaches may be particularly beneficial if the participant identifying as a group member feels ostracised or judged by the wider society, which may be the case for many veterans. In such situations, peer-led groups may decrease isolation and enable trust and connection with others11,15,24.

Outdoor Therapy Intervention Evaluation

Various U. S. review studies have shown outdoor therapy with at-risk youth, focusing on changing negative behaviours and building team and leader skills, is associated with increased self- worth, self-regulation, physical health effects, reduction in anxiety and stress and sleep issues, improved participant social skills, improved critical thinking and reductions in antisocial/ delinquent behaviour48-50.  There is also some evidence of reduced depression and drug and alcohol misuse20,50, with greater outcomes seen for participants involved in peer leadership opportunities50.

An Australian longitudinal evaluation of Operation Flinders (OF), an 8-day camp for at-risk youth, found that participants at higher risk of offending showed significant improvement on self-reports for self-esteem, anger, attitude toward police and de-identification with criminals compared to those at lower risk51. Raymond evaluated OF, using a non-randomised control group design comparing 58 participants with 55 non-participants and showed that although improvements on most measures were seen, these changes were not significant compared to controls52.

Very few studies have been completed with non-youth. Walker et al.53 conducted an evaluation of an Australian outdoor adventure program for 11 adults with severe brain injury and found a trend toward improved mental health. The 18-month program involved peer planning for a 9-day camp run in conjunction with Outward Bound Australia (OBA). Results were not statistically significant, although qualitative personal goal achievement was attained for 10 of the 11 participants.  Lastly, Stuhlmiller completed a qualitative evaluation of an Australian camp to reduce mental health stigma among student nurses54. Two hundred students and 100 mental health service consumers participated in the week-long camp. Student nurse attitudes about mental health consumers shifted in a positive direction.

Lubans et al.’s review of 15 camp evaluations for at-risk youth concluded that while outdoor adventure programs had the potential to improve wellbeing, the findings were mixed48, due to research design limitations resulting in a high risk of bias. Therefore, empirically determining program efficacy is difficult if attempting to compare to other approaches where more controlled research is possible.

POST Approaches for the Veteran Population

Therapist-led Outdoor Therapy Intervention Evaluations

There have been several research studies into therapist-led outdoor therapy for post-deployed veterans. Table 3 summarises research into both outdoor therapy and peer support utilising military populations. Please refer to Table 3 for details of intervention, measures used and main findings. (refer to pdf for Table 3).

There is some evidence that outdoor programs (non-peer led) are linked to positive change for veterans; however the available research results are mixed. Hyer et al.55 published results from a control-group evaluation of Outward Bound for Veterans Program (OBVP) for veterans with chronic combat-PTSD. The camp is non-clinical, is focused on outdoor activity and developing leadership qualities56. Participants included 108 in OBVP and 111 in clinical hospital group therapy and psychiatric support. All were interviewed using high reliability clinical measures before treatment, directly after, and at exit from treatment. They found no significant difference between those in the camp treatment versus the control group, indicating OBVP was equivalent to clinical therapy. Results indicated greater effectiveness for those with lower clinical PTSD scores. Participants reported positive changes to self-esteem and indicated the important role social support played for their wellbeing55.

More recently, Ewert et al.57 evaluated OBVP, assessing 142 CRPD personnel deployed to Iraq and Afghanistan and 175 non-veterans post-participation using scale course evaluation questions. The assessment tool was non-clinical and with reliability or validity reported. Veterans showed significantly higher levels of agreement for increased confidence, physical ability, emotional state and success compared to non-veteran participants, and lower levels in leadership skills, compassion, teamwork and accepting responsibility compared to non-veterans. Ewert et al.58 also studied 266 OBVP veteran participants before and after participation, using the same assessment tool, and showed significant change of between p = .05 and p = 0.01 with effect sizes from .26 to .74 for 11 leadership quality constructs. The authors did not indicate which constructs showed the most significant change.

River Running, a therapist-led 4 day outdoor therapy river camp focused on utilising nature to manage distress and promote relaxation, was qualitatively evaluated by analysing journals and was completed by 10 male and 3 female veterans with diagnosed PTSD35. Participants were selected by defence health staff, and 17 professional staff were present. They reported that the re-experiencing of traumas appeared to diminish over the duration of the camp, avoidance and numbing replaced with “joyful involvement” (p. 335) in the trip experience and hyper-arousal replaced with fatigue from physical activity for the participants35. However, no method details were outlined in the report regarding their analysis approach and no follow up data were  assessed, thus it is uncertain whether these effects were sustained after participation.

