• About The Writers



    View Profile


    PhD, CHE, CTRS

    View Profile

  • The Art of Mentoring

    The dictionary defines a mentor as “a trusted counselor or guide” (Merriam-Webster, 2018). We have all been influenced by mentors in our lives—positive role models who have taken a personal interest in us and both inspired and guided us to strive to reach our full potential.


  • Sobering Facts about Sober Living

    Stories of victory over substance abuse are compelling: The high school athlete who turns his life of opiate abuse into a college career, the young mother who reunites with her toddler after overcoming meth abuse, and the famous actor who emerges anew after a rehab stint. 


Ecotherapy: An Alternative Treatment Modality for Veterans 

Feature Articles

More than two million US veterans have served in Operation Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF) since 2001 (Sayer, 2011). Approximately two-fifths of these veterans received some kind of health care and social services through the Department of Veterans Affairs (VHA, 2009). According to Snyder and Monson, “Over one-third of veterans returning from deployment have a mental health diagnosis, and many more struggle with challenges of reintegration to family and civilian life” (2012, p. 301). While not all returning veterans from OIF and OEF have a mental health diagnosis, most experience some kind of adjustment issues as they reintegrate into civilian and family life because thoughts and behaviors needed to survive in war are not necessarily helpful in a civilian lifestyle. According to the US Department of Defense Task Force on Mental Health (2007), mental health personnel lack the resources and are unable to meet the demands of service members and their families in a timely manner (Snyder & Monson, 2012). 


While more soldiers are surviving the visible wounds of war, they still may carry the invisible wounds of war, largely existential and psychological—moreover, the ethical dimension of combat trauma, namely that of moral injury (Loeffler, 2013). Studies have shown that between 35 and 50 percent of veterans receiving care in the VA health care system have a mental disorder diagnosis (Brancu, Straits-Tröster, & Kudler, 2011; Cohen, Gima, Bertenthal, Kim, Marmar, & Seal, 2010) and according to the VA, approximately 27 percent of veterans from OEF and OIF have been diagnosed with posttraumatic stress disorder (PTSD; Bagalman, 2011). 


What Makes these Wars Different?


According to Matise (2016) we have entered a new era of warfare. Since the terrorist attacks on September 11, 2001, there has been a challenge of the legitimacy of a “just war” (Bell, 2012). The “just war” tradition is being replaced by a “global counter-terrorism” style of warfare of the twenty-first century and has been called “asymmetrical warfare” (Bell, 2012). Asymmetric conflict normally involves two forces differing greatly in their resources. One of the forces has greater military capacity as compared to the opposing forces. The norms and conventions governing conventional conflict were not designed to deal with asymmetric warfare, which is the face of “modern warfare” or sometimes coined “fourth-generation warfare” (Bell, 2012). In such instances, the lesser-resourced force cannot afford to take on the more endowed military force in the same way and they have to adopt novel tactics and innovations in the way they approach their adversary. That makes the war unconventional and this can create many situations where enemy combatants are forced to be more aggressive and brutal in their quest for victory. The tactics employed become more and more gruesome, which creates situations of extremism. The experiences witnessed in asymmetric conflict are fertile grounds for traumatic experiences which can result in PTSD and can involve many situations that present moral issues for soldiers. The conflict between their duties and their conscience can lead to situations in which soldiers’ moral compass may be challenged and even violated. The experiences resulting from such unconventional warfare activities can create situations where traumatic experiences are more probable for those involved (Brock & Lettini, 2013). The personal “nature of unconventional warfare makes the events of war potentially more traumatizing than they would be otherwise” (Matise, 2016). 


Ecotherapy as an Alternative Mode of Treatment


Ecotherapy” is an emerging form of therapy based on the connection between humans with nature. Ecotherapy is a general term for various practices that can lead to healing from the interaction between the human psyche and the natural environment and is an emerging field of ecopsychology that was founded by Theodore Roszak (Fuller, Irvine, Devine­Wright, Warren, & Gaston, 2007). Burls (2007) defined ecotherapy as a study of the natural environment and human psyche relationship. According to Buzzell and Chalquist (2009), ecotherapy is based on the assumption that humans are bonded to the natural environment the same way they are to their relatives and friends. It is developed from the belief that humans are part of nature and that people’s psyches are not separate from the natural environment. This form of therapy is based on a theory that provides people with a chance to interact and explore their connection with the natural environment.


