Center of Excellence – Veteran Voices and Visions

Veteran Voices and Visions: A Peer-facilitated Group Intervention Improving Community Integration for Veterans Experiencing Homelessness and Serious Mental Illness

This pilot study proposes to develop an intervention aimed at decreasing self-stigma and increasing empowerment in Veterans experiencing homelessness and psychosis due to Serious Mental Illness (SMI). “Psychosis” refers to experiences including hearing voices or seeing or feeling things that other people do not (“hallucinations”), believing things that others find strange (“delusions”), speaking in a way that others find hard to follow (“thought disorder”) and experiencing periods of confusion or of being out of touch with reality. These experiences are characteristic of SMI, such as schizophrenia, and are often treated with medication. These experiences can be frightening, alienating, and often lead to isolation and misunderstanding. A significant percentage of homeless veterans experience psychotic symptoms.

The intervention, Veteran Voices & Visions (VVV), adapts various treatments that have been proven to improve symptoms, quality of life, and social functioning for homeless Veterans who are experiencing SMI into a peer-support group intervention. These groups provide a safe space, reduced isolation, normalization, and the ability to learn from and help one another. This supports normalization and facilitates group cohesion around commonly shared but stigmatized, distressing, and poorly understood experiences and ideally lead to a mutual-support community based on shared experience. VVV are co-facilitated by a mental health professional and a peer facilitator who has lived experienced of SMI. While clinician-facilitators are positioned as “experts through training,” the peer facilitator and participants are positioned as “experts through experience” in an explicit validation of the knowledge and experience gained by living with SMI.

These approaches have not previously been brought together to address self-stigma in individuals experiencing homelessness and SMI, especially not amongst Veterans. Developing VVV will require some tailoring to address the Veteran experience and homelessness. By reducing the distress associated with SMI and providing a supportive community of peers, group participants will experience a reduction in self-stigma and will be more likely to engage in treatment services and improve their community integration.

Specific Aims:

1. Develop and refine a VVV facilitator toolkit. This toolkit will consist of orientation for facilitators, links to videos and written materials that can be used for teaching or stimulating discussion, psychoeducation, exercises and activities drawing from CBT, ACT, Hearing Voices, and other sources, adapted to Veterans experiencing homelessness and perceptual disturbances. The toolkit will be developed with feedback from the UCLA VA COE stakeholder mentors.
2. This pilot study will recruit 2 groups of 9 Veterans from the Homeless Primary Aligned Care Team (HPACT), in hopes that 6 complete the program. This site is an outpatient program specifically targeting Veterans experiencing homelessness and SMI. Veterans with experiences of homelessness and perceptual disturbances will be recruited through providers. Perceptual disturbances are broadly defined as encompassing auditory, visual, kinesthetic, olfactory, and gustatory perceptions. Active substance abuse will be an exclusion criterion. We will recruit Veterans of mixed genders and ages who are able to interact with others in a group setting. The intervention can be delivered in twelve sessions, the structure and pace of which are driven by participant needs and interests. The initial sessions involve the introduction of group participants, the establishment of ground rules, and the establishment of group interests and goals. Subsequent sessions are oriented towards psychoeducation about voice-hearing and psychosis; models for understanding psychotic symptoms; coping strategies both in session and for homework, including the role of medication, relationships between thoughts, feelings and behavior, and acceptance and mindfulness; and exploration of the ways group participants understand their voices and symptoms in light of their own personal histories and in terms of the frameworks and coping strategies that are introduced.
3. Use mixed methods to document the adaptation process and examine the outcomes, process, acceptability, and participant satisfaction of the intervention for this population.

PI: Ippolytos Kalofonos, MD PhD