Hawkins, Cory & Crowe conducted a qualitative analysis of a 3-day Paralympic military sports camp for 50 injured contemporary U. S. personnel59. Ten participants volunteered to be interviewed using a semi-structured model. Researchers found that social comparison assisted participant engagement and change with improvements in the sense of competence and autonomy. Another week long Paralympic therapeutic adaptive sports and recreation program called Higher Ground for 18 recently returned injured U. S. veterans from the Iraq and Afghanistan conflicts was evaluated. The quantitative pre-post no control sample study showed significant reductions in self-reported mood disturbance, tension, depression and anger post-camp compared to pre-camp60. No significant difference was found for self-reported quality of life in general, nor for physical health, social relationships nor environment, although the subscale of psychological health showed a significant increase (p = 0.024).

To summarise, while published research indicates that outdoor therapy (non-peer) for non-military veteran populations appear to show promise in increasing mental health, they however show methodological limitations. These include small self-selected sample sizes and a lack of randomised controlled groups, resulting in a convenience sample bias56,48. However, this is not unlike other treatment studies with veterans outlined earlier in this paper. Difficulty exists in finding a sufficient evidence-base because outdoor therapy is often run intentionally with small participant numbers.  It is also difficult to draw conclusions regarding the effectiveness of the outdoor therapy approach and general application  due to program diversity.  It appears, however, that the clinical or self-reported qualitative change noted is of importance and the peer relationships formed and subsequent benefit of social modelling, social support and peer mentoring may be an important area not adequately studied within these outdoor therapy evaluations.

Peer Support Approaches for Veteran Populations

While peer support approaches show a good evidence-base with non-military populations and show potential applicability to veterans, our interest was in finding direct research with veterans as opposed to generalising from the non-military data. Several studies were located evaluating peer support interventions for PTSD and mental health with veteran populations, see Table 3 for detail of intervention, measures and main findings.

Social support for veterans can act as a protective factor, but also appears important for clinical change as a deliberate adjunct to other therapies60. For example Pietrzak et al.61 showed that lower self-reported unit support and post-deployment social support was associated with decreased resilience and psychosocial functioning and greater depression and PTSD for 272 contemporary U. S. Iraq and Afghanistan deployed combat veterans. Unit support association with PTSD and depression was mediated by personal resilience.  Price et al.23 also completed research into the effect of four types of social support on the outcome of exposure therapy for 69 U. S. CRPD veterans experiencing PTSD symptoms from the Iraq and Afghanistan conflicts. They found that positive treatment response was significantly associated with emotional or informational support and positive social interactions, rather than affectionate or tangible support. These elements of support are often intentionally included in peer support models of therapy62.

Based on such studies, if therapy responsiveness is enhanced for CRPD veterans through peer support approaches there is a possibility for improved veteran wellbeing. Travis et al.63 conducted a longitudinal study into telephone-based mutual peer support with 22 veterans and 32 psychiatry outpatients and community mental health centre consumers who experienced ongoing depressive symptoms.  Depression, quality of life, and psychological health all significantly improved over time.  Of particular significance, veterans had significantly better adherence to treatment than non-veterans (2 veterans dropped out compared to 20 non-veterans).

A sense of camaraderie, important in any therapeutic setting64, is significant within veteran culture particularly11,15,24 and seen by Travis et al. where veterans felt they could censor themselves less. A high majority of participants, 94%, stated they would be more satisfied with their general care if they had peer support routinely available. Participants reported having someone who could relate, and who had common experiences, was of particular importance.  Based on the quantitative and qualitative results, the authors concluded that this form of support may be considered valuable and more meaningful for veterans than for non-veterans63. This study demonstrated that veterans may be particularly well suited to this type of intervention support and is thus a potential treatment in combating compliance issues with veterans.

Veteran peer mentor programs in particular have shown to assist treatment adherence and enhance outcomes, improve behaviour and motivation for self-care, potentially de-stigmatise veteran mental illness, correct stereotypes of the mentally weak person, and act as a stress buffer in reducing psychological despair13,65. An increased uptake and responsiveness to other clinical treatment options is also seen36. Significant support exists for the peer approach with veterans, when conducted in a structured, formal and accountable way where appropriate training is provided13. For example, in evaluating the group peer support Veterans Transition Program in Canada with 18 male military personnel returning to civilian life post-combat, Westwood et al.62 found that participation was associated with decreased trauma-related symptoms including defensive avoidance, anxiety, anger and depression.