This process of reconnection tends to make people feel more alive in a sensory capacity and a part of a greater whole, more than just with other people, to counter the sense of isolation and inner numbness. Because such a large part of healing in trauma work is reconnecting individuals with themselves and others, ecotherapy is promising in its evidence as a catalyst for healing. The impact on soldiers, while in a combat setting were most likely exposed to a more natural environment with less modern comforts to disconnect them from their experience of self and others, their return to civilian life can be a shock to their psychobiology. Not only the restoration of psychological well-being, but the potential savings in medical costs makes ecotherapy a viable option in the treatment of combat-related trauma. 


Smith (2014), in the paper titled “The Special Role of Nature in the Recovery from Posttraumatic Stress Disorder: A Theoretical Inquiry,” summarized the relationship between people and nature’s healing role:


  • The immersion in a natural setting dissolves the dualisms of mind-body, psyche-spirit, mind-ecology, and self-other.
  • The human need for spiritual connection is embedded in human nature and is rekindled in unconscious dialogue with nature.
  • Interaction with the natural environment exposes the natural relationship of human existence to the rhythms and cycles of the greater ecological field.
  • Mind and ecology merge in a balanced condition when in nature.
  • Human ecological unconscious is grounded in our species evolution over thousands of years.
  • Indigenous peoples viewed animals and forces of nature as healing agents.
  • Animals recover from trauma in natural settings by returning to a state of physical and emotional equilibrium.
  • Humans, to recover from trauma, need to be reconnected to their bodies and nature in order to gain their natural equilibrium.


Ecotherapists believe that conditions such as despair, grief, and anxiety are caused by disconnection with the ecological instincts (Selhub & Logan, 2012). This is supported by the fact that several people are experiencing stress­related symptoms in the modern world.


According to some ecopsychologists, these conditions are consequences of overreliance on modern technology, causing people to move away or disconnect from their natural environment. According to Burls (2007), humans become strangers to their natural environment by disconnecting from it. In such situations, their sense of identity is challenged and in some strange way, their mental health is affected. According to Buzzell and Chalquist (2009), the conditions that result from disconnecting from nature drives people to engage in destructive habits such as drug abuse and alcoholism. In other words, people who experience conditions such as depression, grief, and anxiety are more likely to start abusing drugs and alcohol. 


Ecotherapy Research Evidence


Several studies have shown that regular interaction with the natural world improves individuals’ mental and physical well-being (Chalquist, 2009). Most of these studies have capitalized on investigating people’s interaction with various outdoor environments such as remote lands, parks, gardens, open spaces, and urban areas. A consistent finding from these studies has shown that interaction with green environment enhances mental well-being and psychological health. It helps individuals to reduce stress-related conditions and improves their mood. According to Buzzell and Chalquist (2009), interaction with the natural world provides the restorative setting for individuals to relax and unwind.


Chalquist (2009) conducted a meta-analysis on the research evidence of ecotherapy and observed these common themes:


  • Disconnection: People are disconnected from the natural world, which produces a variety of psychological symptoms including anxiety, frustration, and depression, which are not solely accounted for by intrapsychic or familial dynamics.
  • Reconnection: The remedy of reconnecting to the natural world—whether through gardens, animals, nature walks, plants—helps to alleviate these symptoms and induce a greater capacity for health, well-being, self-esteem, social connection, and joy.
  • Rekindling: Ecotherapy has the capacity to invigorate an inner aliveness, promoting relationality with self, others, and nature. Ecotherapy techniques work across treatment modalities and can serve as an adjunct to mainline treatments.


Lack of interaction with the natural environment in urban areas has indicated a prominent reason people suffer from stress-related conditions, committing crimes, and drug abuse. Two classic studies proved the benefit of nature in human life (Burls, 2007). The first study, conducted in the 1980s, indicated that prisoners in a Michigan correctional facility whose cell had a view of trees and farmland experienced fewer cases of sickness than those whose cells were completely enclosed. The second study, indicated that patients in a Pennsylvania hospital whose rooms faced green environmental landscapes experienced a quicker recovery than those whose rooms faced a brick wall. These patients also required less attention, fewer painkillers and their outlook was reported as more positive, and their outlook was positive. The finding of hospital patients showed that ecotherapy could be a viable approach to reduce the cost of health and social care. From the same study, patients who are given a chance to interact with the natural environment required less medication and a quicker recovery. 


Another study in a Swedish hospital showed that patients had a tendency to vandalize abstract paintings while not vandalizing landscape paintings (Selhub & Logan, 2012). Other studies have shown that patients react positively to therapeutic images of nature (Nielsen & Hansen, 2007). A study by Fuller and colleagues (2007) indicated that patients who got a chance to interact with nature indicated positive views about their recovery. After investigating the effects of gardens in hospitals, Nielsen and Hansen (2007) found that 54 percent of users indicated less levels of stress after visiting a garden; 24 percent felt rejuvenated, and 18 percent were more positive about their recovery process. These findings showed that ecotherapy could be a viable approach to reduce the cost of health and social care. 


Further studies indicated that most people with mental conditions suffer from adverse side effects after taking psychiatric medications (Buzzell & Chalquist, 2009). Individuals experienced loss of energy, muscle spasms, sleeplessness, restlessness, loss of appetite, and dizziness. Due to the adverse side effects of psychiatric drugs, some people developed drug abuse and alcoholism. However, green treatment, another form of ecotherapy, has had positive side effects. According to Burls (2007), interacting with nature is a more effective way of treating and preventing substance abuse and mental illness. Green treatment also helped to treat other diseases such as high blood pressure, cancer, and diabetes. According to Fuller et al. (2007), green exercising protected individuals from type II diabetes, cancer, coronary heart disease, and musculoskeletal disease. It also lowered blood pressure, boosted the immune system, and improved blood lipid levels. For these reasons, health institutions may advise patients to develop a habit of exercising at least thirty minutes per day (Burls, 2007). Since fewer people are active in larger cities, there may be a higher risk of mental distress that can sometimes lead to other health conditions such as heart disease, obesity, and high blood pressure.  


Ecotherapy in Health Care Settings


There is evidence that ecotherapy is cost-effective as an intervention for treatment for individuals with a wide variety of needs, such as learning disabilities (Bruce, Hill, & Mawinney, 2008) and cancer survivors (Cimprich, 1993). Annerstedt and Währborg (2011) reported that over 90 percent of studies they reviewed demonstrated mental and physical health benefits. Studies in hospital settings showed that patients preferred pictures of the natural environment in their rooms. According to Annerstedt and Währborg (2011), there are some scents associated with nature that even helped to reduce blood pressure in patients. The environmental setting presented to patients while in a health care setting, affected their recovery process positively. For instance, with brighter and more attractive settings that have landscape pictures, patients developed positive feelings about their progress. Exposure to the natural environment also speeded recovery and reduced fatigue. Patients tended to have a more positive attitude, as a result of exposure to the natural environment, which aided recovery and reduced suffering from mental conditions.


Studies have also focused on the counseling milieu. According to Burls (2007), office pictures, kinds of furniture, and other items are very important in a counseling office. Some counselors found it beneficial to their clients to have plants and pets in their offices. They believed that these living things connected their clients with nature, hence making them more effective to guide and counsel clients. Taking clients outdoors has also been argued as a good approach to ensure clients increase their confidence and enhance a more positive attitude to aid recovery. For in­session counseling, imagery of a natural environment, such as pictures, is believed to promote relaxation and positivity.


Ecotherapy in Treating Substance Abuse


Ecotherapy is a cost­effective form of treatment that can also be used to treat substance abuse disorders in individuals. Studies indicated that various forms of ecotherapy helped to assist individuals struggling with drug addiction to reduce symptoms and improve their lives (Selhub & Logan, 2012). Wilderness intervention is among the methods that have been proven to have the ability to help individuals who suffer with the disease of addiction. According to Fuller et al. (2007), spending time outdoors is an opportunity for people to reconnect with themselves and create a sense of self­importance. Exercising can give people a sense of inner calm and solace, which can assist them to strengthen their will to engage in recovery. By strengthening their emotional well-being, substance abusers have a better chance to benefit from recovery therapy. This is possible through:


  • Nature Awakening: According to Burls (2007), the natural environment can trigger spiritual and harmonious feelings. It always helps individuals to connect with their world. The connection helps them to reevaluate life, discard what is less important, and choose what matter most.
  • Mood Enhancing: Studies have shown that natural light helps to enhance mood.
  • People who suffer from stress-related condition are mostly advised to spend some time in an open place where they can access sunlight.
  • Improving Self-Care: People who interact with nature learn to be responsible not only to themselves but also to nature. They learn to rely on themselves. Most rehabilitation centers encourage addicts to spend some time interacting with nature on a daily basis (Richardson et al., 2005). They are also encouraged to take part is physical exercise and understand their nutrition. These exercises help them to start focusing on life. Spending time interacting with the natural environment also helped individuals to reduce anxiety, stress, and depression. Such individuals developed self­esteem, self­care, and focus on more positive and productive lives.