Although a peer support program exists for ADF military personnel in their first year of service9, a wide-scale program for ADF veterans does not appear available. In contrast, veteran programs such as Shoulder to Shoulder (STS)66 in the UK and Buddy to Buddy (BTB)36 in the U.S. utilise the peer support framework.  Whereas STS utilises civilian volunteers to support veterans, BTB trains veterans to provide peer support to CRPD veterans, and views peer mentoring and social support as an integral component to the treatment approach for veterans. Preliminary research into the BTB program showed that after participation, 50% stated they had used resources/services suggested by their buddy and more than 20% self-referred to formal treatment as a result of participation when they had not previously accessed any formal treatment36. A Canadian veteran program, Operational Stress Injury Social Support (OSISS), also provides peer and family support to current serving personnel and veterans in one-on-one and in group formats13,67,68. A program evaluation completed by the Department of National Defence and Veterans Affairs Canada67 indicated that over 900 personnel and veterans were utilising the service and OSISS appeared to be the only form of ongoing social support for many veterans.

POST for Veteran Populations 

Bringing both outdoor therapy and peer support together, POST approaches addressing veteran wellbeing have been in operation for many years, but as yet not formally or systematically evaluated. Of those programs evaluated, many remain organisational reports and not subject to peer-review and journal publication. Given the limited published literature, relevant organisational reports have been included in this review. Examples of non-evaluated POST approaches for CRPD veterans are outlined in Table 4. (refer to pdf for Table 4)

POST programs for veterans that have been evaluated are included in Table 3 with details of materials and findings. Rivers of Recovery (ROR) is a U. S. fly-fishing camp run by Vietnam veterans for CRPD veterans. ROR also includes a focused post-camp outreach program to aid veteran mental health69,70. The program provides more than 200 CRPD veterans with camps for men and women and couples every year69. Mowatt and Bennett analysed the content of letters written by 67 male participants of ROR during 2010 to their sponsors, who assisted financially for camp attendence71. The authors found four themes: camaraderie is necessary while receiving treatment; veterans experienced ongoing regret; reflection was involved in the process of memory reconciliation; participants saw benefits from involvement in outdoor recreational activity. A high risk of bias in results appears evident in this research however, because participants may have felt obligation to justify the sponsor’s costs and express gratitude.

Research available on the ROR website appears rigorous and uses sound within-subject longitudinal methodology72. The participants, 67 men and 2 women post-deployed veterans with PTSD diagnosis, were assessed 1 month prior to the fly fishing excursion (baseline), the last day of the fly fishing retreat, and at 1 month follow up using reliable self-report questionnaires72. The study found statistically significant reductions in perceived stress, PTSD symptoms (19% reduction, with some no longer meeting PTSD diagnosis) and sleep issues, compared to the initial baseline prior to camp participation70. Significant reductions in anxiety, depression and somatic stress symptoms and negative mood states, with a significant increase in positive mood states were also found. Results also showed a significant reduction in stress indicated by daily cortisol production between the first and second days for 23 participants. This was measured by salivary cortisol, urinary catecholamines (e.g., epinephrine and norepinephrine) and immune function (salivary immunoglobulins). The research is however limited due to being an organisational report with no control group reported.

Closer to home, Trojan’s Trek (TT) appears to be the only Australian program evaluated and available for review. This evaluation is also an organisation report and has not been subject to peer-review and not available via standard journal publication. Data from TT’s first camp in 2009 was evaluated by ACPMH56 using self-report questionnaires and interviews with 10 participants and their partners before camp, immediately after camp and at 2-months follow-up. Outcomes showed a trend toward mental health improvement. However, only 5 participants completed post-intervention questionnaires, limiting statistical analysis.  Some respondents showed diminished perceived benefit of camp involvement after 2 months compared to immediately after the camp, and those who did not complete follow-up showed initial higher ratings of unhappiness with life than those who completed follow-up questionnaires. Due to the small sample size, self-selection and the lack of a control group, conclusions could not be drawn regarding the camp’s effectiveness. However, positive qualitative results from diary and interviews were evident. The most common goals at the start of the trek were managing anger and improving communicationand the camp was most effective in managing day to day problems and achieving these goals56.

Programs for veteran populations such as TT and ROR both utilised medallions as symbols for belonging, accomplishment, and legacy-making69, providing culture specific meaning-making important in many therapy approaches with veterans14. TT and ROR are two evaluated examples of where peer support programs have been applied within an outdoor therapy setting for veterans.


In this paper the effects of deployment, standard treatment for veterans, and challenges to treatment with CRPD veterans experiencing military-related mental illness have been outlined.  The evidence for the effectiveness of outdoor therapy, peer support approaches and POST with non-military and contemporary veteran populations has also been reviewed.

CRPD veterans experience a relatively high level of mental health issues in contrast to the non-military population3,5,6.  Despite recommendations for individual and group PE and CBT therapies supported by research these appear predominantly from the generalisation of non-military population studies to military and veteran populations. Such therapies may be under-utilised by a section of the veteran population, given the unique characteristics and reluctance of this population to engage with these approaches17. Treatment response and retention may be lower than for other populations accessing similar treatment due to the nature of deployment-related PTSD and the culture of military service.