Ecotherapy in Outdoor Interventions


There has been documentation about the relaxing effects caused by excursions into the wilderness. Studies have shown that people who visit nature experience relief from daily stressors (Buzzell & Chalquist, 2009). The wilderness also gives a sense of belonging and connection to oneself and the environment. A study on stressed and fatigued students indicated that students who spent time in the environment experienced psychological restoration and improved mood (Annerstedt & Währborg, 2011). Another study indicated that wilderness therapy was more effective at promoting confidence, self­esteem, and interpersonal skills (Annerstedt & Währborg, 2011).


Some psychologists recommend allowing children to experience the environment as a part of healthy growth and development. According to Fuller and colleagues (2007), children who grew up with freedom to explore their natural environment tended to develop more of a sense of worthiness and responsibility toward the environment. They also could better control their emotions. Studies indicated that children who had no contact with the natural environment were more likely to experience stressful moments than those who grew up in rural areas where they could more readily explore the natural environment. Another study found that most people enjoyed visiting parks that have different types of plants and were inhabited by animals (Banks & Banks, 2002). These studies suggested that humans are sensitive to biodiversity in their environment and benefit positively from interaction with nature.


Ecotherapy in Practice: Heroes on the Water (HOW)


Heroes on the Water (HOW) was founded in 2007 and the program’s mission is to “help warriors relax, rehabilitate, and reintegrate through kayak fishing and the outdoors” (Matise & Price-Howard, In Press). By providing adaptive kayaks and equipment as needed, the HOW program empowers veterans to decompress and reconnect with themselves, others, and to become a part of a community (other HOW participants and mentors) and a larger purpose to help others. A mixed-methods exploratory study examined the impact of ecotherapy (HOW) on the treatment of veterans (Matise & Price-Howard, In Press). The study looked at the four categories of symptoms related to PTSD as outlined in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5; APA, 2013). The reduction in self-reported symptoms were as follows: stress (56 percent); reexperiencing (60 percent); avoidance (63 percent); and hypervigilance (62 percent). Implications for counselors and directions for future research are discussed. This pilot study contributed to the growing evidence-based practices of utilizing ecotherapy as an adjunct to treatment for behavioral health issues with veterans and other individuals. The healing philosophy of HOW is summed up in the following statement: 


The way to get feelings out is to catch and release. When we used to go fishing, we pulled every fish we caught out of the water and took it home. Then we realized fish were living creatures. We developed a new way to fish called catch and release. We caught the fish, then we set the fish free. That’s all we need to do with feelings. We can deal with a caught- feeling, then release the feeling and old belief, and Life teaches us something new. Then along comes another feeling, emotion, another belief, and a new lesson. It’s a natural, organic process called spiritual and emotional growth (Beattie, 2009, p. 231).


According to Jim Dolan, HOW’s founder, kayak fishing provides triple therapy: physical (paddling and fishing), occupational (learning new skills), and mental (relaxation from being on the water; Nichols, 2015). As of this writing, HOW has sixty-four chapters in thirty-five states and the United Kingdom and Australia. HOW works by interacting with veterans and talking about their trauma as they kayak and fish in a natural environment. The HOW program provides an alternative and complementary therapy option for individuals suffering with PTSD and other psychological disorders.


Implications for Counselors


The unique stresses of deployment and combat-related issues for individuals and families leave their mark in the way of symptoms, disorders, interpersonal struggles, and displacement (Matise, 2016). These unique stressors can also extend to the treatment providers helping these individuals and their families by way of “vicarious trauma” and compassion fatigue. It is essential for professionals to remain resilient by addressing their own needs in therapy, as needed and to maintain their own social networks for support. Recognizing and addressing the signs of burnout, fatigue, irritableness, and ineffectiveness need to give counselors pause for reflection and to take action so that they remain intact as healthy individuals. If counselors are not in a state of health, they are less likely to be as effective in helping others achieve stability and mental well-being. Knowing when to seek additional support, in the way of adjunctive treatments such as ecotherapy, is essential for counselors who treat victims of trauma. 




Treatment for veterans of OIF and OEF are largely dependent on the identification of the mental health issues affecting them. Treatments are done by utilizing psychotherapy, medication, group therapy, and other forms of treatment modalities that may serve as adjuncts to healing and recovery (Matise, 2016). A combination of these methods of treatment is also employed in treatment regimens for mental illnesses. 


In order to adequately and accurately meet the needs of individual veterans, a culturally integrated counseling model is imperative. Culture and diversity are necessary components of counselor competence (Sue, Arredondo, & McDavis, 1992). Carrola and Corbin-Burdick (2015) provide a framework for counselors to better understand soldiers’ unique cultural perspectives and how it affects their views of their traumatic experiences. This will help in creating a strong therapeutic alliance with these individuals by not disregarding the personal and important aspects of their identity. This can also enable counselors to provide effective treatment options for those seeking treatment. 


Evidence that veterans can experience posttraumatic growth (PTG) has been supported by multiples studies (Tedeschi & NcNally, 2011). PTG is the notion that people are able to grow in life areas even after experiencing negative events which are traumatic (Moore, 2017). While there needs to be more research in this area, ecotherapy and organizations like HOW can be a catalyst to foster and facilitate posttraumatic growth of veterans by developing boundaries, structure, and education in a safe environment, as well as to reconnect them with their natural environment and with consistent and compassionate companionship. Ecotherapy helps individuals reconnect to the natural environment and can reduce stress-related symptoms, boost health, well-being, social interaction, happiness, and self-esteem.


The studies showed the importance of the natural environment to humans and suggested that humans have a special connection to nature. More than 50 percent of Americans believe that protecting the environment is more important than energy production (Selhub & Logan, 2012). Connection to the natural environment eventually develops an emotional affinity to the environment. Humans have an innate connection to the natural environment and ultimately, the connection between humans and nature is what brings joy, happiness, and emotional well-being. It is what helps people who suffer with stress-related symptoms to restore a sense of peace and ultimately thrive. Reestablishing our connection to the natural environment not only can restore our well-being, but can also help us to become more humanely human.











American Psychiatric Association (APA). (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: Author. 
Annerstedt, M., & Währborg, P. (2011). Nature­assisted therapy: Systematic review of controlled and observational studies. Scandinavian Journal of Public Health, 39(4), 371–88.
Bagalman, E. (2011). Congressional Research Service: Suicide, PTSD, and substance use among OEF/OIF veterans using VA health care: Facts and figures. Retrieved from https://pdfs.semanticscholar.org/cfce/ce687b1ba6cec2121926c81eaddd3002b2fd.pdf
Banks, M. R., & Banks, W. A. (2002). The effects of animal­-assisted therapy on loneliness in an elderly population in long­term care facilities. The Journals of Gerontology Series A: Biological Sciences and Medical Sciences, 57(7), M428–32. 
Beattie, M. (2009). The new codependency: Help and guidance for today’s generation. New York, NY: Simon & Schuster.

Bell, D. M. (2012). The moral crisis of just war: Beyond deontology toward a professional military ethic. Retrieved from http://faithandwar.org/index.php/god-man-and-war/43-history-of-war/158-the-moral-crisis-of-just-war 

Brancu, M., Straits-Tröster, K., & Kudler, H. (2011). Behavioral health conditions among military personnel and veterans: Prevalence and best practices for treatment. North Carolina Medical Journal, 72(1), 54–60.
Brock, R. N., & Lettini, G. (2013). Soul repair: Recovering from moral injury after war. New York, NY: Beacon Press.
Bruce, J., Hill, P., & Mawinney, K. (2008). An urban farm in Northern Ireland as an instrument for social integration. Paper presented at the Thirteenth Annual Conference of the International Association for the Scientific Study of Intellectual Disabilities, August 25–30, 2008.
Burls, A. (2007). People and green spaces: Promoting public health and mental well-being through ecotherapy. Journal of Public Mental Health, 6(3), 24–39.
Buzzell, L., & Chalquist, C. (Eds.). (2009). Ecotherapy: Healing with nature in mind. San Francisco, CA: Sierra Club Books.