Currently only a very small number of peer-reviewed research  into POST approaches exist compared to other approaches, despite being commonly used, particularly in the U.S. The evidence for veteran POST approaches are organisational based reports without peer review and publication in academic journals. The methodology strengths are mixed, with some outdoor therapy (non-peer) evaluations supporting positive outcomes  but which are limited in reliability, not unlike other research into therapeutic approaches with veterans. The conclusions which can be directly drawn about POST approaches are thus somewhat limited given this and the inherent design limitations with using small group therapies. However, the quantitative research available to date which directly explores  the POST approach with veterans, supports its use.

In contrast, the research for structured peer support with veterans is promising. There is strong evidence to indicate that therapies which include structured peer support for veterans are efficacious based on the research with both veteran and non-veteran populations is outlined in Tables 2 and 3. In particular, veterans show greater engagement in mutual peer support and may be well suited to this therapy approach61. Although there are practical and ethical risks in  any peer support approach, and also in generalising methods across diverse U. S. and Australian veteran cultures, the peer support approach is promising in its potential application to Australian CRPD veterans for a number of reasons. From the reviewed literature and studies into peer support approaches, it is reasonable to conclude that veteran peer-mentor interventions have the potential to:  (a) be perceived as more accessible than professional-led therapies, (b) directly impact positive therapeutic change and retention for veterans, and (c) encourage access to professional mental health support. Existing veteran social support programs build on the camaraderie which naturally develops as an aspect of deployment and provide social norming and modelling23,36 which could lead to more sustained and meaningful change for participants. In addition, under well-structured programs, veterans may benefit from having a strong identification with peers and leaders56,11,24.

Thus, further research is warranted into the efficacy of POST approaches with veterans where structured peer support is a core aspect of the outdoor therapeutic approach. Such research would add further to current knowledge and treatment practice regarding the potentially significant role POST approaches could play within the wider context of treatment for the veteran population.


Conflict of Interest/Acknowledgements

The literature review was completed within the context of a research article thesis submission for partial requirements for the degree of Masters of Psychology (Clinical), under supervision from Dr Nadine Pelling Senior Lecturer, School of Psychology, Social Work and Social Policy and Clinical Psychologist. The research article included an evaluation of Trojan’s Trek, a POST program. Funding was provided by Trojan’s Trek to the University of South Australia in relation to this evaluation. No stipulations regarding research outcomes or use of funds was attached to the provision of funding. The author had no relationship to this organisation prior to completion of this research and review.




1. Jordan, K. Counselors helping service veterans re-enter their couple relationship after combat and military services: A comprehensive overview. The Family Journal: Counseling and Therapy for Couples and Families 2011; 19:263-273. doi: 10.1177/1066480711406689

2. O’Toole, B., Marchall, R., Schureck, R. & Dobson, M. Combat, dissociation and           posttraumatic stress disorder in Australian Vietnam veterans. Journal of Traumatic          Stress 1999; 12:625-640. doi: 10.1023/A:1024765001122 3. McEwen, B., Nasveld, P., Palmer, M., Anderson, R. Allostatic load: A review of the literature [Report] 2012. Canberra, AU: Department of Veterans’ Affairs. Retrieved from 4. Pietrzak, E., Pullman, S., Cotea, C. & Nasveld, P. Effects of deployment on health behaviours in military forces: A review of longitudinal studies. Journal of Military and Veterans’ Health, Review Articles 2013; 21:14-23.  Retrieved from 5. Bleier, J., McFarlane, A., McGuire, A., Treloar, S., Waller, M., & Dobson, A. Risk of adverse health outcomes associated with frequency and duration of deployment with the Australian Defence Force. Military Medicine 2011; 176(2):139-146. 6. Hodson, S., McFarlane, A., Van Hooff, M., & Davies, C. Mental health in the Australian Defence Force: 2010 ADF Mental Health and Wellbeing Study [Executive Report] 2011; Canberra, AU: Department of Defence. Retrieved from 7. Mental health risk after wars’ end.The Australian 2012; Sept 25. Retrieved from: 8. Kaplan, M., Huguet, N., McFarland, B. & Newsom, J. Suicide among male veterans: a prospective population based study. Journal of Epidemiology and Community Health 2007; 61(7):619-624. 9. Commonwealth of Australia. Capability through mental fitness: 2011 ADF Mental Health and Wellbeing Strategy, 2011; Department of Defence: Canberra. Retrieved from: 10. Kinney, W. Comparing PTSD among returning war veterans. Journal of Military and Veterans’ Health, Review Articles 2012; 20(3):21-23. 11. Rothbaum, B., Gerardi, M., Bradley, B. & Friedman, M. Evidence-based treatments for posttraumatic stress disorder in Operation Enduring Freedom and Operation Iraqi Freedom military personnel. In J. Ruzek, P. Schnurr, J. Vasterling, & M. Friedman (Eds),  Caring for veterans with deployment-related stress disorders 2011; 215-239. Washington, DC: American Psychological Association. 12. van Wingen, G., Geuze, E., Caan, M., Kozicz, T., Olabarriaga, S., Denys, D., ... Fernandez, G. Persistent and reversible consequences of combat stress on the mesofrontal circuit and cognition. Proceedings of the National Academy of Sciences 2012; 109: 15508-15513. doi:10.1073/pnas.1206330109 13. Grenier, S., Darte, K., Heber, A. & Richardson, D. The Operational Stress Injury Social Support Program: A peer support program in collaboration between the Canadian Forces and Veterans Affairs Canada. In C. Figley & W. Nash (Eds.), Combat stress injury: Theory, research, and management 2006: 261-293. New York, NY: Routledge. 14. Osran, H., Smee, D., Sreenivasan, S., & Weinberger, L. Living outside the wire: Toward a transpersonal resilience approach for OIF/OEF veterans transitioning to civilian life. The Journal of Transpersonal Psychology 2010; 42:209-235. 15. Creamer, M. & Forbes, D. Treatment for posttraumatic stress disorder in military and veteran populations. Psychotherapy: Theory, Research, Practise, Training 2004; 41:388-398. doi: 10.1037/0033-3204.41.4.388 16. Hall, L. Counselling military families: What mental health professionals need to know 2008. New York, NY: Routledge. ISBN-10: 0415956889. 17. Keller, R., Greenberg, N., Bobo, W., Roberts, P., Jones, N. & Orman, D. Soldier peer mentoring care and support: Bringing psychological awareness to the front. Military Medicine 2005; 170:355-361. 18. Sharpless, B. & Barber, J. A clinician’s guide to PTSD treatments for returning veterans. Professional Psychology: Research and Practice 2011; 42:8-15. doi:10.1037/a0022351 19. Creamer, M., Wade, D., Fletcher, S., & Forbes, D. PTSD among military personnel. International Review of Psychiatry 2011; 23:160–165. doi:10.3109/09540261.2011.559456 20. Forbes, D., Creamer, M., Phelps, A., Bryant, R., McFarlane, A., Devilly, G., ... Newton, S. Australian guidelines for the treatment of adults with acute stress disorder and post-traumatic stress disorder. Australian and New Zealand Journal of Psychiatry 2007; 41:637-648. 