Carrola, P., & Corbin-Burdick, M. (2015). Counseling military veterans: Advocating for culturally competent and holistic interventions. Journal of Mental Health Counseling, 37(1), 1–14.

Chalquist, C. (2009). A look at the ecotherapy research evidence. Ecopsychology, 1(2), 1–11. 
Cimprich, B. (1993). Development of an intervention to restore attention in cancer patients. Cancer Nursing, 16(2), 83–92.

Cohen, B. E., Gima, K., Bertenthal, D., Kim, S., Marmar, C. R., & Seal, K. H. (2010). Mental health diagnoses and utilization of VA non-mental health medical serviceds among returning Iraq and Afghanistan veterans. Journal of General Internal Medicine, 25(1), 18–24. 

Fuller, R. A., Irvine, K. N., Devine­Wright, P., Warren, P. H., & Gaston, K. J. (2007). Psychological benefits of greenspace increase with biodiversity. Biology Letters, 3(4), 390–4. 
Loeffler, G. (2013). Moral injury: An emerging concept in combat trauma. The Resident’s Journal, 8(4), 2. 
Matise, M. J. (2016). Mental health services for military veterans and their families. The Kentucky Counseling Association Journal, 1(1), 4–18.
Matise, M. J., & Price-Howard, K. (In press). Ecotherapy as treatment modality for working with veterans with posttraumatic stress disorder. 
Moore, B. (2017). Posttraumatic growth in combat veterans. Retrieved from: https://pro.psychcentral.com/posttraumatic-growth-in-combat-veterans/0018206.html. 
Nielsen, T. S., & Hansen, K. B. (2007). Do green areas affect health? Results from a Danish survey on the use of green areas and health indicators. Health & Place, 13(4), 839–50. 
Nichols, W. J. (2015). Blue Mind: The surprising science that shows how being near, in, on or under water can make you happier, healthier, more connected, and better at what you do. New York, NY: Back Bay Books.
Richardson, C. R., Faulkner, G., McDevitt, J., Skrinar, G. S., Hutchinson, D. S., & Piette, J. D. (2005). Integrating physical activity into mental health services for persons with serious mental illness. Psychiatric Services, 56(3), 324–31.

Sayer, N. A. (2011). Response to commentary: The challenges of co-occurrence of postdeployment health problems. Retrieved from https://www.hsrd.research.va.gov/publications/internal/forum05_11.pdf 

Selhub, E. M., & Logan, A. C. (2012). Your brain on nature: The science of nature’s influence on your health, happiness, and vitality. Hoboken, NJ: Wiley & Sons.
Smith, J. L. (2014). The special role of nature in the recovery from posttraumatic stress disorder: A theoretical inquiry (Master’s Thesis). Retrieved from https://www.researchgate.net/publication/270703405_THE_SPECIAL_ROLE_OF_NATURE_IN_THE_RECOVERY_FROM_POST-TRAUMATIC_STRESS_DISORDER_A_THEORETICAL_INQUIRY
Snyder, D. K., & Monson, C. M. (2012). Integration and implications for clinical practice and research. In D. Snyder & C. Monson (Eds.), Couple-based interventions for military and veteran families: A practitioner’s guide (pp. 287–305). New York, NY: The Guilford Press.
Sue, D. W., Arredondo, P., & McDavis, R. J. (1992). Multicultural counseling competencies and standards: A call to the profession. Journal of Counseling and Development, 70(4), 477–86.
Tedeschi, R. G., & McNally, R. J. (2011). Can we facilitate posttraumatic growth in combat veterans? American Psychologist, 66(1), 19.
United States Department of Defense Task Force on Mental Health. (2007). An achievable vision: Report of the Department of Defense Task Force on Mental Health. Retrieved from http://intransition.dcoe.mil/files/MHTFReportFinal.pdf
Veterans Health Administration (VHA). (2009). Analysis of VA health care utilization among US Global War on Terrorism (GWOT) veterans- Operation Enduring Freedom, Operation Iraqi Freedom. Retrieved from http://www.networkofcare.org/library/GWOT_4th%20Qtr%20FY08%20HCU.pdf