21. Lee, E. Complex contribution of combat-related post-traumatic stress disorder to veteran suicide: Facing an increasing challenge. Perspectives in Psychiatric Care 2012; 48:108–115. doi: 10.1111/j.1744-6163.2011.00312.x 22. McGuire, A., Bredhauer, K., Anderson, R., & Warfe, P. Review of PTSD group treatment programs [Final Report]. Canberra, AU: Centre for Military and Veterans Health 2011. Retrieved from 23. Price, M., Gros, D. F., Strachan, M., Ruggiero, K. J., & Acierno, R. The role of social support in exposure therapy for Operation Iraqi Freedom/Operation Enduring Freedom veterans: a preliminary investigation. Psychological Trauma: Theory, Research, Practice, and Policy 2011. Online publication. doi: 10.1037/a0026244 24. Warfe, P., Kenardy, J., McGuire, A., Pietrzak, E., Bredhauer, K. Review of PTSD programs: International literature review of evidence-based best practice treatments for PTSD. Centre for Military and Veterans’ Health 2011. Retrieved from: 25. Beidel, D., Frueh, B., Uhde, T., Wong, N. & Mentrikoski, J. Multicomponent behavioural treatment for chronic combat-related posttraumatic stress disorder: a randomised controlled trial. Journal of Anxiety Disorders 2011; 25:224-231. doi: 10.1177/0145445504270872 26. Ready, D. J., Sylvers, P., Worley, V., Butt, J. Mascaro, N., & Bradley, B. The impact of group-based exposure therapy on the PTSD and depression of 30 combat veterans. Psychological Trauma: Theory, Research, Practice, and Policy 2012; 4:84-93. doi: 10.1037/a0021997 27. Swanson, L., Favorite, T., Horin, E., & Arnedt, J. A combined group treatment for nightmares and insomnia in combat veterans: a pilot study. Journal of Traumatic Stress 2009; 22:639-642. doi: 10.1002/jts.20468 28. Khoo, A., Dent, M., & Oei, T. Group Cognitive Behaviour Therapy for military service-related post-traumatic stress disorder: Effectiveness, sustainability and repeatability. Australian and New Zealand Journal of Psychiatry 2011; 45: 663-672. doi:10.3109/00048674.2011.590464 29. Macdonald, A., Monson, C., Doron-Lamarca, S., Resick, P., Palfai, T. Identifying patterns of symptom change during a randomised controlled trial of cognitive processing therapy for military-related posttraumatic stress disorder. Journal of Traumatic Stress 2011; 24:268-276. doi: 10.1002/jts.20642 30. Blevins, D., Roca, J., & Spencer, T. Life guard: Evaluation of an ACT-based workshop to facilitate reintegration of OIF/OEF veterans. Professional Psychology: Research and Practice 2011; 42(1):32-39.  doi: 10.1037/a0022321 31. Morland, L., Hynes, A., Mackintosh, M., Resick, P. & Chard, K. Group cognitive processing therapy delivered to veterans via telehealth: a pilot cohort. Journal of Traumatic Stress 2011; 24:465-469. doi: 10.1002/jts.20661 32. Reger, G., & Gahm, G. Virtual reality exposure therapy for active duty soldiers. Journal of Clinical Psychology: In Session 2008; 64:940-946. 33. McLay, R., Wood, D., Webb-Murphy, J., Spira, J., Wiederhold, M., Pyne, J. & Weiderhold, B.  A randomised, controlled trial of virtual reality-graded exposure therapy for post-traumatic stress disorder in active duty service members with combat-related post-traumatic stress disorder. Cyberpsychology, Behavior, and Social Networking 2011; 14:223-229.  doi:10.1089/cyber.2011.0003 34. Chard, K., Schumm, J., Owens, G., & Cottingham, S. A comparison of OEF and OIF veterans and Vitetnam veterans receiving cognitive processing therapy. Journal of Traumatic Stress 2010; 23(1):25-32. doi: 10.1002/jts.20500 35. Dustin, D., Bricker, N., Arave, J., Wall, W. & Wendt, G. The promise of river running as a therapeutic medium for veterans coping with post-traumatic stress disorder. Therapeutic Recreation Journal 2011; 45(4):326-340. 36. Greden, J., Valenstein, M., Spinner, J., Blow, A., Gorman, L, Dalack, G., ... Kees, M. Buddy-to-buddy, a citizen soldier peer support program to counteract stigma, PTSD, depression and suicide. Annals of the New York Academy of Sciences 2010; 1208:90-97. Issue: Psychiatric and Neurologic Aspects of War. doi: 10.1111/j.1749-6632.2010.05719.x 37. Cantwell, J. Exit Wounds: One Australian’s war on terror 2012. Carlton, Victoria, AU: Melbourne University Press. 38. Garcia, H., Kelley, L., Rentz, T., & Lee, S. Pretreatment predictors of dropout from cognitive behavioural therapy for PTSD in Iraq and Afghanistan war veterans. Psychological Services 2011; 8:1-11. doi: 10.1037/a0022705 39. Sara, S. Support group says returning veterans need help, ABC News 2013, January 16. Retrieved from 40. Center for Behavioral Health Statistics and Quality. Nearly half of substance abuse treatment facilities offer mentoring or other peer support services. Data Spotlight, National Survey of Substance Abuse Treatment Services 2011, Jan 11. Retrieved from: 41. Humphreys, K., Wing, S., McCarty, D., Chappel, J., Gallant, L., Haberle, B., ...Weiss, R. Self-help organizations for alcohol and drug problems: Toward evidence-based practice and policy. Journal of Substance Abuse Treatment 2004; 26(3):151-65. doi: 10.1016/S0740-5472(03)00212-5 42. Hogan, B., Linden, W., & Najarian, B. Social support interventions: Do they work? Clinical Psychology Review 2002; 22(3):381-440.  doi: 10.1016/S0272-7358(01)00102-7 43. Lucksted, A., McNulty, K., Brayboy, L. & Forbes, C. Initial evaluation of the peer-to-peer program. Psychiatric Services 2009; 60:250-253. Retrieved from 44. Rowe, M., Bellamy, C., Baranoski, M., Wieland, M., O’Connell, M., Benedict, P., ...Sells, D. A peer-support, group intervention to reduce substance use and criminality among persons with severe mental illness. Psychiatric Services 2007; 58:955-961. doi: 10.1176/ 45. Sledge, W., Lawless, M., Sells, D., Wieland, M., O’Connell, M., Davidson, L. Effectiveness of peer support in reducing readmission of persons with multiple psychiatric hospitalizations. Psychiatric Services 2011; 62:541-544. 46. Dorgo, S., Robinson, K., & Bader, J. The effectiveness of a peer-mentored older adult fitness program on perceived physical, mental, and social function. Journal of the American Academy of Nurse Practitioners 2009; 21(2):116-122. doi: 10.1111/j.1745-7599.2008.00393.x 47. Thrasher, S., Power, M., Morant, N., Marks, I., Dalgleish, T. Social support moderates outcome in a randomised controlled  trial of exposure therapy and (or) cognitive restructuring for chronic posttraumatic stress disorder. Canadian Journal of Psychiatry 2010; 55:187-190. 48. Lubans, D., Plotnikoff, R., & Lubans, N. Review: A systematic review of the impact of physical activity programmes on social and emotional well-being in at-risk youth. Child and Adolescent Mental Health 2012; 17:2-13. doi: 10.1111/j.1475-3588.2011.00623.x 49. Shellman, A. Looking into the black box. Journal of Experiential Education 2011; 33:402–405. doi:10.5193/JEE33.4.402 50. Werhan, P. & Groff, G. Research update: The wilderness therapy trail, Parks & Recreation 2005; 40(11):24 – 29. 51. Evaluation of Operation Flinders Wilderness – Adventure Program for Youth at Risk 2001. Mohr, Heseltine, Howells, Badenoch, Williamson & Parker. The Forensic & Applied Psychology Research Group, UniSA. Retrieved via UniSA Summons database. 52. Raymond, I. Risk, criminogenic need and responsivity: an evaluative framework applied to the Operation Flinders wilderness therapy program for youth-at-risk (unpublished honours thesis) 2003. University of South Australia, Adelaide. 53. Walker, A., Onus, M., Doyle, M., Clare, J., & McCarthy, K. Cognitive rehabilitation after severe traumatic brain injury: A pilot programme of goal planning and outdoor adventure course participation. Brain Injury 2005; 19:1237–1241. doi:10.1080/02699050500309411 54. Stuhlmiller, C. Breaking down the stigma of mental illness through an adventure camp: a collaborative education initiative. Australian e-Journal for the Advancement of Mental Health 2003; 2. doi: 10.5172/jamh.2.2.90 55. Hyer, L., Boyd, S., Scurfield, R, Smith, D. & Burke, J. Effects of Outward Bound experience as an adjunct to inpatient PTSD treatment of war veterans. Journal of Clinical Psychology 1996; 52:263-278. doi: 10.1002/(SICI)1097-4679(199605)52:3<263::AID-JCLP3>3.0.CO;2-T 56. Australian Centre for Posttraumatic Mental Health. Evaluation of Trojan’s Trek: Final report 2010, February. Retrieved from 57. Ewert, A., Frankel, J., Van Puymbroeck, M. & Luo, Y. The impacts of participation in Outward Bound and military service personnel: The role of experiential training. Journal of Experiential Education 2010; 32(3):313–316. doi: 10.5193/JEE.32.3.255 58. Ewert, A., Van Puymroeck, M., Frankel, J. & Overholt, J. Adventure education and the returning military veteran: What do we know? Journal of Experiential Education 2011; 33(4):365–369. doi: 10.5193/JEE33.4.365 59. Hawkins, B., Cory, A. & Crowe, B. Effects of participation in a paralympic military sports camp on injured service members: Implications for therapeutic recreation. Therapeutic Recreation Journal 2011; 45:309-325. 60. Ljungberg, I., Kroll, T., Libin, A., & Gordon, S. Using peer mentoring for people with spinal cord injury to enhance self-efficacy beliefs and prevent medical complications. Journal of Clinical Nursing 2011; 20:351-358. doi: 10.1111/j.1365-2702.2010.03432.x 61. Pietrzak, R., Johnson, D., Goldstein, M., Malley, J., Rivers, A., Morgan, C. & Southwick, S. Psychosocial buffers of traumatic stress, depressive symptoms, and psychosocial difficulties in veterans of Operations Enduring Freedom and Iraqi Freedom: The role of resilience, unit support, and postdeployment social support. Journal of Affective Disorders 2010; 120:188-192. doi: 10.1016/j.jad.2009.04.015 62. Westwood, M., McLean, H., Cave, D., Borgen, W. & Slakov, P. Coming home: A group-based approach for assisting military veterans in transition. The Journal for Specialists in Group Work 2013; 35:44-68. doi:10.1080/01933920903466059 63. Travis, J., Roeder, K., Walters, H., Piette, J., Heisler, M., Ganoczy, D., ... Pfeiffer, P. Telephone-based mutual peer support for depression: A pilot study. Chronic Illness 2010; 6:183-191.  doi:10.1177/1742395310369570 64. Bernes, K. The elements of effective counselling 2005. Retrieved from 65. McGrane, M. Post-traumatic stress disorder in the military: the need for legislative improvement of mental health care for veterans of Operation Iraqi Freedom and Operation Enduring Freedom." Journal of Law and Health 2011; 24(1):183+. 66. Leonard, J. Stress in war veterans in Birmingham on the rise. BBC News 2012, August 17. Retrieved from 67. Department of National Defence and Veterans Affairs Canada. Interdepartmental Evaluation of the OSISS Peer Support Network (CRS No.1258-138) 2005. Ottawa, ON, CA: Author. Retrieved from 68. Lebeau, M., Darte, K., & Cargnello, J. Peer support for Canadian injured soldiers and their families: The results of a needs analysis. Paper presented at the 24th International Society for Traumatic Stress Studies Annual Meeting 2008, November. Chicago, IL. 69. Flammang, J. Mending waters: young veterans find solace, regain confidence on the river. JH Weekly 2011, August 16. Retrieved from 70. Prestwich, V. Nonprofit helps veterans cope with post-war issues. The Vernal 2010, July 15. Retrieved from:,439680#comments 71. Mowatt, R. & Bennett, J. War narratives: Veteran stories, PTSD effects, and therapeutic fly-fishing. Therapeutic Recreation Journal 2011; 45(4):286-308. 72. Wynn, G. Rivers of recovery. No date. Retrieved from:   73. Creamer, M., Elliot, P., Forbes, D., Biddle, D., Hawthorne, G. Treatment for combat-related posttraumatic stress disorder: Two year follow-up. Journal of Traumatic Stress 2006; 19:675-685.  doi: 10.1002/jts.20155 74. Yoder, M., Tuerk, P., Price, M., Grubaugh, A., Strachn, M., Myrick, H., & Acierno, R. Prolonged exposure therapy for combat-related posttraumatic stress disorder: Comparing outcomes for veterans of different wars. Psychological Services 2012; 9:16-25. doi: 10.1037/a0026279 75. Berrick, J., Young, E., Cohen, E. & Anthony, E. ‘I am the face of success’: Peer mentors in child welfare. Child and Family Social Work 2011; 16:179-191.  doi: 10.1111/j.1365-2206.2010.00730.x 76. Herrera, C., Grossman, J., Kauh, T., & McMaken, J. Mentoring in schools: An impact study of Big Brothers and Big Sisters school-based mentoring. Child Development 2011; 82:346-361.  doi: 10.1111/j.1467-8624.2010.01559.x 77. Ott, C. & Doyle, L. An evaluation of the small group norms challenging model: Changing substance use misperceptions in five urban high schools. The High School Journal 2005; 88:45-55. doi:10.1353/hsj.2005.0003 78. Purcell, D., Latka, M., Metsch, L., Latkin, C., Gomez, C., Mizuno, Y., ... Borkowf, C. Results from a randomised controlled trial for a peer-mentoring intervention to reduce HIV transmission and increase access to care and adherence to HIV medications among HIV-seropositive injection drug users. Journal of Acquired Immune Deficiency Syndrome 2007; 46:35-47. doi: 10.1097/QAI.0b013e31815767c4 79. Robinson, E. & Niemer, L. A peer mentor tutor program for academic success in nursing. Nursing Educational Perspectives 2010; 31:286-289. doi: 10.1043/1536-5026-31.5.286 80. Rowe, M., Benedict, P., Sells, D., Dinzeo, T., Garvin, C., Schwab, L., Baranoski, M., Girard, V., & Bellamy, C. Citizenship, community, and recovery: A group- and peer-based intervention for persons with co-occurring disorders and criminal justice histories. Journal of Groups in Addiction and Recovery 2009; 4:224-244. doi:10.1080/15560350903340874 81. Smith, B. A randomised study of peer-led, small group social norming intervention designed to reduce drinking among college students. Journal of Alcohol and Drug Education 2004; 47(3):67-75.  Retrieved from 82. Stewart, M., Kushner, K., Greaves, L., Letourneau, N., Spitzer, D., Boscoe, M. Impacts on a support intervention for low-income women who smoke. Social Science and Medicine 2010; 71(11):1901-1909. doi: 10.1016/j.socscimed.2010.08.023 83. Tracy, K., Burton, M., Miescher, A, Galanter, M., Babuscio, T., Frankforter, T., ... Rounsaville, B. Mentorship for alcohol problems (MAP): a peer to peer modular intervention for outpatients. Alcohol and Alcoholism 2012; 47:42-47.  doi: 10.1093/alcalc/agr136 84. Lundberg, N., Bennett, J. & Smith, S. Outcomes of adaptive sports and recreation participation among veterans returning from combat with acquired disability. Therapeutic Recreation Journal 2011; 45:105-120. Retrieved from 85. Mosack, K., Wendorf, A., Brouwer, A., Patterson, L., Ertl, K., Whittle, J., Morzinski, J. & Fletcher, K. Veterans service organization engagement in 'POWER,' a peer-led hypertension intervention. Chronic Illness 2012 February 8:1-13. Published online. doi : 10.1177/1742395312437978 86. Cohen, J. Statistical power analysis for the behavioural sciences 1998 (2nd ed.). New York, NY: Lawrence Erlbaum Associates.

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